Pneumonia

Definition
infection of the parenchyma of the lung( ), caused by bacteria, fungi( , virus, parasite etc. Pneumonia may also be caused by other factors including X-ray, chemical, allergen

Pneumonia is an acute

Epidemiology

The morbidity and mortality of pneumonia are high especially in old people.

Etiology

There are two factors involved in the formation of pneumonia , including pathogens and host defenses.

Classification
Classification of anatomy Classification of pathogen Classification of acquired environment

.Classification by pathogen
Pathogen classification is the most useful to treat the patients by choosing effective antimicrobial agents

Bacterial pneumonia
(1) Aerobic Gram-positive bacteria,such as streptococcus pneumoniae, staphylococcus aureus, Group A hemolytic streptococci (2) Aerobic Gram-negative bacteria, such as klebsiella pneumoniae, Hemophilus influenzae, Escherichia coli (3) Anaerobic bacteria

Atypical pneumonia
Including Legionnaies pneumonia ,
Mycoplasmal pneumonia ,chlamydia pneumonia.

Fungal pneumonia
Fungal pneumonia is commonly caused by candida( ) and aspergilosis( ). pneumocystis jiroveci

Viral pneumonia
Viral pneumonia may be caused by adenoviruses, respiratory syncytial virus, influenza, cytomegalovirus, herpes simplex

Pneumonia caused by other pathogen

Rickettsias (a fever rickettsia), ( parasites( ) protozoa

.Classification by anatomy
1. Lobar : Involvement of an entire
lobe

2. Lobular : Involvement of parts

of the lobe only, segmental or of alveoli contiguous to bronchi (bronchopneumonia).

3. Interstitial

Lobar pneumonia

Lobular pneumonia

Interstitial pneumonia

Classification by acquired environment

Community acquired pneumonia CAP

acquired pneumonia HAP NP Nursing home acquired pneumonia,NHAP ( Immunocompromised host pneumonia,(ICAP) (
Hospital

Diagnosis
Give a definite diagnosis of pneumonia To evaluate the degree of the pneumonia To definite the pathogen of the pneumonia

Diagnosis
History

and physical examination(5W) X-ray examination Pathogen identification

Differentiation

Pulmonary tuberculosis Lung cancer Acute lung abecess Pulmonary embolism Noninfectious pulmonary infiltration

Pathogen identification

Sputum: More than 25 white blood cells (WBCs) and less than 10 epithelial cells. Nasotracheal suctioning BAL, ETA, PSB, LA Blood culture or pleural effusion culture Serologic testing (immunological testing) Molecular Techniques

The principal of therapy

Select antibiotics According to guideline

Therapy
The therapy should always follow confirmation of the diagnosis of pneumonia and should always be accompanied by a diligent effort to identify an etiologic agent. Empiric therapy,(4-8h) Combined empiric therapy to target therapy

It is important to evaluate the severity degree of pneumonia

The critical management decision is whether the patient will require hospital admission. It is based on patient characteristics, comorbid illness, physical examinations, and basic laboratory findings.

The diagnostic standard of sever pneumonia

Altered mental status Pa02<60mmHg. PaO2/FiO2<300, needing MV Respiratory rate>30/min Blood pressure<90/60mmHg Chest X-ray shows that bilateral infiltration, multilobar infiltration and the infiltrations enlarge more than 50% within 48h. Renal function: U<20ml/h, and <80ml/4h

CAP (

CAP refers to pneumonia acquired outside of hospitals or extended-care facilities . Streptococcus pneumoniae remains the most commonly identified pathogen. Other pathogens include Haemophilus influenzae, mycoplasma pneumoniae, Chlamydophilia pneumoniae, Moraxella catarrhalis and ects. Drug resistance streptococcus pneumoniae(DRSP)

Clinical manifestation
The onset is accute Respiratory symptoms Extrapulmonary symptoms

signs
Consolidation signs Moist rales Respiratory rate or heart rate

Laboratory examination
WBC X-ray features

Diagnosis
Clinical diagnosis Pathogen diagnosis Evaluate the severity degree of pneumonia

Therapy
Antiinfectious therapy(Combined empiric therapy to target therapy) Supportive therapy

Empiric therapy (1)

Outpatient<60 years old and no comorbid diseases Common pathogens: S pneumoniaes, M pneumoniae, C pneumoniae, H influenzae and viruses

A new generation macrolide A beta-lactam: the first generation cephlosporin A fluoroquinolone

Empiric therapy (2)

Outpatient>65 years old or having comorbid diseases or antibiotic therapy within last 3 months Common pathogens: S pneumoniae(drugresistant), M pneumoniae, C pneumoniae, H pneumoniae, H influenzae, Viruses, Gram-negative bacilli and S aureus

A fluoroquinolone A beta-lactam / betalactamase inhibitor The second generation cephalosporin or combination of a macrolide

Empiric therapy (3)

Inpatient : Not severely ill. Common pathogen:S pneumoniae, H influenzae, polymicrobial, Anaerobes, S aureus, C pneumoniae, Gramnegative bacilli.

The second or third generation cephalosporin plus A macrolide A betalactam/betalactamase inhibitor. A newer fluoroquinolone

Empiric therapy (4)

Inpatient severely ill Common pathogens:S pneumoniae, Gramnegative bacilli, M pneumoniae, S aureus and viruses

The second or third generation cephalosporin plus A macrolide A betalactam/betalactamase inhibitor. A newer fluoroquinolone Vancomycin

Empiric therapy (5)

Patients in ICU without Pneudomonas aeruginosa infection

The second or third generation cephalosporin plus A macrolide A betalactam/betalactamase inhibitor. A newer fluoroquinolone Vancomycin

Empiric therapy (6)

Patients in ICU with Pneudomonas aeruginosa infection

A antipneudomonas aeruginosa betalactam/betalactamase inhibitor plus fluoroquinolone

prognosis

preventive

HAP
HAP refers to pneumonia acquired in the hospital setting. Enteric Gram-negative organisms, S. aureus, Pneudomonas aeruginosa, ects.

The pathogen of HAP

Gram-negative

bacteria (GNB) account for 55% to 85% of HAP infections gram-positive cocci account for 20% to 30% and some other pathogens.

EPIDEMIOLOGY

General risk factors for developing HAP include age more than 70 years, serious comorbidities, malnutrition, impaired consciousness, prolonged hospitalization, and chronic obstructive pulmonary diseases.

EPIDEMIOLOGY

HAP is the most common infection occurring in patients requiring care in an intensive care unit (ICU), with incidence rates ranging from 6% up to 52%, much higher than the 0.5% to 2% incidence reported for hospitalized patients as a whole. This increased incidence is due to the fact that patients located in an ICU often require mechanical ventilation, and mechanically ventilated patients are 6 to 21 times more likely to develop HAP than are nonventilated patients. Mechanical ventilation is associated

PATHOGENESIS
Aspiration :Microaspiration of contaminated oropharyngeal secretions seems to be the most important of these factors, as it is the most common cause of HAP. Inhalation Contamination

Clinical manifestations
The onset is acute or insidious Respiratory symptoms Physical signs

Laboratory examinations

Chest X-ray

diagnosis
Clinical diagnosis Pathogen diagnosis Evaluate the severity degree of pneumonia

Treatment (1)

Antibiotic therapy: antimicrobial therapy begin promptly because delays in administration of antibiotics have been associated with worse outcomes. The initial selection of an antimicrobial agent is almost always made on an empiric basis and is based on factors such as severity of infection, patient-specific risk factors, and total number of days in hospital before onset.

Treatment (2)

All empiric treatment regimens should include coverage for a group of core organisms that includes aerobic gram negative bacilli (Enterobacter spp, Escherichia coli, Klebsiella spp, Proteus spp, Serratia marcescens, and Hemophilus influenzae) and gram-positive organisms such as Streptococcus pneumoniae and Staphylococcus aureus.

Treatment (3)

In patients with mild or moderate infections and no specific risk factors for resistant or unusual pathogens, monotherapy with a second-generation cephalosporin such as cefuroxime; a nonpseudomonal third-generation cephalosporin such as ceftriaxone; or a beta-lactam/betalactamase inhibitor such as ampicillin/sulbactam, ticarcillin/clavulanate, or piperacillin/tazobactam may be appropriate. For patients in this low-risk category who have an allergy to penicillin, it is appropriate to initially use a fluoroquinolone

Treatment (4)

Patients with severe infections with specific risk factors should have broadened empiric coverage. Combination therapy should be employed in these cases because of the high rate of acquired resistance among these organisms. Appropriate combinations for this group of patients include an aminoglycoside or ciprofloxacin in addition to a betalactam with antipseudomonal coverage. Additionally, vancomycin should be considered if the patient has risk factors that suggest methicillin-resistant Staphylococcus aureus could be a pathogen.

Prevention
Release aspiration Washing hands vaccination

ICHP ( )

Pneumonia in an immunocompromised host describes a lung infection that occurs in a person whose ability to fight infection is greatly impaired. (Non-HIV-ICH)

Causes, incidence, and risk factors

Immunosuppression can be caused by HIV infection, leukemia, organ transplantation, bone marrow transplant, and medications to treat cancer. Microorganisms include all kinds of bacteria and virus(CMV), candida( ) and aspergilosis( ). pneumocystis carinii PCP,

Symptoms

The onset is incidous , but clinical Symptoms are severe. Fever Nonproductive (dry) cough or cough with mucus-like, greenish, or pus-like sputum PCP Fungal infection

Diagnosis

Earlier finding and diagnosis Pathogen diagnosis Chest x-ray Sputum gram stain, other special stains, and culture Arterial blood gases Bronchoscopy Chest CT scan, Tissue diagnosis

Treatment

Antimicroorganism therapy The goal of treatment is to get rid of the infection with antibiotics or antifungal agents. The specific drug used will depend on what kind of organism is causing the problem. One drug may kill one type of organism, but not another. Respiratory treatments (to remove fluid and mucus) and oxygen therapy are often needed.

Pneumococcal pneumonia

Abstraction
Pneumococcal pneumonia is produced by streptococcal pneumoniae It is the most commonly occurring bacterial pneumonia

Etiology
Streptococcus pneumonia
are encapsulated, gram-positive cocci that occur in chains or pairs The capsule which is a complex polysaccharide has specific antigenicity Type 3 is the most virulent, usually causing severe pneumonia in adults, but type 6,14,19 and 23 are virulents is children

Bacteria are introduced into the lungs by the four routes

Source colonization Air Non-pulmonary infection Contiguous infection

Route aspiration inhalation blood stream direct extention

Response Outcome

lung defenses

pneu.

pathogenesis

Pneumococci usually reach the lungs by inhalation or aspiration. They lodge in the bronchioles, proliferation and initiate an inflammatory process.

Pathology
Congestion red hepatization grey hepatization resolution)

Pathology

Red hepatilization

All of the four main stages of the inflammatory reaction described above may be present at the same time In most cases, recovery is complete with restoration of normal pulmonary anatomy

Clinical manifestations

Clinical manifestations (1)

Many patients have had an upper respiratory infection for several days before the onset of pneumonia Onset usually is sudden, half cases with a shaking chill The temperature rises during the first few hours to 39-40

Clinical manifestations (2)

Typically, patients have the symptoms of high fever , shaking chill, sharp chest pain, cough, dyspnea and blood-flecked sputum. But in some cases, especially those at age extremes symptoms may be more insidious.

Clinical manifestations (3)

The pulse accelerates Sharp pain in the involved hemi thorax The cough is initially dry with pinkish or blood-flecked sputum Gastrointestinal symptoms such as, anorexia, nausea, vomiting abdominal pain, diarrhea may be mistaken as acute abdominal inflammation

Signs 1
The acutely ill patient is tachypneic, and may be observed to use accessory muscles for respiration, and even to exhibit nasal flaring Fever and tachycardia are present, frank shock is unusual, except in the later stages of infection or DIC

Signs 2
Auscultation of the chest reveals bronchovesicular or tubular breath sounds and wet rales over the involved lung A consolidation occurs, vocal and tactile fremitus are increased

Laboratory examinations

Laboratory examinations (1)

The peripheral white blood cell (WBC) count Before using antibiotic, the culture of blood and of expectorated purulent sputum between 24-48 hours can be used to identify pneumococci Colony counts of bacteria from bronchoalveolar lavage washings obtained during endoscopy are seldom available early in the course of illness Use of the PCR may amplify pneumococcal DNA and improve potential for detection

X-ray examination
Chest radiographs is more sensitive than physical examination PA and lateral chest radiographs are invaluable to detect pneumonia

X-ray examination
Usually lobar or segmental consolidation suggests a bacterial cause for pneumonia If blunting of the costophrenic angle is noted, pleural effusion may be exist.

The features of CT

Air-bronchogram sign

Complications
In 5% to 10% of patients, infection may extend into the pleural space and result in an empyema

In 15% to 20% of patients, bacteria may enter the blood stream (bacteremia) via the lymphatics and thoracic dust. Invasion of the blood stream by pneumococci may lead to serious metastatic disease at a number of extra pulmonary sites (meningitis, arthritis, pericarditis, endocarditis, peritonitis, ostitis media etc).

Complications
sepsis
lung abscess or empyema pleural effusion pleuritis ARDS ARF pneumothorax Extrapulmonary infections

Diagnosis
According to history, the clinical signs , physical examinations, laboratory examinations and radiographic features it is not difficult to make the diagnosis

Differential diagnosis
pulmonary tuberculosis Other microbial pneumonias:
klebsiella pneumonia, staphylococal pneumonia, pneumonias due to G (-) bacilli, viral and mycoplasmal Acute lung abscess

Bronchogenic carcinoma Pulmomary infarction

Treatments
Antibiotics Support therapy Therapy of complications

Antibiotic therapy (1)

All patients with suspected pneumococcal pneumonia should be treated as promptly as possible with penicillin G The dose and route of delivery may have to be on the basis of patients status adverse reaction or complication that occur

Antibiotic therapy (2)

For patients who are believed to be allergic to penicillin, one may select the first or second generation cephalosporin or advanced macrolide+ -lactam or respiratory fluoroquinolone alone. For patients with PRSP, one may select the second and third generation cephalosporin or advanced macrolide+ -lactam or respiratory fluoroquinolone alone. In some cases, vancomycin may be used.

Antibiotic therapy
Treatment with any effective agent should be given for at least 5 to 7 day or after the patients have been afebrile for 2-3 days

Supportive measure

Supportive measure are generally used in the initial management of acute pneumococcal pneumonia, such measures include Bed rest Monitoring vital signs and urine output Administering an occasional analgesic to relieve pleuritic pain Replacing fluids, if the patient is dehydrated Correcting electrolytes Oxygen therapy

Treatment of complications
Empyema develops in appoximately 5% of patients
with pneumococcal pneumonia, although pleural effusion commonly develop in 10%- 20% patients Chest X-ray with lateral decubitus films are often useful in the early recognition of pleural effusion, pleural fluid that is removed should be subjected to routing examination If pneumococcal bacteremia occurs, extra pulmonary complications such as arthritis, endocarditis must be excluded, because the therapy requires higher dosages Treatment of infections shock

Prognosis
Prognosis is much better Any of the following factors makes the prognosis less favorable and convalescence more prolonged elderly: involvement of 2 or more lobes underlying chronic diseases (heart lung kidney) normal temperature and WBC count <5000 immunodeficiency with severe complication

Prevention
The most important preventive tool available is using a poly valent pneumococcal vaccine in those with chronic lung diseases, chronic liver diseases, splenectomy, diabetes mellitus and aged

Staphylococcus pneumonia
Staphylococcal
pneumonia is usually caused by staphylococcus aureus

It is often a complication
of influenza, but may be primary, particularly in infants and the aged

It occurs in immunocompromissed patients such as diabetes mellitus hematologic disease ( leukemia, lymphoma, leukopenia ) AIDS, liver disease, malnutrition, alcoholism Staphylococcal bacteremia complicating infections at other sites (furuncles, carbuncles) may cause hematogenous pulmonary involvement (due to blood spread)

 Some or all of the symptoms of pneumococcal

pneumonia (high fever, shaking chill, pleural pain, productive cough) may be present, sputum may be copious and salmon-colored

Prostration is often marked According the symptoms, signs of pneumonia,

leukocytosis and a positive sputum or blood culture, the diagnosis can be made

 Gram stain of the sputum provides earliest diagnostic clue Chest X-ray early in the disease shows many small round areas of densities that enlarge and coalesce to from abscess, and leave evidence of multiple cavities

 Until the sensitivity results are know, a penicillinaseresistant penicillin or a cephalosporin should be given Therapy is continued for 2 weeks after the patient has become afebrile and the lungs have shown signs of clearing Vancomycin is the drug of choice for patients allergic to penicillin and cephalosporin and for those not responding to other antistaphylococcal drugs, mainly used in MRSA.

Pneumonia caused by klebsiella

Klebsiella pneumonia ( also named Friedlander pneumonia) is an acute lung infection, caused by Klebsiella pneumoniae 1, it occurs much more in aged, malnutrition, chronic alcoholism, and in whom with bronchial pulmonary disease

 This pneumonia is most likely to be found in man with middle age, onset usually is sudden, with high fever, cough, pleuritic pain, abundant sputum, cyanosis, tachycardia my be present, half cases with a shaking chill Shock appears in early stage

 Clinical manifestations are similar to sever pneumococcal pneumonia The sputum is viscid and ropy, and may be brick red in color Chest X-ray shows a downward curve of the horizontal interlobar fissure, if the right upper lobe is involved Areas of increased radiance whithin dense consolidation suggest cavitation It constitutes 2% of bacterial pneumonia, but mortality may be as high as 30%

 When an elderly patient suffered from acute pneumonia with sever toxic symptom, viscid and brick red, sputum must consider this disease The diagnosis is determined by bacterial examination of sputum Early using antimicrobial therapy is important for patients with survivable illillnesses, aminoglycoside (Kanamycin, Amikacin, Gentamycin ) and the third generation cephalosporin are often used.

Mycoplasmal pneumonia

Mycoplasmal pneumonia is caused by Mycoplasmal pneumoniae one of the smallest organisms 125-150 m capable of replication in cell-free media

Mycoplasmal pneumoniae is

Infection is spread form

person to person by respiratory secretions expelled during bouts of coughing, causing epidemic

 It commonly occurs in children, adolescent, mainly

in fall and winter

It constitutes more than 1/3 of non bacterial

pneumonias, or 10% of pneumonias from all cause

Cellular infiltrate around bronchioles, and in

alveolar interstitium, consists mostly of mononuclear elements

Clinical findings
The illness begins insidiously with constitutional symptomatology: malaise, sore throat, cough, fever, myalgia Half of cases have no symptom

Chest X-ray
Chest X-ray findings are manifold Most patients have unilateral lower lobe segmental abnormalities The earliest signs are an interstitial accentuation of marking with subsequent patch air space consolidation and thickened bronchial shadows

 The pneumonia may persist for 3-4 weeks a slight leukocytosis is seen, with a normal differential count The diagnosis is generally proved by a single antibody titer of 1:32 or greater, a titer of cold agglutinins of 1:32 or greater a single Ig M determination The most promising in terms of speed, sensitivity and specificity is PCR although cost and lack of general availability limit its routine use

Therapy
A definite clinical response is seen to erythromycin and some other newer macrolide

Legionnaies Pneumonia
Legionella can be an opportunistic pathogen. Patients with immunosuppression are at increased risk for infection. But sometimes outbreaks do occur in previously healthy individuals.

Legionellae are small, gram-negative, obligately aerobic baclli. .

Legionnaires disease is acquried by inhaling aerosolized water containing Legionella organisms or possibly by pulmonary aspiration of contaminated water. The contaminated water are derived from humidifiers, shower heads, respiratory therapy equipment, industrail cooling water. Because of the frequently use of air conditioner, Legionnaies pneumonia is also seen in CAP

Clinical manifestations
The onset of L.pneumonia is sometimes severe. High fever, rigors, and significant hypoxemia are usually seen in patients with L.pneumonia. Failure to rapidly appropriate therapy in these cases is likely to result in a poor outcome.

Common signs include cough, dyspnea, pleuritic chest pain, gastrointestinal symptoms, especially diarrhea or localized abdominal pain, nausea, vomitting are a prominent finding in 20% to 40% of patients with L.pneumonia.

Physical examination
Physical finding are often similar to other pneumonias. Rales are usually present over involved areas Pulse rate is not coincide to the body temperate.

Chest X-ray

No diagnostic features on the chest X-ray distinguish it from other pneumonia Infiltrates can be unilateral, bilateral, patchy, or dense, and can spread very quickly to involve the entire lung, pleural effusion, usually

Laboratory examination
Serologic testing is the most often used for establishing a diagnosis. A fourfold or greater rise in antibody is considered definitively exist for Legionella.

Diagnosis

According to history, clinical signs, X-ray features and serologic testing, we can diagnose it.

Therapy

Erythromycin is considered the drug of choice.It should be given until clinical improvement is seen.It usually lasts 2-3 weeks.

Candidiasis
Candidiasis is an opportunistic disease, it is caused by candida.

Clinical signs
Respiratory signs: fever,cough, sputum production, dyspnea. X-ray shows no specific.It is similar to acute pneumonia.

diagnosis

Mainly according to sputum culture or biopsy of lung.

Therapy

Nystatin or various azole drugs

Aspergillosis

Aspergillosis refers to infection with any of species of the genus Aspergillus

Clinical signs
The disease generally occurs in immunosuppressed and anticancer therapy patients. There are four types of pulmonary aspergillosis.

Clinical signs of Pulmonary aspergillosis

Presents as chronic productive cough, hemoptysis, dyspnea, weight loss, fatigue, chest pain, or fever Sometimes patients with pulmonary aspergillosis accompany with prior chronic lung disease. Typical picture of an aspergilloma is a fungus ball in a cavity in an upper lobe The sputum culture is positive in most patients.

Diagnosis

The repeated isolation of Aspergillus from sputum or the demonstration of hyphae in sputum or BALF suggests endobronchial infection.

Treatment
With intravenous amphotericin B (1.0 to 1.5 mg/kg daily) Patients with severe hemoptysis due to fungus ball of lung may benefit from lobectomy

Therapy to Infectious Shock

Treatment in intensive care units

cardiac rhythm, blood pressure, cardiac performance, oxygen delivery, and metabolic derangements can be monitored

Adequate oxygenation and ventilatory support (sometimes mechanical ventilation) Effective antibiotic therapy Maintain blood pressure, including maintain circulation blood volume, use of dopamine

Summary

1. 2. 3.CAP HAP 4. 5. 6.

Questions
1.What is the differences between CAP and HAP? 2.What is the standard of sever pneumonia? 3.what are the principals of antibiotic therapy of various of pneumonias?

Case report

, ,32 : 6 : 6 , 39, , , , 38, , , , , X : , 6.0*109 /L,N66.2%, 3 , , CT :

T 38 P90 / R18 / BP110/70mmHg NS(-)


IgM 160 CT

 CT

case2

50 : : , , , , CT CT 30mg/d, d

How do we diagnose?

1 58 15 1 B A B C D E

2 35 3 39 C A B C D E

3 E A B C D E

4 20 T37.8 WBC 8 10^9/L 70 X E A B C D E

5 25 9.6 10^9/L 86 1 64 E A B C D E

6. :A A. B. C. D. E.

7 E A B C D. E

8 B A B C D E

9 25 (39.2 ) X C A. B C D E

9 E A B C D E

10. A A. B. C. D. E.