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PNEUMONIA
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EPIDEMIOLOGY
CLINICAL MANIFESTATIONS
Results in more than 600,000 hospitalizations, 64
million days of restricted activity, and 45,000 Vary from indolent to fulminant in presentation
deaths annually and from mild to fatal in severity
Incidence rates are highest at the extremes of - Fever with tachycardia or may have a history
age of chills and/or sweats
- Children <4 years of age and persons >60 - Cough may be either nonproductive or
years of age productive of mucoid, purulent, or blood-
tinged sputum
Risk Factors - Pleuritic chest pain
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CHEST RADIOGRAPH - Neutropenia secondary to pneumonia,
asplenia, or complement deficiencies; chronic
Essential in the diagnosis of CAP, assessing
liver disease; or severe CAP
severity, differentiating pneumonia from other
conditions, and in prognostication (Grade A) 3. Antigen Tests
A new parenchymal infiltrate in the chest - Legionella antigens in urine
radiograph remains the reference diagnostic ‣ Test for L. pneumophila detects only
standard for pneumonia serogroup 1, but this serogroup accounts
A chest x-ray should be done in patients for most community-acquired cases of
suspected to have CAP to confirm the diagnosis Legionnaires' disease
‣ 90% sensitive and 99% specific
A chest x-ray may not be routinely done in patients - Pneumococcus
strongly suspected to have CAP with the following
- Influenza
conditions:
- RSV
1. Healthy individuals or those with stable co-
morbid conditions, and 4. PCR
2. Normal vital signs and physical examination - Generally limited to research studies
findings, and - In patients with pneumococcal pneumonia, an
3. Reliable follow-up can be ensured increased bacterial load documented by PCR
is associated with an increased risk of septic
shock, need for mechanical ventilation, and
A radiographic reading of “pneumonitis” should death
always be correlated clinically. (Grade C)
5. Serology
- Non-infectious causes of pneumonitis may
include fibrosis (immunologic, occupational - A fourfold rise in specific IgM antibody titer
lung disease) between acute- and convalescent-phase
serum samples is generally considered
- If pneumonitis is infectious in nature, it could diagnostic of infection with the pathogen in
relate to the first stage in the process of question
pneumonia.
▪ Congestive phase
‣ Infection is contained within the
interstitial compartment or
peribronchial region before it extends
to involve the alveoli (consolidation)
ETIOLOGIC DIAGNOSIS
1. Gram’s Stain and Culture of Sputum
- Main purpose of the sputum Gram's stain is to
ensure that a sample is suitable for culture
- Adequate for culture, a sputum sample must
have >25 neutrophils and <10 squamous
epithelial cells per low-power field
- Inability to produce sputum can be a
consequence of dehydration
- Even in cases of proven bacteremic
pneumococcal pneumonia, the yield of
positive cultures from sputum samples is 50%
2. Blood Cultures
- Only ~5–14% of cultures of blood from
patients hospitalized with CAP are positive,
and the most frequently isolated pathogen is
S. Pneumoniae
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Co-morbid conditions
- Diabetes Mellitus
- Neoplastic diseases
- Congestive Heart Failure
- Coronary Artery Disease
- Renal Insufficiency
- COPD
- Bronchial Asthma
- Chronic Liver Disease
- Chronic Alcohol Abuse
2 sets of criteria used for assessing management
and prognostication
1. Pneumonia Severity Index
- prognostic model used to identify patients
at low risk of dying
2. CURB-65
- severity-of-illness score
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CA-MRSA
- Determined by the mecA gene, which
encodes for resistance to all B-lactam
drugs
- Five staphylococcal chromosomal cassette
mec (SCCmec) types have been
described
‣ Hospital-acquired strain usually has
type II or III, whereas CA-MRSA
has a type IV SCC mec element
- Often susceptible to trimethoprim-
sulfamethoxazole, clindamycin, and
tetracycline in addition to vancomycin and
linezolid
Gram Negative Bacilli
- Enterobacter spp. are typically resistant to
cephalosporins; the drugs of choice for use
against these bacteria are usually
fluoroquinolones or carbapenems
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Pseudomonas aeruginosa
Those with history of chronic or prolonged (>7
days within the past month) use of broad-
spectrum antibiotic therapy
Those with severe underlying
bronchopulmonary disease (COPD,
bronchiectasis)
Malnutrition
Chronic use of steroid therapy >7.5mg/day2.
Treatment
- CA-MRSA
‣ Either linezolid or vancomycin should
be added to the initial empirical
regimen
‣ Vancomycin does not reach significant
concentrations in epithelial lining fluid,
whereas concentrations of linezolid at
this site exceed the MIC for MRSA
during the entire dosing interval
- Fluoroquinolones and telithromycin
suggest that a 5-day course is sufficient for
otherwise uncomplicated CAP
‣ A longer course is required for patients
with bacteremia, metastatic infection,
TREATMENT or infection with a virulent pathogen
Therapy with a macrolide or a fluoroquinolone such as P. aeruginosa or CA-MRSA
within the previous 3 months is associated with
an increased likelihood of infection with a
“Although the newer antipneumococcal
resistant strain of S. pneumoniae
quinolones such as levofloxacin or moxifloxacin are
- A fluoroquinolone-based regimen should be also options for therapy, it is recommended that
used for patients recently given a macrolide, they be reserved as potential second line agents
and vice versa for the treatment of pulmonary tuberculosis,
particularly for multidrug-resistant tuberculosis.”
CAP admitted to ICU
- The risk of infection with P. aeruginosa or CA- FAILURE TO IMPROVE
MRSA is increased, and coverage should be
considered when a patient has risk factors or 1. Noninfectious conditions (pulmonary edema,
a Gram's stain suggestive of these pathogens pulmonary embolism, lung carcinoma, radiation
and hypersensitivity pneumonitis, and connective
tissue disease involving the lungs).
How long is the duration of treatment for CAP? 2. The pathogen may be resistant to the drug
Duration of treatment is 5 to 7 days for low risk selected, or a sequestered focus (e.g., a lung
uncomplicated bacterial pneumonia (Grade B). abscess or empyema) may be blocking access of
For moderate-risk and high-risk CAP or for those the antibiotic(s) to the pathogen.
with suspected or confirmed Gram-negative, S. 3. The patient may be getting either the wrong drug
aureus or P. aeruginosa pneumonia, treatment or the correct drug at the wrong dose or
should be prolonged to 14 - 21 days (Grade B) frequency of administration.
A treatment regimen of 10-14 days is 4. It is also possible that CAP is the correct
recommended for Mycoplasma and diagnosis but that an unsuspected pathogen
Chlamydophila pneumonia while Legionella (e.g., CA-MRSA, M. tuberculosis, or a fungus) is
pneumonia is treated for 14-21 days (Grade B) the cause.
A 5-day course of oral or IV therapy for low-risk 5. Nosocomial superinfections—both pulmonary and
CAP and a 10-day course for Legionella extrapulmonary
pneumonia is possible with new agents such as
the azalides, which possess a long half-life and
achieve high tissue levels that prolong its duration COMPLICATIONS
of effect (Grade B) Respiratory failure
Patients should be afebrile for 48 to 72 hours with
Shock and multiorgan failure
no signs of clinical instability before
discontinuation of treatment (Grade B) Coagulopathy
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Exacerbation of co-morbid illnesses
FOLLOW-UP
Fever and leukocytosis usually resolve within 2–4
days in otherwise healthy patients with CAP, but
physical findings may persist longer
Chest radiographic abnormalities are slowest to
resolve and may require 4–12 weeks to clear
Follow-up radiograph can be done ~4–6 weeks
later
If relapse or recurrence is documented,
particularly in the same lung segment, the
possibility of an underlying neoplasm must be
considered
PROGNOSIS
Depends on the patient's age, co-morbidities, and
site of treatment (inpatient or outpatient)
Young patients without comorbidity do well and
usually recover fully after ~2 weeks.
The overall mortality rate for the outpatient group
is <1%.
Ventilator-Associated Pneumonia- development
For patients requiring hospitalization, the overall of new infiltrates on CXR, fever, purulent sputum
mortality rate is estimated at 10%, with ~50% of 48-72 hrs after endotracheal intubation
deaths directly attributable to pneumonia.
Non-MDR
PREVENTION - Nearly identical to the pathogens found in
severe CAP
The main preventive measure is vaccination
- Predominate if VAP develops in the first 5–7
Influenza outbreak days of the hospital stay
- unprotected patients at risk from MDR
complications should be vaccinated
immediately and given chemoprophylaxis with - If patients have other risk factors for HCAP
either oseltamivir or zanamivir for 2 weeks Virus
Fungi
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‣ Multiple
EPIDEMIOLOGY
On any given day in the ICU, an average of 10% QUANTITATIVE-CULTURE APPROACH
of patients will have pneumonia—VAP in the Discriminate between colonization and true
overwhelming majority of cases infection by determining the bacterial burden
Highest hazard ratio in the first 5 days and a - The more distal in the respiratory tree the
plateau in additional cases (1% per day) after ~2 diagnostic sampling, the more specific the
weeks results and therefore the lower the threshold
of growth necessary to diagnose pneumonia
PATHOGENESIS and exclude colonization
Colonization of the oropharynx with pathogenic
microorganisms CLINICAL APPROACH
Aspiration of these organisms from the Clinical Pulmonary Infection Score (CPIS)
oropharynx into the lower respiratory tract - allows the selection of low-risk patients who
Compromise of the normal host defense may need only short-course antibiotic therapy
mechanisms or no treatment at all
- The absence of bacteria in gram-stained
endotracheal aspirates makes pneumonia an
TREATMENT
unlikely cause of fever or pulmonary infiltrates
- The absence of an MDR pathogen in tracheal
aspirate cultures eliminates the need for MDR
coverage when empirical antibiotic therapy is
narrowed
VENTILATOR-ASSOCIATED PNEUMONIA
The most obvious risk factor is the endotracheal TREATMENT
tube, which bypasses the normal mechanical
factors preventing aspiration The majority of patients without risk factors for
MDR infection can be treated with a single agent
- Microaspiration
‣ Around one-third of colonized patients The standard recommendation for patients
develop VAP with risk factors for MDR infection is for three
antibiotics: two directed at P. aeruginosa and one
- Pathogenic bacteria can form a glycocalyx at MRSA
biofilm on the tube's surface that protects
them from both antibiotics and host defenses
FAILURE TO IMPROVE
- Overwhelming host defenses
40% failure rate for MRSA infection treated with
‣ Hyperglycemia vancomycin
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VAP due to Pseudomonas has a 50% failure rate
A persistently elevated or rising CPIS value by
day 3 of therapy is likely to indicate failure
PROGNOSIS
Crude mortality rates of 50–70%
Patients who develop VAP are at least twice as
likely to die as those who do not
** Taken from the lecture ppt only, use at your own risk :) Goodluck
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