1. A 41 year old man known case of DM presents with 2 day history of productive cough, fever and associted with pleuritic chest pain. His cough is productive of thick yellowish color. Vitals show temperature 39.4, BP 118/68, Heart rate 98, Respiratory rate 24 & O2 Sat. 86% on room air

2. A 41 year old man known case of DM presents with 2 day history of productive cough, fever and associted with pleuritic chest pain. His cough is productive of thick yellowish color. Vitals show temperature 39.4, BP 118/68, Heart rate 98, Respiratory rate 24 & O2 Sat. 86% on room air

3. Case On Examination Respiratory exam shows bronchial breathing in left middle zone with egophony & decrease breath sound in left lower lung base C.V, Abdominal & GU exam are normal

4. What is the next step? Oxygen Chest X ray CBC, chemistry, electrolyte, blood culture, sputum culture and gram stain, urine antigen test, ABG

5. What are the radiological finding?

6. left lower lobe opacity with pleural effusion.

7. What is the next step Admission ?? Aspiration of pleural effusion ?? Monitor & Control of sugar, electrolyte, acid base disturbance and vitals Start empirical antibiotic and symptomatic ttt

8. CBC show WBC count of 18,400 with shift to left

10. A 52 year old man is admitted with one week history of dry cough, fever and headache. He appeared obtunded, tachypneic and was hypotensive. Two of his workmates have been admitted in hospital with pneumonia in last month.

11. What the history suggest? semi-conscious, hypotensive and tachypneic Two of his workmates have been admitted Chest X-ray & ABG have been requested & done

12. What are the radiological finding?

13. Chest radiograph shows dense consolidation in both lower lobes.

14. What is the most likely diagnosis? On admission ABG show a PaO 2 of 53 mmHg, PaCO 2 of 46 mmHg pH 7.32, HCO 3, oxygen sat. 86 on room air

15. What is the next step? ABC : Oxygen mask, IV fluid Admission start empirical antibiotic treatment Send CBC, Chemistry and electrolytes Sputum for gram stain and culture, urine antigen test & blood culture

17. Diagnostic approach to community-acquired pneumonia in adults

18. General consideration More cases occurring during the winter months. Mechanism : microaspiration more than 100 microbes (bacteria, viruses, fungi, and parasites) Most common cause of pneumonia is strept. pneumoni Never forget Mycobacterium tuberculosis

19. Risk Factors Alcoholism, malnutrition, chronic pulmonary disease of any kind, cigarette smoking, infection with HIV, diabetes mellitus, cirrhosis of the liver, anemia, prior hospitalization for any reason, renal insufficiency, and coronary artery disease (with or without recognized congestive heart failure), prior viral infection

20. Types of CAP Typical (40-60%) Strep. Pneumonia H. influenza Maroxella Atypical (10-30%) Legionella Mycoplasma Chlamydia

21. Natural history of atypical pneumonia M. pneumoniae or C. pneumoniae infection is often self- limited but can cause severe CAP Mycoplasma pneumonia Is the most common atypical pathogens responsible for CAP in adults Legionella pneumonia Hyponatremia (Na 125-130 mmol/L) is more common than with other forms of pneumonia. Delayed treatment significantly increases the associated mortality rate

22. Clinical Evaluation

26. Investigation 1. Chest X-ray Clinical features and radiographic changes are usually enough to start treatment. False negative chest radiographs may occure if it taken very early (<24 hr’s), dehydrated or in immunocompromised patient.

27. Investigation 1. Chest X-ray Clinical features and radiographic changes are usually enough to start treatment. False negative chest radiographs may occure if it taken very early (<24 hr’s), dehydrated or in immunocompromised patient.

28. Investigation Why? False negative chest radiographs may occure if it taken very early (<24 hr’s), dehydrated or in immunocompromised patient.

29. Chlamydia pneumonia. Chest radiograph shows multifocal, patchy consolidation in the right upper, middle, and lower lobes.

30. Mycoplasma pneumonia. Chest radiograph shows a vague, ill-defined opacity in the left lower lobe

32. Investigation 1. X-ray 2. CBC, chemistry, electrolytes, Sputum for gram stain and culture, Blood culture, and pulse oxymetry or ABG !! Why? positive for a pathogen in 7 to 16 percent of hospitalized patients 3. Specific tests Legionella, C. pneumonia and Mycoplasma Bronchoscopy and bronchoalveolar lavage

33. Investigation 1. X-ray 2. CBC, chemistry, electrolytes, Sputum for gram stain and culture, Blood culture, and pulse oxymetry or ABG !! Why? positive for a pathogen in 7 to 16 percent of hospitalized patients 3. Specific tests Legionella, C. pneumonia and Mycoplasma Bronchoscopy and bronchoalveolar lavage

34. Urin Antigen Test

35. How to Make the Decision to Admit

36. the decision to admit assessment of patient prognosis and selection of an appropriate site of care. The 2007 consensus guidelines from IDSA and the ATS recommend either the CURB-65 or Pneumonia Severity Index (PSI)

37. CURB-65 uses five prognostic variables Confusion (based upon a specific mental test or disorientation to person, place, or time)

38. Urea (blood urea nitrogen in the United States) >7 mmol/L (20 mg/dL) CURB-65 uses five prognostic variables

39. Confusion (based upon a specific mental test or disorientation to person, place, or time) Urea (blood urea nitrogen in the United States) >7 mmol/L (20 mg/dL) Respiratory rate >30 breaths/minute CURB-65 uses five prognostic variables

40. Confusion (based upon a specific mental test or disorientation to person, place, or time) Urea (blood urea nitrogen in the United States) >7 mmol/L (20 mg/dL) Respiratory rate >30 breaths/minute Blood pressure [BP] (systolic <90 mmHg or diastolic <60 mmHg) CURB-65 uses five prognostic variables

41. Confusion (based upon a specific mental test or disorientation to person, place, or time) Urea (blood urea nitrogen in the United States) >7 mmol/L (20 mg/dL) Respiratory rate >30 breaths/minute Blood pressure [BP] (systolic <90 mmHg or diastolic <60 mmHg) Age >65 years CURB-65 uses five prognostic variables

42. Other requirement for hospital admission pneumonia complications (e.g. hypoxia persist & respiratory Acidosis ) exacerbation of underlying disease inability to take oral medication issues affecting outpatient care like living situation Comorbid illness (e.g. HF, DM, RF, neurological dysfunction, Malnourished and postsplenectomy state…)

43. Pneumonia severity index This scoring system evaluates 20 different clinical and laboratory indices Coexisting Illnesses Neoplastic disease Liver disease Congestive heart failure Cerebrovascular disease Renal disease Physical Examination Altered mental status Respiratory rate >30 breaths per min Systolic blood pressure <90 mm Hg Temperature 40°C (104°F) Pulse rate >125 breaths per min Age Nursing home resident Laboratory Arterial pH <7.35 Blood urea nitrogen >30 mg/dL (11 mmol/L) Sodium <130 mmol/L Glucose >250 mg/dL (14 mmol/L) Hematocrit <30% PaO 2 <60 mm Hg Pleural effusion

44. Risk class I - Older than 50 years, no preexisting illness or vital sign abnormality Risk class II - < 70 points Risk class III - 71-90 points Risk class IV - 91-130 points Risk class V - > 131 points

45. Risk class I - Older than 50 years, no preexisting illness or vital sign abnormality Risk class II - < 70 points Risk class III - 71-90 points Risk class IV - 91-130 points Risk class V - > 131 points

46. Risk class I - Older than 50 years, no preexisting illness or vital sign abnormality Risk class II - < 70 points Risk class III - 71-90 points Risk class IV - 91-130 points Risk class V - > 131 points

47. Management Close monitoring of vital signs, O 2 saturation and ABG result If level of conscious deteriorate look for evidence of sepsis or organ dysfunction. suctioning of secretions & chest physiotherapy proper hydration, nutrition & early mobilization Treatment of underlying disese

50. Antibiotic Treatment Antibiotic should be reevaluated based on lab. result and clinical response

51. Antibiotic Treatment for MRSA Vancomycin or linezolid(be aware of possibility of false positive)linezolid for Pseudomonas piperacillin/tazobactam, imipenem, meropenem, or cefepime meropenemcefepime

52. Antibiotic Treatment

53. Follow up Antibiotic therapy should not be stopped until the patient is afebrile for 48 to 72 hours and is clinically stable.

54. Follow up Clinical improvement should be observed in 48-72 hours. cough resolves within 8 to 14 days and crackles heard on auscultation clear within 3 weeks. The chest radiograph usually clears within 4 to 12 weeks according to individual health state and underlying lung disease

55. Follow up When patient can be switched to oral therapy?

56. Follow up If discharged to continue treatment as out patient: Patients should be instructed to return if their condition deteriorates. Patients should be told that some symptoms can last up to 30 days (e.g. fatigue, cough with or without sputum production, dyspnea & chest pain). follow-up chest radiograph in approximately 6 weeks to ensure resolution of consolidation to exclude endobronchial obstruction.

57. Follow up If no improvement within 72 hours?? Wrong drug Wrong dose Wrong Diagnosis

58. Follow up If no improvement within 72 hours?? 1. Organism that is not covered by the initial empiric antibiotic regimen 2. Secondary to drug resistance 3. Nonbacterial infection or unusual pathogens (e.g. PCP, TB) 4. Drug fever 5. Complication such as empyema or abscess. 6. Other differential diagnosis (e.g. malignancies, inflammatory conditions, PE, HF…)

59. Follow up If no improvement within 72 hours?? 1. Organism that is not covered by the initial empiric antibiotic regimen 2. Secondary to drug resistance 3. Nonbacterial infection or unusual pathogens (e.g. PCP, TB) 4. Drug fever 5. Complication such as empyema or abscess. 6. Other differential diagnosis (e.g. malignancies, inflammatory conditions, PE, HF…)

60. Re-evaluate nonresponse is seen in about in 6 to 15% of whom require hospitalization If Patients show no clinical improvement within 72 hours are considered nonresponders

61. Re-evaluate careful history, physical examination, and review of the medical record. careful observation with or without therapy is warranted for 4 to 8 weeks if no improving or progression of disease chest CT & fiberoptic bronchoscopy ( diagnose 90% of cases) should be considered If negative, further evaluation with thoracoscopic or open lung biopsy may be necessary.

62. Immunocompromised Early imaging (CT scan) is critical, bronchoscopy & biopsy can be concedered Empiric therapy should started early

63. Immunocompromised In severely ill patients with Legionella pneumonia rifampin may be recommended for use in combination with macrolides. The duration of therapy can be extended to 21 day.

64. General Consideration Patients without spleen may die of pneumococcal pneumonia and sepsis pulmonary consolidation is found only at autopsy (not x- ray) defective clearance of pneumococci from the bloodstream, death may occur in as little as 24 h Pattern of infection could be Community- acquired, Nosocomial or Reactivation

65. Clinical Evaluation In elderly & immunocompromised may have minimal cough, no sputum production, and no fever & minimal signs on physical exam 1. respiratory rate above 24 breaths/minute (45 to 70 percent of patients) 2. Tachycardia 3. Tiredness & confusion.

66. Common organism 1. Aspiration? Anaerobe 2. Alcoholic and drug abuser ? Increase incidence of Klebsiella 3. COPD ? Increase incidence of H. influenza & Pseudomonus. 4. Immunocompromised? Staph., Viral, PCP…

67. A 52-year-old woman developed fever, cough, and dyspnea. She also developed a rash that was prominent over the face and the trunk. The chest radiograph showed interstitial infiltrates, with suggestion of a micronodular process. The Tzanck smear results from the skin vesicle suggest