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

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

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

What is the next step?OxygenChest X rayCBC, chemistry, electrolyte, blood culture, sputum culture and gram stain, urine antigen test, ABG

What are the radiological finding?

left lower lobe opacity with pleural effusion.

What is the next stepAdmission ??Aspiration of pleural effusion ??

Monitor & Control of sugar, electrolyte, acid base disturbance and vitals

Start empirical antibiotic and symptomatic ttt

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

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.

What the history suggest?semi-conscious, hypotensive and tachypneicTwo of his workmates have been admitted

Chest X-ray & ABG have been requested & done

What are the radiological finding?

Chest radiograph shows dense consolidation in both lower lobes.

What is the most likely diagnosis?

On admission ABG show a PaO2 of 53 mmHg, PaCO2 of 46

mmHg pH 7.32 , HCO3 , oxygen sat. 86 on

room air

What is the next step?ABC : Oxygen mask , IV fluidAdmissionstart empirical antibiotic treatmentSend CBC, Chemistry and electrolytes

Sputum for gram stain and culture, urine antigen test & blood culture

Diagnostic approach to Diagnostic approach to community-acquired community-acquired pneumonia in adultspneumonia in adults

General considerationMore cases occurring during the winter

months.Mechanism : microaspiration more than 100 microbes (bacteria,

viruses, fungi, and parasites)Most common cause of pneumonia is

strept. pneumoniNever forget Mycobacterium tuberculosis

Risk FactorsAlcoholism, 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

Types of CAPTypical (40-60%)

Strep. PneumoniaH. influenzaMaroxella

Atypical (10-30%)LegionellaMycoplasmaChlamydia

Natural history of atypical pneumoniaM. pneumoniae or C. pneumoniae infection is

often self-limited but can cause severe CAPMycoplasma pneumonia Is the most common atypical pathogens

responsible for CAP in adultsLegionella pneumoniaHyponatremia (Na 125-130 mmol/L) is more

common than with other forms of pneumonia.Delayed treatment significantly increases the

associated mortality rate

Clinical Evaluation

Clinical Evaluation

Clinical Evaluation

Clinical Evaluation

Investigation1. 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.

Investigation1. 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.

InvestigationWhy?

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

Chlamydia pneumonia. Chest radiograph shows Chlamydia pneumonia. Chest radiograph shows multifocal, patchy consolidation in the right upper, multifocal, patchy consolidation in the right upper,

middle, and lower lobesmiddle, and lower lobes..

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

Investigation1. X-ray2. 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

Investigation1. X-ray2. 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

Urin Antigen Test

How to Make the Decision to Admit

the decision to admitassessment 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)

CURB-65 uses five prognostic variables

Confusion (based upon a specific mental test or disorientation to person, place, or time)

Confusion (based upon a specific mental test or disorientation to person, place, or time)

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)

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)

CURB-65 uses five prognostic variables

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

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

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)

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

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

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

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…)

Pneumonia severity indexThis scoring system evaluates 20 different

clinical and laboratory indices

Coexisting IllnessesNeoplastic diseaseLiver diseaseCongestive heart failureCerebrovascular diseaseRenal diseasePhysical ExaminationAltered mental statusRespiratory rate >30 breaths per minSystolic blood pressure <90 mm HgTemperature <35°C (95°F) or >40°C (104°F)Pulse rate >125 breaths per min

AgeNursing home residentLaboratoryArterial pH <7.35Blood urea nitrogen >30 mg/dL (11

mmol/L)Sodium <130 mmol/LGlucose >250 mg/dL (14 mmol/L)Hematocrit <30%PaO2 <60 mm Hg

Pleural effusion

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

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

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

ManagementClose monitoring of vital signs, O2 saturation and

ABG resultIf level of conscious deteriorate look for evidence

of sepsis or organ dysfunction.suctioning of secretions & chest physiotherapyproper hydration, nutrition & early mobilizationTreatment of underlying disese

Antibiotic Treatment

Antibiotic should be Antibiotic should be

reevaluated based on lab. reevaluated based on lab.

result and clinical responseresult and clinical response

Antibiotic Treatmentfor MRSA

Vancomycin or linezolid(be aware of possibility of false positive)

for Pseudomonas piperacillin/tazobactam, imipenem, meropenem, or cefepime

Antibiotic Treatment

Follow up

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

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

Follow upWhen patient can be switched to oral therapy?

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 .

Follow upIf no improvement within 72 hours??

Wrong drugWrong doseWrong Diagnosis

Follow upIf no improvement within 72 hours??

1.Organism that is not covered by the initial empiric antibiotic regimen

2.Secondary to drug resistance3.Nonbacterial infection or unusual pathogens

(e.g. PCP , TB)4.Drug fever5.Complication such as empyema or abscess.6.Other differential diagnosis (e.g.

malignancies, inflammatory conditions, PE, HF…)

Follow upIf no improvement within 72 hours??

1.Organism that is not covered by the initial empiric antibiotic regimen

2.Secondary to drug resistance3.Nonbacterial infection or unusual pathogens

(e.g. PCP , TB)4.Drug fever5.Complication such as empyema or abscess.6.Other differential diagnosis (e.g.

malignancies, inflammatory conditions, PE, HF…)

Re-evaluatenonresponse is seen in about in 6 to

15% of whom require hospitalizationIf Patients show no clinical

improvement within 72 hours are considered nonresponders

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.

ImmunocompromisedEarly imaging (CT scan) is critical,

bronchoscopy & biopsy can be concederedEmpiric therapy should started early

ImmunocompromisedIn 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.

General ConsiderationPatients 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

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. Tachycardia3. Tiredness & confusion.

Common organism1. Aspiration?

Anaerobe

2. Alcoholic and drug abuser ? Increase incidence of Klebsiella

3. COPD ? Increase incidence of H. influenza &

Pseudomonus.

4. Immunocompromised? Staph. , Viral , PCP…

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