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PNEUMONIA

 is defined by acute symptoms and signs of lower respiratory tract infection (LRTI) without other
obvious cause. Frequently, a new pulmonary infiltrate on chest radiograph is needed for definite
diagnosis
 CAP is acquired in the community, and is different from hospital acquired or nosocomial
pneumonia (e.g HAP)

Etiology of Disease

• CAP has many causes and includes many different pathogens.

COMMON – viruses (Influenza, Para influenza, Respiratory Syncitial Virus (RSV), Adenovirus Rhinovirus

-bacteria (Streptococcus pneumoniae, Haemophilus influenza, Chlamydia pneumophila,


Mycoplasma pneumoniae, Legionella sp., Enteric Gram Negative organisms)

UNCOMMON - parasite, fungi

KEY LEARNING POINT


• Streptococcus pneumoniae is the most common bacterial cause of CAP, and is vaccine preventable.

ANSORP Study
International Journal of Antimicrobial Agents 31 (2008) 107–114

HIGHLIGHTS:
• High prevalence of S. pneumoniaeas an etiological pathogen -29.2%
• The relatively high prevalence of mixed infections -17.2 %
• Antimicrobial practice for the treatment of CAP -Cephalosporin/Macrolide (41.3)
• Clinical outcomes - Mortality 7.3 %
PHILHEALTH
Reimbursement packages:
–Pneumonia (moderate risk) – Php 15,000
–Pneumonia II (high risk) – Php 32,000
• Should have at least 4 days (96 hours) confinement) with at least 3 days of IV antibiotics (effective
2015).

The Global Burden of Disease Study (GBD) provides an up-to-date analysis of the burden of lower
respiratory infections
– Among 195 countries
– From 1990-2016
Burden of Viral Disease
• The burden of non-bacterial LRTI is largely unknown
• The GBD study estimates that after pneumococcus, RSV and Influenza are major causes of LRTI

Burden of Viruses as Pathogens


• There have been only a small number of surveillance studies in which the burden of viral infections in
CAP were reported. – 16 studies included adults
• 9 looked at viral pathogens

 Influenza , HRV and RSV are the most common viral causes of LRTI in adults
 Bacterial and viral co-infections were observed in 6.5% (35/535) of the cases, with H.
influenzae+ HMPV being the most frequent combination.
 The prevalence of respiratory virus varied from 1.8 to 21%. Most of the studies used
polymerase chain reaction (PCR) for the detection of virus, but serologic tests were applied in
some reports.
 However, the true burden of non-bacterial LRTI is truly difficult to establish, since diagnosis is
dependent on surveillance, and availability of diagnostic tests

Pathophysiology
• CAP usually occurs when there is a breakdown of HOST defenses, and PATHOGENS reach the lower
respiratory mucosa

TRANSMISSION
• The pneumococci bacteria are common inhabitants of the human respiratory tract, and may be
isolated from the nasal passages and throat of 5% to 70% of normal healthy adults, depending on the
population and setting
Person to person
– Respiratory droplets
– Not everyone will develop disease
– Some will become carriers
– Asubset will progress from nasopharyngeal colonization to disease manifestation

Risk Factors for CAP/ LRTI


• Elderly patients with co-morbidities were at greater risk of CAP throughout the Asia-Pacific region and
most elderly patients with CAP had underlying medical conditions
Risk factors for Flu-Pneumonia
• Purpose:
-to investigate the clinical features and factors contributing to the severity and mortality of flu-
p.
–Retrospective study of consecutive patients hospitalized with flu-p from December 1999
through March 2016

Disease Severity
FACTOR ODDS RATIO
Advanced age (≥ 65 years) 2.74 [1.07-7.01]
Unclassified, compared with primary 3.31 [1.07-10.28]
viral pneumonia
Diabetes mellitus 2.74 [1.01-7.46]
Acute kidney injury 14.69 [1.34-161.38]

Diagnosis
• It is usually a clinical diagnosis with radiologic and/or microbiologic support
• The extent of the diagnostic work up is dependent on the clinical presentation of the patient

DIAGNOSTIC TESTS OUTPATIENT INPATIENT


LOW MODERATE HIGH (ICU)

Sputum CS Not routinely yes yes


Blood CS Not routinely Not routinely yes
Legionella urinary antigen Not routinely Not routinely yes
Streptococcal urinary antigen Not routinely Not routinely yes
Invasive work up (e.g.BAL) Not routinely Not routinely Not routinely yes
Others Not routinely yes

Severity Assessment
• There are several tools used to assess disease severity. These tools help in triage, as well as
prognostication

C U R B 65
CONFUSION
UREMIA BUN >7mmol
RR >30
SBP<90 or DBP<60
Age >65
CURB Score Risk Disposition
0 or 1 0.6-3 % mortality Outpatient care
2 6-9 % mortality Inpatient vs. observation
≥3 14% mortality Inpatient
4-5 27% mortality ICU

PNEUMONIA SEVERITY INDEX (PSI)


 A more complex tool
 Uses different indices including comorbidities, laboratory tests, and imaging

SCORE RISK CLASS


Age<50, no comorbids, no PE abnormalities I
<71 II
71-90 III
91-130 IV
>130 V

Treatment
• Treatment regimens are initially empiric based on assessment of severity of illness, clinical
presentation, and co-morbidities.
• Ideally, therapy is modified to definitive treatment based on microbiologic or culture data.
KEY POINTS: TREATMENT
• Timely initiation of therapy: treatment (within 4–8 h) for hospitalized patients with CAP can improve
outcome and should be used.
• In patients with severe pneumonia, therapy should be started even sooner because any delay in
therapy has deleterious consequences.
• Duration of therapy: 5–7 d of treatment is effective in the treatment of CAP.
• Longer durations may be required based on the pathogen identified or if response is suboptimal

Converting from oral to intravenous therapy:


the use of objective criteria combined with integrated case management may lead to shorter
hospitalizations, without compromising clinical outcomes or leading to increased readmission rates
related to pneumonia.

PHARMACOLOGY PEARL
• Oral and IV bioavailability of 2nd generation FQ, Macrolides, and Clindamycin are the same

Vaccination
•Since CAP has many different etiologies, not all pneumonias are vaccine preventable.
•The most common cause of CAP, Pneumococcal pneumonia, is a VACCINE PREVENTABLE DISEASE
TYPE OF VACCINES
• There are 2 MAJOR TYPES of pneumonia vaccines. Both vaccines are inactive
–A polysaccharide vaccine (e.g. PPSV 23)
–A conjugate vaccine (e.g. PCV 7, PCV 10, or PCV 13)

•Each vaccine contains multiple serotypes of the S. pneumoniae as denoted by the number
–For example, PCV 13 has 13 serotypes.

• The conjugate and the polysaccharide vaccines are COMPLEMENTARY


• The conjugate vaccines are more immunogenic

Vaccine Efficacy
• PPV vaccine was found to be effective in preventing the following:
– Invasive Pneumococcal Disease (IPD) among immunocompetentadults1
– Definitive pneumococcal pneumonia1
– Presumptive pneumococcal pneumonia1
• Nursing home residents
– 23-valent pneumococcal vaccine prevented pneumonia and improved survival2
• Hospitalized Adults with CAP
– Survival was significantly improved in adults who received pneumococcal vaccination3

Vaccine Safety
• Pneumococcal vaccines are very safe. The most common adverse effects are injection site reactions
(e.gredness, soreness)

SUMMARY
• CAP affects infants and older adults w/ comorbidities
• Burden from CAP is significant
• Diagnosis is based on clinical presentation and laboratory and radiographic data
• Triage will depend on CURB-65, PSI scores
CAP is classified as low, moderate, or high risk
• Treatment depends on severity of disease
• The risk of severe disease appears to increase w/ dual or mixed bacterial-viral infections
• Remember viruses can cause pneumonia too!

SUMMARY : VACCINES
• There are 2 types of vaccines for Pneumonia – PCV and PPV • These vaccines are complementary,
efficacious, and safe • There are certain dosing indications and dosing schedules for these vaccines