PNEUMONIIInflama ii acute ale parenchimului pulmonar determinate de infec ii i uneori de agen i chimici i iradiere Pneumonii comunitare nosocomiale

PNEUMONII1. Prima cauz de mortalitate infec ioas 2. Cel mai frecvent patogen Streptococcus pneumoniae 3. Manifest ri clinice - comune - particularit i func ie de agentul etiologic

PNEUMONII3. Evolu ia, prognosticul - etiologie, vrst , comorbiditate 4. Identificarea ag. etiologic < 50% cazuri 5. Terapie ini ial empiric - epidemiologie, etiologie - antibiorezisten a

PNEUMONII COMUNITAREADULTStreptococcus pneumoniae 40% Haemophylus influenzae Mycoplasma pneumoniae Legionella pnumophila Chlamydia pneumoniae Klebsiella pneumoniae Staphyloccocus aureus Virusul influaenza

60% 90%

10%

PNEUMONII COMUNITARECOPII 6ani VRSTNIC(forme grave)Haemophylus influenzae tip B Virus sincitial respirator Virus parainfluenzae Micoplasma pneumoniae Chlamydia pneumoniae Klebsiella pneumoniae Staphyloccocus aureus Germeni anaerobi Legionella pneumophila

1. Pneumonii comunitare Etiologia-vrsta -anotimp -profesie -comorbiditate-alcoolism - Klebsiella pneumoniae -BPOC- S. pneumoniae, H. influenzae, -diabet- St. aureus, bacili gram neg, -post gripal St. aureus, -fibroza chistic - Pseudomonas aeruginosa -cancer bronhopulmonar- Moraxella chataralis

PATOGENIE1. secre ii orofaringiene - S. pneumoniae, H. influenzae, M.pneumoniae 2. aerosoli infecta i Legionella pneumophila,C.pneumoniae, M.pneumoniae,virus influenzae, M. tuberculosis, Histoplasma 3. diseminare hematogen - S. aureus

PATOGENIE1. apararea local sc zut- fum tori, fibroza chistic , bron ectazii, BPOC

2. apararea sistemic sc zut- 65 ani - alcoolism - boli cronice: - diabet, - insuf. renal , hepatic , cardiac - imunoincompeten - primar : - secundar : leucemii, limfoame, infec ie HIV, post chimio i corticoterapie, radioterapie

MORFOPATOLOGIE1. Pneumonie tipic- S. pneumoniae, S.aureus, bacili gram negativi

- lobar -segmental - bronhopneumonie 2. Pneumonie intersti ial- H. influenzae, M.pneumoniae, C. pneumoniae, Legionella, virus gripal, Pneumocystis carinii, etc

MANIFEST RI CLINICE PNEUMONIA TIPIC1.Simptome- febra, frison, durere toracic , - tuse, expectora ie mucopurulent , c r mizie

2. Examen fizic- tahipnee, cianoz - matitate - vibra ii vocale accentuate - suflu tubar, raluri crepitante - tahicardie, normo sau hTA

PNEUMONIA ATIPIC1. Simptomefebra, frisoane, rinoree, catar nazal, congestie conjunctival , tuse, expectora ie uscat , seroas manifest ri extrarespiratorii: cutanate, neurologice, hepatice

2. Examen fizic- tahipnee, tahicardie, -f r

modific ri sonoritate i murmur resirator

EXAMENE PARACLINICE PNEUMONIA TIPIC1. Rx. grafia pulmonar- opacitate segmental , - opacitate lobar , delimitare scizural structur relativ omogen - opacit i macronodulare bronhopneumonice, pneumatocele

- evolu ia: rezolu ie, abcedare - pleurezia parapneumonic

PNEUMONIA TIPIC1. Rx. grafia pulmonar- 30% pnumonia P carinii - pneumonia hematgena

fals negativa

1.CT

mai sensibila pentru diagnostic

- pnumonia retrocardiaca, - pneumonia ascunsa coaste, diafragm - microabcese - cauze subiacenta - neoplazii - adenopatii mediastinale

EXAMENE PARACLINICE PNEUMONIA ATIPIC1. Rx. grafia pulmonar- desen intersti ial accentuat hilobazal - evolu ia: rezolu ie - luni - pleurezia parapneumonic , cantitate mic

EXAMENE PARACLINICE PNEUMONIA TIPIC2. Hemoleucograma- leucocitoz - neutrofilie - VSH crescut

PNEUMONIA ATIPIC2. Hemoleucograma- NL normal- limfocitoz - VSH normal

IDENTIFICAREA AGENTULUI PATOGEN-Examen sput - sputa indusa salina 2% nebulizare sol.

- Examen secre ii bron ice - LBA (lavaj bronho-alveolar) - bronhoscopie - asiparat transtraheal

IDENTIFICAREA AGENTULUI PATOGEN- Examen sput , secre ii bron ice- produs>25PMN si 1:20 IgG >1:128 sau de 4 ori crestere IgG- Legionella Atc anti Legionella un titru>1:256 de 4 ori pana la 1:128

Factori de risc - prognostic grav1. F. demografici - vrsta >65ani, reziden a institu ionalizat 2. Boli coexistene - renale, hepatice, diabet insuf. cardiac , neoplasme, 3. Ex.fizic - FR>30/min AV>120/min TA40 si 30/min paO2/FiO2 > 25 Rx. - cre terea infiltratelor cu 50% in 48 ore Nevoie de vasopresoare >4 ore

COMPLICA II PNEUMONIA TIPICMortalitatea 0,4-50% 1. oc toxico-septic - IRA (SDRA) 2. Pleurezie, empiem, piopneumotorax 3. Abcedare S aureus, BGN, S pneumniae tip III

4. Pericardit , mediastinit 5. Glomerulonefrita ( complexe imune) 6. Agravare/declansare IC la pacienti cu boli cardiace 7. Agravare IR /declansare IRA la varstnici, pacienti cu boli renale cronice

PNEUMONIA PNEUMOCOCICEtiopatogenieS. pneumoniae80 tipuri - 50% rezisten la penicilin

IdentificareEx. sput - frotiu: coci gram +, capsula i, lanceola i, diplo, lan uri culturi -geloz snge - inhibare cu optochin

Manifest ri clinicepneumonie tipic - lobar

evolu ie cu ameliorare la 2-3 zile sub antibioterapie boal pneumococcic invaziv - cu bacteriemie i metastaze septice - vrstnici, alcoolici, - comorbiditate

Factori de risc boala pneumococic invaziv- vrsta 65 ani - alcoolismul cronic - comorbiditatea

:

- imunodeficien a congenital i dobndit - infec ia cu S. pneumoniae rezistent la penicilin

TratamentS. pneumoniae1. sensibil la penicilin - penicilin G 1-2 mil iv la 4ore 2. rezisten intermediar la penicilin - penicilin G 10-20 mil iv 24ore - amoxicilin / ac. clavulanic 2-6g/zi - cefotaxim 1-2g la 6 ore iv, - ceftriaxon 2g/zi 3. rezisten la peniciin - vancomicin , imipenem, ticarcilina clavulanat

ProfilaxieVaccinare S. pneumoniae16 valent, 23 valent - Pneumovax

Indica ii- 2-65 ani cu boli cronice i

imunoincompeten - >65ani

Eficien a : 5 anireducerea bolii pneumococice invazive

PNEUMONIA STAFILOCOCICEtiopatogenieS. aureus- coc gram+ - agresiv : enzime: hialuronidaz ,proteaze, lipaze toxine: TSS -1,toxina piretogen

antibiorezisten

Manifest ri clinicepneumonie tipic - lobar , bronhopneumonie sputa- purulent , purulent hemoptoic evolu ie grav - oc toxico-septic, metastaze septice - abcedare - pleurezie, piopneumotorax

Rx. Pulmonarpneumonie - lobar , cavita ie bronhopneumonie cu pneumatocele pleurezie, piopneumotorax

IdentificareS. aureus Ex. sput - frotiu: coci gram + culturi -agar - colonii g lbui teste de coagulazopozitivitate Hemocultur , lichid pleuralAntibiogram - rezisten a la meticilin - rezisten a la vancomicin

TratamentS. aureus1. sensibil la penicilin - penicilin G 4 mil iv la 4ore 2. sensibil la meticilin - oxacilina, meticilin 6 - 10g iv 24ore - cefazolin 2g la 8 ore iv, - betalactamine+aminoglicozide, rifampicina 3. rezisten la meticilin - vancomicin 1g la 12 ore

PNEUMONIA BACILI GRAM Haemophilus influenzae Ex. sput : frotiucocobacili gram -, pleiomorfi, mici, ncapsula i

culturi : agar chocolat, njurul coloniilor de stafilococ

- pneumonii : BPOC, fum tori, vrstnici, neoplazici, sarcin

PNEUMONIA cu Haemophilus influenze- azitromicina, claritromicina sau alternative

- amoxicilina/clavulanat - doxiciclina - fluoroquinolone

PNEUMONIA BACILI GRAM K. pneumoniae Ex. sput : frotiucocobacili gram negativi, imobiliantibiorezisten : cefalosporinaze betalactamaze

PNEUMONIA BACILI GRAM Klebsiella pneumoniae- pneumonii : alcoolici, diabetici, BPOC, imunocompromi i - pneumonie lobar , lob superior, pleurezie frecvent TRATAMENT: - cefalosporine genera ia III + aminoglicozizisau

+piperacilina/clavulanat

PNEUMONIA cu Legionella pneumophila(bacil gram neg slab colorat Gram)

- patogen oportunist aerob, intra i extracelular

- surse de contaminare: noroiul b l ilor,rezervoare de ap , bazine, sisteme de iriga ie, aer condi ionat, sauna, etc2-15% pneumonii comunitare, 15-50% pneumonii nosocomiale

1. Manifest ri pulmonare - forma u oar - febra Pontiac - pneumonie atipic - pneumonie lobar , multisegmental 2. Manifest ri extrapulmonare - gastrointestinale, hepatice, splenomegalie - mialgii - cardiace - miopericardit - neurologice - confuzie, sindr. meningean

1. Rx pulmonar - pneumopatie intersti ial - pneumonie segmental - pneumonie lobar , multisegmental 2. Ex biologice - leucocitoz , neutrofilie, hiponatriemie 2. Diagnostic etiologic- identificare : L pneumophila - medii charcoal(cisteina, fier ph7) - Ag Lp-1 sput , urin(radioimunotestare)

- PCR

- Pneumnie atipic i risc de infec ie cu L. pneumophila- macrolide : eritromicina, claritromicina(500mg iv 12 ore)

azitromicina,- chinolone: pefloxacine 400mg la 12 ore

ciprofloxacine 500mg la 12 ore - rifampicina 300-600mg po , iv la 12 ore

PNEUMONIA cuMycoplasma pneumoniae- Mycoplasma pneumoniae - germenpleiomorf, f r perete celular, parazit intracelular

- 1. coriz , faringit , otit , traheobron it - 2. pneumonie atipic - 3. Maniest ri extrapulmonare

- 3. Manifest ri extrapulmonare - cutanate: eritem polimorf, eritem maculopapular, sindr. Stevens Jonson, - stomatit ulcerativ - miozit - miopericardit -meningoencefalite Tratament : macrolide, tetraciclina

PNEUMONIA cuChlamydii - Cl pneumoniae - patogen ubicvitar- coriz , faringit , otit , traheobron it - pneumonie atipic , segmental tratament- claritromicina, azitromicina

- Cl psittaci - patogen al p

s rilor

PSITACOZA- Cl psittaci - febra, cefalee, mialgii, adenopatie cervical - pneumonie intersti ial - mio-pericardit -tulb. gastrointestinale, splenomegalie, icter - meningoencefalit - rash

PNEUMONIA cu Pneumocystis carinii- Pneumocystis carinii - patogen oportunist,trofozit - prechist , chist cu 8 corpusculi intrachistici f r perete celular, parazit intracelular

- infecta i HIV - pneumonie atipic - Rx grafie: pneumopatie intersti ial - CT: atenuare sticl mat identificare : colora ie Giemsa2, albastru demetilen, violet crezil

PNEUMONIA cu Cytomegalovirus- Cytomegalovirus replicare n celule nucleate - inciden a : gazde imunocompromise(transplant organe,HIV CD4 < 100 celule/mm 3 , etc)

- pneumopatie intersti ial

- FO - retinopatie hemoragic - tratament : ganciclovir 5mg/kg la 12 re

TRATAMENT PNEUMONIA COMUNITARScor PORT (Pneumonia Patient Outcomes Research Team )

1. IN AFARA SPITALULUI -pacien i60ani -vrstnici institu ionaliza i -antibioterapie ambulatorie ineficient - factori de prognostic grav - complica ii - condi ii ce fac imposibil antibioterapia la domiciliu

TRATAMENT 2. IN UNIT I DE TERAPIE INTENSIV RESPIRATORIE- stare de oc

-TA7,5cm - concomiten a sondelor naso-gastrice - antecedente: fumat, BPOC

PNEUMONII NOSOCOMIALEDiagnosticfebra expectoratie mucopurulenta absente leucocitoza la neutropenici infiltrate pulmnare

Pneumonia de ventilatorDiagnostic:- descre terea PaO2/FiO2 - secre ii distale persistente - ex. bacteriologic secre ii bron ice distale

Pneumonia nosocomial- gravitate medie, oricand debutataCefalosporine II, III nepseudomoniazice (cefotaxim, ceftriaxon), IV betalactamine/inhib. betalactamazic

+Clindamicina

Pneumonia nosocomial- risc Pseudomonas aeruginosa Cefalosporine antipseudomoniazice(ceftazidim 2g la 8 ore, cefoperazon ),

Peniciline antipseudomoniazice(ticarcilin /clavulanat, piperacilin /tazobactam),

Carbamapeneme(imipenem 500mg la 6ore)