Introduction

0 Pneumonia is an inflammation of the lung

parenchyma (i.e. alveoli rather than the bronchi)
of infective origin.

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0 It is the most common infectious cause of death.

0 It is usually characterized by consolidation.

0 Consolidation is a pathological process in which

the alveoli are filled with a mixture of
inflammatory exudate, bacteria & WBC

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 EPIDEMIOLOGY

0 Occurs throughout the year

0 Results from different etiological agents
varying with the seasons
0 Occurs in persons of all ages
0 Clinical manifestations severe in very
young, elderly & in chronically ill
patients
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 Risk factors

1. Comorbidity- Neoplastic disease, neurological

problem
2. Alcoholism
3. Advanced age
4. Asthma
5. Immunosuppression

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 Etiology
Potential etiologic agents in CAP - Bacteria
Viruses
Fungi
Protozoa

Potential bacteriologic causes can be divided into two

types
0 Typical bacterial pathogens
0 Atypical bacterial pathogens
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 Typical bacterial pathogens

0 Streptococcus pneumoniae  30% to 60% ,Severe

illness, death
0 Haemophilus influenzae10%
0 S. aureus (in selected patients)
0 gram-negative bacilliKlebsiella pneumoniae
Pseudomonas aeruginosa

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 Atypical bacterial pathogens

0 Mycoplasma pneumoniae
0 Chlamydophila pneumoniae
0 Legionella pneumophillia
0 These organisms are intrinsically resistant to all - B
lactam agents macrolide, a fluoroquinolone, or a
tetracycline.
0 Poor dental hygiene-anaerobes
0 HIV- p.carnii
0 Birds- Chlamydia psittaci
0 Cattle or parturient cat-Coxiella burnetti
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 CLASSIFICATION
Classified based on two types
Base on Location Type
0 Lobar pneumonia
0 Bronchopneumonia

Environmental Type
0 Community- acquired pneumonia (CAP)
0 Hospital-acquired pneumonia (HAP)

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 Lobar pneumonia
0 Lobar pneumonia is acute bacterial infection of a
part of lobe the entire lobe, or even two lobes of
one or both the lungs.

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 Bronchopneumonia
0 Bronchopneumonia is infection of the terminal
bronchioles that extends into the surrounding
alveoli resulting in patchy consolidation of the
lung.

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 Community Acquired
Pneumonia (CAP)
Pneumonia which develops in an otherwise
healthy person outside of hospital or have
been in hospital for less than 48hrs

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 Nosocomial pneumonia
(HAP)
Pneumonia that was not incubating upon
admission developing in a patient
hospitalized for greater than 48 hrs.

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 PATHOPHYSIOLOGY
Microbial invasion of the normally sterile lower
respiratory tract

Three routes-
0 Inhaled as aerosolized particles
0 Haematogenous spread from an extrapulmonary
site of infection
0 Aspiration of oropharyngeal contents
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 Defence mechanisms that
protects lung from infection
0 Anatomic barriers –epiglottis, larynx
0 Cough reflexes
0 Tracheobronchial secretions
0 Mucocilliary lining
0 Cell & humoral mediated immunity
0 Dual phagocytic system-alveolar macrophages &
neutrophils
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Invasion occurs as a result of
0 Defect in host defence mechanism
0 Overwhelming inocculum
0 Lung infection with viruses suppress the
antibacterial activity of the lung by
impairing alveolar macrophage function &
mucocilliary clearance thus setting the
stage for secondary bacterial pneumonia.

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 Clinical Manifestations
0 Indolent to fulminant in presentation
0 Mild to fatal in severity
0 Typical symptoms –
Fever
Chills
Cough
Rust coloured sputum
Mucopurulent sputum
Dyspnea ( shortness of breath)
Pleuritic chest pain
0 Elevated WBC
0 Bacteraemic Pneumonia 17
 Chest X-ray
For Lobar Pneumonia
Consolidation
confined to
one or more
lobes (or
segments of
lobes) of
lungs.

Lobarpneumonia
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 Chest X-ray
For Bronchopneumonia

•Patchy
consolidation
usually in the
bases of both
lungs.

Bronchopneumonia

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 Diagnosis
Clinical diagnosis
0 History
0 Signs & symptoms
0 Chest x-ray
0 CT-Scan

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 Diagnosis
Etiological diagnosis
0 Gram's Stain and Culture of Sputum
0 Blood Cultures
0 Antigen Tests
0 Polymerase Chain Reaction
0 Serology
0 Bronchoalveolar lavage
0 Bronchoscopy

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 Complications

Possible complications include:

0 Acute respiratory distress syndrome (ARDS)
0 Fluid around the lung (pleural effusion)
0 Lung abscesses
0 Respiratory failure (which requires a
breathing machine or ventilator)
0 Sepsis, which may lead to organ failure

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 COMMUNITY ACQUIRED
PNEUMONIA
Pneumonia is most common in winter because of
seasonal increase in viral infections

Mortality
1%- Non hospitalized patients
13.7%-Hospiatalized patients
19.6%-Bacteremic patients
<36.5%- Intensive care unit
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 HOSPITAL ACQUIRED
PNEUMONIA
0 Pneumonia that was not incubating upon admission
developing in a patient hospitalized for greater than 48
hrs

0 10-15% of all hospital acquired pneumonia, usually

presenting with sepsis or&/or respiratory failure

0 50% acquired on ICU

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 Predisposing features
Reduced host defence against bacteria
0 Reduced immune defences (Corticosteroid treatment,
diabetes, malignancy)
0 Reduced cough reflux (Post operative)
0 Disordered mucocilliary clearance (Anaesthetic agents)
Aspiration of nasopharyngeal or gastric secretions
0 Immobility or reduced conscious level
0 Vomiting, Dysphagia,
0 Nasogastric intubation

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0 Most bacterial nosocomial infection occur by
microaspiration of bacteria colonizing the
patients oropharynx or upper GI tract
0 Most common pathogen – Aerobic gram
negative bacilli
0 Most commonly exposed to multiresistant
hospital pathogen
0 86% nosocomial infection-mechanical
ventilation
0 Mortality-0 to 50%

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 Bacterial introduction into LRT
Endotracheal intubation
Infected ventillatiors / nebuliser /bronchoscopy
Dental or sinus infection
Bacteraemia
Abdominal sepsis
Intravenous canula

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 Causative organisms
Common organisms
Gram negative bacteria-
0 Escherichia coli
0 Klebsiella sp.
0 Pseudomonas aeruginosa
Gram positive bacteria-
0 Streptococcus pneumoniae
0 Staphylococcus aureus

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 Treatment
Goals of therapy-

0 Eradication of the offending organism.

0 Selection of an appropriate antibiotic.

0 To minimize associated morbidity.

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General approach to treatment
0 Adequacy of respiratory function
0 Humidified oxygen for hypoxemia
0 Bronchodilators (albuterol)
0 Chest physiotherapy with postural drainage
0 Adequate hydration if necessary
0 Expectorants such as guaifenesin
0 Chest pain- analgesics

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Selection of an antimicrobial
agent
0 Empirical use of relatively broad spectrum antibiotic
0 Narrow spectrum antibiotics to cover specific
pathogen
0 Potential pathogens involved
0 Age
0 Previous &current medication history
0 Underlying disease
0 Present clinical status

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Antibiotic doses for treating pneumonia

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Treatment for special cases
1. Patient less than 60 years & without comorbidities:-
Azithromycine ( 500mg OD) *1day
( 250mg OD) *4days
Norfloxacin/Levofloxacin (400mg OD) *7days

2. Outpatient greater than 65 years:-

Norfloxacin (400mg OD) *7days or
Ceftriaxon (1-2 g/day) / Cifixim (2-4 g/day) 3rd gen
cefalosporins +
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 Macrolides like Azithromycin ( 500mg OD) *1day
( 250mg OD) *4days
3. Patient is hospitalised but not severely ill:-
Combination of 3rd gen cefalosporins + Macrolides
Ceftriaxone + Azithromycin
OR
Norfloxacin/Levofloxacin (400mg OD)
4. If the patient is hospitalised but not severely ill:-
Combination of 3rd gen cefalosporins + Macrolides
Ceftriaxone + Azithromycin
and newer fluroquinolones (Gatifloxacin)

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5. Patient hospitalised & severely ill:-
Combination of 3rd gen cefalosporins + Macrolides
Ceftriaxone + Azithromycin
and newer fluroquinolones (Gatifloxacin)
We can add Vancomycin.
6. Patient with icu admission:-
3rd gen cefalosporins + Fluroquinolones
(Gatifloxacin)
+
Nutritional supplements + Saline
Vancomycin/Meropenam

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7. For HAP:-
Cephalosporins + Aminoglycocides

8. For antipseudomons cephalosporins:-

Ceftazidime + Cefexime

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 Drugs with usual doses

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