Andriy Lepyavko, MD, PhD Department of Internal Medicine № 2

1. Definition 2. Classification 3. Diagnostic criteria 4. CAP – clinical signs, treatment 5. Nasocomial pneumonia 6. Aspiration pneumonia 7. Pneumonia in the immunocompromised host

 “The most wide spread and fatal of all acute diseases, pneumonia, is now Captain of the Men of Death” Sir William Osler The Principles and Practice of Medicine, 1901

 Sixth most common cause of death  The most common cause of infection-related mortality  Incidence /  Costs of treatment exceed $12 billion  Inpatient treatment costs 25 times more than outpatient treatment

 Pneumonia – this is an inflammation in the lung parenchyma caused by bacteria, viruses or fungi which is characterized by intraalveolar exudation

I. Etiology (if it is known) II. Variants:  Community-acquired pneumonia  Nosocomial pneumonia – when patient was hospitalized with any another diagnosis, and after 48 hours in the hospital (not earlier!) pneumonia was diagnosed, or pneumonia after artificial lung ventilation  Pneumonia due to aspiration. It results from the aspiration of gastric contents in addition to aspiration of upper respiratory flora in secretions.  Pneumonia in immunocompromised host – patients with AIDS or immunodeficit of other origin. Causes of pneumonia – viruses, fungi of saprofites (E.coli etc.)

III. Localization (side, lobe, segment) IV. Stages of severity:  Mild stage –conciousness is clear, t less than 38, heart rate less than 90, BP normal, dyspnea mild in case of physical activity, CXR – small infiltration  Moderate – conciousness is clear, sweating, general weakness, t 38-39, heart rate , moderate dccreased BP, dyspnea, large size of infiltration  Severe – t 39-40, conciousness is not clear, heart rate more than 100, low BP, severe dyspnea, cyanosis, large size of infiltration and presence of complications V. Complications.

 I – patients in the age 2-65 without concomitant diseases, are outpatients  II – patients 60, with concomitant diseases, are outpatients, but near 25 % of them treatment will not be effective, and they will need hospitalization  II – patients 60, with concomitant diseases, are inpatient  II – patients 60, with concomitant diseases, have to be treated in the Emergency department

 I – patients without risk factors, with mild or moderate severity pneumonia which was diagnosed at any day of hospitalization or severe early pneumonia (at first 5 days of hospitalization)  II – patients with risk factors + I  III – patients with risk factors and severe pneumonia or late pneumonia

 Route of entry - Inhalation - Aspiration - Bloodborne  Host/ organism dynamics tipped by - Defect in host defences - Virulent organism - Overwhelming inoculum

 Nasal hair  Dynamics of airflow  Cough  Mucous  Mucociliary apparatus  Bacterial interference  Immunoglobulin  Surfactant  Fibronectin  Complement  Cytokines  Alveolar macrophages  Polymorphonuclear leucocytes  Cell-mediated immunity

 Predisposition – CHF, diabetes, alcoholism, COPD  Classic symptoms – cough, fever, sputum production, dyspnea  Clinical syndrome – fever, pleuritic chest pain, productive cough with mucopurulent sputum  Focal pulmonary findings (rales, crapitation or signs of consolidation) – less sensitive than CXR  General blood analysis – increased ESR, leucocytosis, shift to the left  Sputum analysis – causative microorganism and its sencitivity to antibiotics may be found

 CXR with infiltrates – diagnosis “pneumonia” is invalid without it

Most common pathogens:  Streptococcus pneumoniae (9% to 75%; mean, 33%),  Haemophilus influenzae (0 to 50%; mean, 10%),  Legionella species (0 to 50%; mean, 7%),  Chlamydia pneumoniae (0 to 20%; mean, 5%).  Mycoplasma pneumoniae

 Macrolide Claritromycin (Clacid) 0,5 g 2-3 t/day, Azitromycin (Sumamed) 0,5 g 1t/d Roxitromycin (Rulid) 0, 15 g 2t/d Midekamycin (Macropen) 0,4 g 3 t/d  Amoxicillin + clavulonic acid 0, 625 g t/d “+” – there is i/v form as well  Doxycyclin 0,1 g 2 t/d

 Cephalosporin Cefuroxim 0,75-1,7 g i/m 3 times per day Cefatoxini 1-2 g i/m, i/v 2 t/d Ceftazidini 1 g i/m, i/v 2-3 t/d  Respiratory fluoroquinolone Cyprofloxacini (Cyprobai) 0,2 g 2 t/d or 0,5 g 2 t/d i/v

 I – Macrolide, doxacyclin (?)  II – Cefalosporine, Amoxiclav, Macrolide  III - Cefalosporine, Amoxiclav, Macrolide  IV - Cefalosporine, Amoxiclav, Macrolide, Fluoroquinolone

 At least 5 days  Until afebrile for hours  Stable vital signs  Longer course needed if Initial antibiotic choice did not cover the pathogen Extrapulmonary infection (meningitis) Lung abscess, cavitation or empyema Gram negative pathogen or S.aureus

 Staphylococcus aureus  Gram-negative microorganisms - Pseudomonas, Klebsiella, Proteus, enterobacteria, E.coli  Fungi - Candida, Aspergillus, Rizopus.

 Clindamicini i/m, i/v every 6 hours, total - 1 g/day  Aztreonam (Azactam) – i/v, i/m every 8 hours, average – 3-6 g/day  Vancomycini – i/v every 8-12 hrs, average – 30 mg/kg/d, max – 3 g/d  Rifampicini – orally 0,15 g 2 t/d, i/m 1,5-3 g every 8-12 hrs Useful combinations:  Clindamycini+Aztreonam  Clindamycin+Vancomycin  B-lactam+Vancomycin  Floroquinolon+Rifampicin

Most effective are:  Aminoglycozyde (tobramycin, sizomycin)+ Metronidazol  Cephalosporini III-IV generation+Metronidazol

 Cephalosporine III-IV generation  Aminoglycozyde (tobramycin, sizomycin)

 Annual Influenza immunization

Thanks for your attention!