Michael Weber RPA-C, MPAS Touro College Pneumonia More than 3 million cases occur annually in the United States. 20% result in hospitalization incidence of nosocomial pneumonia range from 4-7 episodes per 1000 hospitalizations. Approximately 25% of patients in intensive care units (ICUs) develop pneumonia Pneumonia is more prevalent during the winter months and in colder climates. Left untreated, pneumonia may have an overall mortality rate of more than 30%. 40,000-70,000 die each year It is the most lethal hospital acquired infection Pneumonia Infection of the pulmonary parenchyma, alveolar spaces and interstitial space Infection may be confined to an entire lobe or may be segmental M/C cause of pneumonia in adults is bacterial pneumonia Strep Pneumoniae, Staph Aureus, H. Influenzae, Moraxella Cat, Legionella, Klebsiella Mycoplasma is a bacteria-like pneumonia m/c seen in in older children and younger adults Etiology Continued Major causes in children and infants are Viruses RSV (Respiratory syncytial virus) , Adenovirus, Para influenza, Influenza A and B and Viral Exanthems (Varicella, Measles, Rubella) Parasitic and Fungal causes are also seen in adults and children Predisposing Factors Viral infections Decreased Consciousness Chronic ETOH Aspiration Approximately 45% of healthy subjects aspirate during sleep The oropharynx of hospitalized patients may become colonized with aerobic gram-negative bacteria within a few days of admission. Therefore, nosocomial pneumonia is caused predominantly by the gram-negative bacilli Institutionalization Inhalation Smoking Heart Failure COPD Age extremes Immunosuppression Microbial Pathogens That Cause Pneumonia Community Acquired Hospital Acquired HIV Infection 1. S. Pneumoniae 1. Pseudomonas 1. PCP 2. Mycoplasma 2. S. Aureus 2. M. Tuberculosis 3. H. Influenza 3. Enteric Aerobic 3. S. Pneumoniae 4. Chlamydia Gram Neg Bacilli 4. H. Influenza 5. Legionella 4. Oral Anaerobes 6. M. Catarralis 7. S. Aureus 8. Nocardia Spp 9. Virus 10. Fungal 11. M. Tuberculosis Criteria For Admission 1. Elderly > 65 yrs old 2. Significant co morbidity (Kidney, heart, lung disease, DM, Neoplasm, Immunosupression) 3. Leukopenia (< 5,000 WBC) 4. S. Aureus, Gram Neg Bacilli, or anaerobes as the cause of infection 5. Suppurative complications (Empyema, Meningitis, endocarditis) 6. Tachypnea (> 30/min), Tachycardia (>125 /min), Hypotensive(<90 mmHg systolic), Hypoxemia (ApO2 <60), Altered mental status Pneumococcal Pneumonia S. Pneumoniae is the M/C cause of bacterial pneumonia M/C cause of Community-Acquired pneumonia M/C in winter months M/C at the extremes of age Caused by inhalation or aspiration Usually starts as a simple URI S&S Single shaking chill Fever (102-103) Pain with breathing on the affected side (Pleurisy) Cough Dyspnea Rust colored sputum Tachycardia, Tachypnea N/V and myalgia Wheezes and Ronchi Labs Leukocytosis with a left shift Gram Stain of sputum shows Gram Positive lancet shaped diplococci Positive blood cultures are definitive evidence of pneumococcal infection XR Dense consolidation confined to a single lobe TX Pen G is drug of choice for penicillin-sensitive strains of S. pneumoniae About 25% of strains of S. pneumoniae are resistant to penicillin Alternative TX Amoxicillin/ Augmentin (High dose) Zithromax Erythromycin Clindamycin Cephalexin Cefazolin ceftriaxone The newer quinolones are preferred therapy for penicillin-resistant strains and as an alternative to penicillin for penicillin-sensitive strains EX: Avelox Bed rest, Fluids, Analgesics for pain Prophylaxis with vaccine for children >2, immunocomprimised Pt’s and well Pt’s Staphylococcal Pneumonia Accounts for ~2% of community acquired pneumonia and ~10- 15% of hospital acquired. People at risk: Infants, elderly, debilitated Pt’s, immunosupressed, IVDA, and Cystic fibrosis Pt’s S. Aureus gains lung access by two routs Aspiration Heamatogenous spread (embolization) Causes severe infection which can be seen after intubation Commonly seen after outbreaks of influenza and measles S&S Recurrent rigors Abscess formation Empyema formation Fever Cough N/V Dyspnea Tachycardia & Tachypnea Pluritic pain/chest pain Systemic toxicity DX Sputum culture grows S. Aureus Gram-Stain shows Clusters of gram positive cocci Culture empyema fluid Blood cultures Thoracentesis XR Show multiple nodular infiltrates and plural effusion Abscess will show if present (Air fluid level) Lobar consolidation is infrequent Prognosis & TX Mortality rate is 30-40% Recommended tx is Penicillinase-resistant penicillin Oxacillin Nafcillin Alternative TX Vancomycin 1gm I.V Q12 hours Linezolid (Zyvox) 600mg I.V Q12 hours If Methicillin Resistant (on the rise!!!) Tx with Vancomycin Other ABX depend on C&S If VRE, Pray! Linezolid (Zyvox) Streptococcal Pneumonia Group A Beta-hemolytic Strep are rare cause of pneumonia It was at its peak during WW I Usually seen in previously healthy Pt’s The occasional case is seen as a complication of influenza, measles, chicken pox, or pertussis S&S Fever chills Dyspnea Productive Cough Chest pain ( usually abrupt) Pleurisy Thchycardia & Tachypnia N/V Plural effusion DX Suspect in Pt’s with with Plural effusion associated with Measles, chicken pox, pertussis, influenza, Strep Pharyngitis, Scarlet fever Gram Stain shows Gram positive cocci in chains Thoracentesis shows sero-sanguineous or purulent fluid XR shows lobar infiltrate and empyema fluid DX Response to Tx is slow but mortality rate is low Amp 2gm I.V Q6 hours Amox 1gm po TID Macrolide Penicillin G 500,000 – 1 million units IV Q 4-6 h. Doxy Cephalosporins Telithromycin Alternative TX (pen resistant) FQ’s 3rd generation Cephalosporins Vanco Zyvox Plural effusions which are thin should be drained via Thoracentesis If plural fluid is thick and loculated, drain by tube thorcostomy If fluid is not drained appropriately, thoracotomy may be needed for removal Klebsiella Pneumonia Rarely seen in a well host M/C seen in Pt’s which are immunocompromised, neutropenia, and **alcoholics and **Diabetic Pt’s Usually due to colonization of the oropharynx with microaspiration **Causes Friedlander’s pneumonia (Currant Jelly sputum with abscess formation and upper lobe involvement) Most often encountered in hospital aquired pneumonia S&S Currant Jelly sputum Fever Pluritic chest pain SOB Dyspnea N/V Sepsis DX Gram Stain of sputum shows Gram negative Bacilli Sputum culture grows Klebsiella Positive cultures from: Blood Plural fluid Tracheal aspirate XR shows upper lobe involvement +/- abscess formation TX Mortality rate is 25-50% Primaxin (Imienemem) or Merrem (Meropenem) If resistance: Polymyxin E (Colistin) Hemophilus Influenzae Common cause of Pneumonia 2nd to only S. Pneumoniae 6 different types classified as A-F Colonization is seen in the nasopharynx and the upper respiratory tracts **Strains of H. Influenzae seen in adults are commonly seen to colonize in Pt’s with Chronic bronchitis. (Smokers) Seen to cause pneumonia in children <2 yrs old S&S Cough Coryza Purulent Green Sputum Fever Chills Rales TX Gram Staining of sputum: Small gram-negative coccobacilli X-R: 30% of H. influenzae strains produce B-lactamase and are resistant to ampicillin B- lactamase negative: Amp Amox TMP/SMX Zithromax (Azithro) Biaxin (Clarithro) Doxycycline B- lactamase Positive: Augmentin 2nd, 3rd cephalosporin FQ’s Zithromax (Azithro) Biaxin (Clarithro) Prophylaxis: Vaccine for all children in 3 doses (2, 4, 6 mo of age) Legionnaire’s Pneumonia More than 30 different species M/C is L. Pneumophila Accounts for 1-8% of all pneumonias M/C seen in summer and fall Known habitat of L. pneumophila is water: Air conditioning systems, shower heads, lakes, rivers Caused by inhalation or inspriation Person to person contact has not been shown Incubation period is 2-10 days Risk factors are smoking, ETOH, steroid use, immunosupression, and advanced age S&S Spectrum of the disease is seen with 1. Asymptomatic seroconversion 2. Pontiac fever: Self-limited flu like illness with out pneumonia 3. Pneumonia 4. Rare, soft tissue infections High Fever (103-104) Cough (Non productive than Productive) Headache Bradycardia Diarrhea, confusion, lethergy DX Staining: Pleomorphic Gram Negative bacilli Culture: This is definitive method of Dx Antibody testing: Urinary Testing: Shows Legionella Assay in urine Bronchoscopy Aspirates and brushings Culture of plural fluid X-R: Early disease: Unilateral, patchy lobar infiltrate Late Disease: B/L involvement and Plural effusions TX Macrolides: Azithromycin Clarithromycin Quinolones Levaquin Avelox Cipro Tetracyclines Doxycycline Minocycline Tetracycline Others: TMP/SMX Rifampin Mycoplasmal Pneumonia M/C pathogen seen in lung infections among children and young adults form 5-35 y.o. M/C seen in summer and fall Incubation period is 1-3 weeks Causes 10-20% of all pneumonias “Walking Pneumonia” “Atypical Pneumonia” S&S Sore throat Chills Coryza Malaise Dry cough which can progress to mucopurulent and blood streaked sputum Physical exam tends to be unimpressive in contrast with Pt’s c/o DX Leukocytosis +/- increased ESR X-R: Interstitial infiltrates located in the lung base with streaks radiating from the hilus to the base Cold Agglutinin positive in 50% of cases Serum Mycoplasma IgM/IgG TX Doxycycline Erythromycin Azithromycin Clarithromycin Fluoroquinolones (Levaquin, Avelox and FActive) Antipyretics and cough suppressants Chlamydial Pneumonia Seen in late childhood and peak in young adults Transmission is from person to person (respiratory aerosol) primarily in schools and family 50% of older adults have serologic evidence of prior infection Studies have shown an association between Chlamidia pneumo and atherosclerotic disease of the coronary arteries S&S Pharyngitis Pneumonitis Cough Fever Sputum production Pt’s are not seriously ill DX & TX Dx with serologic tests The usual clue is pneumonia with no pathogen on culture and unresponsive to B-lactam meds Drug of choice is Doxycycline Alternative Erythromycin Zithromax Quinolone Aspiration Pneumonia Due to abnormal entry of fluids, secretions, or particulate matter into the lower air way Seen with 3 different syndromes which vary based on the nature of the aspirate Chemical Pneumonitis Bacterial infection Mechanical Abstruction Seen in Pt’s with absent gag reflex, Decreased level of consciousness and oral feedings Chemical Pneumonitis Seen with aspiration of material which is directly toxic to the lung Mendelson’s syndrome: Pneumonitis due to aspiration of stomach contents Seen with acute dyspnea, tachypnea, tachycardia, cyanosis, bronchospasam, fever, pink frothy sputum. CXR: Infiltrates involving Right or both lower lobes. ABG: Hypoxemia Tx Most important is respiratory support with mechanical ventilation Tracheal suction Corticosteroids ABX Mortality rates of bacterial super-infection is 50% Bacterial Infection M/C form of aspiration pneumonia M/C Anaerobic pathogens which colonize in the gingival creases of the mouth Seen with: Cough, fever, purulent sputum CXR: + infiltration in either lung field depending on the position of the Pt during aspiration Tx: Ventilation if needed, Culture of sputum to determine appropriate ABX tx Mechanical Obstruction Seen with aspiration of particulate matter Drowning victims and oral feeding Pt’s Seen with acute dyspnea, cyanosis, apnea, and rapid death (Upper airway) CXR: Atelectasis, Hyperinflation of involved lung. Cardiac shadow may shift away from the abnormal lung. F.B which are in the lower airway for long periods of time and not picked up on CXR cause recurrent pneumonias TX: Bronchoscopy to remove the F.B DX X-R: Diffuse B/L Perihilar infiltrates 10-20% have normal CXR ABG: Hypoxemia PFT’S: Altered diffusing capacity Leukocytosis (Mild) Culture material from sputum, bronchoalveolar lavage QUESTIONS Mycotic Infections and Pneumocystis Carinii Pneumonia Fungal Pneumonia M/C caused by Blastomycosis Histoplasma capsulatum Coccidioides immitis Less common Candidia Cryptococcus Aspirgillus M/C seen in immunosuppressed Pt’s (HIV, Cancer Pt’s and Chemo Pt’s) Histoplasmosis Caused by Histoplasma Capsulatum A fungus found in soil contaminated with bird and bat dropings Found in eastern and central USA, eastern Canada, Mexico, Central America, Africa and south east Asia Common along the Ohio and Mississippi river valley Infection is through inhalation, leading to proliferation Can spread hematogenous to other organs Wide spread disease is seen in immunosupressed and HIV Pt’s S&S Most cases are asymptomatic Positive Histoplasmin skin test and liver and splenic calcification with past infection Influenza type illness Fever cough Chest pain Staging Acute Histoplasmosis is usually asymptomatic Fever, cough, X-R may show pneumonia Almost never fatal. May last 1 wk- 6 months Progressive Disseminated Usually fatal with in 6 wks hematogenous spread from the lungs Fever, cough, dyspnea, Wt. loss, ulceration of the mucus membranes, Hepatosloenomegly, Adrenal gland involvement Chronic cavitary Progressive Seen in elderly with COPD. X-R shows cavities Disseminated Disease in immunocompromised Usually seen in HIV Pts with CD4 < 100 Multiple organ involvement. X-R shows miliary pattern Labs Sputum culture in rarely positive except in chronic disease Blood and Bone marrow culture is positive 80% of the time Urine Antigen Assay is positive >90% in disseminated infection Titers positive 80% of time TX Itraconazole 200-400mg per day for weeks to months Fluconazole Voriconazole posaconazole Amphotericin B: For Pt’s who cont tolerate PO meds and is reserved for the initial treatment of moderately severe or severe infection due to its potential toxicity relapse is common Aids Pt’s usually need life long Itraconazole TX Coccidioidomycosis Valley fever Due to inhalation of Mold that grows in soil in Southwestern USA, Mexico, and South America Common opportunistic infection in HIV Pts in endemic areas (25% of AIDS Pts) Can lead to multiple organ involvement and meningitis Incubation period of 10-30 days S&S Fever Cough (slightly productive) Chills chest pain Pharyngitis Arthralgia with periarticular swelling of knees and ankles Erythema nodosum Meningitis in 30-50% of disseminated infections Labs Leukocytosis and Eosinophilia Serologig tests (IgM) are useful in the DX Imaging X-R: Nodular pulmonary infiltrates Thin walled cavities Hilar Lymphadenopathy Plural effusions Empyema and Abscess formation Lytic lesions TX Itraconazole Fluconazole Posaconazole Amphotericin B Meningitis Amphotericin B Fluconazole for mild meningitis Bone involvement Fluconazole or itraconazole x 6 months Cryptococcosis Encapsulated budding yeast found world wide in soil and dried pigeon droppings Infection through inhalation Rarely seen to develop in immunocompetent Pt’s S&S Targets the CNS Headaches Confusion Mental status change Cranial nerve involvement Nuchal rigidity Meningitis seen in 50% of cases Labs CSF shows Increased opening pressure Increased protein Decreased glucose Budding encapsulated fungus cells TX Aids related: Fluconazole for no less than 10 weeks Itraconazole 6-12 months Amphotericin B for high risk Pt’s (some studies sugest starting 1st line with Flucytosine) Blatsomycosis Caused by inhalation of mold that turns into yeast Seen in South central and Midwestern USA and Canada May be asymptomatic Disseminated disease is seen M/C with lesions at the skin, bone and urogenital tract S&S Cough which can progress to bloody purulent sputum Fever / chills Chest pain and dyspnea Raised verrucous lesion (Disseminated lesion) Ribs and vertebrae M/C involved Epididymitis, prostatitis Labs Leukocytosis Anemia X-R Pulmonary infiltrates with hilar lymphadenopathy TX Itraconazole x 2-3 months Amphotericin B Fluconazole Aspergillosis Aspirgillus Fumigatus is the M/C form Usually found in dead leaves, compost piles, stored grain, and dead vegetation Due to inhalation Almost always found in immunosupressed Pt’s S&S Chronic productive cough Hemoptysis Fever/Chills Can rapidly progress in immunpsupressed Pt’s. Formation of Aspergilloma (Fungus Ball) Tangled mass of hyphe, fibrin, exudate seen on CXR Labs Commonly seen in AIDS Pt’s with a CD4 <50 Isolation of Aspergillus from sputum Bronchaloveolar lavage Bronchoscope Bx Tx Pt’s with a fungus ball and hemoptysis may benefit from a lobectomy Amphotericin B given I.V Itraconazole Prognosis depends on how immunosuperssed the Pt is Pneumocystis Carinii (PCP) Known as an Opportunistic infection and a late complication of HIV Occurs in Pt’s with a CD4 <200 Opportunistic infections are the leading cause of death in HIV Pt’s 80% of Aids Pt’s die of other diseases other than Aids PCP is one of the M/C infections in HIV 31% of Pt’s have a relapse within 6 months. 66% of Pt’s relapse within 12 months Also seen in cancer Pt’s and Pt’s on cytotoxic drugs 50% of deaths due to respiratory failure in patients with AIDS were attributed to P carinii S&S Thought to occur from air borne transmission Abrupt onset. Tachypnea and SOB Fever Cough, usually non-productive Retrosternal chest pain Dyspnea +/- bibasilar crackles Wt. loss Usually clear breath sounds 2% of Pt’s obtain Pneumothorax Labs CXR: B/L Patchy interstitial infiltrates (Early) Focal consolidation, nodules and cavitations with plural effusion (Late disease) may be normal in 10-39% of patients ABG: Hypoxemia with hypocapnia CD4 < 200 Increased LDH Sputum culture and stain Bronchoalveolar lavage Lung Bx (not common) TX It is appropriate to start empiric Tx if clinically suspected Drug of choice: TMP/SMX (Bactrim) x 21days Alternative Med: 2. Pentamidine 3. Dapsone 4. Primaquine plus clindamycin 5. Atovaquone (Mepron) O2 Prednisone Prophylaxis: Bactrim Prognosis: Untreated = 100% fatality in Aids Pts Early Tx = 10-20% in Aids Pts Recurrence rate with out prophylaxis = 30% PCP STOP!