Pneumonia
Community acquired Pneumonia ( CAP )
Hospital acquired Pneumonia ( HAP)
( Ventilator associated Pneumonia (VAP) )
is the most serious form of HAP…
Health care Associated Pneumonia (HCAP)
2005
• Community acquired Pneumonia( CAP)
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Pneumonia in a Community Resident outside the hospital setting
• Hospital acquired (Nosocomial) Pneumonia( HAP )
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Pneumonia that occurs 48 hours or more after admission
• Ventilator associated Pneumonia (VAP)
• HAP that develops more than 48 hours after intubation.
• Health care Associated Pneumonia (HCAP)
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In 2005 ATA /IDSA Introduced HCAP ( previously CAP ) (Multidrug Resistance Pathogens )
Residence in a Nursing Home or other long-term care facility
Attend at a Hospital or Hemodialysis clinic within prior 30 days
IV therapy, wound care, or IV chemotherapy within the prior 30 days
Pneumonia that occurs in a non-hospitalized patient with extensive healthcare
contact…
Hospitalization in an acute care hospital for two or more days within the prior 90 days
Community Acquired Pneumonia
• Pneumonia is a lower respiratory infection involving the lungs especially
affecting the Alveoli characterized by filling of the alveolar space with
inflammatory cells and fluids ….
• Clinically characterized by respiratory symptoms , cough, sputum ,
dyspnea , pleuritic chest pain with fever, chills , tachypnea , tachycardia
and the appearance of a new infiltrate / opacity on CXR
• In the elderly symptoms differ ( with fewer respiratory symptoms )
confusion, failure to thrive, fall, and worsening of chronic underlying
illness e.g. CHF
• Severity ranges from mild to life threatening
Etiology : Pathogens differ in different continents or geographic areas.
Outpatients are different from Inpatients , ICU and from Nursing Home
Microbiology
 Pathogens :
• Bacteria : Strept Pneumoniae , H. Influenzae , Chlamydia , Mycoplasma and
Legionella
• Viruses : Adenovirus, Influenza and Para influenza, …RSV
• Fungal : Histoplasmosis , Coccidomycosis, Blastomycosis, Pneumocystis Jiroveci
in HIV , or other immune suppressed patients
• Rare causes are Fungi and Parasite .
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Majority are caused by Bacteria
S. Pneumoniae ( GPC)
H. Influenzae (GNR )
Chlamydia
Mycoplasma
Other : Staph, Legionella, Moraxella, Gram negative bacilli
1/3 of CAP are caused by viruses
Streptococcus pneumoniae is the most common cause worldwide.
Epidemiology
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In the US more than 5 million / year
20 % ~ more than a Million  Hospitalized
In 2005 > 60 000 died
Cost ~ 10 billon /year
Age : Highest at extreme of ages , Elderly
More in Males
More in African and Native Americans
More in Winter
Mortality highest in hospitalized patients and those with risk factors
Pathogenesis
• Bacteria enter the lung through several routes:
• 1. Micro Aspiration the most common way. (From previously colonized
oropharynx)
• 2. Macro ( Aspiration ) (stroke, seizure, CVA) Loss of neurologic
protection of the upper airway
• 3. Inhalation of Legionella or TB ( airborne)
• 4. Hematogenous: from extra pulmonary sites of infection
• 5. Direct extension / spread from nearby (e.g., liver abscess).
• 6. Critically ill / ICU / Ventilator: Retrograde spread from a colonized
stomach to the oropharynx
• The lungs are exposed to invading pathogens and colonized
oropharyngeal bacteria yet it remains sterile and pneumonia is infrequent
because of the antibacterial respiratory defenses
• Pulmonary defenses :
• Muco-Ciliary, Phagocytes, Antibody Response…
• Pneumonia develops if Host defenses are overwhelmed by infectious
pathogen
Pathogenesis…
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Poor Immune system >> Poor immune response >> Pneumonia
Immune dysfunction ( Severe illness, Sepsis or Steroid / Chemo )
Chronic Illness ( CHF, DM, CRF, COPD, Chronic Liver Disease)
Anatomic abnormalities (endobronchial obstruction, bronchiectasis)
Or
Adequate Immune System : overwhelmed by virulent microorganism.
• Virulence factors: some microorganisms develop ways to overcome host
defenses
• Chlamydia produces cilio-static factor.
• Mycoplasma shears off cilia.
• Influenza virus reduces tracheal muco-ciliary clearance.
• S. pneumoniae produces factors that inhibits phagocytosis
• Mycobacterium &Legionella are resistant to the anti microbicidal activity
of phagocytes
Risk factors
Impairs pulmonary defenses >> increased
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risk of CAP
Chronic lung diseases , Smokers, Asthma ,COPD, Bronchiectasis ,Fibrosis
Alcoholics (x9) Homeless , Prisoners
Immunosuppressed, Spleenectomy, Cancer , HIV (x 40 )
Chronic liver or chronic kidney diseases , CHF ,CVA
Seizures, Dementia
Recent Abx
Elderly
Malnutrition
Military recruits
Steroids
Inhaled steroids, ipratropium and bronchodilators
PPI , H2 blockers
Antipsychotics
Specific risk factors
PNEUMONIA
Exposure to birds
Psittacosis
Exposure to bat or bird droppings
Histoplasma
Exposure to Rabbits
Tularemia
Cruise ship or hotel previous 2 weeks
Legionella
Exposure to farm animals
Q fever , Coxiella Burnetti
IVDU
Staph Aureus, Anaerobes , TB
MRSA focus, Live in crowded conditions
CA-MRSA
Bronchiectasis
Staph and Pseudomonas
Neutropenia
Recent Abx
Gram Negative
Microbiology …
OUTPATIENT
INPATIENT
ICU / SEVERE CASES
S. Pneumoniae
S. Pneumoniae
S. Pneumoniae
Mycoplasma Pneumoniae
Mycoplasma Pneumoniae
Staph Aureus
H Influenzae
Chlamydia Pneumoniae
Legionella
Chlamydia Pneumoniae
H Influenzae
Gram Negative Bacilli
Pseudomonas & E. Coli
Respiratory Viruses
Influenza A & B
RSV , Adenoviruses
Para Influenza
Legionella
H Influenzae
Aspiration / Anaerobes
Microbiology Is Changing
Respiratory Viruses
Multidrug Resistance
• Symptoms:
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Fever, cough, sputum, pleuritic chest pain, shortness of breath chills & shakes
Headache, Nausea, Vomiting, Diarrhea, Fatigue, Myalgia, Joint pain
Non respiratory symptoms : Confusion & falls ( in the elderly ) …
Pleuritic pain more with bacterial pneumonia
Rusty sputum to pneumococcal pneumonia
Hemoptysis “ more with Klebsiella & TB
Constant repetitive harsh dry cough with fever 3days + more with Mycoplasma
Pneumonia plus GI symptoms (diarrhea, abdominal pain ) myalgia's, headache
confusion and high fever ~ 104 think Legionella
Viral pneumonia usually with dry non productive cough , ha, malaise
Signs:
Chest signs : ( Bronchial breath sounds, dullness , crackles, pleural rub, rhonchi )
Fever , Tachypnea , Tachycardia
Elderly ( Hypothermia , confusion, hypotension , falls …. )
Diagnosis
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– Diagnosis is suggested by symptoms and signs .
– Should be confirmed by CXR which almost always show some infiltrate …
– CXR is Indicated in All cases of suspected CAP ( T 100+, P 100, RR > 20 )
Rarely false negative CXR …attributed to an infection very early in the course ,
Neutropenia, Dehydration, and Pneumocystis Pneumonia
Pneumocystis Pneumonia : 1/3 of patients have normal CXR early in the disease
CXR is essential in an elderly or chronically ill patient who can have pneumonia
with only non respiratory findings “ confusion, hypotension , loss of appetite, fall,
failure to thrive “
CXR to confirm Dx , can help identify severe , complicated cases
(Multi- Lobar Pneumonia , Pleural Effusion, Cavitation )
If S&S of pneumonia with Negative CXR : Diagnosis is “ Bronchitis “ therefore
NO Abx is needed if no underlying lung disease…
Investigations …Labs …
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WBC
Electrolytes ,Glucose , BUN & Creatinine
ABG ( if hypoxia )
PPD ( if suspect TB )
2 sets of Blood culture : (T < 95 or > 103 , Neutropenia, Severe CAP , Asplenic,
Chronic liver disease , alcoholics, homeless )
Pleural Aspiration for pleural fluid > 1 cm on a lateral decubitus CXR
• Sputum: ?
CT ?
Bronchoscopy ?
Lung Biopsy ?
Gram stain… and sputum culture
Diagnosis ……Sputum ?
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Not recommended for OP
Low diagnostic yield in CAP
Not cost effective
positive reports can not separate Colonization from Infection
Organism growing from sputum is not definitive proof that it is the etiologic agent.
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Only 1/3 of the elderly can produce “ suitable “sample
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Gram stain: Needs Good quality sputum sample ( < 10 SEC /LPF Squamous epithelial
cells, plus Neutrophils ) Most labs reject sputum with more than 10 SECs/LPF
Difficult to get a good quality sample
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Rinsing mouth prior to expectoration
No food for 2 hours prior to expectoration
Immediate Inoculation into the culture media …
Obtained Prior to antibiotic treatment ( Recommendation is < 6 hours )
• When to order “ Sputum “
• Pretreatment sputum is recommended for hospitalized patients …
if performed on a good quality sputum with appropriate measures :
 If Patient …
• Failed antibiotic therapy (either outpatients or hospitalized patients)
• Cavitary lesions
• Severe obstructive or structural lung disease e.g. Bronchiectasis
• Pleural Effusion
• Immune compromised
• Active Alcohol Abuse
• ICU patients
• Suspected “ Drug Resistance Bacteria or Unusual Pathogens “
• Special stains of sputum for certain organisms when clinically indicated
(e.g. Acid fast for mycobacteria, Direct fluorescent antibody for
Pneumocystis )
Serology
• Routine serological tests are NOT recommended because of the time
required and the expense
• Serology is necessary if :
• Critically ill or non responders …
• ‘ Pneumonia Outbreak ‘ with negative blood and sputum culture
• Coxiella is suspected ( Q fever) or Pneumocystis
• S Pneumoniae : Pneumococcal urine antigen is 80 % sensitive and > 90%
specific, positive even after Abx use, and weeks after the illness…
• Legionella Urine Antigen , sensitivity is 90% specificity is 99%, can be
positive even after proper Abx, and weeks after the onset , use in patients
with strongly suspected rapidly progressive legionellosis
• Direct fluorescent antibody test for Influenza virus ‘Rapid Influenza Test’
• Sensitivity measures the actual positives (the percentage of people who
are identified as having the condition).
• Specificity measures the negatives (percentage of healthy people who are
identified as NOT having the condition).
Diagnosis: Serology
• Mycoplasma Pneumoniae : Enzyme Immunoassay (EIA)
sensitivity ~ 98 and specificity of 99.7
• Chlamydia Pneumoniae : Direct antigen testing and PCR.
• C. Psittica : Complement fixation
• Legionella :Urine antigen
• Coxiella Burnetti : PCR and culture
• Adenovirus : Culture and EIA
• Para influenza & Influenza : Rapid diagnostic tests , PCR, EIA
Differential Diagnosis
• Pulmonary Embolism - most serious missed
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Pulmonary Edema
Bronchitis
Exacerbation of COPD or heart failure
Pulmonary Fibrosis
Lung cancer
Pneumonitis
Sarcoidosis
Other diagnostic tools
• CT Scan : Should NOT be used routinely
 Indications: 1. Non responders
2. Helps identifies Cavitation
3. Loculated Pleural effusion
• Thoracentesis : If a pleural effusion of > 1 cm the fluid should
be aspirated
• Bronchoscopy / BAL “ broncho-alveolar lavage ”
• Lung Biopsy
Decision For Hospitalization
• Who can be safely treated at home ??
• Decision should be based on medical and social considerations
• Q: Able to care for himself , able to take oral meds, Adherence ?
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Preexisting condition, living conditions , cognition, vitals ,labs, CXR and
physical findings
Low risk > Home Moderate risk > Hospital High risk > ICU
Most CAP cases are treated as an OP
Hospitalization If
Multiple risk factors have “ poor outcome ”
RR 30 , BP < 90 / < 60 , Multilobar pneumonia , Confusion, BUN > 20 ,
PO2 <60 , PCO2 > 50 …Acidosis… Require oxygen , ivf , cardiac monitor
or iv Abx , ?? severe cases
TO assess pneumonia severity …there are Many Prediction Models...
• PSI = Pneumonia severity index
Pneumonia Outcome Research Team ( PORT ) Study
•  Prognostic Scoring Index
• Mortality prediction rules , helps physicians guide the
admission decision
• classifies patients into one of 5 classes , points are calculated
on factors such as age, sex, comorbidities, signs, labs , CXR
• Mortality prediction rules classifies patients into one of 5
classes
Points
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Class
0 – 50 = I
51-70 = II
71-90 = III
91-130 = IV
131-395 = V
Mortality
0.1 % Class I & II : Treat at Home
0.6%
0.9% Intermediate : (Individualized )
9.3%
27% Class IV & V : Admit
PORT :
Pneumonia Outcome Research Team Prognostic Scoring Index
Questions :
Age , Sex , Nursing home
Comorbidities :
Cancer , Liver disease , CHF , CVA , CKD …
Physical Exam :
AMS , Pulse > 125 , RR > 30 , SBP < 90 , T < 95 or > 104
Labs :
PH < 7.35 , BUN > 30 , Na < 130 , G > 250 , HCT < 30 , PO2 < 60 , O2 Sat <
90 % …
CXR : Pleural effusion
For each of variables add points , range is from 10-30 Points …Calculate
Age for a man
Age (in years)
Age for a woman
Age (in years) - 10
Nursing home resident
+10
Coexisting illnesses
Neoplastic disease (active)
+30
Chronic liver disease
+20
Heart failure
+10
Cerebrovascular disease
+10
Chronic renal disease
+10
Physical examination findings
Altered mental status
+20
Respiratory rate ≥30/minute
+20
Systolic blood pressure <90 mmHg
+20
Temperature <35°C or ≥40°C
+15
Pulse ≥125 beats/minute
+10
Laboratory and radiographic findings
Arterial pH <7.35
+30
Blood urea nitrogen ≥30 mg/dL (11
mmol/L)
+20
Sodium <130 mmol/L
+20
Glucose ≥250 mg/dL (14 mmol/L)
+10
Hematocrit <30 percent
+10
Partial pressure of arterial oxygen <60
mmHg*
+10
Pleural effusion on chest x-ray
+10
C U R B - 65
Another way to assess Pneumonia Severity
C = Confusion
U = Urea > 42 mg
R = Respiratory rate ≥30/min
B = Blood pressure ≤ 90 / ≤60 mmHg
65 = Age ≥ 65 years
Score 0 or 1 can be treated as OP .
Score of 2 …Admit .
Patients with scores of ≥ 3 ICU.
• Simplified C R B - 65
…one point for each
For PCP Using clinical judgment without blood test
if patient is 65 + and has one of these variable , then admission to hospital is
reasonable Confusion , RR > 30 ,BP < 90 / < 60
These are Guidelines …Not Rules Use Clinical Judgment …
No rule is absolute
Treatment
Supportive : Hydration, Oxygen, Analgesics, Antipyretics , IVF
Empiric Therapy : (< 6 hours ) proven to reduce mortality .
Empiric Therapy > 90 % respond very well Do NOT wait for diagnostics
Guidelines for Empiric treatment are based on:
 Likely Pathogens , Severity , Comorbidities , Local susceptibility
 Location ( OP / Inpatient / ICU )
 Modifying factors ( Cardio pulmonary disease or other factors )
 Clinical Trials, Efficacy of agents , Safety Profile of Abx, Cost
 Risk factors for antimicrobial resistance :
( Age > 65 year , Abx past 3 months, Alcoholism,
Immunosuppressed , exposure to child in a day-care center)
What is proven to lower mortality ?
1. Antibiotic within 6 hours
2. Two Abx agents in Pneumococcal Pneumonia with bacteremia
Beta Lactams : Penicillin's , Cephalosporin  Gram Positive organisms.
Monobactams (Aztreonam ) , Carbapenem ( Meropenom , Ertapenem )
Macrolides: ( Azithromycin , Clarithromycin , Erythromycin )
 S Pneumoniae, H Influenzae, Mycoplasma, Legionella and Chlamydia …also
covers Streptococci, staph, enterococci
Quinolones : Moxifloxacin , Levaquin & Ciprofloxacin….
Once daily , Oral antibiotics ( or iv ) Covers  Pneumococci, including drug
resistance ( DRSP) , Gram negative and the atypical pathogens
They penetrate very well into respiratory secretions .
Highly bioavailable ~ 100 % the same serum level achieved with oral or iv
therapy Recommended to give IV , to Ensure Absorption, once the patient shows
response , change to oral therapy
Anti Pneumococcal Quinolones : ( Respiratory ) Moxifloxacin and Levaquin
Anti Pseudomonal Quinolone : ( Ciprofloxacin and Levaquin )
Although all anti pneumococcal quinolone are effective against pneumococci, they differ
in their intrinsic activity against Pneumococci …on the basis of MIC they can be ranked
…the most effective being Moxifloxacin , then Levaquin
Empiric Abx for Outpatients
Outpatient treatment in otherwise healthy , no recent Abx …
• Azithromycin 500 mg / day or Doxycycline 100 mg bid
Outpatient Tx for patients with comorbidities or who was on Abx last 3 m
• Respiratory Fluoroquinolone (Moxifloxacin , Levaquin) Or
Amoxicillin or Augmentin plus Macrolide ( Zithro )
( Can substitute Doxycycline for Zithro )
Why ?
Those Patients with Comorbidities failed Macrolides alone Tx because of
(DRSP )
Outcome of Empiric Out Patient Treatment
90% will improve in 2 days ( Less Cough, Dyspnea, WBC ,Pain, and Fever )
5% will slowly improve after 48 hours
5% will not improve in 2 days or feel worse , need to be reassessed …
Therefore : patient need to be informed if after 72 hours , if they don’t improve , or
develop fever 101, or are short of breath, hemoptysis , confusion or pleuritic chest
pain …to come back to be checked
~ Half Of The 5 % experience progression and require hospital admission.
The overall mortality rate for the outpatient group is < 1%.
Excellent prognosis for the young, or otherwise healthy individuals
Young healthy adults feel well enough to return to work in 4 or 5 days; almost all
recover in 2 weeks
Older patient & those with comorbidities can take few weeks to fully recover
Pneumonia due to S . Pneumoniae and Influenza virus in the elderly with
comorbidities can be fatal
Empiric Inpatient Treatment (Not ICU)
Treat for Drug resistance pneumococcal and Atypicals …Always with iv Abx
• Monotherapy with a Respiratory Quinolone (Moxifloxacin , Levofloxacin ) or
• Combination of β-lactam ( Rocephin, Augmentin ) plus ( Macrolide or
Doxycycline ) .
For patients with specific risk factor
For Anaerobic infection (Aspiration pneumonia) Use Quinolone or Rocephin Plus
Anaerobic coverage “ Clindamycin or Metronidazole or Zosyn or Timentin “
If Pseudomonas is a consideration Two Anti pseudomonal Agent ( Zosyn, Timentin,
Meropenom , Cefepime) plus Anti pseudomonas Quinolone ( Ciprofloxacin or
Levofloxacin )
Suspected concomitant Meningitis (? Pneumococcal) Vancomycin & Rocephin
For Cavitary infiltrate or Empyema : Treat as MRSA (Vancomycin, Zyvox )
Bronchiectasis or ( COPD with Recent Abx & Steroids ):
( Treat For Pseudomonas, S Pneumonia & Legionella )
Allergy to penicillin : Maxipime =Ceftazidine 3rd gen ,or Fortaz =Cefepime 4th gen
Legionella : Levaquin or Zithro
Principles Of Antibiotic Therapy
RECOMENDATION
Based on / Evidence
First Dose of Abx Within 6 Hours
Observational Studies
Treat all for possible Pneumococci and Atypical
Observational Studies pt. age 65+
Macrolide Monotherapy for OP or IP with NO risk
for DRSP or Gram Negative or Aspiration
Randomized controlled trials
For OP & IP with risk for DRSP or Gram Negative
use 1. Macrolide & Oral Beta lactam or
2. Quinolone Monotherapy
Randomized controlled trials &
Observational Studies
For OP at risk for DRSP the Oral Beta lactam
should be (Cefuroxime, or high dose Ampicillin or
Augmentin)
In vitro susceptibility and expert
opinion
IP with risk for DRSP IV Beta lactam should be (
Rocephin, iv High dose Ampicillin or Augmentin )
In vitro susceptibility and expert
recommendation
Limit Anti pseudomonas to patient with
Expert Opinion
pseudomonas Risk factor ( to prevent resistance )
Limit Vancomycin use to empiric therapy of very
severe illness ( meningitis ) to avoid overuse
Expert Opinion
Choose most active agent to minimize future
resistance and best clinical benefit
Expert Opinion
Monitoring hospitalized patients
Most Patients show clinical response in 1-3 days and stabilize in 3–7 .
Vital signs, Temp , WBC , Symptoms & Clinical signs.
Check sputum and blood culture results If done … adjust therapy
Evaluation of Response to Therapy :
Clinical improvement, relief of cough, sputum, dyspnea, improved appetite ,ability to
take oral medications Normal Temp for 36 hours … WBC decline
Normal functioning GI system …switch to highly bioavailable oral Abx
Prepare to discharge if medically and socially stable
Duration of Abx : 5 – 7 days for mild – moderate CAP
If more serious ( MRSA , Pseudomonas or bacteremia) can take as long as ~ 3 weeks
Radiological improvement lags behind clinical improvement
Highest Mortality “ Pseudomonas followed by Klebsiella ,E coli, Staph Aureus “
Non Responders
Patients Who Do Not Respond Within 72 Hours Of Appropriate Abx
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Worsening or progressive clinical deterioration …needing ventilator
Non responding , delay in clinical repose
By day three if pneumonia patient does not improve , despite proper antibiotics,
Reconsider the diagnosis …
Does the patient has pulmonary embolism, or pulmonary edema or other …
If this is an infection , is this an Unusual or virulent organism , Abx resistance,,
coinfection, obstructive process, immune suppressed, TB or fungal infection or
Cancer ?
Workup for Non responders : Start all over … Retake the history, Recheck labs,
reports of sputum, blood cultures, CXR , urine …Repeat CXR request CT if not done ,
Request Pulmonology consult ? Bronchoscopy and BAL to obtain microbiology and
cytology , if pleural effusion Diagnostic Tapping …transfer to a higher level of care
Risk factors for ( Non responding or treatment failure ) : Multilobar pneumonia
,Cavitation, pleural effusion, leucopenia, high PSI ,liver disease
Protective factors : Prior pneumonia vaccine & Influenza vaccine,
: using Quinolone
Radiological Follow up
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Every patients with pneumonia especially smokers > 40 should have a
follow-up CXR after ~ 6 weeks to document resolution which may lag
several weeks…behind clinical improvement
Resolution
Bacterial in 2-4 weeks
Viral : 4 weeks +
Mycoplasma : 6 weeks +
Persistence of infiltrate after 6 weeks raises suspicious for Cancer or TB
 Up to 2% of hospitalized patients with CAP have Lung Cancer (with
pneumonia distal to an obstructed bronchus)
• 50% of these cancers are evident on the initial chest film.
• The other 50% manifest as failure of pneumonia to resolve
radiologicaly and are diagnosed at bronchoscopy …
Complications
Respiratory failure , Pleural effusion , Abscess, Empyema, Shock, Sepsis, CHF,
MI, GI Bleed, Renal failure, Multi organ failure, Bleeding , Bacteremia which
can lead to metastatic infection ( septic arthritis or meningitis ) in addition to
worsening of already existing comorbidities
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More than 60,000 people died in 2005 from CAP ‘
Poor prognostic factors include
Elderly > 60
Multi-Lobar
WBC < 5000
Comorbidities ( Alcoholics, CHF, Chronic Liver or Renal Disease , Immune
Suppressed, Positive Blood Cultures)
Pleural Effusion
• Seen in ~ 40% of patients hospitalized for CAP mostly “ simple - Para
pneumonic “ must differentiate it from empyema by sampling the fluid
• Pneumococcal pneumonia is the infection most commonly complicated by
pleural effusion , other pathogens ( H. Influenzae , Mycoplasma,
Legionella and TB)
• All patients with a pleural effusion should have a lateral decubitus CXR .
If the effusion is > 1 cm in height, the fluid should be aspirated.
 If frank pus  Chest tube …
 Thoracotomy and Decortication may be necessary.
Lung abscess
– Uncommon
– Risk factors : Conditions associated with impaired cough reflex
and/or aspiration, such as alcoholism, anesthesia, drug abuse,
epilepsy, and CVA
– Dental caries , Bronchiectasis ,Bronchial carcinoma and
Pulmonary infarction
• Etiology
– Combination of Aerobic and Anaerobic Bacteria
– Anaerobic bacteria ( Bacteroides )
– Aerobic ( Streptococcus milleri , Staph aureus , S. pneumoniae
H. influenzae ,Pseudomonas aeruginosa ,E. coli , Klebsiella
pneumoniae )
Recurrent pneumonia
• Of patients hospitalized for CAP ~ 10–15 % have another episode within
two years.
• If the recurrence affects the same anatomic location as the previous
episode, the most likely cause is an obstructed bronchus due to either a
tumor or a foreign body.
• CT of the Chest often detects pulmonary anatomic defects (e.g.
Bronchiectasis ) that might be the cause of the recurrence.
• COPD and repeated macro Aspiration are the most common causes of
recurrent pneumonia.
Prevention
 Influenza and Pneumococcal Vaccines … Protective
( when patient is afebrile , before discharge )
 Yearly Influenza Vaccine : > 6 m and up
 Pneumococcal vaccine Q 5 years :
 Adults …65 +
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…Age 2-64 “ high risk “ with Chronic health problems ( Heart
disease , lung disease , Sickle cell disease, Alcoholics, DM, Cirrhosis, Immune
suppressed , HIV , Asplenics , Asthmatics , Hodgkin's, Lymphoma, organ
transplant, Nephrotic )
~ 50 % of adults
 Smoking Cessation Counseling
• Avoid Abx for simple uncomplicated infection ( Sinusitis, URI, Bronchitis ,
Asymptomatic UTI )
• Avoid “ double “ antibiotic coverage
• De- escalate Broad spectrum Abx
• Short courses of Abx
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No antibiotics for Single Positive Blood culture for Coagulase Negative Staph
( Common colonizer of skin )
The most serious pathogens (MRSA , Pseudomonas, Klebsiella, C diff and Multi
Drug Resistance Bacteria ) are the product of our Antibiotic abuse
20 % of hospitalized patients in the US acquire Clostridium Difficile and about
30% of those develop C diff associated diarrhea ( mild self limiting to severe life
threatening pseudomembranous colitis )
Health care Associated Pneumonia ( HCAP )
o Residence in a Nursing Home or other long-term care facility
o Attend Hospital or Hemodialysis clinic within 30 days
o Hospital Admission for two or more days within 90 days
o IV Therapy, or IV Chemo , wound care, within 30 days
Increased risk for
 1. Multidrug-Resistant (MDR) pathogens
 2. Poly Microbial
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Microbiology —Common pathogens include Aerobic Gram-negative Bacilli
(e.g. E. Coli, Klebsiella , Enterobacter, Pseudomonas, Acinetobacter) and Grampositive Cocci ( Staph Aureus, including MRSA, Streptococcus )
Same increased risks with “ HAP / VAP “
Hospital acquired Pneumonia ( HAP)
• Pneumonia that occurs 48 hours or more after admission
• Highest risk is in patients on mechanical ventilation
Sputum Gram stain and culture are indicated for all patients
• Complicates up to 1% of hospitalizations
• Mortality: 30-50%
• Etiology of HAP differs …
• CVA : Aspiration With Pneumoniae & Anaerobes
• Ventilator : Pseudomonas , Gram negative Coliforms, Staph including
MRSA
• Organ Failure : Gram negative Coliforms
• Airway Obstruction : Anaerobic
• HIV and Chronic Steroid users : Fungi, Pneumocystis
• Neutropenia < 500 : Candida and Aspergillus
• Management: Antibiotics
• Combination ( 2 – 3 antibiotics )
• Primaxin, Aminoglycoside, Meropenom , Clindamycin , add Vancomycin
for MRSA or Zithro for Legionella
• Antifungal
• Resistance to Macrolides becoming more common
• Decision for hospitalization should be based on medical and social
considerations
• If pneumonia does not respond think Pulmonary Embolism - most
serious missed
• Respiratory or Pulmonary Quinolones are (Levaquin & Moxifloxacin)
• Cipro is a Gram Negative Abx
• Antibiotics within 6 hours proven to lower mortality
• Avoid Abx for simple uncomplicated infection ( Sinusitis, URI, Bronchitis …)
Healthy Outpatients : Treat with Azithromycin or Doxycycline
Outpatient with comorbidities or who was on Abx last 3 m Treat with
Quinolone or ( Zithro ) plus (Amoxicillin or Augmentin )