Pneumonia

Andriy Lepyavko, MD, PhD
Department of Internal Medicine № 2

1. Definition
2. Classification
3. Diagnostic criteria
4. CAP – clinical signs, treatment
5. Nasocomial pneumonia
6. Aspiration pneumonia
7. Pneumonia in the immunocompromised host
 “The most wide spread and fatal of all acute
diseases, pneumonia, is now Captain of the
Men of Death”
Sir William Osler

The Principles and Practice of Medicine, 1901
 Sixth most common cause of death
 The most common cause of infection-related
mortality
 Incidence 170-280/10 000
 Costs of treatment exceed $12 billion
 Inpatient treatment costs 25 times more than
outpatient treatment
 Pneumonia – this is an inflammation in the
lung parenchyma caused by bacteria, viruses or
fungi which is characterized by intraalveolar
exudation
I. Etiology (if it is known)
II. Variants:
 Community-acquired pneumonia
 Nosocomial pneumonia – when patient was
hospitalized with any another diagnosis, and
after 48 hours in the hospital (not earlier!)
pneumonia was diagnosed, or pneumonia after
artificial lung ventilation
 Pneumonia due to aspiration. It results from the
aspiration of gastric contents in addition to
aspiration of upper respiratory flora in
secretions.
 Pneumonia in immunocompromised host –
patients with AIDS or immunodeficit of other
origin. Causes of pneumonia – viruses, fungi of
saprofites (E.coli etc.)
III. Localization (side, lobe, segment)
IV. Stages of severity:
 Mild stage –conciousness is clear, t less than 38, heart
rate less than 90, BP normal, dyspnea mild in case of
physical activity, CXR – small infiltration
 Moderate – conciousness is clear, sweating, general
weakness, t 38-39, heart rate 90-100, moderate
dccreased BP, dyspnea, large size of infiltration
 Severe – t 39-40, conciousness is not clear, heart rate
more than 100, low BP, severe dyspnea, cyanosis, large
size of infiltration and presence of complications
V. Complications.
 I – patients in the age 2-65 without concomitant
diseases, are outpatients
 II – patients <2 or >60, with concomitant
diseases, are outpatients, but near 25 % of them
treatment will not be effective, and they will
need hospitalization
diseases, are inpatient
diseases, have to be treated in the Emergency
department
 I – patients without risk factors, with mild or
moderate severity pneumonia which was
diagnosed at any day of hospitalization or
severe early pneumonia (at first 5 days of
hospitalization)
 II – patients with risk factors + I
 III – patients with risk factors and severe
pneumonia or late pneumonia
 Route of entry
- Inhalation
- Aspiration
- Bloodborne
 Host/ organism dynamics tipped by
- Defect in host defences
- Virulent organism
- Overwhelming inoculum
 Nasal hair
 Dynamics of airflow
 Cough
 Mucous
 Mucociliary apparatus
 Bacterial interference
 Immunoglobulin
 Surfactant
 Fibronectin
 Complement
 Cytokines
 Alveolar macrophages
 Polymorphonuclear leucocytes
 Cell-mediated immunity
 Predisposition – CHF, diabetes, alcoholism, COPD
 Classic symptoms – cough, fever, sputum production,
dyspnea
 Clinical syndrome – fever, pleuritic chest pain,
productive cough with mucopurulent sputum
 Focal pulmonary findings (rales, crapitation or signs of
consolidation) – less sensitive than CXR
 General blood analysis – increased ESR, leucocytosis,
shift to the left
 Sputum analysis – causative microorganism and its
sencitivity to antibiotics may be found
 CXR with infiltrates – diagnosis
“pneumonia” is invalid without it
Most common pathogens:
 Streptococcus pneumoniae (9% to 75%; mean,
33%),
 Haemophilus influenzae (0 to 50%; mean, 10%),
 Legionella species (0 to 50%; mean, 7%),
 Chlamydia pneumoniae (0 to 20%; mean, 5%).

 Mycoplasma pneumoniae
 Macrolide
Claritromycin (Clacid) 0,5 g 2-3 t/day,
Azitromycin (Sumamed) 0,5 g 1t/d
Roxitromycin (Rulid) 0, 15 g 2t/d
Midekamycin (Macropen) 0,4 g 3 t/d
 Amoxicillin + clavulonic acid
0, 625 g 2-3-4 t/d
“+” – there is i/v form as well
 Doxycyclin
0,1 g 2 t/d
 Cephalosporin
Cefuroxim 0,75-1,7 g i/m 3 times per day
Cefatoxini 1-2 g i/m, i/v 2 t/d
Ceftazidini 1 g i/m, i/v 2-3 t/d
 Respiratory fluoroquinolone
Cyprofloxacini (Cyprobai) 0,2 g 2 t/d or 0,5 g 2 t/d
i/v
 I – Macrolide, doxacyclin (?)
 II – Cefalosporine, Amoxiclav, Macrolide
 III - Cefalosporine, Amoxiclav, Macrolide
 IV - Cefalosporine, Amoxiclav, Macrolide,
Fluoroquinolone
 At least 5 days
 Until afebrile for 48-72 hours
 Stable vital signs
 Longer course needed if
Initial antibiotic choice did not cover the
pathogen
Extrapulmonary infection (meningitis)
Lung abscess, cavitation or empyema
Gram negative pathogen or S.aureus
 Staphylococcus aureus
 Gram-negative microorganisms -
Pseudomonas, Klebsiella, Proteus,
enterobacteria, E.coli
 Fungi - Candida, Aspergillus, Rizopus.
 Clindamicini i/m, i/v every 6 hours, total - 1 g/day
 Aztreonam (Azactam) – i/v, i/m every 8 hours, average – 3-6
g/day
 Vancomycini – i/v every 8-12 hrs, average – 30 mg/kg/d, max
– 3 g/d
 Rifampicini – orally 0,15 g 2 t/d, i/m 1,5-3 g every 8-12 hrs
Useful combinations:
 Clindamycini+Aztreonam
 Clindamycin+Vancomycin
 B-lactam+Vancomycin
 Floroquinolon+Rifampicin
Most effective are:
 Aminoglycozyde (tobramycin, sizomycin)+
Metronidazol
 Cephalosporini III-IV
generation+Metronidazol
 Cephalosporine III-IV generation
 Aminoglycozyde (tobramycin, sizomycin)
 Annual Influenza immunization
Thanks for your
attention!

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Andriy Lepyavko, MD, PhD

Department of Internal Medicine № 2

Sir William Osler

 Legionella species (0 to 50%; mean, 7%),

 Chlamydia pneumoniae (0 to 20%; mean, 5%).

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