Pneumonia measles by mikeholy


									Michael Weber RPA-C, MPAS
     Touro College
   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
         Approximately 25% of patients in intensive care units (ICUs) develop pneumonia
   Pneumonia is more prevalent during the winter months and in colder
   Left untreated, pneumonia may have an overall mortality rate of more than
   40,000-70,000 die each year
   It is the most lethal hospital acquired infection
   Infection of the pulmonary parenchyma, alveolar spaces
    and interstitial space
   Infection may be confined to an entire lobe or may be
   M/C cause of pneumonia in adults is bacterial
       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
                    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

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
   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
   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

   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
   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
   Recurrent rigors
   Abscess formation
   Empyema formation
   Fever
   Cough
   N/V
   Dyspnea
   Tachycardia & Tachypnea
   Pluritic pain/chest pain
   Systemic toxicity

 Sputum culture grows S. Aureus
 Gram-Stain shows Clusters of gram positive cocci
 Culture empyema fluid
 Blood cultures
 Thoracentesis
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
   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
   Fever
   chills
   Dyspnea
   Productive Cough
   Chest pain ( usually abrupt)
   Pleurisy
   Thchycardia & Tachypnia
   N/V
   Plural effusion

   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
   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
   **Causes Friedlander’s pneumonia (Currant Jelly sputum with
    abscess formation and upper lobe involvement)
   Most often encountered in hospital aquired pneumonia

   Currant Jelly sputum
   Fever
   Pluritic chest pain
   SOB
   Dyspnea
   N/V
   Sepsis

   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

   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

   Cough
   Coryza
   Purulent Green Sputum
   Fever
   Chills
   Rales
   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
   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)
Diarrhea, confusion, lethergy
   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
        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”
   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

   Leukocytosis
   +/- increased ESR
   X-R: Interstitial infiltrates located in the lung
    base with streaks radiating from the hilus to the
   Cold Agglutinin positive in 50% of cases
   Serum Mycoplasma IgM/IgG

   Doxycycline
   Erythromycin
   Azithromycin
   Clarithromycin
   Fluoroquinolones (Levaquin, Avelox and
   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
   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

   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

   Most important is respiratory support with mechanical
   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

   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
Mycotic Infections and
Pneumocystis Carinii
                  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)

   Caused by Histoplasma Capsulatum
      A fungus found in soil contaminated with bird and bat
   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
   Most cases are asymptomatic
   Positive Histoplasmin skin test and liver and
    splenic calcification with past infection
   Influenza type illness
   Fever
    cough
   Chest pain

   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
   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

   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

   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
   Incubation period of 10-30 days

   Fever
   Cough (slightly productive)
   Chills chest pain
   Pharyngitis
   Arthralgia with periarticular swelling of knees and
   Erythema nodosum
   Meningitis in 30-50% of disseminated infections
 Leukocytosis and Eosinophilia
 Serologig tests (IgM) are useful in the DX
X-R: Nodular pulmonary infiltrates
Thin walled cavities
Hilar Lymphadenopathy
Plural effusions
Empyema and Abscess formation
Lytic lesions
   Itraconazole
   Fluconazole
   Posaconazole
   Amphotericin B
   Meningitis
       Amphotericin B
       Fluconazole for mild meningitis
   Bone involvement
       Fluconazole or itraconazole x 6 months
   Encapsulated budding yeast found world wide in
    soil and dried pigeon droppings
   Infection through inhalation
   Rarely seen to develop in immunocompetent
   Targets the CNS
   Headaches
   Confusion
   Mental status change
   Cranial nerve involvement
   Nuchal rigidity
   Meningitis seen in 50% of cases
   CSF shows
     Increased opening pressure
     Increased protein

     Decreased glucose

     Budding encapsulated fungus cells
   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)
   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
   Cough which can progress to bloody purulent
   Fever / chills
   Chest pain and dyspnea
   Raised verrucous lesion (Disseminated lesion)
   Ribs and vertebrae M/C involved
   Epididymitis, prostatitis
   Leukocytosis
   Anemia
                           X-R
 Pulmonary infiltrates with hilar lymphadenopathy
Itraconazole x 2-3 months
Amphotericin B
   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

   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

   Commonly seen in AIDS Pt’s with a CD4 <50
   Isolation of Aspergillus from sputum
   Bronchaloveolar lavage
   Bronchoscope
   Bx

   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

   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
   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)

   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%

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