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Muhammad Ilyas
Pulmonology Division Dept.Of Internal Medicine
Faculty Of Medicine Hasanuddin University
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Definition:◦ … an acute infection of the pulmonary
parenchyma that is associated with at leastsome symptoms of acute infection,
accompanied by the presence of an acuteinfiltrate on a chest radiograph, orauscultatory findings consistent withpneumonia, in a patient not hospitalized or
residing in a long term care facility for > 14days before onset of symptoms
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CAP is a common illness, with increasedmortality in certain population, particularlythe elderly and those with severe illness
The association between advance age andmortality is well known
Sir William Oslers infamous view was that
pneumonia was the “friend of the aged” thatoften allowed patients with advanced illnessto die peacefully
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It is more difficult to diagnose pneumonia inthe elderly than in young patient because theusual clinical clues for its diagnosis might beabsent at the time of onset of the illness
Cardinal signs and symptoms, such ascough, fever and dyspnea, may be not
present in same older patient withpneumonia
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Metlay et al : studied 1812 pneumonia
patient and observed that both repiratory andnonrespiratory symptoms were lesscommonly reported by older patient than byyounger patient
Other ways in which advanced age couldinderectly increas CAP mortality include ahigh frequency of comorbid illness as well as
a predisposition to more virulent pathogensand pathogenic mechanisms
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Pneumonia can also lead to worsening f
chronic medical illness, such as COPD andCHF
The Coexistence of neurological and GIdesease in the elderly may account for their
increased risk of aspiration as a commonmechanisms of infection
Immune dysfunction is common in the
elderly, either as a consequence ofcomorbid illness or directly due to ageingself
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◦ Age◦ Alcoholism◦ Smoking◦
Asthma◦ Immunosuppression◦ Institutionalization◦ COPD◦ PVD◦ Dementia
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◦ Men: age and smoking, weight gain RR 1.5 for age 50-54, 4.17 for > 70
Smoking, current: RR 1.5; heavy: 2.54; Quit<10 yrs: 1.5
Weight gain >40 kg since age 21
◦ Women: smoking, BMI, weight gain
BMI 25-26.9, RR 1.53: BMI >30, RR 2.22
Exercise protective: RR 0.66 for most active◦ Alcohol consumption NOT associated with
increased risk in men or women
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◦ older, unemployed, unmarried
◦ common cold in the previous year
◦ asthma, COPD; steroid orbronchodilator use
◦ Chronic disease
◦ Amount of smoking◦ Alcohol NOT related to increased risk
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◦Age◦Bacteremia (for S. pneumoniae)
◦Extent of radiographic changes
◦Degree of immunosuppression
◦Amount of alcohol
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Streptococcus pneumoniae
Haemophilus influenzae
Bordetella pertussis Chlamydia pneumoniae
Legionella pneumophila
Mycoplasma pneumoniae
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◦
S. pneumoniae: 20-60%◦ H. influenzae: 3-10%
◦ Ch. pneumoniae: 4-6%
◦ Myc.pneumonaie: 1-6%
◦ Legionella spp. 2-8%◦ S. aureus: 3-5%
◦ Gram negative bacilli: 3-5%
◦ Viruses: 2-13%
40-60% - NO CAUSE IDENTIFIED
2-5% - TWO OR MORE CAUSES
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Present in nasopharynx ofasymtomatic individuals
High incidence of colonization ininfants under 2 years of age
Low incidence in young people
High incidence in people in their 70s
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Pneumonia develops over several days
Cough, sputum , dyspnoea, chest pain andmyalgia
In healthy young adults: Hyperacutepresentation with a dramatic rigor
Older people, an insidious presentation,
with only confusion and hypothermia Examination: Consolidation, x-ray reveals
infiltration
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Evaluation for CAPHistory, PE, CXR
No infiltrate
manage/evaluate for alternate diagnosisInfiltrate + clinical evidence of pneumonia
evaluate for admission
outpatient:
empiric treatment with macrolide, doxycycline, FQ
hospitalize
labs
medical ward:abx < 8 hrs ICU: abx < 8 hrs
no pathogen identified
B-lactam + macrolide
FQ
no pathogen identified
B-lactam + macrolide
B-lactam + FQ
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Laboratory Tests: CXR
CBC with differential
BUN/Cr
glucose liver enzymes
electrolytes
Gram stain/culture of sputum
pre-treatment blood cultures oxygen saturation
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CXR◦ usually needed to establish diagnosis
◦ prognostic indicator
◦ rule out other disorders
◦ may help in etiological diagnosis
Only 3% of outpatients and 28% of ER patients withsuggestive signs and symptoms actually have
pneumonia
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RR > 30 PaO2/FiO2 < 250, or PO2 < 60 on room air
Need for mechanical ventilation
Mulitlobar involvement
Hypotension
Need for vasopressors
Oliguria
Altered mental status
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Rational use of microbiologylaboratory
Pathogen directed antimicrobial
therapy whenever possible Prompt initiation of therapy
Decision to hospitalize based on
prognostic criteria
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Outpatient:◦ macrolide
◦ doxycycline
◦
Fluoroquinolone
NOT IN ANY SPECIFIC ORDER
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Patients in ICU:3GC + macrolide3GC + FQ
B/B-I + macrolideB/B-I + FQ
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◦ Second generation generationcephalosporin plus a macrolide, non-pseudomonal third generation
cephalosporin plus a macrolide, or afluoroquinolone alone were all associatedwith a lower 30 day mortality in patientswith CAP.