PNEUMONIA

Arto Yuwono Soeroto Sub Bag Pulmonologi Bagian Ilmu Penyakit Dalam FK UNPAD / RSUP Dr. Hasan Sadikin Bandung

PNEUMONIA
DEFINITION Inflammation and consolidation of lung tissue due to an infectious agent

CLASSIFICATION Community Acquired Pneumonia (CAP) - Pneumonia that develops outside hospital Hospital Acquired pneumonia - Pneumonia that develops72 hours or more after admission to hospital Institution acquired pneumonia - Pneumonia that includes hospital, nursing homes, etc.

 Common disease In USA

12 cases per 1000 The 6th leading cause of death 3.3 4 million cases/year 600000 1000000 admission Mortality : 1% - 50%

In Indonesia :
2nd leading cause of death

 Common :
Fever Chilling Pleurisy chest pain Cough Sputum :non productive, productive, rusty, bloody, foul odor in lung abscess

 TYPICAL
Clinically as above Due to : Pneumococcus, staphylococcus, H Influenzae

ATYPICAL
More indolent illness Non productive cough/ mucoid Due to Legionella, mycoplasma, Chlamydia

One cannot reliably distinguish typical and atypical

 NON RESPIRATORY MANIFESTATION

Headache Nausea Vomiting Abdominal pain Diarrhea Myalgia arthralgia

Elderly complain fewer symptoms then younger patients

Clues to the Etiology of Pneumonia from the History and Physical Exam
Feature
Environmental Exposure to contaminated air-conditioning cooling towers, recent travel associated with a stay in a hotel, exposure to a grocery store mist machine, visit or recent stay in a hospital with contaminated (by L pneumophila) potable water Pneumonia after windstorm in an endemic area Outbreak of pneumonia in shelters for homeless men, jails, military training camps Exposure to contaminated bat caves, excavation in endemic areas

Organisrn
Legionella pneumophila

Coccidioides immitis Streptococcus pneumoniae Mycobacterium tuberculosis S. pneumoniae Chlamydia pneumoniae Hisroplasma capsulatum Coxiella burnetii C. psittaci Burkholderia(Pseudvmon as) pseudomallei (melioidosisJ M. tuberculosis

Animal contact Exposure to infected parturient cats, cattle, sheep, or goats Exposure to turkeys, chickens, ducks, or psittacine birds
Travel history Travel to Thailand or other countries in Southeast Asia Pneumonia in immigrants from Asia or India

Feature

Organisrn

Occupational history Pneumonia in a health-care worker who works in a large city with patients infected wit.h HIV

M. tuberculosis
S. pneumoniae Staphylococcus aureus S. pneumoniae Klebsiella pneumoniae S. aureus S. pneumoniae Hemophilus influenzae Moraxella catarrhalis S. pneumoniae H. influenzae Legionella spp. Pneumocystis carinii Cylomegalovirus Strongyloides stercvralis S. pneumvniae P. carinii S. pneumoniae H. influenzae Cryptvcoccus neoformans M. tuberculosis Rhodococcus equi

Host factors Diabetic ketoacidosis Alcoholism

Chronic obstructive lung disease Solid organ transplant recipient (pneumonia occurring > 3 months after lransplant) Sickle cell disease HIV infection CD4 cell count < 2(N)/uL

Feature
Physical findings Periodontal disease with foul-smelling sputum Bullous myringitis Absent gag reflex, altered level of consciousness, or a recent seizure

Organisrn
Anaerobes, may be mixed aerobic- anaerobic infection

Mycoplasma pneumoniae
Polymicrobial (oral aerobic and anaerobic bacteria) can be macro- or microaspiration

Encephalitis

Cerebellar ataxia Erythema multiforme Erythema nodosum Ecthyma gangrenosum Cutaneous nodules (abscesses) and CNS findings

M. pneumoniae C. burnetii L. pneumophila M. pneumoniae L pneumophila M, pneumoniae C. pneumoniae M. tuberculosis P. aeruginosa Serratia marcescens Nocardia species

 Constitutional
- Fever - Hypothermia - Afebrile in 20% cases

Thorax
- Consolidation
Dullness Tactile fremitus Whispering pectoriloquy Bronchial breath sound

- additional lung sounds

- Crackles - Pleural friction rub (10%)

 OPACITY ON CHEST RADIOGRAPH DD/:

Infection Hemorrhage Edema Fluid Malignancy Inflammation due to other causes (Vascullitis, Drug Reaction)

Certain Radiographic Patterns Commonly Associated with some Microbial Agents

TABEL 2. Diferensial diagnosis beberapa pola gambaran radiologis yang sering ditemukan pada penderita pnemonia.

Focal opacity Streptococcus pneumoniae Mycoplasma pneumoniae Legionella pneumophila Staphylococcus aureus Chlamydia pneumoniae Mycobacterium tuberculosis Blastomyces dermatitidis Interstitial Viruses M. pneumoniae Pneumocystis carinii C. psittaci

Multifocal opacities S. aureus Coxiella burnelii L pneumophila S. pneumoniae Miliary M. tuberculosis Histoplasma capsulatum C. immitis B. dermatitid.is Varicella zoster

Interstitial pneumonia with lymphadenopathy Epstein-Rarr virus Francisella tularensis C. psittaci M. pneumoniae Fungi

Cavitation Mixed aerobic anaerobic (lung abscess) Aerobic gram-negative bacilli M. tuberculosis L. pneumophila Cryptococcus neoformans Nocardia asteroides Actinomyces israelii Coccidioides immitis P. carinii Bulging fissure Klebsiella pneumoniae L. pneumophila

Segmental or lobar pneumonia with lymphadenopathy M. tuberculosis (primary infection) Atypical rubeola

Pneumatoceles S. aureus S. pyogenes P. carinii Round* pneumnnia C. burnetii S. pneumoniae L pneumophila S. aureus

 DUE TO :

The Cause can not be determined from the clinical presentation Complete microbiological studies can isolate only < 50 % of causative pathogen and take long enough time (> 48 hours) Pathogen isolated from sputum cannot be sure as the causative agent
Etiologic diagnosis of pneumonia categorized as definite or probable

SO :

TABEL 3. Guidelines for Determining the Etiology of CAP

Definite

Blood cultures positive for a pathogen Pleural fluid positive for a pathogen Presence of Pneumocystis carinii in induced sputum or in bronchoalveolar lavage fluid A fourfold or greater rise in antihody titer to Mycoplasma pneurnoniae, Chlamydia pneumoniae . Isolation of Legionella pneunrophila or a fourfold rise in antibody titer or positive urinary antigen test for Legionella Positive direct fluorescence antibody test for Legionella plus an antibody titer of 1:256 for Legionella Serum or urine positive for Streptococcus pneurnoniae antigen Isolation of Mycobacterium tuberculosis from sputum

Probable

Heavy or moderate growth of a predominant bacterial pathogen on sputum culture and a compatible Grams stain Light growth of a pathogen in which sputum Grams stain reveals a bacterium compatible with the culture results

ADMISSION DECISION

Important step after diagnosis has been made Indication for admission :
Risk factors for a complicated course or Mortality in Patients with CAP Age > 65 years Co-morbid illnesses that are likely to be made worse by the pneumonia, especially chronic renal failure, ischemic heart disease, congestive heart failure, and severe COPD Concurrent malignancy Postsplenectomy state Altered mental status Alcoholism Immunosuppresive therapy Respiratory rate > 30 breaths per minute Diatolic blood pressure < 60 mm Hg : systolic blood pressure < 90 mmHg

Hypothermia Creatinine > 150 mm/l or BUN > 7 mm/l Leukopenia < 3,000/ul or leucocytosis > 30,000/ul O2 < 60 mmHg or Pco2 > 48 mmHg while breathing room air Albumin < 30 gm/l Hemoglobin < 9 gm/l Pseudomonas aeruginosa or Staphylococcus aureus as the cause of the Pneumonia Bacteremic pneumonia Multilobe involvement on chest radiograph Rapid radiographic progression of the pneumonia defined as increase in the size of the pulmonary opacity of > 50 % within 36 h

 OUT PATIENTS
Chest X ray Complete leucocyte count Electrolyte Creatinine Oxygen saturation Sputum culture and gram stain

IN PATIENTS
As above Sputum culture and gram stain Blood culture (twice)

SPUTUM CULTURE AND GRAM STAIN

REPRESENTATIVE SPECIMEN
PMN > 25 EPHITEL < 10
PER LOW POWER FIELD

METHODS
Sputum from cough Aggressive :
Bronchoscopy Transthoracic needle biopsy Open lung biopsy

 SEROLOGY FOR PATHOGEN

M. Pneumoniae C. Pneumoniae Coxiella Bornetti Legionella Pneumophilla Adenovirus Influenza/Parainfluenza RSV

PNEUMOLYSIS S. PNEUMONIAE
If sputum can not be collected

 INITIAL THERAPEUTIC APPROACH IS EMPIRICIAL ONCE THE ETIOLOGIC DIAGNOSIS HAS BEEN MADE CHANGE TO THE CHEAPEST, NARROWEST SPECTRUM AGENT THAT SENSITIVE

TABEL 4. Panduan terapi empiris pada penderita community acquired pneumonia (American Thoracic Society 1993)
Grup I Umur < 60 th Ringan sedang Rawat jalan Tidak ada ko POLA PATOGEN - S. Pneumonia - M. Pneumoniae - Respiratory Syncitinc virus - C. Pneumoniae - H. Influenzae Lainnya : Legionella, S. Aureus, M. Tuberkulosis, Jamur Gram Negative Batang (GNB) Grup II Umur > 60 th Atau < 60 th Ringan sedang Rawat jalan Komorbid (+) POLA PATOGEN - S. Pneumoniae - RSU - H. Influenzae - GNB - S. Aureus - Lainnya : M. Catarhalis, legionella, M. Tuberculosis, Jamur Grup III Semua umur Sedang Rawat inap bangsal Komorbid +/POLA PATOGEN - S. Pneumoniae - H. Influenzae - Polimikrobial (termasuk anaerob GNB) - Legionella Sp - S. Aureus - C. Pneumoniae - RSV - Lainnya : M. Pneumoniae, Moraxella, Catarrhalis M. Grup IV Semua umur Berat Rawat inap ICU Komorbid +/POLA PATOGEN - S. Pneumoniae - Legionella - GNB - H. Influenzae - M. Pneumoniae - RSV - Lainnya : > M. TBC Jamur

Grup I

Grup II

Grup III

Grup IV

ANTIBIOTIK - Makrolid - Terasiklin

ANTIBIOTIK - Sefalosporin generasi II - TrimetroprimMakrolid : Eritromisin sulfametoxazol Kalau intoleran thd - Betalaktam/ eritromisin atau ada betalaktamase kecurigaan H. inhibitor + Influenzae berikan Eritromisin atau makrolid generasi baru makrolid lainnya : klaritromisin, Azitromisin

ANTIBIOTIK - Sefalosporin generasi II/IV - Beta laktam / betalaktamase inhibitor + makrolid

ANTIBIOTIK - Makrolid + - Sefalosporin Gen III dengan aktivitas anti Pseudomonas atau anti Pseudomonas lainnya (Ciprofloxacin imipenem/Cilastin)

TABEL 5. PENGOBATAN EMPIRIS UNTUK CAP (INFECTIOUS DISEASES SOCIETY OF AMERICA 2000) Pasien Rawat Jalan : - Fluorokuinolon - Doksisiklin - Makrolida Pasien Rawat Inap : Kamar rawat umum : - Sefalosporin spektrum luas + makrolida - Inhibitor B laktamase/B laktam + makrolida - Fluorokuinolon tunggal ICU : - Sefalosporin spektrum luas atau inhibitor B laktamase/ Blaktam + makrolida atau fluorokuinolon

PATIENTS WITH MILD TO MODERATE HAP, NO UNUSUAL RISK FACTORS, ONSET ANY TIME OR PATIENTS WITH SEVERE HOSPITAL ACQUIRED PNEUMONIA WITH EARLY ONSET
CORE ORGANISMS Enteric gram-negative bacilli (non Pseumomonal) Enterobacter - E. Coli - Klebsiella - Proteus - Serratia - Hemophilus - Methicillin-sensitive S. Aureus - Streptococcus pneumoniae

CARE ANTIBIOTICS Cephalosporin Second Generation Or non pseudomonal third generation Beta-lactam/betalactamase inhibitor if allergic to penicillin : fluoroquinolone or clindamycin + aztreonam

PATIENTS WITH MILD TO MODERATE HAP, WITH RISK FACTORS, ONSET ANY TIME
CORE ORGANISMS Anaerobes (resent abdominal surgery, withnessed aspiration) Staphylococcus aureus (coma, head trauma, diabetes mellitus, renal failure) Legionella (high-dose steroids) Pseudomonas aeruginosa (prolonged ICU stay, steroids, structural lung disease) CORE ANTIBIOTICS Clindamycin or betalactam/beta-lactamase inhibitor
+/- Vancomycin (until methicillin-resistant S. Aureus is ruled out) Erythromycin +/- rifampin Treat as severe hospital acquired pneumonia

PATIENTS WITH SEVERE HOSPITAL-ACQUIRED PNEUMONIA WITH RISK FACTORS EARLY ONSET OR PATIENTS WITH SEVERE HAP, LATE ONSET
CORE ORGANISMS, PLUS P. Aeruginosa Acinetobacter species Consider MRSA THERAPY Aminoglycoside or ciprofloxacin Plus one of the following Antipseudomonal penicillin Beta-lactam/beta-lactamase inhibitor Ceftazidime or cefoperazone Impinem Aztreonam * +/- Vancomycin

Excludes patients with immunosuppression Aztreonam efficacy is limited to enteric gram negative bacilli and should not be used in combination with an aminoglycoside if gram positive or H.