Pneumonias

1. Pneumonias By Mira Iliescu MD

2. Community Acquired Pneumonia 6 mil/year 6th leading cause of death

3. Epidemiology Mortality overall 13.7% hospitalized+ ambulatory: 5.1% hospitalized 13.6% pneumococcus 12.3% higher rates with G-, Staph

4. Prognostic Factors(?mortality) underlying neurologic disease, CHF, malignancy BUN>20 RR>20+ hypothermia+systolic hypotension bacteremia multilobar disease

5. (2) BTS- CURB criteria confusion BUN<19.6 RR> 30/min BP diastolic<60mmHg 2 out of 3 ?mortality 9-21 fold

6. Poor outcome in CAP age>65 years comorbid illness+ AMS temp>38.5 sepsis+MODS delays in Abx atypical clinical presentation

7. PORT I, II outpatient IV, V inpatient III individualized decisions

8. Pathogenesis colonization of the orophryngx: G+, G- inhlation: Legionella, TB, viruses ARDS ? TNF, IL6, IL8

9. Pathogens Study 1 pneumoccocus 15% H influenza 7.3% atypical 8% nondiagnosed 37% Study 2 M pneumoniae 29% pneumococcus 12.6% C pneumonia 8.9% influenza 7.4% H influenzae 6.6%

10. PCN Resistant and Drug Resistant Pneumococcus age >65 beta-lactam therapy in the last 3 mo ETOH abuse immunosuppressive disease/ steroid use comorbidity child in day care center

11. Enteric G- NH resident cardio-pulm disease comorbidities recent abx therapy

12. Pseudomonas Aeruginosa Structural lung disease steroid therapy (>10mg prednisone/day) abx>7 days in the last month malnutrition

13. Cardiopulmonary Pathology and Modifying Factors Present Absent S pneumonia (DRSP) S pneumonia H influenza H influenza atypical M pneumonia aerobic G- C pneumonia Legionella viruses Respiratory viruses Legionella

14. Risks Factors for P aerugionsa Present S pneumonia Legionella H influenzae enteric G- S aureus M pneuminia/ C pneumonia viruses Absent S pneumonia Legionella H influenza enteric G- S aureus M pneumonia/ C pneumonia viruses

15. Condition- Pathogen ETOH: S pneumoniae, anaerobs, G- bacilli COPD/ smoker: S pn, H influ, M catarrhalis, S aureus poor oral hygiene: anaerobs bats: Histoplsma birds: C psittaci, Histoplasma rabbits: Francisella tularensis

16. (2) SW: coccidioidomycosis farm animals: coxiella burnetti large vol aspiration: anaerobs, chemical pn IVDA: TB, S aureus, anaerobs

17. Pneumococcus Preceded by viral infection mortality (hospitalized patients> 20%) > 40% PRSP intermediate: 0.12 mg/ml< MIC <2 mg/dl high: MIC> 2MG/DL INCREASED RISK OF DEATH MIC >4mg/dl

18. (2) Multiple drug resistance: macrolide trimethoprim- sulfa cipro/ levofloxacin

19. Legionella Pneumophila G- organism/ urinary antigen presentation may include confusion diarrhea ? LFT’s bradicardia hyponatremia

20. Mycoplasma Pneumonia Hemolytic anemia myocarditis hepatitis meningoencephalitis

21. S aureus Complicates influenza right side endocarditis pneumatocele

22. C pneumonia (TWAR agent) “adult croup” copathogen supportive therapy

23. Aspiration/ Lung Abscess Polymicrobial/ anaerobs superior segment of lower lobes/ posterior segment of the upper lobe cavity with ragged inner wall/ thick wall lung abscess (edentulous) lung malignancy chronic aspiration foreign body

24. Influenza RNA virus type A (more severe) and B A: amantadine/ rimantadine A, B: oseltamivir/ zanamivir Pneumonia: S pneumo, S aureus, G-, H influenzae

25. HIV positive S pneumoniae, H influenzae, P aeruginosa PCP, TB

26. Hantavirus Rodent fulminant respiratory failure high mortality

27. Diagnosis 15% positive blood cultures sputum G stain serology fourfold ? BAL/ bx: HIV/ immunosuppressed patient

28. Therapy Criteria for early oral therapy: absence of fever x 2 readings unstable medical illness absent decline WBC improving symptoms

29. Cardiopulmonary Disease/ Modifying Factors Present: IV betalactam with pneumococcal activity+ macrolide antipneumococcal quinolone (gati, mofloxacin) Absent IV azuthromycin quinolone doxy+ beta lactam

30. Severe CAP +/- P aeruginosa Risks Present: cipro+ antipneumococcal, antipseudomonal beta lactam Nonpseudomonal quinolone/macrolide+ beta lactam with antipseudomonal,antipneumococcal activity+aminoglycosid Absent; macrolide or quinolone+ beta lactam with antipneumococcal activity

31. Vaccination Pneumococcal vaccination all patinets> 65 all patients with cardiopulmonary diseases, asplenia, HIV, hematologic malignancy repeat after 5 years

32. (2) Influenza vaccination: yearly unvaccinated patients during influenza outbreak: vaccine+ antiviral for 2 weeks

33. Nosocomial Pneumonia Incidence 10% general surgery 20% mechanical ventilated: 1%/day in the first month 70% ARDS

34. Classification Early onset VAP the first 4 days of mechanical ventilation risk: 3% in the first 5 days Late onset VAP 4 days Mortality: 50%

35. Risk Factors Patients related critical illness: septic shock comorbidity: DM, CRF, COPD, surgery sinusitis Therapy related: sedatives corticosteroids antacids cytotoxic meds enteral feedig ET tube nasogastric tube

36. No risk factors/mild-moderate HAP/early severe HAP G - (non pseudomonal) enterobacter E colli Klebsiella Proteus MRSA S pneumonia/ H influenza

37. Risks factors/mild-moderate HAP/early-late HAP core pathogens anaerobs S aureus (coma, head trauma, DM, CRF) Legionella (high dose steroids)

38. Risks factors/ severe HAP/ early- late HAP core pathogens P aeruginosa Acinetobacter MRSA

39. Diagnosis Criteria new/progressive infiltrate 2 of the following: fever, leukocytosis, purulent sputum

40. No Risks factors/mild-moderate HAP/early severe HAP Core antibiotics cephalosporin: 2nd generation, nonpseuomonal 3rd generation, 4th generation beta lactam/ beta lactamase inhibitor PCN allergy: clinda/ quinolone+ aztreonam

41. Risk factors/ mild-moderate/early late HAP Core antibiotics + clinda vanco

42. Severe HAP Cipro or aminoglycoside + anti pseudomonal pcn beta lactam/beta lactamase ceftazidime/ cefoperazone/cefepime imipenem/ meropenem aztreonam +/- vanco

43. Monotherapy Severe HAP not caused by drug resistant organism Piperacillin/ tazobactam imipenem meropenem cefepime ciprofloxacin

44. Prevention Prophylactic abx: not a standard of care adapted ET tube allowing suctioning of supraglotic secretions