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Community Acquired Pneumonia
Community Acquired Pneumonia
Pneumonia
Definition : It is defined as the infection of lung parenchyma. Types : CAP (Community acquired pneumonia) HAP (Hospital acquired pneumonia) VAP (Ventilator associated pneumonia)
PNEUMONIA
CAP
HCAP
HAP
VAP
ETIOLOGY
Agent Factors Typical pathogens : Streptococcus pneumoniae Haemophilus influenza S. aureus GNB Klebsiella Pneumoniae Pseudomonas aeruginosa
Atypical pathogens : Chlamydiaophila pneumoniae Mycoplasma pneumoniae Legionella spp. Respiratory viruses Influenza Adeno RSV
Rare pathogens : Fungi Protozoa New viruses - Hantavirus Metapneumovirus Coronavirus (SARS) Changing trends : MDR strains of GNB and CA MRSA can cause necrotising pneumonia
HOST FACTORS
Alcoholism - Klebsiella pneumoniae, oral anaerobes,S Pneumoniae, M. Tb COPD and/or Smoking H. influenza, Moraxella catarrhalis,Pseudomonas, S. Pneumoniae Structural lung disease Pseudomonas aeruginosa,Burkholderia cepacia,S. aureus Decreased level of consciousness Oral anaerobes, gram neg bacilli
Exposure to birds Chlamydia psittaci H. capsulatum Stay in hotel or on cruise ship in previous 2 weeks Legionella
PATHOPHYSIOLOGY
Host defences trigger inflammatory response which lead to clinical syndrome of pneumonia Inflammatory mediators from macrophages and neutrophils create alveolar capillary leak equivalent to that seen in ARDS.
PATHOLOGY
Intact immunity or typical pathogen Localisation of infection and so lobar pneumonia pattern 4 Stages : Edema Red Hepatization-Erythrocytes Gray Hepatization-neutrophils Resolution-Macrophages Immunocompromised or atypical pathogensBronchopneumonia pattern
CLINICAL MANIFESTATIONS
CAP can vary from mild diseases to fatal in severity Symptoms : Cough, dyspnea, chestpain if parietal pleura involved Others : Fever, constitutional symptoms Signs
DIAGNOSIS
Clinical Radiological Etiological : Gram stain and culture of sputum Blood cultures Antigen tests PCR Serology
DIFFERENTIAL DIAGNOSIS
Acute exacerbation of COPD Heart Failure Pulmonary embolism Radiation Pneumonitis Acute Bronchitis
TREATMENT
Principles : Decide according to severity whether the patient is a candidate for outpatient or inhospital treatment Try to cover organism as per local epidemiological pattern Keep in mind the drug resistance patterns IV drugs when hospitalised Cover for pseudomonas and MRSA when suspected
PSI (Pneumonia Severity Index) variables : 20 in number CURB variables : C-Confusion U-Urea(>7 mmols) R-Respiratory rate (>30) B-Blood pressure (<90 sys or <60 diastolic)
ANTIBIOTIC GROUPS
Macrolides-Covers atypical org. but DRSP cases ineffective B-Lactams-No atypical coverage but DRSP cases effective Fluroquinolones-Less resistance and covers both Aminoglycosides-Add on drug for pseudomonas Drugs for MRSA
OUTPATIENT
(ORAL)
INHOSPITAL (I.V.)
NONICU
ICU
DUAL/TRIPLE DRUGS
Definitive Treatment
What if organism isolated sensitive to Penicillins and we have started with B lactum+Macrolide or Fluroquinolones
What if no response and drug resistant to FQ+Macrolides+Penicillins (MDR)
DURATION OF THERAPY
Uncomplicated CAP : 5-day course suffices Bacteremic CAP/Virulent organism 10-14 days
Fever- Falls in 2 days Leucocytosis-decreases in 4 days Physical findings persist slightly longer Chest radiographic abnormalities may take 4-12 weeks to resolve
Consider Noninfectious condition Resistance to drug Superinfection with new nosocomial pathogen
COMPLICATIONS
Seen usually when MDR pathogens present Respiratory Failure Shock and Multiorgan failure with DIC Metastatic infection Lung Abscess Complicated pleural effusion
PROGNOSIS
PREVENTION
Immunocompromised/Susceptible Vaccination
Community outbreak Chemoprophylaxis+Vaccination