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PHARMACOTHERAPY

PNEUMONIA

Martianus P,
S.Farm.,M.Farm.Klin.,Apt
DEFINITION

 Pneumonia is an infection of the pulmonary parenchyma. Despite being the


cause of significant morbidity and mortality, pneumonia is often
misdiagnosed, mistreated, and underestimated.

 Pneumonia
 Infection of the lungs.
 Alveoli (air sacs of lungs) fill with fluid and pus, making breathing more
difficult.

 Pneumococcal pneumonia
 Caused by bacteria called pneumococcus (Streptococcus pneumoniae).

 Can also be caused by other bacteria, viruses, fungi, parasites.


Pneumonia - Symptoms

• Cough (productive or • Chills/Sweats


non-productive) • Fatigue
• Dyspnea • Headache
• Pleuritic chest pain • Diarrhea (Legionella)
• Fever or hypothermia • URI, sinusitis
• Myalgias (Mycoplasma)
Findings on Exam

• Physical:
• Vitals: Fever or hypothermia
• Lung Exam: Crackles, rhonchi, dullness to percussion
or egophany.
• Labs:
• Elevated WBC
• Hyponatremia – Legionella pneumonia
• Positive Cold-Agglutinin – Mycoplasma pneumonia
PATOPHYSIOLOGY

Pneumonia results from the proliferation of microbial


pathogens at the alveolar level and the host’s response to
those pathogens. Microorganisms gain access to the lower
respiratory tract in several ways.The most common way is
by aspiration from the oropharynx.
How is pneumonia spread?

 Most cases of pneumonia are spread person-to-person


by coughing out of tiny droplets.
 Some pathogens can live in nose and throat without causing
disease.
 But when inhaled into lungs, they can cause pneumonia.
 While many people are exposed to pneumococcus, usually
only those with underlying health issues develop
pneumonia.
Who is at higher risk for pneumonia?

 People with some medical conditions are at higher risk


for pneumonia, including: heart disease, lung disease,
diabetes, etc.

 Smoking also increases risk of developing pneumonia.


What is invasive pneumococcal disease?

 Occurs when pneumococcus gets into part of the body


normally free of bacteria.
 Pneumococcus in blood = bacteremia.
 Pneumococcus in spinal fluid = meningitis.
 People with bacteremia and meningitis can become very
sick, disabled, and in 10-15% of adult cases they die.
What is the relationship between flu and
pneumonia?

 During flu pandemics before 2009, up to 1 in 3 flu


victims developed pneumonia.

 2009 H1N1 flu pandemic


 Study found more than 3 times the number of cases of
invasive pneumococcal disease than expected during the
month that the flu peaked in Denver.
 Up to 62% of the cases of pneumococcal pneumonia may
have been associated with pandemic H1N1.
Pneumonias – Classification…..

CAP • Community Acquired


HCAP • Health Care Associated
HAP • Hospital Acquired
ICUAP • ICU Acquired
VAP • Ventilator Acquired

MDR • Multidrug-resistant
Types of Pneumonia
• Community-Acquired (CAP)
• Health-Care Associated Pneumonia (HCAP)
– Hospitalization for > 2 days in the last 90 days
– Residence in nursing home or long-term care facility
– Home Infusion Therapy
– Long-term dialysis within 30 days
– Home Wound Care
– Exposure to family members infected with MDR bacteria
• Hospital-Acquired Pneumonia (HAP)
– Pneumonia that develops after 5 days of hospitalization
– Includes:
• Ventilator-Associated Pneumonia (VAP)
• Aspiration Pneumonia
Types of Pneumonia
• Community-Acquired (CAP)
• Health-Care Associated Pneumonia (HCAP)
– Hospitalization for > 2 days in the last 90 days
– Residence in nursing home or long-term care facility
– Home Infusion Therapy
– Long-term dialysis within 30 days
– Home Wound Care
– Exposure to family members infected with MDR bacteria
• Hospital-Acquired Pneumonia (HAP)
– Pneumonia that develops after 5 days of hospitalization
– Includes:
• Ventilator-Associated Pneumonia (VAP)
• Aspiration Pneumonia
Common Bugs for Pneumonia
Community-Acquired HCAP or HAP
• Streptococcus pneumoniae • Pseudomonas aeruginosa
• Mycoplasma pneumoniae • Staphylococcus aureus
• Chlamydophila psittaci or (Including MRSA)
pneumoniae
• Klebsiella pneumoniae
• Legionella pneumophila
• Serratia marcescens
• Haemophilus influenzae
• Acinetobacter baumanii
• Moraxella catarrhalis
• Staphylococcus aureus
• Nocardia
• Mycobacterium tuberculosis
• Influenza
• RSV
• CMV
• Histoplasma, Coccidioides,
Blastomycosis
Diagnosis of pathogen

• Sputum Culture
– < 10 Squamous Epithelial Cells
– > 25 PMNs

• Blood Cultures
• Strep. pneumo urinary antigen
• Legionella urinary antigen
• HIV test?
Special Clues on Chest X-ray

• Lobar pneumonia – Strep. Pneumonia


• Diffuse interstitial infiltrates –
Pneumocystis
• RUL infiltrate – Tuberculosis
• Diffuse interstitial infiltrates – Tuberculosis
in HIV
Inpatient or Outpatient Treatment of CAP

• Patient’s safety at home


• PORT score
• Clinical Judgement
PORT Score
PORT Score
Treatment
Empirical Antibiotic Treatment Of Community-acquired Pneumonia
Treatment
Empirical Antibiotic Treatment Of Community-acquired Pneumonia
Treatment
Empirical Antibiotic Treatment Of Community-acquired Pneumonia
Treatment of CAP

• Outpatient:
– Macrolide (Azithromycin)
– Fluoroquinolone (Levaquin, Moxifloxacin)
– Doxycycline
• Inpatient:
– Beta-Lactam + Macrolide
• Ceftriaxone + Azithromycin
– Fluoroquinolone (Levaquin, Moxifloxacin)
• For suspicion of highly resistant Strep. pneumoniae
Treatment of HCAP, HAP, VAP
• Antipseudomonal cephalosporin (Cefepime, Ceftazidime)
+ Vancomycin
• Anti-pseudomonal Carbapenem (Imipenem, Meropenem)
+ Vancomycin
• Beta-Lactamase/Beta-Lactamase Inhibitor (Pip-Tazo –
Zosyn) + Pseudomonal Fluoroquinolone (Cipro) +
Vancomycin
• Aminoglycoside (Gentamycin, Amikacin) + Vancomycin
Special Cases!
• HIV
• Pneumocystis jirovecii
• Mycobacterium tuberculosis
• Cryptococcus
• Histoplasmosis
• Transplant Patients
• Fungi (Aspergillosis, Cryptococcus, Histoplasmosis)
• Nocardia
• CMV
• Neutropenic Patients
• Fungi ( Aspergillosis)
• Gram-negatives
More Special Cases

• Smokers: S. pneumo, H. • Deer mouse exposure:


influenzae, M. catarrhalis Hantavirus
• Alcoholics: S. pneumo, • Bat exposure: Histoplasma
Klebsiella, anaerobes capsulatum
• IV Drug User: S. aureus, • Rat exposure: Yersinia pestis
Pneumocystis, anaerobes • Rabbit exposure: Francisella
• Splenectomy: encapsulated tularensis
organisms (S. pneumo, H. • Bird Exposure: C. psitacci,
influenzae) Cryptococcus neoformans
• Cystic fibrosis: Pseudomonas, • Bioterrorism: Bacillus
S. aureus anthracis, F. tularensis, Y. pestis
Pneumococcal Vaccine
• What does it cover?
– Protects against 23 serotypes of Strep. Pneumoniae (90% of invasive pneumonia
infections)
• Who should get it?
– Anyone over age 65
– Anyone with chronic medical problem such as cancer, diabetes, heart disease, lung
disease, alcoholism, cirrhosis, sickle cell disease, kidney failure, HIV, damaged spleen
or no spleen, CSF leaks
– Anyone receiving cancer therapy, radiation, steroids
– Alaskan natives and certain Native American populations
• How often to get it?
– Give second dose if >5 years from first dose if > 65, cancer, damaged spleen, kidney
disease, HIV or any other condition lowering immune system function
What vaccines will help protect you from
pneumonia?

 In the United States, there are several vaccines


available for preventing pneumonia:
 2 pneumococcal vaccines
 vaccines against Haemophilus influenzae type b (Hib),
whooping cough, chickenpox, measles, and flu

 Adults should check with their doctors – they may need


vaccines or boosters to vaccinations that they got as
children.