pneumonia ken lyn-kew, m.d.. normal chest x-ray courtesy of up to date

PneumoniaPneumonia

Ken Lyn-Kew, M.D.Ken Lyn-Kew, M.D.

Normal Chest X-RayNormal Chest X-Ray

Courtesy of Up To Date

Review of Lung AnatomyReview of Lung Anatomy

http://www.meddean.luc.edulumenMedEdGrossAnatomythorax0thor_lecthorax1.jpg

RUL

RML

RLL

LUL

LLL

Lingula

What is pneumonia?What is pneumonia?

• Infection of the Infection of the lung parenchymalung parenchyma

• Causative agents Causative agents include bacteria, include bacteria, viruses, fungiviruses, fungi

www.netmedicine.com/xray/xr.htm

How do we classify How do we classify pneumonia?pneumonia?

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

• Nosocomial/Hospital Acquired Nosocomial/Hospital Acquired PneumoniaPneumonia

• Others, such as PCP, BOOPOthers, such as PCP, BOOP

CAPCAP

• CAP = pneumonia in person not CAP = pneumonia in person not hospitalized or residing in a long-hospitalized or residing in a long-term care facility for term care facility for 14 days 14 days

Clinical Infectious Diseases 2000;31:347-82

CAP - Why do we care about CAP - Why do we care about it?it?

• 5.6 million cases annually5.6 million cases annually

• 1.1 million require hospitalization1.1 million require hospitalization

• Mortality rate =12% in-hospital; near Mortality rate =12% in-hospital; near 40% in ICU patients40% in ICU patients

Am J Respir Crit Care Med 163:1730-54, 2001

CAP – Patient StratificationCAP – Patient Stratification


CAP – TestingCAP – Testing

• CXRCXR

• Sputum Gram Stain and cultureSputum Gram Stain and culture

• Pulse oximetry Pulse oximetry

• Routine lab testing – CBC, BMP, LFTsRoutine lab testing – CBC, BMP, LFTs

• ABGABG

• Thoracentesis if pleural effusion Thoracentesis if pleural effusion presentpresentAm J Respir Crit Care Med 163:1730-54, 2001

CAP – Modifying FactorsCAP – Modifying Factors


CAP – Modifying FactorsCAP – Modifying Factors


MODIFYING FACTORS THAT INCREASE THE RISK OFINFECTION WITH SPECIFIC PATHOGENSPenicillin-resistant and drug-resistant pneumococci Age > 65 yr B-Lactam therapy within the past 3 mo Alcoholism Immune-suppressive illness (including therapy w/ corticosteroids) Multiple medical comorbidities Exposure to a child in a day care centerEnteric gram-negatives Residence in a nursing home Underlying cardiopulmonary disease Multiple medical comorbidities Recent antibiotic therapyPseudomonas aeruginosa Structural lung disease (bronchiectasis) Corticosteroid therapy (10 mg of prednisone per day) Broad-spectrum antibiotic therapy for > 7 d in the past month Malnutrition

CAP – AlgorithmsCAP – Algorithms


Duration of TherapyDuration of Therapy

• ? ? ? ? ? ?? ? ? ? ? ?

• 5 -7 days - outpatients5 -7 days - outpatients

• 7-10 days – inpatients, 7-10 days – inpatients, S. pneumoniaeS. pneumoniae

• 10-14 days – 10-14 days – Mycoplasma, Chlamydia, Mycoplasma, Chlamydia, LegionellaLegionella

• 14+ days - chronic steroid users14+ days - chronic steroid users


CAP -The Switch to Oral CAP -The Switch to Oral AntibioticsAntibiotics

• Switch if patient meets the following:Switch if patient meets the following:– Inproved cough and dyspneaInproved cough and dyspnea– Afebrile on 2 occasions 8 hours apartAfebrile on 2 occasions 8 hours apart

• If otherwise improving way waive this If otherwise improving way waive this criteriacriteria

– Decreasing WBC countDecreasing WBC count– Functional GI tract with adequate PO Functional GI tract with adequate PO

intakeintakeAm J Respir Crit Care Med 163:1730-54, 2001

CAP - PreventionCAP - Prevention

• Influenza VaccineInfluenza Vaccine

• Pneumococcal VaccinePneumococcal Vaccine

RememberRemember

• Influenza VaccineInfluenza Vaccine

• Pneumococcal VaccinePneumococcal Vaccine

• After discharge – Follow up CXR to exclude After discharge – Follow up CXR to exclude cancercancer

BEFORE DISCHARGE!!!!

HAPHAP

• Pneumonia occurring ≥48 h post Pneumonia occurring ≥48 h post admissionadmission

• Excludes infection incubating at time Excludes infection incubating at time of admissionof admission


HAP - EpidemiologyHAP - Epidemiology

• 5 to 10 cases per 1,000 hospital 5 to 10 cases per 1,000 hospital admissionsadmissions

• Incidence MUCH higher with Incidence MUCH higher with mechanical mechanical ventilationventilation (6-20 fold higher) (6-20 fold higher)

• Second most common nosocomial Second most common nosocomial infection but number one for M & Minfection but number one for M & M

• Mortality near 70% in patients with HAPMortality near 70% in patients with HAP• Increased length of stay by 7-9 daysIncreased length of stay by 7-9 days


HAP – StratificationHAP – Stratification


HAP – Failure of TherapyHAP – Failure of Therapy

• Incorrect diagnosis – it is not pneumoniaIncorrect diagnosis – it is not pneumonia– Atelectasis, CHF, PE with infarction, lung Atelectasis, CHF, PE with infarction, lung

contusion, chemical pneumonitis, ARDS, contusion, chemical pneumonitis, ARDS, pulmonary hemorrhagepulmonary hemorrhage

• Pathogen resistancePathogen resistance

• Host factors that increase mortalityHost factors that increase mortality– Age > 60, prior pneumonia, chronic lung diseaseAge > 60, prior pneumonia, chronic lung disease– immunosuppressionimmunosuppression

• Antibiotic resistanceAntibiotic resistance


HAP - PreventionHAP - Prevention

• Hand washingHand washing• VaccinationVaccination

– InfluenzaInfluenza– PneumococcusPneumococcus

• Isolation of patients with resistant Isolation of patients with resistant respiratory tract infectionsrespiratory tract infections

• Enteral nutritionEnteral nutrition• Choice of GI prophylaxisChoice of GI prophylaxis• Subglottoc secretion removal?Subglottoc secretion removal?


PCPPCP

www.netmedicine.com/xray/xr.htm

Pneumocystis CariniiPneumocystis Carinii //Pneumocystis jiroveciPneumocystis jiroveci11 Pneumonia (PCP)Pneumonia (PCP)• Uncommon until 1980’s with Uncommon until 1980’s with

emergence of HIV diseaseemergence of HIV disease

• Caused by organism most closely Caused by organism most closely related to fungirelated to fungi

• Mode of transmission unclear, but Mode of transmission unclear, but felt to represent reactivation of felt to represent reactivation of latent infectionlatent infection

PCP reference = Harrison’s Principles of Internal Medicine

11http://www.cdc.gov/ncidod/EID/vol8no9/02-0096.htm

PCP PneumoniaPCP Pneumonia

• Gradual onset of symptomsGradual onset of symptoms

• Common symptoms include fever, Common symptoms include fever, cough, progressive dyspneacough, progressive dyspnea

• Many patients asymptomaticMany patients asymptomatic

• May present as a spontaneous May present as a spontaneous pneumothoraxpneumothorax

PCP – Lab WorkPCP – Lab Work

• CD4 <200CD4 <200• LDHLDH

– Elevated in HIV+ persons w/ PCPElevated in HIV+ persons w/ PCP– Very high values and increasing levels in face Very high values and increasing levels in face

of therapy correlate w/ poorer prognosisof therapy correlate w/ poorer prognosis• ABGABG

– PaO2 <70 indication for steroidsPaO2 <70 indication for steroids• Lung samplingLung sampling

– Definitive diagnosis dependent on isolation of Definitive diagnosis dependent on isolation of PneumocystisPneumocystis

PCP - TreatmentPCP - Treatment

• TMP/SMX (TMP/SMX (trimethoprim/sulfamethoxazoletrimethoprim/sulfamethoxazole))– Drug of choiceDrug of choice– High incidence of side effects in HIV+ ptsHigh incidence of side effects in HIV+ pts

• Dapsone + TMPDapsone + TMP

• Clindamycin + primaquineClindamycin + primaquine

• AtovaquoneAtovaquone

• Pentamadine IVPentamadine IV

PCP - ProphylaxisPCP - Prophylaxis

• TMP/SMX* – DS 3x/wk or SS qdTMP/SMX* – DS 3x/wk or SS qd

• Dapsone +/- pyrimethamine*Dapsone +/- pyrimethamine*

• Aerosolozed pentamadineAerosolozed pentamadine

• AtovaquoneAtovaquone

*= also prophylaxis for *= also prophylaxis for ToxoplamaToxoplama

MKSAP QuestionsMKSAP Questions

A 72-year-old man is hospitalized because of fever, chills, and cough A 72-year-old man is hospitalized because of fever, chills, and cough that have persisted for the past week. His medical history includes that have persisted for the past week. His medical history includes congestive heart failure, chronic bronchitis, and diabetes mellitus. congestive heart failure, chronic bronchitis, and diabetes mellitus. On physical examination, he is alert and in moderate respiratory On physical examination, he is alert and in moderate respiratory distress. His temperature is 39 °C (102.2 °F), pulse rate is 120/min, distress. His temperature is 39 °C (102.2 °F), pulse rate is 120/min, respiration rate is 36/min, and blood pressure is 100/60 mm Hg. The respiration rate is 36/min, and blood pressure is 100/60 mm Hg. The physical examination reveals crackles in both lung fields at the physical examination reveals crackles in both lung fields at the bases. The jugular venous wave is noted 12 cm above the right bases. The jugular venous wave is noted 12 cm above the right atrium, and a soft S3 gallop is present on auscultation. atrium, and a soft S3 gallop is present on auscultation. The leukocyte count is 21,000/μL, serum sodium is 124 meq/L, and The leukocyte count is 21,000/μL, serum sodium is 124 meq/L, and serum creatinine is 2.4 mg/dL. Chest x-ray shows infiltrates in the serum creatinine is 2.4 mg/dL. Chest x-ray shows infiltrates in the right upper, left upper, and left lower lobes. Bronchiectactic changes right upper, left upper, and left lower lobes. Bronchiectactic changes are seen throughout the lower lung fields bilaterally. Measurement are seen throughout the lower lung fields bilaterally. Measurement of arterial blood gases obtained on room air shows the following: of arterial blood gases obtained on room air shows the following: pH, 7.38; Paco2, 32 mm Hg; and Pao2, 58 mm Hg. pH, 7.38; Paco2, 32 mm Hg; and Pao2, 58 mm Hg. Which one of the following antibiotic regimens is the most Which one of the following antibiotic regimens is the most appropriate for this patient?appropriate for this patient? ( A ) Doxycycline( A ) Doxycycline( B ) Azithromycin( B ) Azithromycin( C ) Ceftriaxone( C ) Ceftriaxone( D ) Ciprofloxacin( D ) Ciprofloxacin( E ) Piperacillin-tazobactam and levofloxacin( E ) Piperacillin-tazobactam and levofloxacin

• Educational ObjectiveEducational Objective

• Select an appropriate empiric antibiotic regimen for a patient with severe Select an appropriate empiric antibiotic regimen for a patient with severe community-acquired pneumonia with structural lung disease. community-acquired pneumonia with structural lung disease.

• CritiqueCritique (Correct Answer = (Correct Answer = EE))

• This patient has severe community-acquired pneumonia (pneumonia This patient has severe community-acquired pneumonia (pneumonia severity index class 5) complicated by evidence of bronchiectasis on chest severity index class 5) complicated by evidence of bronchiectasis on chest radiograph. Risk factors responsible for this patient’s increased risk of radiograph. Risk factors responsible for this patient’s increased risk of mortality include his advanced age, the presence of significant mortality include his advanced age, the presence of significant comorbidities, unstable vital signs, significant hypoxia, hyponatremia, and comorbidities, unstable vital signs, significant hypoxia, hyponatremia, and acute renal failure. Although the actual pathogen is not identified in most acute renal failure. Although the actual pathogen is not identified in most cases of community-acquired pneumonia, the most common causes are cases of community-acquired pneumonia, the most common causes are Streptococcus pneumoniaeStreptococcus pneumoniae, , LegionellaLegionella species, aerobic gram-negative species, aerobic gram-negative bacilli, bacilli, Haemophilus influenzaeHaemophilus influenzae, , Mycoplasma pneumoniaeMycoplasma pneumoniae, and respiratory , and respiratory viruses. viruses. Pseudomonas aeruginosaPseudomonas aeruginosa is more common among patients with is more common among patients with structural lung disease, such as bronchiectasis. Because this patient has structural lung disease, such as bronchiectasis. Because this patient has life-threatening pneumonia, and especially because he has structural lung life-threatening pneumonia, and especially because he has structural lung disease, coverage of disease, coverage of P. aeruginosa P. aeruginosa is recommended. Piperacillin-is recommended. Piperacillin-tazobactam combined with levofloxacin would effectively provide double tazobactam combined with levofloxacin would effectively provide double coverage for coverage for P. aeruginosaP. aeruginosa and would cover atypical pathogens. In clinical and would cover atypical pathogens. In clinical trials, doxycycline has been shown to be an effective regimen for patients trials, doxycycline has been shown to be an effective regimen for patients with mild to moderate pneumonia, but concern about resistant with mild to moderate pneumonia, but concern about resistant pneumococcal species in severe cases and a lack of extended gram-pneumococcal species in severe cases and a lack of extended gram-negative spectrum would argue against its use here. Coverage of negative spectrum would argue against its use here. Coverage of LegionellaLegionella and and MycoplasmaMycoplasma species should be a high priority; therefore, species should be a high priority; therefore, ceftriaxone alone is not a viable treatment option. Azithromycin covers ceftriaxone alone is not a viable treatment option. Azithromycin covers S. S. PneumoniaePneumoniae, , H. InfluenzaeH. Influenzae, and most atypicals, but lacks coverage against , and most atypicals, but lacks coverage against P. aeruginosaP. aeruginosa. Some strains of . Some strains of S. pneumoniaeS. pneumoniae are resistant to are resistant to ciprofloxacin; levofloxacin has enhanced coverage against ciprofloxacin; levofloxacin has enhanced coverage against S. pneumoniaeS. pneumoniae and might be a more appropriate choice. and might be a more appropriate choice.

• An 84-year-old man with chronic obstructive pulmonary An 84-year-old man with chronic obstructive pulmonary disease is taken to the emergency department from his disease is taken to the emergency department from his nursing home because of fever and increased shortness of nursing home because of fever and increased shortness of breath. On physical examination, he is confused. His breath. On physical examination, he is confused. His temperature is 39.4 °C (103 °F), pulse rate is 110/min, temperature is 39.4 °C (103 °F), pulse rate is 110/min, respiration rate is 32/min, and blood pressure is 110/60 mm respiration rate is 32/min, and blood pressure is 110/60 mm Hg. His mucous membranes are dry, and his neck is supple. Hg. His mucous membranes are dry, and his neck is supple. Lung examination reveals only distant breath sounds. The Lung examination reveals only distant breath sounds. The remainder of the examination is normal. The leukocyte remainder of the examination is normal. The leukocyte count is 14,000/µL with a left shift. Oxygen saturation is count is 14,000/µL with a left shift. Oxygen saturation is 85% by pulse oximetry. Chest radiograph shows changes of 85% by pulse oximetry. Chest radiograph shows changes of emphysema and right lower lobe and right middle lobe emphysema and right lower lobe and right middle lobe infiltrates. The patient is unable to produce sputum. infiltrates. The patient is unable to produce sputum.

• Which of the following intravenous antibiotics is Which of the following intravenous antibiotics is most appropriate?most appropriate?

• ( A ) Ceftriaxone( A ) Ceftriaxone( B ) Ceftriaxone plus azithromycin( B ) Ceftriaxone plus azithromycin( C ) Ciprofloxacin( C ) Ciprofloxacin( D ) Azithromycin( D ) Azithromycin( E ) Imipenem( E ) Imipenem


• Manage a patient with pneumonia acquired in a nursing home who meets Manage a patient with pneumonia acquired in a nursing home who meets criteria for inpatient management.criteria for inpatient management.

• CritiqueCritique (Correct Answer = (Correct Answer = BB))

• This patient is best managed in the hospital because of risk of a poor This patient is best managed in the hospital because of risk of a poor outcome as defined by the Pneumonia PORT (Patient Outcomes Research outcome as defined by the Pneumonia PORT (Patient Outcomes Research Team) study. He has evidence of dehydration (dry mucous membranes), Team) study. He has evidence of dehydration (dry mucous membranes), possibly indicating poor oral intake in addition to insensible fluid losses due possibly indicating poor oral intake in addition to insensible fluid losses due to fever. He is therefore a candidate for parenteral treatment with fluid to fever. He is therefore a candidate for parenteral treatment with fluid replacement as well as antibiotics. The principal pathogens causing replacement as well as antibiotics. The principal pathogens causing community-acquired pneumonia are community-acquired pneumonia are Streptococcus pneumoniaeStreptococcus pneumoniae, , Haemophilus influenzae, Moraxella catarrhalisHaemophilus influenzae, Moraxella catarrhalis, and atypical pathogens , and atypical pathogens such as such as Legionella Legionella spp. A nursing-home patient also has an increased risk spp. A nursing-home patient also has an increased risk of gram-negative pathogens, such as of gram-negative pathogens, such as Klebsiella pneumoniaeKlebsiella pneumoniae. Ciprofloxacin . Ciprofloxacin has less activity than levofloxacin against has less activity than levofloxacin against S. pneumoniaeS. pneumoniae, and there have , and there have been ciprofloxacin failures in patients with serious pneumococcal been ciprofloxacin failures in patients with serious pneumococcal infections. Ceftriaxone alone covers infections. Ceftriaxone alone covers H. influenzaeH. influenzae, , M. catarrhalisM. catarrhalis, and most , and most strains of strains of S. pneumoniaeS. pneumoniae and and K. pneumoniaeK. pneumoniae but lacks activity against but lacks activity against atypical pathogens. Azithromycin may also be effective coverage, as it is atypical pathogens. Azithromycin may also be effective coverage, as it is effective against atypical pathogens, some gram negative pathogens, and effective against atypical pathogens, some gram negative pathogens, and most strains of most strains of S. pneumoniaeS. pneumoniae, but increasing resistance of , but increasing resistance of S. pneumoniaeS. pneumoniae to macrolides such as azithromycin may be of concern in a severely ill to macrolides such as azithromycin may be of concern in a severely ill patient. Imipenem has broad-spectrum activity against all of the patient. Imipenem has broad-spectrum activity against all of the conventional bacterial pathogens, but lacks activity against atypical conventional bacterial pathogens, but lacks activity against atypical pathogens. A combination of ceftriaxone and azithromycin adequately pathogens. A combination of ceftriaxone and azithromycin adequately covers all likely pathogens. covers all likely pathogens.

• A 78-year-old man is evaluated because of a 4-A 78-year-old man is evaluated because of a 4-day history of fever and cough productive of thick day history of fever and cough productive of thick sputum. He has never smoked. Clarithromycin, sputum. He has never smoked. Clarithromycin, given for the past 8 days, has been ineffective. A given for the past 8 days, has been ineffective. A blood culture drawn in the office 2 days ago is blood culture drawn in the office 2 days ago is reported to be growing gram-positive cocci in reported to be growing gram-positive cocci in pairs, most likely pairs, most likely S. pneumoniaeS. pneumoniae. Chest . Chest radiograph shows an infiltrate in the right lower radiograph shows an infiltrate in the right lower lobe. The patient is unable to produce sputum for lobe. The patient is unable to produce sputum for examination. examination.

• Which of the following antibiotics, Which of the following antibiotics, administered intravenously, is the most administered intravenously, is the most appropriate initial therapy?appropriate initial therapy?

• ( A ) Azithromycin( A ) Azithromycin( B ) Levofloxicin( B ) Levofloxicin( C ) Ceftazidime( C ) Ceftazidime( D ) Trimethoprim-sulfamethoxazole( D ) Trimethoprim-sulfamethoxazole


• Identify the most appropriate treatment for a patient with bacteremic Identify the most appropriate treatment for a patient with bacteremic pneumococcal pneumonia not responding to clarithromycin.pneumococcal pneumonia not responding to clarithromycin.


• This patient with bacteremic pneumonia is not improving on therapy This patient with bacteremic pneumonia is not improving on therapy with clarithromycin, suggesting a clarithromycin-resistant isolate. with clarithromycin, suggesting a clarithromycin-resistant isolate. Gram-positive cocci in pairs growing from the blood culture suggest Gram-positive cocci in pairs growing from the blood culture suggest pneumococci. Fluoroquinolones with increased activity against pneumococci. Fluoroquinolones with increased activity against pneumococci, such as levofloxacin and sparfloxacin, would be pneumococci, such as levofloxacin and sparfloxacin, would be beneficial for this patient. beneficial for this patient.

• Clarithromycin and other macrolides, such as erythromycin and Clarithromycin and other macrolides, such as erythromycin and azithromycin, bind to the bacterial ribosome and inhibit bacterial azithromycin, bind to the bacterial ribosome and inhibit bacterial protein synthesis. Resistance to macrolides occurs by induction of a protein synthesis. Resistance to macrolides occurs by induction of a methylase enzyme that modifies the ribosome and thereby alters the methylase enzyme that modifies the ribosome and thereby alters the drug target or by active specific efflux. The first mechanism affects drug target or by active specific efflux. The first mechanism affects clarithromycin, erythromycin, and azithromycin as well as the clarithromycin, erythromycin, and azithromycin as well as the nonmacrolide, clindamycin, but the second mechanism affects only nonmacrolide, clindamycin, but the second mechanism affects only the macrolides. Since both resistance mechanisms affect all the macrolides. Since both resistance mechanisms affect all macrolides in clinical use in the United States, the choice of macrolides in clinical use in the United States, the choice of azithromycin would not be appropriate for a patient failing azithromycin would not be appropriate for a patient failing clarithromycin. Since there is epidemiologic linkage between clarithromycin. Since there is epidemiologic linkage between resistance to macrolides and resistance to penicillin and to resistance to macrolides and resistance to penicillin and to trimethoprim-sulfamethoxazole, trimethoprim-sulfamethoxazole trimethoprim-sulfamethoxazole, trimethoprim-sulfamethoxazole would not be appropriate for this patient. Ceftazidime, in contrast to would not be appropriate for this patient. Ceftazidime, in contrast to ceftriaxone and cefotaxime, has only limited activity against ceftriaxone and cefotaxime, has only limited activity against pneumococci and would therefore be a poor choice. pneumococci and would therefore be a poor choice.

• A 29-year-old woman with HIV infection and A 29-year-old woman with HIV infection and a CD4 cell count of 633/µL has had 3 days a CD4 cell count of 633/µL has had 3 days of fever, chills, productive cough, and chest of fever, chills, productive cough, and chest pain. Physical examination shows signs of pain. Physical examination shows signs of consolidation in the left lower lung fields. consolidation in the left lower lung fields. Her leukocyte count is 8600/µL, and chest Her leukocyte count is 8600/µL, and chest radiograph shows a left lower lobe infiltrate. radiograph shows a left lower lobe infiltrate.

• Which of the following organisms is Which of the following organisms is most likely present in her sputum?most likely present in her sputum?

• ( A ) ( A ) Mycoplasma pneumoniaeMycoplasma pneumoniae( B ) ( B ) Streptococcus pneumoniaeStreptococcus pneumoniae( C ) ( C ) Legionella pneumophilaLegionella pneumophila( D ) ( D ) Pseudomonas aeruginosaPseudomonas aeruginosa( E ) ( E ) Pneumocystis cariniiPneumocystis carinii


• Identify the cause of community-acquired pneumonia in a patient with HIV Identify the cause of community-acquired pneumonia in a patient with HIV infection and a high CD4 cell count.infection and a high CD4 cell count.


• The spectrum of opportunistic infections to which an HIV-infected person is The spectrum of opportunistic infections to which an HIV-infected person is susceptible is a function of host cellular and humoral immunocompetence. In susceptible is a function of host cellular and humoral immunocompetence. In patients with CD4 cell counts greater than 500/µL, conventional pathogens are patients with CD4 cell counts greater than 500/µL, conventional pathogens are more common than opportunistic pathogens. Community-acquired pneumonia more common than opportunistic pathogens. Community-acquired pneumonia with typical clinical features is most often caused by encapsulated bacteria, with typical clinical features is most often caused by encapsulated bacteria, particularly particularly Streptococcus pneumoniaeStreptococcus pneumoniae and and HaemophilusHaemophilus species. Risk factors species. Risk factors for community-acquired pneumonia in patients with HIV infection include for community-acquired pneumonia in patients with HIV infection include cigarette smoking and using injected drugs. cigarette smoking and using injected drugs.

• The typical presentation of bacterial pneumonia caused by encapsulated The typical presentation of bacterial pneumonia caused by encapsulated organisms is the abrupt onset of fever, chills, productive cough, and pleuritic organisms is the abrupt onset of fever, chills, productive cough, and pleuritic chest pain. Patients with bacterial pneumonia have usually had symptoms for chest pain. Patients with bacterial pneumonia have usually had symptoms for 3 to 5 days, in contrast to patients with 3 to 5 days, in contrast to patients with Pneumocystis cariniiPneumocystis carinii pneumonia, pneumonia, whose symptoms have usually been present for several weeks. Focal whose symptoms have usually been present for several weeks. Focal pulmonary infiltrates and leukocytosis are the laboratory hallmarks of bacterial pulmonary infiltrates and leukocytosis are the laboratory hallmarks of bacterial pneumonia in patients with or without HIV infection. pneumonia in patients with or without HIV infection. Pneumocystis carnii Pneumocystis carnii pneumonia generally presents with diffuse interstitial infiltrates. pneumonia generally presents with diffuse interstitial infiltrates.

• Mycoplasmal disease is unusual in patients with HIV infection and is unlikely to Mycoplasmal disease is unusual in patients with HIV infection and is unlikely to present with such an abrupt onset of respiratory symptoms or productive present with such an abrupt onset of respiratory symptoms or productive cough. cough.

• LegionellaLegionella pneumophilapneumophila is an unusual cause of pneumonia in patients with HIV is an unusual cause of pneumonia in patients with HIV infection but has been reported in association with nosocomial outbreaks. infection but has been reported in association with nosocomial outbreaks.

• PseudomonasPseudomonas aerugihosa aerugihosa infections of the respiratory tract are more infections of the respiratory tract are more commonly seen in patients with more advanced HIV disease who have commonly seen in patients with more advanced HIV disease who have indwelling venous catheters or in patients who have been hospitalized. indwelling venous catheters or in patients who have been hospitalized. P. P. aerugihosaaerugihosa is a very unusual cause of community-acquired pneumonia in is a very unusual cause of community-acquired pneumonia in patients with CD4 cell counts greater than 500/µL. patients with CD4 cell counts greater than 500/µL.

pneumonia ken lyn-kew, m.d.. normal chest x-ray courtesy of up to date

Documents

cap cap

days cap

boop slide

date slide

j respir crit care med

pneumonia cap community

cap algorithms

days mycoplasma