1. This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of Department of Medicine and Nephrology Consultant. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. Pneumonia Presented By: Abdulmajeed Alzkeri Medical Student

3. Background Diagnosis Treatment Complications Cases

4. Background There are two types of pneumonia: 1.Community-acquired pneumonia; A.Typical B.Atypical 2. Nosocomial pneumonia

5. Typical CAP; Common agent: -S. Pnuemonia ( 60% ) -H. Influenza ( 15% ) -Aerobic gram-negative rods ( 6% to 10% )_ Klebsiella -S. Aureus (2% to 10% )

6. Clinical features A. Symptoms: -Acute onset of fever and shaking chills -Cough productive of thick, purulent sputum -Pleuritic chest pain ( suggests pleural effusion ) -Dyspnoea B. Signs: -Tachycardia, Tachpnea -Late inspiratory crackles, bronchial breath sounds, increase tactile and vocal fremitus, dullness on percusion

7. Atypical CAP; Common agents: -Mycoplasma pneumonia ( most common ) -Chlamydia pneumonia -Chlamydia psittaci -Coxeilla burnetti -Legionella spp. -Virsues; infuenza virus ( A and B ), adenoviruses, parainfluenza virus, RSV

8. Clinical features A. Symptoms; -Insidious onset_ headache, sore throat, fatigue, myalgias -Dry cough -Fevers ( chills are uncommon ) B. Signs; -Pulse-temperature dissociation -Wheezing, rhonchi, crackles

9. Diagnosis PA and lateral CXR Sputum for gram stain: -Commonly contaminated with oral secration. -A good speciment has a sensitivity of 60% and specificity of 85% for identifying gram positive cocci in chains ( S. Pneumonia ) Sputum culture: Specificity is improved if the predominant organism growing on the culture media correlate with the Gram stain

10. Special stains of sputum in selcted cases a.Acid fast stain ( Mycobacterium spp. ) if TM is suspected b.Silver stain ( fungi, pneumocystis carinii ) for HIV/immunocompromised patients Urinary antigen assay for Legionella in selected patients Two pretreatment blood cultures from different sites

11. Treatment The decision to hospitalize or treat as an outpatient is probably the important decision to be made Patients stratified into three classes based on severity by using CURP-65

12. CURP-65 Any of: Confusion Urea > 7mmol/l Respiratory rate 30/min Blood pressure ( systolic < 90 mmHg or diastolic < 60 mmHg ) Age 65 years 0 or 1 2 3 or more Likely to be suitable for home treatment Consider hospital supervised treatment : -Short stay inpatient -- Hospital supervised outpatients Manage in hospital as sever pneumonia Assess for ICU admission, especially if CURB-65 score = 4 or 5

13. Antimicrobial therapy Outpatient Treatment Macrolide OR Doxycycline OR Fluoroquinolone antibiotic Alternative: — amoxicillin and clavulanate potassium combination — cefuroxime axetil — cefpodoxime — cefprozil

14. Hospitalized Patients on General Medical Floor B-Lactam plus a macrolide OR Fluoroquinolone antibiotic alone Hospitalized Patients in Intensive Care Unit B-Lactam plus a macrolide OR B-Lactam plus a fluoroquinolone antibiotic (Substitute clindamycin for B-lactam in penicillinhypersensitivepatients.)

15. Complications Pleural effusion ( parapneumonic effusion ) -In more than 50% in patients with CAP -Resolve with treatment of the pneumonia with antibiotics -Thoraocentesis should be performed if the effusion is significant ( >1 cm on lateral decubitus film ). Send fluid for Gram stain, culture, PH, cell count, determination of glucose, protein and LDH levels.

16. Pleural empyema: -In 1 to 2%of all cases of CAP ( up to 7% of hospitalized patients with CAP ) Acute respiratory failure

17. Case 1 27 years old Saudi gentleman came from Omerah last week presented to ER complaining of headache, malaise, low grade fever and dry cough with vomiting later on. CXR showed Rt. Upper lobe infiltrate. Blood test showed picture of haemolytic anaemia with raised Abs.

18. Diagnosis Mycoplasema pneumonia Treatment Erythromycin 500 mg four times daily for 7-10 days

19. Case 2 40 year old gentleman who have malaise, myalgia, headache, fever up to 40 and rigors. Also, the patient thachypenic with an initially dry cough and became productive and purulent. The CXR showed lobar infiltration. U & E showed hyponatraemia. Urinary antigen positive.

20. Diagnosis: Legionella pneumophila Treatment: Clarithromycin

21. Case 3 An 85 tear old nursing home resident has dementia such that she requires assistance in all activates of daily life. She has a 3-day history of fever and productive cough. Chest X- ray reveals a right middle lobe consolidation. What is the most likely mechanism of infection? Aspiration oral bacterial mucosa

22. References Clinical Medicine by Clark and Kumar Case files American Thoracic Society

23. Thank you