acute pneumonia david hassin, tel-aviv medical center

Acute PneumoniaAcute Pneumonia

David Hassin, Tel-Aviv Medical Center David Hassin, Tel-Aviv Medical Center

Community-Acquired PnumoniaCommunity-Acquired Pnumonia

Bacterial Pneumonia:Bacterial Pneumonia:► Streptococcus pneumonia Streptococcus pneumonia

(16% - 60%).(16% - 60%).► Haemophilus influenzae Haemophilus influenzae

(3% - 38%).(3% - 38%).► Staphylococcus aureus Staphylococcus aureus

(2% - 5%). (2% - 5%).► Gram-negative rods Gram-negative rods

(7% - 18%): (7% - 18%): Pseudomonas aeuginosa, Pseudomonas aeuginosa,

Klebsiella pneumonia, E. coli…Klebsiella pneumonia, E. coli…

Atypical Pneumonia:Atypical Pneumonia:

► Mycoplasma pneumonia. Mycoplasma pneumonia. ** ► Chlamydophila pneumoniaeChlamydophila pneumoniae► Chlamydophila psittaci.Chlamydophila psittaci.► Coxiella burnetii.Coxiella burnetii.► Legionella pneumophila.Legionella pneumophila.► Chlamydia trachomatis.Chlamydia trachomatis.► Viral pneumonia:Viral pneumonia:

Influenza A and B, adenovirus Influenza A and B, adenovirus (types 3,4 and 7), parainfluenza (types 3,4 and 7), parainfluenza virus, respiratory syncytial virus.virus, respiratory syncytial virus.

** 50% or 7% to 28% of CAP. 50% or 7% to 28% of CAP.

Medical History and Physical Examination of CAPMedical History and Physical Examination of CAP Bacterial PneumoniaBacterial Pneumonia::► Chronic underlying diseases: Chronic underlying diseases:

COPD, CHF, DM, alcohol COPD, CHF, DM, alcohol abuse asplenia, myeloma, abuse asplenia, myeloma, AIDS…. (58% to 89%).AIDS…. (58% to 89%).

► Advanced age.Advanced age.► Sudden onset.Sudden onset.► True rigors.True rigors.► Pleuritic chest pain.Pleuritic chest pain.► Productive cough, purulent Productive cough, purulent

”rusty” sputum.”rusty” sputum.► Consolidation.Consolidation.► Pleural effusion.Pleural effusion.

Atypical PneumoniaAtypical Pneumonia::► Younger patients.Younger patients.► Environmental history: Environmental history:

exposure to young children exposure to young children and sick people. Exposure to and sick people. Exposure to birds, sheep, goats, cattle, birds, sheep, goats, cattle, domestic animals. Exposure domestic animals. Exposure to air coolers, wearlpools, to air coolers, wearlpools, hospital water supply…hospital water supply…

► Gradual onset.Gradual onset.► Non productive cough.Non productive cough.► Sore throat and hoarseness.Sore throat and hoarseness.► Minimal findings on physical Minimal findings on physical

examination.examination.► Bullous myringitis, (5%).Bullous myringitis, (5%).► Diarrhea, (Legionella).Diarrhea, (Legionella).

Vibratory Palpation and Auscultation of the Lungs Vibratory Palpation and Auscultation of the Lungs and Pleuraand Pleura

► Tactile Fremitus, Vocal fremitus, is best felt or heard with low Tactile Fremitus, Vocal fremitus, is best felt or heard with low pitched sounds: 99, 44…pitched sounds: 99, 44…

► Vocal Fremitus diminished or absent:Vocal Fremitus diminished or absent: thickened pleura, pleural thickened pleura, pleural effusion, pneumothorax, atelectasis.effusion, pneumothorax, atelectasis.

► Vocal Fremitus increased:Vocal Fremitus increased: consolidation, lung fibrosis. consolidation, lung fibrosis.► Auscultation for voice sounds is more sensitive then palpation.Auscultation for voice sounds is more sensitive then palpation.

Whispered Pectoriloquy, Bronchophony in consolidation. Whispered Pectoriloquy, Bronchophony in consolidation. Voice sounds helpful in lining pleural effusion fluid level. Voice sounds helpful in lining pleural effusion fluid level.

Percussion of the Lungs and PleuraPercussion of the Lungs and Pleura

► Percussion sounds:Percussion sounds: tympanytympany, , hyperresonancehyperresonance, , resonanceresonance,,impaired resonanceimpaired resonance, , dullnesdullnes, , flatnessflatness. .

► Definitive Percussion:Definitive Percussion: outlines the border between outlines the border between lung resonance and dullness of pleural effusion, lung resonance and dullness of pleural effusion, the upper border of the liver, the heart and the the upper border of the liver, the heart and the lung bases ( 10lung bases ( 10thth ribs ). ribs ).

► Anteriorly liver dullness at the Rt. 6Anteriorly liver dullness at the Rt. 6thth rib, the rib, the stomach tympany at the Lt. 6stomach tympany at the Lt. 6thth rib – Traube’s rib – Traube’s semilunar space. semilunar space.

► DullnessDullness in the upper lung: neoplasm, in the upper lung: neoplasm, consolidationconsolidation, atelectasis, thick pleura., atelectasis, thick pleura.

► Dullness in the lower lung: pleural effusion Dullness in the lower lung: pleural effusion and the above.and the above.

► Flatness results from massive pleural effusion.Flatness results from massive pleural effusion.

Traube’s semilunar spaceTraube’s semilunar space

dulldull

resonanceresonance dulldull

Auscultation of the Lungs and PleuraAuscultation of the Lungs and Pleura

► Vesicular Breathing: long inspiratory and short expiratory soundVesicular Breathing: long inspiratory and short expiratory sound► Bronchial Breathing: short inspiratory and long expiratory soundBronchial Breathing: short inspiratory and long expiratory sound► Asthmatic Breathing: expiration sound prolonged and whizzingAsthmatic Breathing: expiration sound prolonged and whizzing► Amphoric Breathing: like blowing air over the mouth of a bottleAmphoric Breathing: like blowing air over the mouth of a bottle► Bronchovesicular Breathing. Bronchovesicular Breathing.

VesicularVesicular

BronchialBronchial

AsthmaticAsthmatic

Physical Examination of the Lungs and Pleura Physical Examination of the Lungs and Pleura

Lobar Pneumonia – ConsolidationLobar Pneumonia – Consolidation..

Tracheal deviationTracheal deviation 00

FremitusFremitus

PercussionPercussion dull or flatdull or flat

Breath soundsBreath sounds bronchialbronchial

Voice soundsVoice sounds

RalesRales crepitant ralescrepitant rales

Laboratory Diagnosis of CAP.Laboratory Diagnosis of CAP. Bacterial PneumoniaBacterial Pneumonia::

► Leukocytosis.Leukocytosis.► Elevated CRP (sen.-100%)Elevated CRP (sen.-100%)► Purulent sputum, “rusty”.Purulent sputum, “rusty”.► Gram stain: > 25 leuk. < 10 Gram stain: > 25 leuk. < 10

epithelial cells. (x 100)epithelial cells. (x 100) Bacteria.Bacteria.► Sputum culture.Sputum culture.► Positive blood cultures,Positive blood cultures, (1% - 16%).(1% - 16%).► Hepatitis.Hepatitis.

Atypical PneumoniaAtypical Pneumonia::

► Serum antibody assays:Serum antibody assays: Mycoplasma pneumoniae.Mycoplasma pneumoniae. Chlamydophila pneumoniae.Chlamydophila pneumoniae. Coxiella burnetii.Coxiella burnetii. Legionella pneumophila.Legionella pneumophila.► Ag. In the urine, (L. pneu.).Ag. In the urine, (L. pneu.).► Cold agglutinins, (M. pneu.)Cold agglutinins, (M. pneu.)► Hepatitis, (Q. fever, L. pne.)Hepatitis, (Q. fever, L. pne.)► Hyponatremia, elevated Cr. Hyponatremia, elevated Cr.

Hypophosphatemia, LDH- Hypophosphatemia, LDH- (Legionella pneumophilla). (Legionella pneumophilla).

Sputum Examination and Gram stain: 30% to 40% fail to Sputum Examination and Gram stain: 30% to 40% fail to produce sputum. >25 Neut. < 10 epithelial cells (x 100)produce sputum. >25 Neut. < 10 epithelial cells (x 100)

Streptococcus Pneumonia

Staph. Aureus Gram Negative RodsGram Negative Rods..

Klebsiella PneumpniaKlebsiella Pneumpnia

Haemophilus InfluenzaHaemophilus Influenza

Chest x-ray of Bacterial PneumoniaChest x-ray of Bacterial Pneumonia

Streptococcus pneumoniaeStreptococcus pneumoniae

Haemophilus influenzaeHaemophilus influenzae Klebbsiella pneumoniaKlebbsiella pneumonia Staph. aureusStaph. aureus

Chest x-ray of Atypical Pneumonia SyndromeChest x-ray of Atypical Pneumonia Syndrome

Mycoplasma pneumoniaMycoplasma pneumonia Chlamydophila pneumoniaChlamydophila pneumonia

Coxiella burnetiiCoxiella burnetii Chlamydophila psittaciChlamydophila psittaci Viral pneumoniaViral pneumonia

Legionella pneumophilaLegionella pneumophila

Other Pneumonia SyndromesOther Pneumonia Syndromes

► Nosocomial pneumonia.Nosocomial pneumonia.► Respirator associated pneumonia.Respirator associated pneumonia.► Aspiration pneumonia.Aspiration pneumonia.► Pneumonia in the immunosuppressed host.Pneumonia in the immunosuppressed host.► Tuberculosis.Tuberculosis.► Viral pneumonia: Adenovirus, Influenza, SARS, Viral pneumonia: Adenovirus, Influenza, SARS,

Hantavirus, Varicella… Hantavirus, Varicella… ► Fungal pneumonia: Histoplasmosis,Fungal pneumonia: Histoplasmosis,

Coccediodomycosis, Cryptococcosis.Coccediodomycosis, Cryptococcosis.► Pulmonary infiltrates with eosinophilia, (PIE). Pulmonary infiltrates with eosinophilia, (PIE).

Severity Index of CAP by the PORT StudySeverity Index of CAP by the PORT Study..

The 30-day mortality was lowest (0.1%):The 30-day mortality was lowest (0.1%):► Younger then 50 years.Younger then 50 years.► No coexisting condition, (neoplasia, CHF, CVA, No coexisting condition, (neoplasia, CHF, CVA,

renal disease, liver disease).renal disease, liver disease).► Normal physical findings, including mental status.Normal physical findings, including mental status.► Pulse < 125 beats per minute.Pulse < 125 beats per minute.► Temperature < 35 and > 40.Temperature < 35 and > 40.

Empiric Antibacterial Selection for CAPEmpiric Antibacterial Selection for CAP

DrugsDrugsAdvantagesAdvantagesDisadvantagesDisadvantages

Macrolides: Macrolides: Clarithromycin. Clarithromycin. Azithromycin. Azithromycin. Erythromycin. Erythromycin.

11 ( (Active vs. most common Active vs. most common pathogens, also atypical. pathogens, also atypical. 2) Good results in clinical 2) Good results in clinical trials even with in vitro trials even with in vitro resistant strains. resistant strains. 3) Reduced mortality 3) Reduced mortality combined w. Cephalosporincombined w. Cephalosporin

11 ( (20%20%--30%30% in vitro in vitro resistance vs. S. pneumon. resistance vs. S. pneumon. 2) Breakthrough pneumoco. 2) Breakthrough pneumoco. Bacteria with resistant strains. Bacteria with resistant strains. 3) H. influenza resistant to Er. 3) H. influenza resistant to Er. 4) Mortality> then ceph. With 4) Mortality> then ceph. With

macrolide or fluoroquinolonmacrolide or fluoroquinolon . .

AmoxicillinAmoxicillin..

Active against 90%-95% of Active against 90%-95% of S. pneumoniae treated with S. pneumoniae treated with 3-4 gr. / day3-4 gr. / day . .

11 ( (Lacks activity against Lacks activity against atypical and atypical and ββ-lactamase -lactamase producing bacteria. producing bacteria. 2) Recent clinical trials of 2) Recent clinical trials of efficacy - modest efficacy - modest..

Amoxicillin-Amoxicillin-clavulanateclavulanate..

11 ( (Active vs. Active vs. ββ-lactamase -lactamase producing bacteria. producing bacteria. 2) Good clinical trials2) Good clinical trials . .

Gastrointestinal intoleranceGastrointestinal intolerance



Cefuroxime axetilCefuroxime axetil

11 ( (Active vs. 75%-85% of Active vs. 75%-85% of S. pneumoniae and all S. pneumoniae and all H. influenzae. H. influenzae. 2) Efficacious in 2) Efficacious in outpatients CAP trials outpatients CAP trials . .

11 ( (Amoxicillin more active Amoxicillin more active vs. S. pneumoniae. vs. S. pneumoniae. 2) No activity vs. atypical 2) No activity vs. atypical pathogens pathogens . .

DoxycyclineDoxycycline..

11 ( (Active vs. 90%-95% of Active vs. 90%-95% of S. pneumoniae. Also S. pneumoniae. Also active vs. H.influenzae active vs. H.influenzae and atypical pathogens. 2) and atypical pathogens. 2) Good outcome with Good outcome with CAP of hospitalized pt. 3) CAP of hospitalized pt. 3)

Well toleratedWell tolerated . .

Very limited recent Very limited recent clinical publicationsclinical publications..

ClindamycinClindamycin..

11 ( (Active vs. 90% of Active vs. 90% of S. pneumoniae. S. pneumoniae. 2) Active vs. anaerobic inf. 2) Active vs. anaerobic inf. 3) Preferred vs. strep. g. A3) Preferred vs. strep. g. A . .

11 ( (No activity vs. atypical No activity vs. atypical pathogens and H. influ. pathogens and H. influ. 2) Limited published data 2) Limited published data on CAP on CAP..



Fluoroquinolones: Fluoroquinolones: Levofloxacin, Levofloxacin, Moxifloxacin, Moxifloxacin,

Gatifloxacin, Gatifloxacin, GemifloxacinGemifloxacin..

11 ( (Active vs.>98% S. pneu. Active vs.>98% S. pneu. Also H. influ. Atypical Also H. influ. Atypical agents and MSSA. agents and MSSA. 2) Meta-analysis of trials: 2) Meta-analysis of trials: better then better then ββ-lactams -lactams and macrolides. and macrolides. 3) Well tolerated3) Well tolerated . .

11 ( (Abuse will result in Abuse will result in resistance; resistance resistance; resistance emerged on therapy. emerged on therapy. 2) Expensive2) Expensive . .

Cephalosporins: Cephalosporins: Ceftriaxone, Ceftriaxone,

CefotaximeCefotaxime..

11((Active vs. 90%-95% of Active vs. 90%-95% of S. pneumonia also S. pneumonia also H. influ. And MSSA. H. influ. And MSSA. 2) Pareteral drugs of 2) Pareteral drugs of choice vs. S. p., extensive choice vs. S. p., extensive clinical trial experience clinical trial experience . .

11 ( (No activity vs. atypical No activity vs. atypical agents. agents. 2) Higher mortality of 2) Higher mortality of ceph. Alone then ceph. ceph. Alone then ceph. plus macrolide or plus macrolide or fluoroquinolone alone fluoroquinolone alone . .

Cephalosporin Cephalosporin Plus MacrolidePlus Macrolide

11 ( (Ceph. better vs. S. Ceph. better vs. S. pneu. Macrolide vs. pneu. Macrolide vs. atypical. 2) Retrospective atypical. 2) Retrospective analysis: reduced analysis: reduced mortality in mortality in

bacteremic S. pneubacteremic S. pneu . .

Data uncontrolledData uncontrolled..



Fluoroquinolone Fluoroquinolone Plus Plus

CephalosporinCephalosporin

May increase antimicrobial May increase antimicrobial activity vs. S. pneumoniaactivity vs. S. pneumonia..

No documented benefitNo documented benefit

Penicillin GPenicillin G

11 ( (Preferred treatment vs. Preferred treatment vs. penicillin sensitive penicillin sensitive S. pneu. Along with S. pneu. Along with ceftriaxon and amoxicillin. ceftriaxon and amoxicillin. 2) Extensive documented 2) Extensive documented

clinical efficacy clinical efficacy . .

Limited activity against Limited activity against other common other common pulmonary pathogenspulmonary pathogens . .

TelithromycinTelithromycin

11 ( (Active in-vitro vs. most Active in-vitro vs. most S. pneu. (Also macrolide S. pneu. (Also macrolide resistant) H. influenza resistant) H. influenza and atypical agents. 2) and atypical agents. 2) Clinical trials: equivalence Clinical trials: equivalence to macrolides, amoxicillin, to macrolides, amoxicillin, trovafloxacintrovafloxacin..

Clinical trials considered Clinical trials considered preliminarypreliminary..



Linezolid.Linezolid.

1) Active vs. most gram 1) Active vs. most gram positives including resistant positives including resistant S. pneu. and S. aureus. S. pneu. and S. aureus. 2) Efficacy comparable to 2) Efficacy comparable to ceftriaxon vs. pneu. pneum. ceftriaxon vs. pneu. pneum. 3) oral plus parenteral. 3) oral plus parenteral.

1) Lacks established 1) Lacks established activity vs. atypical activity vs. atypical agents. agents. 2) Expensive.2) Expensive.

Ertapenem.Ertapenem.

1) Clinical efficacy for CAP 1) Clinical efficacy for CAP comparable comparable to ceftriaxon. 2) Once to ceftriaxon. 2) Once daily. daily.

1) No activity vs. atypical 1) No activity vs. atypical agents. agents. 2) Less active vs. 2) Less active vs. pseudomonas aerug.pseudomonas aerug.

Gemifloxacin.Gemifloxacin.

1) The most active among 1) The most active among the fluoroquinolons vs, the fluoroquinolons vs, S. pneumonia. S. pneumonia. 2) Clinlcal CAP 2) Clinlcal CAP trials: good results.trials: good results.

1) High rate of rash. 1) High rate of rash. 2) Only oral formulation.2) Only oral formulation.

Percentage of Resistance to Antibiotics of Percentage of Resistance to Antibiotics of Streptococcus PneumoniaStreptococcus Pneumonia..

Guide to Empirical Choice of Antimicrobial Agent for Guide to Empirical Choice of Antimicrobial Agent for Treating Patients with Community-Acquired PneumoniaTreating Patients with Community-Acquired Pneumonia

Initiation of antibiotic therapy within 4 hours of presentation has been associated with a shorter hospital stay

independent of clinical or demographic parameters.

MasaccioMasaccio

Pulmonary Host Pulmonary Host DefensesDefenses

Causative Agents of Acute PneumoniaCausative Agents of Acute Pneumonia..

Medical and Environmental History of Pneumonia Medical and Environmental History of Pneumonia

acute pneumonia david hassin, tel-aviv medical center

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