Pulmonary Infection Disease

Cheng Zhang ， Respiratory Medicine ，

Affiliated Hospital of Jining Medicine college
23,Feb
Pneumonia
Bacterial Pneumonia
 General Consideration
• Definition:
• location:distal airways ， alveoli ， and
interstitium of the lung .
• causes: pathogenic
microorganisms ， physical or chemical
agents ， immunologic injury ， allergic
diseases and medicine
• Bacteria Pneumonia is the commonest
Pneumonia and also the one of the
commonest infection disease
 Epidemiology
• In United States ， CAP affects 4 million
adults per year ， costs ＄ 9.7
billion ， 20% admitted
• Prevalent rate :0.8~1.5% per year,highest
rates at the extremes 0f age and during
winter months
• Mortality ： 1~5% in out-patients ， 12% in
hospital ， 40% in ICU
• .
• Aging,smoking,alcoholism,comorbid medical
conditions and immunosuppression ， such
as
AIDS,immunodepressants,transplantation,C
OPD,AIDS ， malignant tumor ， diabetes
mellitus,mutation of pathogenic
microorganisms and abusage of antibiotics
and poverty are also partially responsible
 Pathogenesis
Pulmonary defence mechanisms
cough reflex,mucociliary clerance
system,immune responses prevent aspiration of
oropharyngeal secretions(contaning bacteria or
inhalation of infected aerosols) .
Pneumonia occurs or not dependents on defects of
normal host defence mechanism or numbers
and virulence of bacteria
• Pathogenic organisms could raech the lower
respiratory tract and result in Pneumonia via
the following ways
• a.Aspiration of infected aerosols
• b.Dissemination via blood stream
• c.Spreading by the adjacent organ infections
• d.Aspiration of permanent planting
organisms in the upper air way
• e.Aspiration of gastric-oesophageal reflux
 Classification
Anatomical Classification
A.Lobar Pneumonia （ Alveolar
Pneumonia ）

Start with alveolitis produced by bacteria
and expand to the other alveoli
throughout the lobe via the pores of
Kohn ， and result segments or even
whole lobe infection
 Classification
• Parenchyma infection
• Lobe consolidation,bronchus not be involved
• Streptococcus pneumonia is the main
pathogen
• X-ray will show segment or lobar
consolidation shadow
B.Lobular
pneumonia （ bronchopneumonia )
• Pathogens spread via bronchi and produce
infection in the bronchiole ， distal
bronchiole and alveoli
• Often secondary to some other
diseases ， such as
bronchitis ， bronchiectasis ， long-term
lying in bed
 Classification
• Pathogens ： Streptococcus pneumonia ，
Staphylococci ， viruses ， Mycoplasma
pneumonia
• Rales(often heard) ， no signs of
consolidation
• X-ray ： the irregular patch infiltration
shadows go along with the lung markings
and no appearance of consolidation
• Lower lobe is easier to be involved
 Classification
C.Interstitial pneumonia
Involving interstitium ， including the
alveolar walls and the connective tissue
• Alveoli septa infiltration of
lymphocytes ， macrophages ， and plasma
cells
• It could be caused by infection of bacteria ，
mycoplasma ， chlamydia ， virus ， pneu
mocystis carinii and so on
 Classification
Aetiological Classification
A.Bacterial Pneumonia

Classified as Streptococcus pneumonia ，
Staphylococci aureus ， Alpha hemolytis
streptococcus ， Klebsiella pneumoniae ，
Hemophilus influenza ， Pseudomonas
aeruginosa pneumonia
 Classification
B.Atypical Pathogens Pneumonia

Legionella ， Mycoplasma and Chlamydia
C.Viral pneumonia

Coronavirus ， adenovirus ， Respiratory
syncytial virus ， Influenza virus ， Measles
virus ， Cytomegalovirus ， Herpes simplex
virus
 Classification
D.Fungal pneumonia
• Candida albicans ， Aspergillus,and
Actinomycetes
E.Other Pathogens Associated Pneumonia
• Rickett‘s
organism ， toxoplasmosis ， protozoa ， p
arasite(echinococcosis,schistosomiasis)
F.Physical and chemical Pneumonia
• Radiation pneumonia
• Chemical pneumonia
• Lipoid pneumonia
 Classification
Classification According To The
Circumstances The Patient
Acquire Pneumonia

A.Community-acquired
pneumonia ， CAP
Occurs outside of hospital or less than 48
hours after admission in a patient who is not
hospitalized or residing in a long-term care
facility for more than 14 days before the
onset of symptoms
 Classification
Essentials diagnosis ：
• Symptoms and signs ： cough with or
without purulent sputum ， dyspnea ， with
or without chest pain
• Fever
• Bronchial breath sounds or rales are freqent
auscultatory findings
• WBC>10×109/L or<4×109/L,with or without
shift to the left
 Classification
• Parenchymal infiltration or interstitial changes with
or without pleural effussion on chest radiograph
Any one of the first four points above plus the last
one ， and exclude other pulmonary
tuberculosis,neuoplasm,non-fectious,pulmonary
edema,atelectasis,pulmonary embolism,ILD,the
diagnosis of CAP could be confirmed.

The pathogens include Streptococcus
pneumoniae ， Hemophilus influenza ， Moraxelle
catarrhalis ， and atypical pathogens
 Classification
B.Hospital-Acquired
Pneumonia ， HAP/Nosocomial
Pneumonia ， NP
Occurs more than 48 hours after admission to
the hospital and excludes any infection
present at the time of admission
Essentials diagnosis ：

At least two of the following ：
fever ， cough ， leukocyosis ， purulent
sputum
 Classification
• New or progressive parenchymal infiltrate on
chest radiograph
• Especially common in patients requiring
intensive care or mechanical ventilation
Organisms ：
• In patients without high infection risk factors
are Streptococcus
pneumoniae ， Hemophilus
influenza ， Staphylococcus aureus,
Escherichia coli,Klebsiella pneumoniae
 Classification
• In patient with high risk factors are
Streptococcus pneumoniae ， Pseudomonas
aeruginosa ， Enterobacter ， Klebsiella
pneumoniae and so forth
 Clinical Findings
• Pneumonia can range in severity from mild to
fulminant and fatal.
• The typical pneumonia is characterized by the
sudden onset of fever ， cough productive of
purulent or bloody sputum, with or without pleuritic
chest pain, shortness of breath or distress.
• The physical signs associated with pneumonia are
fever ， tachypnea, tachycardia ， nasal flaring ，
cyanosis
• Dullness to percussion may be detected if a
parapneumonic pleural effusion or empyema is
complicated
 Diagnosis and Differential
Diagnosis
.first upper/lower respiratory tract
infections
Secondly.orther diseases that mimicthe
pneumonia should be excluded
• Pulmonary tuberculosis
 Often have an insidious onset and general toxic

symptoms ， such as low-grade fever ， night

sweat ， fatigue ， weight lost and so forth

X-ray ： Shadows mainly located in the upper
zone ， irregular density ， slow disappearance ，
cavity formation and bronchial disseminationn
 Sputum smear could get positive results

 Patients will not respond to the common antibiotic

 Diagnosis and Differential
Diagnosis
• Lung cancer

Neoplasm must be excluded in any patient who has
pneumonia which clears slowly radiologically or
repeats in same part of lung
 Further investigations include
CT ， MRI,bronchoscopy and sputum cytologic
examination may help
 Diagnosis and Differential
Diagnosis
• Lung Abscess

Early stage similar ， but large amount of
purulent sputum will be coughed up while the
disease progresses
 X-ray shows cavity with fluid level
 Diagnosis and Differential
Diagnosis
• pulmonary thromboembolism
 There are phlebothrombosis factors,such as
thrombophlebitis,diseases of heart and
lung,trauma,surgery,neoplasm and so forth

Hemoptysis ， syncope and dyspnea are the
characteristic manifestations
 X-ray lung marking decrease and sometimes a
wedge shadow
 Hypoxemia and hypocapnia
 D-dimer ， CTPA ， Pulmonary arteriography
and MRI can help to differentiate
 Diagnosis and Differential
Diagnosis
• Non-Infectious Pulmonary Infiltration
Such as pulmonary interstitial fibrosis ，
pulmonary edema ， pulmonary
atelectasis ， pulmonary
eosinophilia ， pulmonary vasculitis and so
on
Assessment of Pneumonia Severity
• Severity evaluation is associated with treatment
• Pneumonia severity depends on the three factors ：
the extent of local inflammation ， the
dissemination of pulmonary inflammation and the
degree of systemic inflammation response
• Besides ， the following risk factors are also
associated with the increase of pneumonia severity
and mortality ：
History
 Age over 65 years old with coexisting illness
Assessment of Pneumonia Severity
Sign

Respiratory rate>30/min
 Pulse rate≥120/min
 Bp<90/60mmHg

temperature≥40℃ or ≤35℃
 Altered mental status
 Existence of extrapulmonary infections such as
meningitis or sepsis
Assessment of Pneumonia Severity
Laboratory and Radiologic Findings

Blood cells count>20×109/L or <4×109/L ， or
neutrophils<1×109/L
 PaO2<60mmHg ， PaO2/FiO2<300,or
PaCO2>50mmHg
 Serum creatinine >106umol/l or serum urea
nitrogen >7.1mmol/l
 Hb<90g/L or HCT<030
Assessment of Pneumonia Severity
 Serum albumin<25g/l

The evidence of sepsis or DIC
 Multilobar involvement,cavity formation,fast
dissemination of the lesion or pleural
effusion on the X-ray film
Assessment of Pneumonia Severity
• So far,there has not been a definition of
severe pneumonia,which is recognized
generally.The definition of severe pneumonia
established by our country is as follow:
 Confusion
 Respiratory rate>30/min
 PaO2<60mmHg ， PaO2/FiO2<300,need for
mechanical ventilation
 Bp<90/60mmHg
Assessment of Pneumonia Severity

 Bilateral or multilobar involvement on the X-ray

film,or≥50% increase of the lesion within the 48
hours after admission
 Oliguria:urinary production<20ml/h,or
<80ml/4h,or acute renal failure need for dialysis
 Etiologic Diagnosis
• Some common methods used clinically to obtain the
sample are as below:
Sputum
 A sputum sample with>25 white blood cells and<10
squamous epithelial cells per low-power field or the
ratio of squamous epithelial cells and white blood
cells <1:2.5 is suitable for culture.
 ≥107cfu/ml could be confirmed as the pathogenic
bacteria, ≤104cfu/ml as contaminated organisms
 The same organisms(>2 times,105-106cfu/ml)could
also be considerd pathogens
 Etiologic Diagnosis
Aspiration via fibrous bronchoscope or
artificial airway

Less chance to be polluted

≥105cfu/ml could be defined as pathogens
Protected specimen brush,PSB

≥103cfu/ml could be defined as pathogens

Bronchial alveolar lavage,BAL

≥104cfu/ml or ≥103cfu/ml in the protected BAL
sample could be defined as pathogens
 Etiologic Diagnosis
Percutaneous fine-needle aspiration

Has good sensitivity and specificity,but has high
incidence of complication
Culture of blood and pleural fluid
 Blood culture should be performed but positive is
low(5%-20%)
 Treatment
• The identification of pathogens is very helpful in
guiding the treatment(target therapy)
• Low sensitivity and specificity and delayed results
• Since the etiology of pneumonia is frequently
unknown, initial antibiotic therapy is often
empirical
• Choice of antibiotics must modified based on
circumstances (CAP or HAP),epidemiology of
community or hospital and cover most likely
pathogens
• The following conditions are also considered
in selecting the antibiotics and
administration route
age
Underlying disease
Radiographic appearance
Prior use of antimicrobials
Severity of pneumonia
Aspiration
hospitalization
• Macrolides ,penicillions,first generation of
cephalosporins or quinolones are preferred for CAP
in adults under age 60 and with no coexisting
illnesses
• For age over 60with comorbidities or reqiring
hospitalization the second or third generation of
cephalosporins ,β-lactams/β-lactamase inhibitors or
quinolones are considered and the combination of
macrolides or aminosides
 Treatment
• Severe pneumonia should broad-
spectrum ， dosage and combination
• The condition of patient should be assessed 48-72
hours after the antibiotic therapy
• When a patient with pneumonia fails to improve 72
hours after administration ， the capital
possibilities listed as follow ：

The pathogens are not covered

The infection of specific pathogens
 Complications or host factors

 Non-infectious disease
 Prevention

• smoking cessation
• Exercise
• Influenza and pneumococcal vaccination
appropriately
 Bacterial Pneumonia

• Streptococcus pneumonia

• Staphylococcal pneumonia
 Streptococcus pneumonia
• Streptococcus pneumonia is caused by
Streptococcus pneumoniae or pneumococcus
pneumoniae
• About half of CAP
• A sudden attack of fever ， chills ， cough ，
bloody sputum and chest pain
• X-ray ： acute pulmonary consolidation
distributed in segment or lobar
 Aetiology and Pathogenesis
• Pneumococci are spherical gram-positive bacteria
• The bacteria are classified as 86 serotype according
to their polysaccharide capsule antigen.
• Pathogenicity and virulence are related toproperties
of the outer capsules and cell walls.
• Susceptible are the previously healthy young
adults ， elderly and infants
• Pneumococci are aerosolized from the
nasopharynx to the alveolus and cause
alveolar wall adema and that followed by
exudation of white blood cells and red blood
cells
• Pneumococci are aerosolized from the
nasopharynx to the alveolus and cause
alveolar wall edema and that is followed by
exudation of white blood cells and red
cells.the edema fluidswith bacteria spreads
rapidly throughout the lobe via the pore of
cohn, resulting in a mostly lobar distribution
of consolidation.Because the inflamation
starts from peripheral lung tissue,the pleural
membrane is easy to be involved and that is
related to the pleuritis and pleural effusion
 Pathology
• Four stages ：

Congestion
 Red hepatisation
 Gray hepatisation

Resolution
 Clinical Manifestations
• A. Symptoms
• Often have a history of cold
,fatigue,drunkness,viral infection before the
onset
 Sudden attack of high fever （ 39-
40℃ ）， chills ， myalgia ， cough ， bloody or
rusty sputum ， dyspnea ， pleuritic chest pain

Nausea ， vomitting ， abdominal
pain ， diarrhea
 Clinical Manifestations
• B. Signs
 Flush ， cyanosis ， braeth rapidly and
shallowly,alae nasi moving
 Moving less on the affected side,Dull to

percussion ， increased tactile ， vocal fremitus ，

bronchial breath sounds ， rales ， pleural friction
rub
 Nature history is 1-2 weeks,defervescence may occur

either gradually or dramatically 5~10 days after

onset or 1~3 days with effective antibiotic therapy
 Clinical Manifestations
• C. complications

Septic shock

Pleuritis
 Empyema

 Pericarditis


Meningitis

Arthritis
 Laboratory Findings
• WBC is increased
• Sputum smear
• Sputum culture
• PCR
• Blood culture or pleural fluid culture
 Radiographic Diagnosis
• Chest radiography may confirm the diagnosis
• Assess severity and response to therapy over time
• Radiographic findingscan range from patchy
airspace infiltrates to lobar consolidation with
air bronchograms.
• Finds pleural effusions and cavitation
• Clearing of pulmonary infiltrates can take 3-4
weeks
 Diagnosis and Differential
Diagnosis
• According to symptoms ， signs and chest
Radiographic findings
• Atypical Clinical Manifestations should
differentiate
 Treatment
• A. Antibiotic therapy

Therapy should be initiated promptly after
the diagnosis of pneumonia is established
 Penicillin ， quinolones or third generation

of cephalosporins ， Vancomycine
 Therapy for two weeks or until the patient is

afebrile for at least 72 hours

 Treatment
• B. Treatment of complications

Therapy according to symptoms ， such as to
relieve chest pain ， thoracentesis when
pleural fluid formation
 Staphylococcal pneumonia
• Staphylococcal pneumonia is an acute pulmonary
suppuration caused by staphylococcus
• It often affects persons with co-morbid illness and
usually has sudden onset of high
fever ， chills ， chest pain ， and purulent
sputum
• X-ray presents with necrotizing pneumonia ， such
as lung abscesses ， air cyst and empyema
• It has a very high mortality if not being treated
properly
 Aetiology and Pathogenesis
• Staphylococci are gram-positive coccus and can be
classified as coagulase-positive （ Staphylococcus
aureus ） coagulase-negative （ S.epidermidis and
S.saprophyticus ）
• The pathogenic materials of staphylococcus are
toxins and enzymes ， such as
hematoxin ， leucocidin ， enterotoxin and so on
• The virulence of staphylococcus can be determined
by testing the coagulase
 Aetiology and Pathogenesis
• The coagulase-positive agent has stronger virulence
• Staphylococci has been implicated in 11%-25% of
CAP and there have been reports about the epidemic
outbreak of methicillin resistent
S.aureus （ MRSA ） in the hospital in the recent
years
 Pathology
• S.aureus can gain access to the lung parenchyma by
two routes ， aspiration of upper respiratory flora
and hematogenous spread
• The pneumonia associated with aspiration will
present with lobar consolidation or extensively
distributed bronchial pneumonia
• Lung abscess ， air cyst ， empyema ， and
pyopneumothorax are the common typical
pathologic changes
 Pathology
• Hematogenous seeding of the lungs with S.aureus
follows embolization from an intravascular nidus of
infection
• Common settings for septic pulmonary
emboliazation are right-sided
endocarditis （ especially common among injection
drug users ） and septic
thromboophlebitis ， which is most often a
complication of an indwelling venous catheter
• The bacterial embolus can also come from
cutaneous infections such as
furuncle ， carbuncle ， cellulites ， and wound
infection
 Clinical Manifestations
• Only rarely does S.aureus cause pneumonia without
predisposing epidemiologic or host factors that
favour colonization of the respiratory tract and/or
that impair defense mechanisms
• Clinical findings is characterized by sudden attack
of high fever （ 39-40℃ ）， chills ， chest
pain ， cough productive of purulent sputum or
blood tinged purulent sputum
• Systemic toxicity includes myalgia ， arthralgia ，
and prostration
 Clinical Manifestations
• Ciuculatory collapse can occur in early stage in case
with severe condition
• The onset can be insidious in patient with HAP and
temperature will go up gradually
• The elderly may present atypical manifestations
• The patient with hematogenous spread usually has a
history of indwelling venous catheter ， wound
infection and drug abuse by intravenous
• They often strat with the symptoms of primary lesion
and have less respiratory manifestations
 Clinical Manifestations
• Few signs can be detected in early stage that is not
parallel with the severe toxic symptoms
• Afterward ， the signs of pneumonia ， pleural
effusion or pneumothorax can be found
• Radiograph shows consolidation of segment or
lobar ， cavity formation ， and air cyst with fluid
level
• Multiple nodular or fluffy infiltrates suggest
hemotogenous spread
 Diagnosis
• The initial diagnosis can be made according to the
systemic toxicity ， produtive cough with blood
stained purulent sputum ， increase of WBC and
radiographic changes
• Aetiological evidence can confirm the diagnosis ，
which can obtain from the culture of
sputum ， pleural fluid and blood
 Treatment
• Semisynthetic penicillins or cephalosporins
combined with aminoglycosides are preferred as the
first antimicrobial choice ， because most of
S.aureus are resistant to penicillin （ -90% ）
• Amoxicillin or ampicillin plus β-lactamase inhibitor
can be used for coagulase-positive Staphylococcus
• Vancomycin and teicoplanin are highly active
against MRSA