ACUTE PULMONARY

INFECTIONS

Zen Ahmad
Medical Faculty, Sriwijaya University
Case presentation
A 55-year-old male with a history of type 2 diabetes, presents
with dyspnea, high fever, chills, and productive cough with
purulent sputum for 2 days duration.
He denies hemoptysis. He has smoked 2 packs of cigarettes
a day for the past 20 years and drinks six beers a day.
On physical exam he appears acutely ill. His vital signs show
a temperature of 40.2°C, pulse is 130 beats/minute, RR is
48x/per minute, BP is 113/60.
Lungs are dull to percussion and bronchial breath sound
heard over the left lower lobe. Chest X-ray showed infiltrates
in the left lower lobe.
Key clinical questions

1. What are the most likely diagnosis in this patient?

2. What are the most likely causative organisms in
this patient?
3. What further diagnostic tests are recommended
for diagnosis?
4. What are the risk factors for pneumonia
5. Can this patient be treated as an outpatient or
should he be admitted?
6. What antibiotic agent would be recommended for
this patient?
What are the most likely diagnosis in this patient?
Differential diagnostic

• Pneumonia
• Tuberculosis
• Acute bronchitis
• Acute exacerbation of chronic bronchitis
• Upper respiratory infection
• Sinusitis
• CHF
• Asthma
• Lung cancer
Definition of pneumonia

An acute infection of the lung parenchyma distal to

the terminal bronchiole, associated with clinical or
radiologic evidence of consolidation of part or
parts of one or both lungs.
Terminology

• Community Acquired Pneumonia versus

Nosocomial pneumonia (HAP; VAP, HCAP
• Typical pneumonia versus atypical pneumonia
• Mild pneumonia; Moderate pneumonia and
Severe pneumonia
• Lobar pneumonia; Bronchopneumonia and
Pleuropneumonia
 Clinical manifestations
• Sudden onset of fever, chills
• Cough
• Sputum production
• Pleuritic chest pain
• Dyspnea; Tachypnea
• Tachycardia
• Extra pulmonary symptoms (nausea, vomiting,
malaise, headache, myalgia)
Physical examinations

Sign of pulmonary consolidation

o Restricted movement of the afflicated hemithorax
o Increased fremitus
o Dullness
o Bronchial breath sounds
o Rales
Clinical manifestations of pneumonia
Features Typical Atypical
Onset Sudden Gradual
Age Younger Older
Appearance Toxic Malaise, fatique
Fever High Low grade
Rigor Common Uncommon
Cough Productive Nonproductive
Sputum Purulent Mucoid
Extra pulmonal Uncommon Common
Pleuritic chest pain Common Uncommon
Lung consolidation Common Uncommon
Gram stain Abundant bacteria Rare bacteria
WBC, difrential Elevated; left shit Normal
Chest x-ray Consolidation Patchy, infiltrate
Patient
- Acute (2 days)
- Dyspnea, High fever, Chills
- Productive cough, purulent
sputum
- T: 39.8°C
- Pulse: 130 x/minute
- RR: 48x/per minute
- Percussion: dull
- Auscultation: bronchial breath
sound over the left lower lobe
- CXR: infiltrates in the left lower
lobe.
Pneumonia
- Sudden onset of fever
- Shortness of breath
- Productive cough, purulent
sputum
- Pleuritic chest pain
- Tachypnea
- Restricted movement of the
afflicated hemithorax
- Increased fremitus
- Dullness
- Bronchial breath sounds; Rales
- CXR: infiltrates (lobar, multilobar,
segmental) or pleural effusions
What are the most likely causative
organisms in this patient?
Microbial causes of pneumonia

CAP Nosocomial Atypical

Pneumonia Pneumonia
S.pneumoniae Gram negative bacilli M.pneumoniae
H.influenzae S.aureus C.pneumoniae
Moraxella catarrhalis Pseudomonas aerugi- Legionella pneumophila
S.aureus nosa

Gram negative bacilli

Virus

Woodhead M.Medicine International 1995; 31 (9)

CAP : Most Common Pathogens

Mild (Ambulatory Moderate (hospitalized, Severe (ICU)*

Patients) non ICU)*
S. Pneumoniae S. Pneumoniae S. Pneumoniae
M. Pneumoniae M. Pneumoniae S. aureus
H. Influenzae C. Pneumoniae H. influenzae
C. Pneumoniae H. influenzae Gram negative bacilli
Viruses Legionella spp Legionella spp
Mixed flora Mixed flora
(aspiration) (aspiration)
excluding Pneumocystis spp. ICU = intensive care unit
File MJ. Tan JS. Cure open Purn Med 1997. 3(2) 89
Bacterial Pathogens in CAP
4,2%
12,5%
33,3%
No pathogen discover
Klebsiella
12,5%
S. aureus
S. pneumoniae
Acinobacter
12,5% Pseudomonas
S.pyogenes
20,8%
16,7%
Persahabatan Hosp. 2000
What further diagnostic tests are
recommended for diagnosis?
Diagnostic
• CXR
• Sputum examination
• Blood count
• Blood cultures
• Serologic studies
• Thoracentesis
• Invasive diagnostic procedures
 Transtracheal aspiration
 Bronchoscopy or BAL
 Direct needle aspiration
CXR

• CXR is the most important diagnostic tool

• New or progressive pulmonary infiltrates
– Lobus consolidation
– Segmental consolidation
– Patchy infiltrate
• Pulmonary cavitations
• Lymphadenopathy
• Pleural effusions
Lobar
pneumonia
Location of pneumonia
Sputum examination

• The key factor to identification of the etiology

• Macroscopic; Gram stain and Sputum culture
• Lower sensitivity
30–50% pathogen could not identifiable
• Frequently contaminated by MO in the URI
What are the risk factors for pneumonia
Risk factors for pneumonia
• Extreme of age
• Underlying co-morbid illness
• Imunocompromise
• Impaired mucociliary clearance
• Alcoholism; Drug abusers
• Smoking
• Endotracheal intubation
• Upper respiratory infection
• Impaired level of consciousness
• An increase in gastric pH (the use of H2 Blocker,
Antacid)
• Neurologic dysfunction
Can this patient be treated as an outpatient
or should he be admitted?
Risk Factors used to determine assignment to risk classes II-V
Risk class for patients with CAP
 Algorithm pneumonia
Patients with Community Acquired pneumonia
Yes
Is the patients over 50 years of age ?
No

Does the patient have a history of any of the

following comorbid conditions ?
Neoplastic disease Yes Assign patient to risk class II-V
Congestive heart failure based on prediction model
Cerebrovascular disease scoring system
Renal disease
Liver disease
No
Does the patient have any of the following on physician
examination ?
Altered mental statis
Pulse  125/minute Yes
Respiratory rate  30/minute
Sistolic blood presure < 90 mmHg
Temperature < 35C or 40 C
No

Assign patient to risk class I

What antibiotic agent would be
recommended for this patient?
The ideal antibiotic in pneumonia

• Bactericidal +++
• Low resistance
• Coverage, almost all of respiratory pathogen
• Single drug
• Once-daily dose
• Safe
• High respiratory penetration
• Cost effective
Antibiotics in pneumonia

• Macrolide
• Tetracycline
• Cotrimoxazole
• Co-Amoxyclav
• Sultamicillin
• - lactam (include cephalosporin)
• Fluoroquinolone
• Aminoglycoside
• Antipseudomonas
CAP Management Issues
• Causative pathogen frequently not found
• Typical and atypical found together
• Therapy must be started early (<8 hours)
• Increasing resistant to penicillin and macrolide
• Atypical: unresponsive against - lactam AB
• Cost and adverse reaction
• Oral route more convenient
• Decision to hospitalize/outpatient
Bartlett: Clin Infect Dis 26:811, 1998.
Whitney et al.New England Journal of Medicine,December 2000
Outpatient treatment (IDSA/ATS 2007)
• Previously healthy and no use of antimicrobials within the previous 3
months
A macrolide
Doxycyline
• Have a comorbid (chronic heart, lung, liver /renal disease; DM;
alcoholism; malignancies; asplenia; immunosuppressing conditions ;
use of immunosuppressing drugs; use of antimicrobials within the
previous 3 months
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin)
A b-lactam plus a macrolide (strong recommendation; level I evidence)
• In regions with a high rate of infection with high-level (MIC _16
mg/mL) macrolide-resistant S. pneumoniae, consider use of
alternative agents listed above in (2) for patients without
comorbidities
Inpatients, non-ICU treatment

• A respiratory fluoroquinolone (strong

recommendation; level I evidence)

• A b-lactam plus a macrolide (strong

recommendation; level I evidence)
Inpatients, ICU treatment
A b-lactam (cefotaxime, ceftriaxone, or ampicillin-
sulbactam)
plus
either azithromycin (level II evidence) or a respiratory
fluoroquinolone (level I evidence) (strong
recommendation)
(for penicillin-allergic patients, a respiratory
fluoroquinolone and aztreonam are recommended)
 Failure of empirical treatment

Incorrect diagnosis Correct diagnosis

Host issues Drug issues Pathogen issues

Local factor Error in drug selection Bacterial
Inadequate host response Error in dose/route Nonbacterial
Complication Compliance
Adverse drug reaction
Prognostic factors
• Extremes of age
• Inappropriate antibiotic therapy
• Shock
• Involvement of  1 lobe
• Peripheral WBC count  5000/l
• Presence of associated disorders (eg:
cirhosis; heart/renal failure)
• Development of extrapulmonary
complications (eg: meningitis, endocarditis)
Mortality in patients with CAP

Study Focus Patients Mortality (%)

Hospitalized and ambulatory 5.1
Hospitalized only 13.6
Elderly 17.6
Bacteriemic 19.6
Nursing home 30.8
Intensive Care Unit 36.5
Fine et al. JAMA 1995;274: 134-141
Complications

• Acute respiratory distress syndrome

• Lung abscess
• Renal failure
• Septic shock
• Pleural effusions/Empyema
• Bacteriemia (Septic arthritis; Endocarditis;
Meningitis; Peritonitis; Endopthalmitis.