Académique Documents
Professionnel Documents
Culture Documents
Cellular
- Macrophages
- Epithelial cells
- Neutrophils
RED HEPATIZATION
- presence of
erythrocytes in the
intraalveolar
exudate
- neutrophils are
also present
PATHOLOGY
GRAY HEPATIZATION
- no new extravasating
erythrocytes
- neutrophils are the
predominant cells
- fibrin deposition is
abundant
- bacteria have
disappeared
PATHOLOGY
RESOLUTION
- macrophages are the
dominant cells
- inflammatory debris
cleared
PATHOLOGY
BRONCHOPNEUMONIA
Patchy
consolidation
in 1 or more lobes
PATHOLOGY
INTERSTITIAL PNEUMONIA
Inflammatory
process involving
the interstitium,
alveolar walls and
connective tissues
PATHOLOGY
MILIARY PNEUMONIA
Numerous discrete
lesions of
hematogenous
spread
CLASSIFICATION (OLD)
Community acquired pneumonia (CAP)
- Typical
- Atypical
*Aspiration
Increased RR
Use of accessory muscles of respiration
Increased tactile fremitus, dull percussion note for
consolidation
Decreased tactile fremitus, flat percussion note for
effusion
Crackles, bronchial breath sounds on auscultation
Non infectious causes of fever and
pulmonary infiltrates that may mimic
CAP
Pulmonary edema
Pulmonary infarction
Acute respiratory distress syndrome (ARDS)
Pulmonary hemorrhage
Lung cancer/metastatic cancer
Atelectasis
Radiation pneumonitis
Drug reactions involving the lung
Extrinsic allergic alveolitis
Pulmonary vasculitis
Pulmonary eosinophilia
Bronchiolitis obliterans and organizing pneumonia
DIAGNOSIS
TYPICAL ATYPICAL
S. pneumoniae M. pneumoniae
H. Influenzae C. pneumoniae
S. aureus Legionella spp.
K. pneumoniae Respiratory viruses
P. aeruginosa
Diagnosis, Empiric Management and Prevention of
COMMUNITY-ACQUIRED
PNEUMONIA
In Immunocompetent Adult
Cough
Tachycardia CR > 100
Tachypnea RR > 20
Fever T >37.8C
At least one abnormal chest findings
- diminished breath sounds, rhonchi, crackles or wheeze
New x-ray infiltrate with no clear alternative such as lung
cancer or pulmonary edema
CHEST RADIOGRAPH
Confirm the diagnosis
of pneumonia
Assess severity of
disease and presence
of complication
Suggest possible
etiology
ETIOLOGIC DIAGNOSIS
Gram Stain
- May help identify pathogens by their
appearance
- Main purpose is to ensure suitability of
sputum for culture (> 25 neutrophils and
<10 squamous epithelial cells per LPF
DIAGNOSTIC TESTS
Sputum Culture
- Sensitivity and specificity is highly
variable (< 50%)
- Greatest benefit is to alert the physician
of unsuspected and/or resistant
pathogens
DIAGNOSTIC TESTS
Blood Culture
- Only 5-14% of cultures of blood are positive
- No longer considered necessary for all
hospitalized CAP patients
- Should be done in certain high-risk patients
(i.e. severe CAP; chronic liver disease
DIAGNOSTIC TESTS
Antigen tests
- Two commercially available tests detect
pneumococcal and Legionella antigens in urine
- Sensitivity and specificity are high for both tests
- Can detect antigen even after the initiation of
appropriate antibiotic therapy
- Limited availability
DIAGNOSTIC TESTS
COMMUNITY-ACQUIRED
PNEUMONIA
In Immunocompetent Adult
SPECIAL CONCERNS
If Pseudomonas is a consideration
- An antipseudomonal, antipneumococcal beta-lactam
(Piperacillin/Tazobactam 4.5 gm IV q4-q6, Cefepime 1-2gm IV q12,
Imipinem 500mg IV q6, Meropenem 1 g IV q8)plus either
Ciprofloxacin 400mg IV q12 or Levofloxacin 750mg IV OD
- The above beta-lactams plus an aminoglycoside (Amikacin
15mg/kg OD or Tobramycin 1.7 mg/kd OD) and Azithromycin
-The above beta-lactams plus an aminoglycoside plus an
antipneumococcal fluoroquinolone
If CA-MRSA is a consideration
- Add Linezolid 600mg IV q12 or Vancomycin 1gm IV q12
LOW RISK CAP
Potential pathogen Empiric Therapy
- S. pneumoniae If previously healthy:
Amoxycillin or
- H. influenzae Extended Macrolide
- C. pneumoniae If with stable co-morbid illness/
- M. pneumoniae recent use of antibiotics:
Co-amoxiclav or
- M. catarrhalis Sultamicillin or
- gram negative bacilli 2nd Gen. cephalosporins or
(enteric) Extended Macrolide
* If with comorid illness
MODERATE RISK CAP
Potential pathogen Empiric therapy
- S. pneumoniae IV beta lactams with or
- H. influenzae without anaerobic
- C. pneumoniae coverage
- M. pneumoniae +
- M. catarrhalis Macrolide
- gram negative bacilli OR
- Legionella pneumophila Alternative:
- Anaerobes: in aspiration IV Antipneumococcal
Fluoroquinolones alone
High risk CAP (IV)
Potential pathogen Empiric Therapy
If no risk for P. aeruginosa or aspiration:
- S. pneumoniae IV 3RD Gen. cephalosporins w/o anaerobic
- H. influenzae coverage + IV Macrolide
OR
- L. pneumophila IV antipneumococcal fluoroquinolone alone
- C. pneumoniae If no risk for P. aeruginosa but with risk for aspiration:
- M. catarrhalis IV beta lactam/beta lactamase inhibitor + IV
antipneumococcal fluoroquinolone
- gram negative bacilli OR
- Anaerobes IV 3RD Gen. cephalosporins with anaerobic
coverage + IV Macrolide
- S. aureus
If with risk for P. aeruginosa:
- P. aeroginosa IV anti-pseudomonal beta lactams +/-
Aminogylcosides
AND
IV macrolide or
IV antipneumococcal fluroquinolone
GENERAL CONSIDERATIONS
Adequate hydration
Oxygen therapy for hypoxemia
Assisted ventilation when necessary
Failure to improve within 48 to 72
hours following therapy
Noninfectious conditions
- Cancer, embolus, hemorrhage
Resistant pathogen
Wrong drug
Right drug, wrong dose
Unusual pathogens
- Mycobacterial, anaerobic, viral, fungal
Nosocomial superinfections
COMPLICATIONS
Respiratory failure
Shock; Multiorgan failure
Bleeding diathesis
Exacerbation of comorbid illnesses
Metastatic infections
- Brain abscess; Endocarditis
Lung abscess
- usually occurs in the setting of aspiration
- should be drained
Pleural effusion
- should be tapped for diagnostic and therapeutic
purposes
Rate of resolution of physical and
laboratory abnormalities
Abnormalities Duration
Fever 2 to 4 days
Cough 4 to 9 days
Crackles 3 to 6 days
Leukocytosis 3 to 4 days
C-reactive protein 1 to 3 days
CXR abnormalities 4-12 weeks
Fever
Leukocytosis
Increase in respiratory secretions
PE findings of consolidation
New or changing radiographic infiltrate
Tachypnea
Tachycardia
Worsening oxygenation
Increased minute ventilation
FACTORS CAUSING
OVERDIAGNOSIS OF VAP
Death
Prolonged mechanical ventilation
Prolonged hospital stay
Development of necrotizing pneumonia
Long-term pulmonary complications
Inability of the patient to return to
independent function
PROGNOSIS
patient transport
Altered lower respiratory host Tight glycemic control; lowering of
defenses hemoglobin transfusion threshold;
specialized enteral feeding
formula
DIAGNOSIS
Blood culture
Endotracheal
aspiration
PSB or BAL via
bronchoscopy
PREVENTION
Hand washing
Surveillance of pneumonia
For mechanically ventilated: extubate
rapidly, minimize circuit changes, drain
tubings regularly
Small bore feeding tube
Elevation of head to 30º