Objectives

�  Understand the clinical differences between community acquired pneumonia and nosocomial pneumonia and the clinical implications of these differences.

�  Causes, recognition, treatment, prognosis

�  Something about Sepsis

Pneumonia

Definitions

�  Pneumonia: An infection of the lung parenchyma

�  CAP: Pneumonia acquired outside a hospital or an extended care facility

�  Nosocomial Pneumonia

�  Hospital Acquired Pneumonia

�  Ventilator Acquired Pneumonia

�  Healthcare acquired pneumonia

PNEUMONIA �  Epidemiology:

�  5.16 to 6.11 cases per 1000 persons per year

�  4-5 million cases

�  Mortality: 20.3/100,000

�  Seasonal: Winters

�  Race

�  Gender

�  Pneumonia & Influenza: 8th leading cause of death

�  Highest in hospitalized patients

�  23% 30-day mortality

Clin Infect Dis. 2003, 37: 1405-1433 Postgrad Med. 2010;122(2):130 Natl Vital Stat Rep. 2008;56(10):1

PNEUMONIA �  PATHOGENESIS

�  Micro-aspiration of oral particulate and microbial matter

�  Host defenses: innate & acquired-defective

�  Overwhelming inoculum

�  Virulent organism

�  Macro-aspiration

�  Hematogenous

�  Contiguous focus Eur Respir J. 2010;36(5):1080 Am Geriatr Soc. 2008;56(4):661 Ann Intern Med. 2010;152(7):418 Eur Respir J. 2010;36(5):1080

PNEUMONIA

�  Virulence factors:

�  Ciliary function of bronchial epithelium: Chlamydophyla

�  Ciliary structure: Mycoplasma

�  Tracheal mucous: Influenza

�  Proteases against IgA: Streptococcus, N. meningitidis

�  Phagocyte resistance: Mycobacterium, Nocardia, Legionella

Eur Respir J. 2010;36(5):1080 Am Geriatr Soc. 2008;56(4):661 Ann Intern Med. 2010;152(7):418 Eur Respir J. 2010;36(5):1080

PNEUMONIA �  Host factors:

�  Smoking

�  Alcohol

�  Hypoxia

�  Alter MS

�  Acidosis

�  Obstruction of airway

�  Cystic fibrosis & Bronchiectasis

�  COPD

�  Uremia

�  Malnutrition

�  Ciliary dysfunction

�  Immunosuppression

�  Splenectomy Eur Respir J. 2010;36(5):1080 Am Geriatr Soc. 2008;56(4):661 Ann Intern Med. 2010;152(7):418 Eur Respir J. 2010;36(5):1080

PNEUMONIA

�  Medications

�  Gastric acid suppression

�  Antipsychotic

�  Inhaled glucocorticoids

�  Ach agents

Eur Respir J. 2010;36(5):1080 Am Geriatr Soc. 2008;56(4):661 Ann Intern Med. 2010;152(7):418 Eur Respir J. 2010;36(5):1080

CAP

CAP: Microbiology Pathogen Cases (%)

�  Streptococcus pneumoniae 20-60

�  Haemophilus influenzae 3-10

�  Staphylococcus aureus 3-5

�  Gram-negative bacilli 3-10

�  Legionella species 2-8

�  Mycoplasma pneumoniae 1-6

�  Chlamydia pneumoniae 4-6

�  Viruses 2-15

�  Aspiration 6-10

�  Others 3-5

Clin Infect Dis 2003;37:1405-1433.

Severe CAP

�  Influenza

�  SARS

�  Bio-terrorism agents: B. anthracis, Y. Pestis, F. tularensis

�  Nursing homes

�  Post-pneumonia: St. aureus, GNRs

�  Splenectomy

Historical Clues

�  Travel:

�  Ohio Valley Histoplasmosis

�  AZ, CA, NM: Coccidioides

�  Bird droppings: Histoplasmosis

�  Bat/rodent-droppings: Hanta virus

�  Secondary pneumonia

Treatment

�  Outpatient versus inpatient

�  Comorbidities: COPD, HD, CKD, DM, Cancer

�  Duration

Severity of Pneumonia �  PSI/Pneumonia Patient Outcomes Research Team (PORT)

�  Higher scores = higher risk categories = higher risk of admission if Rx’d as outpatient & higher mortality

�  Out-patient Rx for Class I ⅈ observation class III;- admission for class IV and V. Reduce admissions by 25-30%

�  Limitations

�  CURB-65: Confusion, Urea, RR, BP Age > 65

�  SCAP

NOSOCOMIAL PNEUMONIA

Definitions �  HAP: Pneumonia that occurs 48 hours or more after

admission and did not appear to be incubating at the time of admission

�  VAP: Occurs more than 48-72 hours after endotracheal intubation

�  HCAP: non hospitalized patients with extensive healthcare contact (IV Rx, wound care, chemo; nursing home resident; long-term care facility resident; out of hospital in an acute care hospital for two or more days; at hospital/dialysis clinic within prior 30 days

HAP

Epidemiology

�  4-7 cases/1000 hospitalization

�  13-18 % of all nosocomial infections

�  Leading cause of death among nosocomial infections: 20-50% mortality

Respir Care. 1994;39(12):1191 Am J Respir Crit Care Med. 2005;171(4):388 Infect Dis Clin North Am. 2004;18(4):939

Pathogenesis �  Colonization: 75% colonized within 48 hours

�  Virulence, Inoculum amount, Host response

�  Intubated patients: colonization; oral secretions; equipment

�  Gastric sterility

�  Inhalation of infectious aerosols

�  Bacteremia from a distant focus

Respir Care. 2005;50(6):725 Am J Respir Crit Care Med. 1997;156(5):1647

Microbiology

�  Similar flora: HAP & VAP?

�  Infect Control Hosp Epidemiol. 2007;28(7):825.

�  VAP: MSSA (9%), MRSA (18%), P. aeruginosa (18%), St. maltophilia (7%), Acinetobacter (8%)

�  HAP: GNR less likely. MRSA (20%), P. aeruginosa (8%),

Clin Infect Dis. 2010 Aug;51 Suppl 1:S81-7

MDR �  Risk factors:

�  Abx last 90 days

�  Hospitalization >= 5 days

�  High frequency of Abx-resistance in community or specific hospital/unit

�  Immunosuppression

�  HCAP

�  Poor functional status

Diagnosis �  Fever

�  Purulent Sputum

�  Leukocytosis

�  Decrease in oxygenation

&

�  New or progressive radiographic infiltrates

�  Autopsy: 69% Sensitivity; 75% Specificity

VAP

Epidemiology & Presentation

�  A type of nosocomial pneumonia which develops 48 hours after mechanical ventilation instituted

�  Incidence 10-25%

�  Mortality 25-50%

�  Presentation:

�  New or progressive infiltrates and one of the following:

�  Fever, purulent secretions, WBCs

�  A change in ventilator mechanics: increased RR, decreased Vt, increased Ve and decreased oxygenation.

Diagnosis �  Radiographs: 40% of patients with Xray diagnosis of

VAP had Pneumonia at autopsy

�  Respiratory sampling:

�  Tracheobronchial sampling

�  Mini-BAL

�  Bronchoscopic sampling

�  BAL

�  Protected Brush

Bronchoscopic & Non-Bronchoscopic Samples

�  Minimizes contamination of alveolar specimen

�  Accurate assessment of cellularity

�  Narrows antibiotics regimen

�  De-escalation of anti-microbial therapy

�  Reduce Abx-resistance

�  No effect on mortality, LOS, LO-MV

Crit Care Med. 2005;33(1):46 Crit Care Med. 2004;32(11):2183 Am J Respir Crit Care Med. 1998;157(2):371 Ann Intern Med. 2000;132(8):621

Diagnosis: VAP �  Microbiology:

�  Gram Stain:

�  Abundant Neutrophils: < 50% Neutrophils excludes VAP

�  Type of bacteria

�  Quantitative cultures

�  Tracheobronchial aspiration: 106 cfu

�  BAL: 104 cfu

�  Protected brushes: 103 cfu

�  Semi-quantitative Cultures:

�  “Heavy”, “moderate”, “light” or “No growth”

Biological Markers �  PROCALCITONIN

�  Origin: Probable evolutionary protection against bacterial infection

�  Robust data:

�  Decrease in use of and length of Abx

�  Increasing values: septic shock and higher mortality

�  Decreasing PCT: de-escalate ABx

�  High PCTs exclude viral infection (except co-infection)

�  Possibly:

�  Low PCT may mean bacterial infection unlikely

Other Diagnostics � Clinical Pulmonary Infection Score (CPIS)

�  Temperature, WBC, Tracheal secretions, Oxygenation, CXR, Progression of pulmonary infiltrates, Tracheal Cultures

�  Score > 6

�  Sensitivity 60%, Specificity 59%

� CRP

� Lung Biopsy

Diagnostic criteria

�  MV > 48 hours

�  New or progressive infiltrates

�  +ve respiratory specimen:

�  Neutrophilic cells

�  Threshold culture

SEPSIS

Definitions �  SIRS:

�  Generic term.

�  May have its cause in non-infectious conditions

�  Temperature, HR, RR/PCO2, WBC

�  Sepsis: Systemic inflammation which is caused by an infection

Definitions

�  Severe Sepsis:

�  Sepsis with hypoperfusion

�  Skin, nailbed, UO, MS changes

�  Septic Shock with low BP despite adequate fluid resuscitation

�  Refractory Shock

�  MOD: PF ration, Creatinine, GCS

CASES

Case 1 �  49-year-old WF h/o bipolar disorder, conversion disorder, found unresponsive at

home. Before intubation in the field, she had a large emesis. She remained unresponsive and her pupils were dilated up on her initial evaluation according to the ER physician. In the emergency room, she became hypotensive and received several boluses of fluid.

�  Temp 96.4. BP 74/54 HR 92

�  CBC 11.7, 14.8/46, 232

�  Chem: 133/3.9, 101/20, 10/0.93, 140

�  Lactate 3.7

�  ABG: 7.29, 46, 170 on 100% O2

�  4 liters of fluid later, SBP 80, HR 80

Case 2 �  84 BM (DM, AF, CAD ESRD on PD) in & out of hospitals

with peritonitis now admitted with peritonitis. He has an altered MS, intubated for 4 days. Antibiotcs. He returns to the ICU with fever 101F, altered MS, respiratory difficulty and is intubated.

�  Temp 101F, BP 80/-, HR 99.

�  PaO2/FiO2 200

�  WBC 3.2 Hgb 8 gm/dl, Plt 23K.

�  Bronchosocpy with BAL: GNR 105 cfu.

Case 3

�  30 HM quadriplegic, otherwise in good health comes with altered MS

�  Exam: Febrile, BP 101/- HR 130, abdomen distended

�  Soon after, hypotensive. Belly firm. IAP: 40. UO drops off from 30/hr to 10/hr. WBC 15k. Creatinine 1.6

Case 4 �  32 WF with ESRD on HD through a Permcath admitted with AMS.

�  Temp 102.3. BP 82/32. HR 130, RR 30

�  CBC 11.4, 9/36, 55

�  ABG 7.2, 9, 34 on 28% O2

Case 5

�  70 WM with Stage 1 Sqamous Cell Cancer admitted to ICU post-op after LUL resection – hypercapnic, supported with BiPAP. On Day 3, he is worse:

WBC 25K Temp 101.3 Intubated and bronched. Not much secretions PCT 3

Thanks