dr. r v s n sarma., md., msc., (canada) consultant physician & chest specialist visit us at:

Dr. R V S N Sarma., MD., MSc., (Canada)Dr. R V S N Sarma., MD., MSc., (Canada)

Consultant Physician & Chest SpecialistConsultant Physician & Chest Specialist

visit us at: www.drsarma.in visit us at: www.drsarma.in

The New Treatment Paradigm – The New Treatment Paradigm –

Selecting Appropriate Empiric AntibioticsSelecting Appropriate Empiric Antibiotics

3

Pneumonias – ClassificationPneumonias – Classification

Nosocomial Pneumonias

4

Community Acquired Pneumonia (CAP)Community Acquired Pneumonia (CAP)

DefinitionDefinition

… … an acute infection of the pulmonary parenchyma an acute infection of the pulmonary parenchyma

that is associated with some symptoms of acute that is associated with some symptoms of acute

infection, accompanied by the presence of an acute infection, accompanied by the presence of an acute

infiltrate on a chest radiograph, or auscultatory infiltrate on a chest radiograph, or auscultatory

findings consistent with pneumonia, in a patient not findings consistent with pneumonia, in a patient not

hospitalized or residing in a long term care facility hospitalized or residing in a long term care facility

for for >> 14 days before onset of symptoms. 14 days before onset of symptoms.

Bartlett. Clin Infect Dis 2000;31:347-82.

5

Guidelines for CAPGuidelines for CAP

American Thoracic Society (ATS)American Thoracic Society (ATS) Guidelines - Management of Adults with CAP (2001)Guidelines - Management of Adults with CAP (2001)

Infectious Diseases Society of America (IDSA)Infectious Diseases Society of America (IDSA) Update of Practice Guidelines Management of CAP Update of Practice Guidelines Management of CAP

in in Immuno-competentImmuno-competent adults (2003) adults (2003) ATS and IDSA joint effort (we will follow this)ATS and IDSA joint effort (we will follow this)

IDSA/ATS Consensus Guidelines on the Management IDSA/ATS Consensus Guidelines on the Management

of CAP in of CAP in AdultsAdults ( (March 2007March 2007))

6

Evidence-based practiceEvidence-based practice Best outcome for patientsBest outcome for patients Best use of resourceBest use of resource Restricts idiosyncratic behaviourRestricts idiosyncratic behaviour

Legal protectionLegal protection Identify research needsIdentify research needs A tool for educationA tool for education Gain public confidenceGain public confidence

Why Guidelines?Why Guidelines?

7

CAP – The Two Types of PresentationsCAP – The Two Types of Presentations

ClassicalClassical

• Sudden onset of CAP• High fever, shaking chills• Pleuritic chest pain, SOB• Productive cough• Rusty sputum, blood tinge• Poor general condition• High mortality up to 20% in

patients with bacteremia• S.pneumoniae causative

• Gradual & insidious onset• Low grade fever• Dry cough, No blood tinge• Good GC – Walking CAP• Low mortality 1-2%; except

in cases of Legionellosis

• Mycoplasma, Chlamydiae, Legionella, Ricketessiae, Viruses are causative

AtypicalAtypical

8

CAP – PathogenesisCAP – Pathogenesis

9

AgeAge Obesity; Exercise is protectiveObesity; Exercise is protective Smoking, PVD Smoking, PVD Asthma, COPDAsthma, COPD Immuno-suppression, HIVImmuno-suppression, HIV Institutionalization, Old age homes etcInstitutionalization, Old age homes etc DementiaDementia

CAP – Risk Factors for PneumoniaCAP – Risk Factors for Pneumonia

ID Clinics 1998;12:723. Am J Med 1994;96:313

10

Community Acquired Pneumonia (CAP)Community Acquired Pneumonia (CAP)

EpidemiologyEpidemiology 4-5 million cases annually4-5 million cases annually ~500,000 hospitalizations – 20% require admission~500,000 hospitalizations – 20% require admission ~45,000 deaths~45,000 deaths Fewest cases in 18-24 yr groupFewest cases in 18-24 yr group Probably highest incidence in <5 and >65 yrsProbably highest incidence in <5 and >65 yrs Mortality disproportionately high in >65 yrs Mortality disproportionately high in >65 yrs Over all mortality is 2-30%; Hospitalized Pt Over all mortality is 2-30%; Hospitalized Pt mort mort <1% for those not requiring hospitalization<1% for those not requiring hospitalization

Bartlett. CID 1998;26:811-38.

11

CAP – The Pathogens InvolvedCAP – The Pathogens Involved40-60% - No causative agent identified

2-5% - Two are more agents identified

12

Streptococcus pneumonia Streptococcus pneumonia (Pneumococcus)Pneumococcus)

Most common cause of CAPMost common cause of CAP About 2/3 of CAP are due to S.pneumoniaeAbout 2/3 of CAP are due to S.pneumoniae These are gram positive diplococciThese are gram positive diplococci Typical symptoms (e.g. malaise, shaking chills Typical symptoms (e.g. malaise, shaking chills

fever, rusty sputum, pleuritic chest pain, cough)fever, rusty sputum, pleuritic chest pain, cough) Lobar infiltrate on CXRLobar infiltrate on CXR May be Immuno suppressed hostMay be Immuno suppressed host 25% will have bacteremia – serious effects25% will have bacteremia – serious effects

13

CAP – Special Features – Pathogen wiseCAP – Special Features – Pathogen wise

Typical – S.pneumoniae, H.influenza, M.catarrhalis – LungsTypical – S.pneumoniae, H.influenza, M.catarrhalis – Lungs

Blood tinged sputum - Pneumococcal, Klebsiella, LegionellaBlood tinged sputum - Pneumococcal, Klebsiella, Legionella

H.influenzae CAP has associated of pleural effusionH.influenzae CAP has associated of pleural effusion

S.Pneumoniae – commonest – penicillin resistance problemS.Pneumoniae – commonest – penicillin resistance problem

S.aureus, K.pneumoniae, P.aeruginosa – not in typical hostS.aureus, K.pneumoniae, P.aeruginosa – not in typical host

S.aureus causes CAP in post-viral influenza; Serious CAPS.aureus causes CAP in post-viral influenza; Serious CAP

K.pneumoniae primarily in patients of chronic alcoholismK.pneumoniae primarily in patients of chronic alcoholism

P.Aeruginosa causes CAP in pts with CSLD or CF, NosocomP.Aeruginosa causes CAP in pts with CSLD or CF, Nosocom

Aspiration CAP only is caused by multiple pathogensAspiration CAP only is caused by multiple pathogens

Extra pulmonary manifestations only in Atypical CAPExtra pulmonary manifestations only in Atypical CAP

14

S. S. aereusaereus CAP – Dangerous CAP – Dangerous

This CAP is not common; Multi lobar InvolvementThis CAP is not common; Multi lobar Involvement Post Influenza complication, Class IV or VPost Influenza complication, Class IV or V Compromised host, Co-morbidities, ElderlyCompromised host, Co-morbidities, Elderly CA MRSA – A Problem; CA MSSA also occursCA MRSA – A Problem; CA MSSA also occurs Empyema and Necrosis of lung with cavitationsEmpyema and Necrosis of lung with cavitations Multiple Pyemic abscesses, Septic ArthritisMultiple Pyemic abscesses, Septic Arthritis Hypoxemia, Hypoventilation, Hypotension commonHypoxemia, Hypoventilation, Hypotension common Vancomycin, Linezolid are the drugs for MRSAVancomycin, Linezolid are the drugs for MRSA

15

CAP – Age wise IncidenceCAP – Age wise Incidence

16

CAP – Age wise MortalityCAP – Age wise Mortality

17

Older, Unemployed, UnmarriedOlder, Unemployed, Unmarried Recurrent common coldRecurrent common cold Asthma, COPD; Steroid or bronchodilator useAsthma, COPD; Steroid or bronchodilator use Chronic diseases, Diabetes, CHF, NeoplasiaChronic diseases, Diabetes, CHF, Neoplasia Amount of smoking Amount of smoking Alcohol is NOT related to increased risk for Alcohol is NOT related to increased risk for

hospitalizationhospitalization

CAP – Risk Factors for HospitalizationCAP – Risk Factors for Hospitalization

ID Clinics 1998;12:723. Am J Med 1994;96:313

18

Age > 65Age > 65 Bacteremia (for S. pneumoniae)Bacteremia (for S. pneumoniae) S. aureus, MRSA , Pseudomonas S. aureus, MRSA , Pseudomonas Extent of radiographic changesExtent of radiographic changes Degree of immuno-suppressionDegree of immuno-suppression Amount of alcohol consumptionAmount of alcohol consumption

CAP – Risk Factors for MortalityCAP – Risk Factors for Mortality

ID Clinics 1998;12:723. Am J Med 1994;96:313

19

CAP – Bacteriology in Hospitalized PtsCAP – Bacteriology in Hospitalized Pts

20

CAP – Evaluation of a PatientCAP – Evaluation of a Patient

21

CAP – Management Guidelines CAP – Management Guidelines

Rational use of microbiology laboratoryRational use of microbiology laboratory Pathogen directed antimicrobial therapy Pathogen directed antimicrobial therapy

whenever possiblewhenever possible Prompt initiation of Antibiotic therapyPrompt initiation of Antibiotic therapy Decision to hospitalize based on Decision to hospitalize based on

prognostic criteria - PORT or CURB 65prognostic criteria - PORT or CURB 65

22

PORT Scoring – PSIPORT Scoring – PSIPneumonia Patient Outcomes

Research Team (PORT)

23

Classification of Severity - PORTClassification of Severity - PORT

24

CAP – Management based on PSI ScoreCAP – Management based on PSI Score

25

CURB 65 Rule – Management of CAPCURB 65 Rule – Management of CAP

26

Algorithmic ApproachAlgorithmic Approach

Step 1Step 1Step 2Step 2

Step 3Step 3

Step 4Step 4

27

Who Should be Hospitalized?Who Should be Hospitalized?

Class I and II Class I and II Usually do not require Usually do not require hospitalizationhospitalization

Class IIIClass III May require brief hospitalizationMay require brief hospitalization

Class IV and VClass IV and V Usually do require hospitalizationUsually do require hospitalization

Severity of CAP with poor prognosis Severity of CAP with poor prognosis

RR > 30; PaORR > 30; PaO22/FiO2 < 250, or PO/FiO2 < 250, or PO22 < 60 on room air < 60 on room air

Need for mechanical ventilation; Multi lobar involvementNeed for mechanical ventilation; Multi lobar involvement

Hypotension; Need for vasopressorsHypotension; Need for vasopressors

Oliguria; Altered mental statusOliguria; Altered mental status

28

CAP – Criteria for ICU AdmissionCAP – Criteria for ICU Admission

Major criteriaMajor criteria

Invasive mechanical ventilation requiredInvasive mechanical ventilation required Septic shock with the need of vasopressorsSeptic shock with the need of vasopressors

Minor criteria (least 3)Minor criteria (least 3)

Confusion/disorientationConfusion/disorientation Blood urea nitrogen ≥ 20 mg%Blood urea nitrogen ≥ 20 mg% Respiratory rate ≥ 30 / min; Core temperature < 36ºCRespiratory rate ≥ 30 / min; Core temperature < 36ºC Severe hypotension; PaO2/FiO2 ratio ≤ 250Severe hypotension; PaO2/FiO2 ratio ≤ 250 Multi-lobar infiltratesMulti-lobar infiltrates WBC < 4000 cells; Platelets <100,000WBC < 4000 cells; Platelets <100,000

29

CAP – Laboratory TestsCAP – Laboratory Tests

• CXR – PA & lateral

• CBC with Differential

• BUN and Creatinine

• FBG, PPBG

• Liver enzymes

• Serum electrolytes

• Gram stain of sputum

• Culture of sputum

• Pre Rx. blood cultures

• Oxygen saturation

30

CAP – Value of Chest RadiographCAP – Value of Chest Radiograph

• Usually needed to establish diagnosis

• It is a prognostic indicator

• To rule out other disorders

• May help in etiological diagnosis

J Chr Dis 1984;37:215-25

31

Infiltrate Patterns and PathogensInfiltrate Patterns and Pathogens

32

CAP – Gram’s Stain of SputumCAP – Gram’s Stain of Sputum

Good sputum samples is obtained only from 39%83% show only one predominant organism

Good sputum samples is obtained only from 39%83% show only one predominant organism

33

Pathogens Retrieved from Blood CulturePathogens Retrieved from Blood Culture

34

Mortality of CAP – Based on Pathogen Mortality of CAP – Based on Pathogen

P. aeruginosa - P. aeruginosa - 61.0 %61.0 %

K. pneumoniae - K. pneumoniae - 35.7 %35.7 %

S. aureus - S. aureus - 31.8 %31.8 %

Legionella -Legionella - 14.7 %14.7 %

S. pneumoniae - S. pneumoniae - 12.0 %12.0 %

C. pneumoniae - C. pneumoniae - 9.8 % 9.8 %

H. influenza - H. influenza - 7.4 % 7.4 %

35

Traditional Treatment ParadigmTraditional Treatment Paradigm

Conservative start with ‘workhorse’ antibiotics

Reserve more potent drugs for non-responders

36

New Treatment ParadigmNew Treatment Paradigm

Hit hard and early with appropriate antibiotic(s)

Short Rx. Duration; De-escalate where possible

37

Objective 2Objective 2Objective 1Objective 1

Avoid Avoid emergence ofemergence ofmultidrug multidrug resistantresistantmicroorganismmicroorganismss

Immediate Immediate Rx.Rx.of patients of patients with serious with serious sepsissepsis

The Therapy ConundrumThe Therapy Conundrum

38

Inappropriate therapy (%)Inappropriate therapy (%)

0

30

50

10

CAP

20

40

HAP HAP on CAP

17

34

45

Kollef, et al. Chest 1999;115:462–474

The Effect of the Traditional ApproachThe Effect of the Traditional Approach

39

New data – Don’t Wait for Results !New data – Don’t Wait for Results !

Switching after susceptibility results

p<0.001

Adequate treatment within ‘a few hours’

Mortality (%) n=75

Tumbarello, et al. Antimicrob Agents Chemother 2007;51:1987–1994

40

Risk assessment approachRisk assessment approach Early Antibiotic selectionEarly Antibiotic selection Change treatment driven by local Change treatment driven by local

surveillancesurveillance Hit hard and hit earlyHit hard and hit early As short a duration as possibleAs short a duration as possible De-escalate when and where possibleDe-escalate when and where possible

CAP Treatment ConsensusCAP Treatment Consensus

41

OPAT – OP Parenteral Antimicrobial TherapyOPAT – OP Parenteral Antimicrobial Therapy

42

Antibiotics of choice for CAPAntibiotics of choice for CAP

43

44

Empiric Treatment – OutpatientEmpiric Treatment – Outpatient

Healthy and no risk factors for DR Healthy and no risk factors for DR S.pneumoniae S.pneumoniae 1. Macrolide or Doxycycline1. Macrolide or DoxycyclinePresence of co-morbidities, use of antimicrobialsPresence of co-morbidities, use of antimicrobialswithin the previous 3 months, and regions with a within the previous 3 months, and regions with a high rate (>25%) of infection with Macrolidehigh rate (>25%) of infection with Macrolideresistant resistant S. pneumoniaeS. pneumoniae1. Respiratory FQ – Levoflox, Gemiflox or Moxiflox1. Respiratory FQ – Levoflox, Gemiflox or Moxiflox2. Beta-lactam (High dose Amoxicillin,2. Beta-lactam (High dose Amoxicillin, Amoxicillin- Amoxicillin-

Clavulanate is preferred; Ceftriaxone, Cefpodoxime, Clavulanate is preferred; Ceftriaxone, Cefpodoxime, Cefuroxime) Cefuroxime) plus plus a Macrolidea Macrolide or Doxycycline or Doxycycline

45

Empiric Treatment – Inpatient – Non ICUEmpiric Treatment – Inpatient – Non ICU

1. 1. A Respiratory Fluoroquinolone (FQ) Levo A Respiratory Fluoroquinolone (FQ) Levo oror

2. 2. A Beta-lactam A Beta-lactam plusplus a Macrolide (or Doxycycline) a Macrolide (or Doxycycline)

(Here Beta-lactam agents are 3 Generation (Here Beta-lactam agents are 3 Generation

Cefotaxime, Ceftriaxone, Amoxiclav)Cefotaxime, Ceftriaxone, Amoxiclav)

3. 3. If Penicillin-allergic Respiratory FQ orIf Penicillin-allergic Respiratory FQ or

Ertapenem is another optionErtapenem is another option

46

Empiric Treatment: Inpatient in ICUEmpiric Treatment: Inpatient in ICU

1. 1. A Beta-lactam (Cefotaxime, Ceftriaxone,A Beta-lactam (Cefotaxime, Ceftriaxone,

or Ampicillin-Sulbactam) or Ampicillin-Sulbactam) plusplus

eithereither Azithromycin Azithromycin oror Fluoroquinolone Fluoroquinolone

2. 2. For penicillin-allergic patients, a respiratoryFor penicillin-allergic patients, a respiratory

Fluoroquinolone and AztreonamFluoroquinolone and Aztreonam

47

Empiric Rx. – Suspected PseudomonasEmpiric Rx. – Suspected Pseudomonas

1. 1. Piperacillin-Tazobactam, Cefepime, Carbapenums Piperacillin-Tazobactam, Cefepime, Carbapenums

(Imipenem, or Meropenem) (Imipenem, or Meropenem) plus either plus either Cipro or LevoCipro or Levo

2. 2. Above Beta-lactam Above Beta-lactam ++ Aminoglycoside Aminoglycoside ++ Azithromycin Azithromycin

3. 3. Above Beta-lactam Above Beta-lactam + + Aminoglycoside Aminoglycoside + + an an

antipseudomonal and antipneumococcal FQantipseudomonal and antipneumococcal FQ

4. 4. If Penicillin allergic - Aztreonam for the Beta-lactamIf Penicillin allergic - Aztreonam for the Beta-lactam

48

Empiric Rx. – CA MRSAEmpiric Rx. – CA MRSA

For Community Acquired Methicillin-ResistantFor Community Acquired Methicillin-Resistant

Staphylococcus aureus (CA-MRSA)Staphylococcus aureus (CA-MRSA)

Vancomycin or LinezolidVancomycin or Linezolid

Neither is an optimal drug for MSSANeither is an optimal drug for MSSA For Methicillin Sensitive For Methicillin Sensitive S. aureus S. aureus (MSSA)(MSSA)

B-lactam and sometimes a respiratoryB-lactam and sometimes a respiratory

Fluoroquinolone, (until susceptibility results).Fluoroquinolone, (until susceptibility results). Specific therapy with a penicillinase-resistantSpecific therapy with a penicillinase-resistant

semisynthetic penicillin or Cephalosporinsemisynthetic penicillin or Cephalosporin

49

Duration of TherapyDuration of Therapy

• Minimum of 5 daysMinimum of 5 days• Afebrile for at least 48 to 72 hAfebrile for at least 48 to 72 h• No > 1 CAP-associated sign of clinical instabilityNo > 1 CAP-associated sign of clinical instability• Longer duration of therapy Longer duration of therapy

If initial therapy was not active against the identified If initial therapy was not active against the identified

pathogen or complicated by extra pulmonary infectionpathogen or complicated by extra pulmonary infection

50

New data – The Speed of Delay ! (Class 4,5)New data – The Speed of Delay ! (Class 4,5)

0

10

20

30

40

50

60

70

80

90

0.5 1 2 3 4 5 6

Delay in treatment (hours) from hypotension onset

Surv

ival

(%)

Each hour of delay carries 7.6% reduction in survival

Kumar, et al. Crit Care Med 2006;34:1589–1596

51

CAP – Summary of Empiric TreatmentCAP – Summary of Empiric Treatment

Outpatient Rx – any one of the threeOutpatient Rx – any one of the three• Macrolide or Doxycycline or FluoroquinoloneMacrolide or Doxycycline or Fluoroquinolone

Patients in General Medical WardPatients in General Medical Ward• 3rd Generation Cephalosporin + Macrolide3rd Generation Cephalosporin + Macrolide• Betalactum / B-I + Macrolide or B / B-I + FQBetalactum / B-I + Macrolide or B / B-I + FQ• Fluroquinolone aloneFluroquinolone alone

Patients in ICUPatients in ICU• 3GC + Macrolide or 3GC + FQ3GC + Macrolide or 3GC + FQ• B/B-I + Macrolide or B/B-I + FQB/B-I + Macrolide or B/B-I + FQ

IDSA guidelines: Clin Infect Dis 2000;31:347-82

52

CAP – Treatment SummaryCAP – Treatment Summary

53

Strategies for Prevention of CAPStrategies for Prevention of CAP• Cessation smokingCessation smoking• Influenza Vaccine (Flu shot – Oct through Feb)Influenza Vaccine (Flu shot – Oct through Feb)

It offers 90% protection and reduces mortality by 80%It offers 90% protection and reduces mortality by 80%• Pneumococcal Vaccine (Pneumonia shot)Pneumococcal Vaccine (Pneumonia shot)

It protects against 23 types of PneumococciIt protects against 23 types of Pneumococci

70% of us have Pneumococci in our RT70% of us have Pneumococci in our RT

It is not 100% protective but reduces mortalityIt is not 100% protective but reduces mortality

Age 19-64 with co morbidity of high for pneumoniaAge 19-64 with co morbidity of high for pneumonia

Above 65 all must get it even without high riskAbove 65 all must get it even without high risk• Starting first dose of antibiotic with in 4 h & OStarting first dose of antibiotic with in 4 h & O22 status status

54

Switch to Oral TherapySwitch to Oral Therapy

Four criteriaFour criteria Improvement in cough, dyspnea & clinical signsImprovement in cough, dyspnea & clinical signs Afebrile on two occasions 8 h apartAfebrile on two occasions 8 h apart WBC decreasing towards normalWBC decreasing towards normal Functioning GI tract with adequate oral intakeFunctioning GI tract with adequate oral intake

If overall clinical picture is otherwise favorable, If overall clinical picture is otherwise favorable, hemodynamically stable; can switch to oral hemodynamically stable; can switch to oral therapy while still febrile.therapy while still febrile.

55

Management of Poor RespondersManagement of Poor Responders

Consider non-infectious illnessesConsider non-infectious illnesses Consider less common pathogensConsider less common pathogens Consider serologic testingConsider serologic testing Broaden antibiotic therapyBroaden antibiotic therapy Consider bronchoscopyConsider bronchoscopy

56

CAP – ComplicationsCAP – Complications

Hypotension and septic shockHypotension and septic shock 3-5% Pleural effusion; Clear fluid + pus cells3-5% Pleural effusion; Clear fluid + pus cells 1% Empyema thoracis pus in the pleural space 1% Empyema thoracis pus in the pleural space Lung abscess – destruction of lung - CSLDLung abscess – destruction of lung - CSLD Single (aspiration) anaerobes, Single (aspiration) anaerobes, PseudomonasPseudomonas

Multiple (metastatic) Multiple (metastatic) Staphylococcus aureusStaphylococcus aureus

Septicemia – Brain abscess, Liver AbscessSepticemia – Brain abscess, Liver Abscess Multiple Pyemic AbscessesMultiple Pyemic Abscesses

57

Pneumocystis carinii (PCP)Pneumocystis carinii (PCP)

Important cause of pneumonia in the severelyImportant cause of pneumonia in the severely

immuno-compromised, i.e. not a “primary atypicalimmuno-compromised, i.e. not a “primary atypical

pneumonia”.pneumonia”. Classically PCP pneumonia presents with slight fever,Classically PCP pneumonia presents with slight fever,

dyspnea and non-productive coughdyspnea and non-productive cough Diagnosis – usually histological (silver staining).Diagnosis – usually histological (silver staining). Treatment – Co-trimoxazole or Pentamidine.Treatment – Co-trimoxazole or Pentamidine.

58

Viruses and PneumoniaViruses and Pneumonia

Pneumonia in the normal hostPneumonia in the normal host• Adults or ChildrenAdults or Children• Influenza A and B, RSV, Adenovirus Para InfluenzaInfluenza A and B, RSV, Adenovirus Para Influenza

Pneumonia in the immuno-compromisedPneumonia in the immuno-compromised• Measles, HSV, CMV, HHV-6, Influenza virusesMeasles, HSV, CMV, HHV-6, Influenza viruses• Can cause a primary viral pneumonia. Cause partial Can cause a primary viral pneumonia. Cause partial

paralysis of “mucociliary escalator” - increased risk of paralysis of “mucociliary escalator” - increased risk of secondary bacterial LRTI. secondary bacterial LRTI. S.aureus pneumonia S.aureus pneumonia is a is a known complication following influenza infection.known complication following influenza infection.

59

CAP – So How Best to Win the War?CAP – So How Best to Win the War?

Early antibiotic administration within 4-6 hoursEarly antibiotic administration within 4-6 hours Empiric antibiotic Rx. as per guidelines (IDSA / ATS)Empiric antibiotic Rx. as per guidelines (IDSA / ATS) PORT – PSI scoring and Classification of casesPORT – PSI scoring and Classification of cases Early hospitalization in Class IV and VEarly hospitalization in Class IV and V Change Abx. as per pathogen & sensitivity patternChange Abx. as per pathogen & sensitivity pattern Decrease smoking cessation - advice / counselingDecrease smoking cessation - advice / counseling Arterial oxygenation assessment in the first 24 hArterial oxygenation assessment in the first 24 h Blood culture collection in the first 24 h prior to Abx.Blood culture collection in the first 24 h prior to Abx. Pneumococcal & Influenza vaccination; Smoking Pneumococcal & Influenza vaccination; Smoking XX

60

Normal CXR & Pneumonic ConsolidationNormal CXR & Pneumonic Consolidation

61

Lobar Pneumonia – S.pneumoniaeLobar Pneumonia – S.pneumoniae

62

CXR – PA and Lateral ViewsCXR – PA and Lateral Views

63

Lobar versus Segmental - Right SideLobar versus Segmental - Right Side

64

Lobar PneumoniaLobar Pneumonia

65

Special forms of ConsolidationSpecial forms of Consolidation

66

Round Pneumonic ConsolidationRound Pneumonic Consolidation

67

Special Forms of PneumoniaSpecial Forms of Pneumonia

68

Special Forms of PneumoniaSpecial Forms of Pneumonia

69

Complications of PneumoniaComplications of Pneumonia

70

EmpyemaEmpyema

71

Mycoplasma Pneumonia Mycoplasma Pneumonia

72

Mycoplasma PneumoniaMycoplasma Pneumonia

73

Chlamydia TrachomatisChlamydia Trachomatis

74

Rare Types of PneumoniaRare Types of Pneumonia

श्रो�त्रम्� श्रो�तेनै�व नै कु� न्डलेनै

दा�नैनै पा�णि�र्� नैते� कुन्कु�नै

विवभा�विते कु�यः� कुरु�� पार्����

पार्�पाकु�र्� नै चन्दानैनै

shrothram shruthae naiva na kundalaena

dhaanaena paanir na thu kankanaena

vibhaathi kaayah karunaa paraanaam

paropakaaraena na chandanaena

BHARTHRU HARI

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To be kind and sympathetic and helping in all possible ways

Enriches the beauty of our body, nay perfume or sandal paste

shrothram shruthae naiva na kundalaena

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vibhaathi kaayah karunaa paraanaam

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