Acute Pulmonary Infections 1

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ACUTE PULMONARY

INFECTIONS

Zen AhmadMedical Faculty, Sriwijaya University


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Case presentation

A 55-year-old male with a history of type 2 diabetes, presentswith dyspnea, high fever, chills, and productive cough withpurulent 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 showa temperature of 40.2C, pulse is 130 beats/minute, RR is48x/per minute, BP is 113/60.

Lungs are dull to percussion and bronchial breath soundheard over the left lower lobe. Chest X-ray showed infiltratesin the left lower lobe.


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Key clinical questions

1. What are the most likely diagnosis in this patient?

2. What are the most likely causative organisms inthis patient?

3. What further diagnostic tests are recommendedfor diagnosis?

4. What are the risk factors for pneumonia

5. Can this patient be treated as an outpatient orshould he be admitted?

6. What antibiotic agent would be recommended forthis patient?


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What are the most likely diagnosis in this patient?


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Differential diagnostic

Pneumonia

Tuberculosis

Acute bronchitis

Acute exacerbation of chronic bronchitis

Upper respiratory infection

Sinusitis

CHF Asthma

Lung cancer


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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.


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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 andPleuropneumonia


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Clinical manifestations

Sudden onset of fever, chills

Cough

Sputum production Pleuritic chest pain

Dyspnea; Tachypnea

Tachycardia Extra pulmonary symptoms (nausea, vomiting,

malaise, headache, myalgia)


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Physical examinations

Sign of pulmonary consolidation

o Restricted movement of the afflicated hemithoraxo Increased fremitus

o Dullness

o Bronchial breath soundso Rales


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Clinical manifestations of pneumonia

Features Typical Atypical

Onset

Age

Appearance

Fever

Rigor

Cough

Sputum

Extra pulmonal

Pleuritic chest pain

Lung consolidation

Gram stain

WBC, difrential

Chest x-ray

Sudden

Younger

Toxic

High

Common

Productive

Purulent

Uncommon

Common

Common

Abundant bacteria

Elevated; left shit

Consolidation

Gradual

Older

Malaise, fatique

Low grade

Uncommon

Nonproductive

Mucoid

Common

Uncommon

Uncommon

Rare bacteria

Normal

Patchy, infiltrate


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Patient

- Acute (2 days)- Dyspnea, High fever, Chills

- Productive cough, purulentsputum

- T: 39.8C- Pulse: 130 x/minute

- RR: 48x/per minute

- Percussion: dull

- Auscultation: bronchial breathsound over the left lower lobe

- CXR: infiltrates in the left lowerlobe.

- Sudden onset of fever- Shortness of breath

- Productive cough, purulentsputum

- Pleuritic chest pain- Tachypnea

- Restricted movement of theafflicated hemithorax

- Increased fremitus- Dullness

- Bronchial breath sounds; Rales

- CXR: infiltrates (lobar, multilobar,segmental) or pleural effusions

Pneumonia


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What are the most likely causativeorganisms in this patient?


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Microbial causes of pneumonia

CAP Nosocomial

Pneumonia

Atypical

Pneumonia

S.pneumoniaeH.influenzae

Moraxella catarrhalis

S.aureus

Gram negative bacilli

Virus

Gram negative bacilliS.aureus

Pseudomonas aerugi-

nosa

M.pneumoniaeC.pneumoniae

Legionella pneumophila

Woodhead M.Medicine International 1995; 31 (9)


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CAP : Most Common Pathogens

Mild (AmbulatoryPatients)

Moderate (hospitalized,non ICU)*

Severe (ICU)*

S. Pneumoniae

M. Pneumoniae

H. Influenzae

C. Pneumoniae

VirusesMixed flora

(aspiration)

S. Pneumoniae

M. Pneumoniae

C. Pneumoniae

H. influenzae

Legionella sppMixed 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


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Bacterial Pathogens in CAP

33,3%

20,8%

16,7%

12,5%

12,5%

12,5%

4,2%

No pathogen discover

Klebsiel la

S. aureus

S. pneumoni ae

Acinobacter

Pseudomonas

S.pyogenes

Persahabatan Hosp. 2000


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What further diagnostic tests arerecommended for diagnosis?


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Diagnostic

CXR

Sputum examination

Blood count

Blood cultures

Serologic studies

Thoracentesis

Invasive diagnostic procedures Transtracheal aspiration Bronchoscopy or BAL

Direct needle aspiration


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CXR

CXR is the most important diagnostic tool

New or progressive pulmonary infiltrates

Lobus consolidation Segmental consolidation Patchy infiltrate

Pulmonary cavitations

Lymphadenopathy

Pleuraleffusions


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Lobarpneumonia


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Location of pneumonia


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Sputum examination

The key factor to identification of the etiology

Macroscopic; Gram stain and Sputum culture

Lowersensitivity

3050% pathogen could not identifiable

Frequently contaminated by MO in the URI


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What are the risk factors for pneumonia


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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


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Can this patient be treated as anoutpatient or should he be admitted?


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


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Risk class for patients with CAP


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Does the patient have a history of any of thefollowing comorbid conditions ?

Neoplastic disease

Congestive heart failureCerebrovascular diseaseRenal diseaseLiver disease

Patients with Community Acquired pneumonia

Is the patients over 50 years of age ?

Does the patient have any of the following onphysician

examination ?Altered mental statisPulse 125/minuteRespiratory rate 30/minuteSistolic blood presure < 90 mmHgTemperature < 35C or 40 C

Assign patient to risk class I

Assign patient to risk class II-V

based on prediction modelscoring system

Yes

Yes

Yes

No

No

No

Algorithm pneumonia


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What antibiotic agent would berecommended for this patient?


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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


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Antibiotics in pneumonia

Macrolide

Tetracycline

Cotrimoxazole Co-Amoxyclav Sultamicillin - lactam (include cephalosporin)

Fluoroquinolone Aminoglycoside Antipseudomonas


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CAP Management Issues

Causative pathogen frequently not found

Typical and atypical found together

Therapy must be started early (


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Outpatient treatment (IDSA/ATS 2007)

Previously healthy and no use of antimicrobials within the previous 3months

A macrolideDoxycyline

Have a comorbid (chronic heart, lung, liver /renal disease; DM;alcoholism; malignancies; asplenia; immunosuppressing conditions ;use of immunosuppressing drugs; use of antimicrobials within theprevious 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 ofalternative agents listed above in (2) for patients withoutcomorbidities


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Inpatients, non-ICU treatment

A respiratory fluoroquinolone (strong

recommendation; level I evidence)

A b-lactam plus a macrolide (strong

recommendation; level I evidence)


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Inpatients, ICU treatment

A b-lactam (cefotaxime, ceftriaxone, or ampicillin-

sulbactam)

plus

either azithromycin (level II evidence) ora respiratory

fluoroquinolone (level I evidence) (strong

recommendation)

(for penicillin-allergic patients, a respiratory

fluoroquinolone and aztreonam are recommended)


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Incorrect diagnosis

Host issues Pathogen issues

Failure of empirical treatment

Correct diagnosis

Drug issues

BacterialNonbacterialError in drug selectionError in dose/routeComplianceAdverse drug reaction

Local factorInadequate host responseComplication


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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 extrapulmonarycomplications (eg: meningitis, endocarditis)


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Mortality in patients with CAP

Study Focus Patients Mortality (%)

Hospitalized and ambulatoryHospitalized only

Elderly

Bacteriemic

Nursing homeIntensive Care Unit

5.113.6

17.6

19.6

30.836.5

Fine et al. JAMA 1995;274: 134-141


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Complications

Acute respiratory distress syndrome

Lung abscess

Renal failure Septic shock

Pleural effusions/Empyema

Bacteriemia (Septic arthritis; Endocarditis;

Meningitis; Peritonitis; Endopthalmitis.

Acute Pulmonary Infections 1

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