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ACUTE PULMONARY INFECTIONS

Zen Ahmad Medical Faculty, Sriwijaya University

Case presentation
A 55-year-old male with a history of type 2 diabetes, presents with dyspnea, high fever, chills, and productive cough with purulent sputum for 2 days duration. He denies hemoptysis. He has smoked 2 packs of cigarettes a day for the past 20 years and drinks six beers a day.

On physical exam he appears acutely ill. His vital signs show a temperature of 40.2C, pulse is 130 beats/minute, RR is 48x/per minute, BP is 113/60.
Lungs are dull to percussion and bronchial breath sound heard over the left lower lobe. Chest X-ray showed infiltrates in the left lower lobe.

Key clinical questions


1. What are the most likely diagnosis in this patient? 2. What are the most likely causative organisms in this patient? 3. What further diagnostic tests are recommended for diagnosis? 4. What are the risk factors for pneumonia 5. Can this patient be treated as an outpatient or should he be admitted? 6. What antibiotic agent would be recommended for this patient?

What are the most likely diagnosis in this patient?

Differential diagnostic
Pneumonia Tuberculosis Acute bronchitis Acute exacerbation of chronic bronchitis Upper respiratory infection Sinusitis CHF Asthma Lung cancer

Definition of pneumonia
An acute infection of the lung parenchyma distal to the terminal bronchiole, associated with clinical or radiologic evidence of consolidation of part or parts of one or both lungs.

Terminology
Community Acquired Pneumonia versus Nosocomial pneumonia (HAP; VAP, HCAP Typical pneumonia versus atypical pneumonia Mild pneumonia; Moderate pneumonia and Severe pneumonia Lobar pneumonia; Bronchopneumonia and Pleuropneumonia

Clinical manifestations
Sudden onset of fever, chills Cough Sputum production Pleuritic chest pain Dyspnea; Tachypnea Tachycardia Extra pulmonary symptoms (nausea, vomiting, malaise, headache, myalgia)

Physical examinations
Sign of pulmonary consolidation
o o o o o

Restricted movement of the afflicated hemithorax Increased fremitus Dullness Bronchial breath sounds Rales

Clinical manifestations of pneumonia


Features
Onset Age Appearance Fever Rigor Cough Sputum Extra pulmonal Pleuritic chest pain Lung consolidation Gram stain WBC, difrential Chest x-ray

Typical
Sudden Younger Toxic High Common Productive Purulent Uncommon Common Common Abundant bacteria Elevated; left shit Consolidation

Atypical
Gradual Older Malaise, fatique Low grade Uncommon Nonproductive Mucoid Common Uncommon Uncommon Rare bacteria Normal Patchy, infiltrate

Patient
- Acute (2 days) - Dyspnea, High fever, Chills - Productive cough, purulent sputum - T: 39.8C - Pulse: 130 x/minute - RR: 48x/per minute - Percussion: dull - Auscultation: bronchial breath sound over the left lower lobe - CXR: infiltrates in the left lower lobe.

Pneumonia
- Sudden onset of fever - Shortness of breath - Productive cough, purulent sputum - Pleuritic chest pain - Tachypnea - Restricted movement of the afflicated hemithorax - Increased fremitus - Dullness - Bronchial breath sounds; Rales - CXR: infiltrates (lobar, multilobar, segmental) or pleural effusions

What are the most likely causative organisms in this patient?

Microbial causes of pneumonia


CAP
S.pneumoniae

Nosocomial Pneumonia
Gram negative bacilli

Atypical Pneumonia
M.pneumoniae

H.influenzae
Moraxella catarrhalis S.aureus

S.aureus
Pseudomonas aeruginosa

C.pneumoniae
Legionella pneumophila

Gram negative bacilli


Virus

Woodhead M.Medicine International 1995; 31 (9)

CAP : Most Common Pathogens


Mild (Ambulatory Patients) Moderate (hospitalized, non ICU)* Severe (ICU)*

S. Pneumoniae M. Pneumoniae H. Influenzae C. Pneumoniae Viruses Mixed flora (aspiration)

S. Pneumoniae M. Pneumoniae C. Pneumoniae H. influenzae Legionella spp Mixed flora (aspiration)

S. Pneumoniae S. aureus H. influenzae Gram negative bacilli Legionella spp

excluding Pneumocystis spp. ICU = intensive care unit


File MJ. Tan JS. Cure open Purn Med 1997. 3(2) 89

Bacterial Pathogens in CAP


4,2% 12,5% 33,3% 12,5% No pathogen discover Klebsiella S. aureus S. pneumoniae Acinobacter Pseudomonas S.pyogenes

12,5% 20,8% 16,7%

Persahabatan Hosp. 2000

What further diagnostic tests are recommended for diagnosis?

Diagnostic
CXR Sputum examination Blood count Blood cultures Serologic studies Thoracentesis Invasive diagnostic procedures Transtracheal aspiration Bronchoscopy or BAL Direct needle aspiration

CXR
CXR is the most important diagnostic tool
New or progressive pulmonary infiltrates Lobus consolidation Segmental consolidation Patchy infiltrate Pulmonary cavitations Lymphadenopathy Pleural effusions

Lobar pneumonia

Location of pneumonia

Sputum examination
The key factor to identification of the etiology

Macroscopic; Gram stain and Sputum culture


Lower sensitivity 3050% pathogen could not identifiable Frequently contaminated by MO in the URI

What are the risk factors for pneumonia

Risk factors for pneumonia


Extreme of age Underlying co-morbid illness Imunocompromise Impaired mucociliary clearance Alcoholism; Drug abusers Smoking Endotracheal intubation Upper respiratory infection Impaired level of consciousness An increase in gastric pH (the use of H2 Blocker, Antacid) Neurologic dysfunction

Can this patient be treated as an outpatient or should he be admitted?

Risk Factors used to determine assignment to risk classes II-V

Risk class for patients with CAP

Algorithm pneumonia
Patients with Community Acquired pneumonia
Is the patients over 50 years of age ?
No Yes

Does the patient have a history of any of the following comorbid conditions ? Neoplastic disease Congestive heart failure Cerebrovascular disease Renal disease Liver disease
No

Yes

Assign patient to risk class II-V based on prediction model scoring system

Does the patient have any of the following on physician examination ? Altered mental statis Pulse 125/minute Respiratory rate 30/minute Sistolic blood presure < 90 mmHg Temperature < 35C or 40 C
No

Yes

Assign patient to risk class I

What antibiotic agent would be recommended for this patient?

The ideal antibiotic in pneumonia


Bactericidal +++ Low resistance Coverage, almost all of respiratory pathogen Single drug Once-daily dose Safe High respiratory penetration Cost effective

Antibiotics in pneumonia
Macrolide Tetracycline Cotrimoxazole Co-Amoxyclav Sultamicillin - lactam (include cephalosporin) Fluoroquinolone Aminoglycoside Antipseudomonas

CAP Management Issues


Causative pathogen frequently not found Typical and atypical found together Therapy must be started early (<8 hours) Increasing resistant to penicillin and macrolide Atypical: unresponsive against - lactam AB Cost and adverse reaction Oral route more convenient Decision to hospitalize/outpatient
Bartlett: Clin Infect Dis 26:811, 1998. Whitney et al.New England Journal of Medicine,December 2000

Outpatient treatment (IDSA/ATS 2007)


Previously healthy and no use of antimicrobials within the previous 3 months A macrolide Doxycyline Have a comorbid (chronic heart, lung, liver /renal disease; DM; alcoholism; malignancies; asplenia; immunosuppressing conditions ; use of immunosuppressing drugs; use of antimicrobials within the previous 3 months
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin) A b-lactam plus a macrolide (strong recommendation; level I evidence)

In regions with a high rate of infection with high-level (MIC _16 mg/mL) macrolide-resistant S. pneumoniae, consider use of alternative agents listed above in (2) for patients without comorbidities

Inpatients, non-ICU treatment


A respiratory fluoroquinolone (strong recommendation; level I evidence) A b-lactam plus a macrolide (strong recommendation; level I evidence)

Inpatients, ICU treatment


A b-lactam (cefotaxime, ceftriaxone, or ampicillinsulbactam) plus either azithromycin (level II evidence) or a respiratory fluoroquinolone (level I evidence) (strong recommendation)

(for penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended)

Failure of empirical treatment

Incorrect diagnosis

Correct diagnosis

Host issues

Drug issues

Pathogen issues
Bacterial Nonbacterial

Local factor Error in drug selection Inadequate host response Error in dose/route Complication Compliance Adverse drug reaction

Prognostic factors
Extremes of age Inappropriate antibiotic therapy Shock Involvement of 1 lobe Peripheral WBC count 5000/l Presence of associated disorders (eg: cirhosis; heart/renal failure) Development of extrapulmonary complications (eg: meningitis, endocarditis)

Mortality in patients with CAP


Study Focus
Hospitalized and ambulatory Hospitalized only Elderly Bacteriemic Nursing home Intensive Care Unit
Fine et al. JAMA 1995;274: 134-141

Patients Mortality (%)


5.1 13.6 17.6 19.6 30.8 36.5

Complications
Acute respiratory distress syndrome Lung abscess Renal failure Septic shock Pleural effusions/Empyema Bacteriemia (Septic arthritis; Endocarditis; Meningitis; Peritonitis; Endopthalmitis.