CLINICAL APPROACH TO

PNEUMONIA

The most widespread & fatal

of all acute diseases, pneumonia,
is now Captain of the Men of
Death : Sir William Osler

Dr Izham Cheong, FRCP

Professor of Medicine,
UNIVERSITI KEBANGSAAN
MALAYSIA
 Facts about pneumonia in USA
6th most common cause of
death.
Increased by 59% between
1979 to 1994.
2-3 million cases of CAP in 10
million visits.
500,000 hospitalizations (258
per 100,000 pop).
45,000 deaths (average 14%
hospitalised).
Cost : about $ US 4.5 billion.
JAMA 1996;275:189

MMWR 1997;46:556
Ten leading causes of hospitalization
and death in Malaysia (2000)
Hospitalization (Total=1,559 280)
Respiratory diseases 6.58%

Deaths (Total=29 447)

Heart disease 15.10%
Septicaemia 10.98
CVA 9.47
Accident 8.79
Neoplasms 8.75
Perinatal diseases 7.28
GI diseases 4.69
Pneumonia 4.33
Renal disease 3.65
Ill-defined diseases 3.62
CLINICAL APPROACH TO PNEUMONIA

Key points to
remember
 KEY POINTS TO REMEMBER WHEN
YOUR PATIENT HAS PNEUMONIA
1. EPIDEMIOLOGY OF RESPIRATORY PATHOGENS

CAP HAP (VAP) NHAP

Typical Gram ve Gram ve
S. pneumoniae P. aeroginosa Klebsiella spp.
H. influenzae Acinetobacter spp. P. aeroginosa
M. catarrhalis Proteus spp.
Klebsiella spp. Gram +ve
Atypical E. cloacae S. aureus
L. pneumophila P. maltophila
M. pneumoniae Legionella spp. Anaerobes
C. pneumoniae
C. psittacosi Gram +ve
C. burnetti S. aureus (MRSA)
S. pneumoniae
Other streptococci
S. epidermidis

Polymicrobial
 KEY POINTS TO REMEMBER WHEN YOUR
PATIENT HAS A PNEUMONIA
2. EARLY EMPIRIC TREATMENT IS ESSENTIAL BECAUSE NO SPECIFIC
PATHOGEN CAN BE IDENTIFIED IN 30% to 70% OF PATIENTS.
OR of 30-d Survival (95% CI)

Relationship of
receiving
an antibiotic
within
a time frame
and 30-day
mortality

Meehan TP, 1997

KEY POINTS TO REMEMBER WHEN YOUR
PATIENT HAS A PNEUMONIA
3.THE RISE IN ANTIBIOTIC RESISTANCE

Penicillin and macrolide resistant

S. pneumoniae

ESBL-producing Klebsiella spp.

MDR pathogens: P. aeroginosa

P. maltophila
Enterobacter spp.
Stenotrophomonas spp.

MRSA + VRSA

VRE
 KEY POINTS TO REMEMBER WHEN YOUR
PATIENT HAS A PNEUMONIA
4. CONTAIN COST WITHOUT NEGATIVELY AFFECTING MORTALITY

Minimize admissions

Oral antibiotics

Shorten hospitalization
 CLINICAL APPROACH TO PNEUMONIA

mild severe

What do
I do?
Clinical Approach to a Patient with CAP
History
Medicine
is
learned
by
the
bedside
and
not
in
the
classroom

Sir William Osler

(1849-1919)
HISTORY

1. WHICH CATEGORY?

HAP (VAP)

CAP
NHAP
HISTORY
2. CAN THE PATIENT BE IMMUNOCOMPROMISED?

DONT TRUST ANY ONE NOWADAYS!!!

HISTORY
3.ANY UNDERLYING LUNG DAMAGE?
HISTORY
4. COMORBIDITY ?

mimic pneumonia
impact on drug treatment
HISTORY
Pulmonary TB
6. WHAT IS HIS JOB?

Any and
everything!! Anthrax
Q fever
HISTORY
7. CONTACT WITH.

Francisella tularensis

Chlamydia pneumoniae

Yersinia pestis
HISTORY Legionellosis

IS IT SAFE TO
TRAVEL??
HISTORY
8. HIGH RISK BEHAVIOURS

IVDU

Yumm-Seng

smoking
HISTORY
9. ASPIRATION ?

unconcious/fits

stroke

Ryles tube
vomiting
 HISTORY
10. WHAT DRUGS ARE YOU TAKING?

Amiodarone

Nitrofurantoin Heroin

Bleomycin Methadone

Chlorambucil Chlorthiaxide

Procarbazine Contrast media

Bulsulfan
Cyclophosphamide Pulmonary oedema

Aziathioprine

Lung infiltrates Methotrexate

Sulphonamides
Clinical Approach to a Patient with CAP
Clinical Presentation
Typical pneumonia
acute
ill-looking,SOB
fever and chills
productive cough,
leukocytosis
pleurisy
Atypical pneumonia
as above +
extrapulmonary features
CNS involvement:
ENT involvement: M. pneumoniae
Diarrheas: M. pneumoniae or
L. pneumophila
Abdominal pain: L. pneumophila
Rash: C. psittacosis
M. pneumoniae
Clinical Approach to a Patient with CAP
Physical examination

Cutaneous findings

Erythema multiforme M. pneumoniae

Maculopapular rash Measles
Erythema nodosum C. pneumoniae
Ecthyma gangrenosum M. tuberculosis
P. aeruginosa

Oral findings

Peridontal disease anaerobic pathogens

Foul smelling sputum
 Clinical Approach to a Patient with CAP
Physical examination

Neurologic disease

Absent gag Aspiration

Altered conciousness
Recent seizure

Cerebellar ataxia M. pneumoniae

L. pneumophila

Encephalitis M. pneumoniae
C. burnetti
Differential Diagnosis of Common Radiographic
Patterns in Patients with Pneumonia
Focal opacity Interstitial

S. pneumoniae Viral
M. pneumoniae M. pneumoniae
L. pneumophila P. carinii
C. pneumoniae C. psittaci
M. tuberculosis
Aspiration
 Differential Diagnosis of Common Radiographic
Patterns in Patients with Pneumonia
Cavitation
Interstitial with lymphadenopathy

Anaerobic abscess
S. aureus
Epstein Barr virus Aerobic gram-neg bacilli
F. tularensis M. tuberculosis
C. psittasi C. neoformans
N. asteroides and A. israelii
Differential Diagnosis of Common Radiographic
Patterns in Patients with Pneumonia
Segmental pneumonia with Miliary
lymphadenopathy

M. tuberculosis M. tuberculosis
Fungal infection H. capsulatum
Varicella zooster
COMMUNITY-ACQUIRED PNEUMONIA
Which patient require hospitalization?

Respiratory rate > 30/min

Diastolic hypotension
Altered mental status
Renal failure
Age > 65 years
Co-existing disease
Leukopenia
Severe anaemia
Acidosis
Hypoxaemia
Multilobar involvement
Systolic BP < 90mmHg
PaO2/FIO < 250

Niederman, 1993; Barlett, 1995; Fine, 1995; Ewig, 1998

 INTERNATIONAL GUIDELINES FOR EMPIRICAL
ANTIMICROBIAL THERAPY
OF COMMUNITY-ACQUIRED PNEUMONIA
Guidelines Outpatient General ward ICU
European penicillin or (2nd or 3rd generation 2nd or 3rd generation
Respiratory aminopenicillins cephalosporin or - cephalosporin + 2nd
Society (1998) Alternatives: lactam/-lactamase inhibitor generation quinolones
macrolodes or IV penicillin) macrolide rifampicin
tetracyclines or 2nd generation
cephalosporins quinolones;
quinolones

Infectious doxycycline -lactam with macrolide Extended spectrum

Diseases macrolide cephalosporin or
Society new floroquinolone OR lactam/-lactamase
of America inhibitor + either IV
(2000) fluoroquinolone or IV
new fluoroquinolone macrolide (if structural
lung disease cover P.
aeroginosa)
WHAT DO I
USE
FOR
MY
PATIENTS
WITH
A
COMMUNITY-
ACQUIRED
PNEUMONIA ?
 HOW DO I EMPIRICALLY TREAT MY PATIENT
WITH
COMMUNITY-ACQUIRED PNEUMONIA?

SETTING THERAPEUTIC OPTIONS

Ambulatory, not Oral macrolide (erythromycin or azithromycin)
requiring hospitalization,
age under 60 years
Ambulatory, not Oral -lactam/-lactamase inhibitor + macrolide
requiring hospitalization, OR
comorbidity or age over
Oral antipneumococcal fluoroquinolone
60 years

Requiring hospitalization -lactam (sulperazone or ceftriaxone) + macrolide

or antipneumococcal fluoroquinolone

Aspiration pneumonia -lactam/-lactamase inhibitor alone

requiring hospitalization (ampicillin/sulbactam, pipericillin/tazobactam))

Izham, 2002
Empiric therapy (pathogen unknown or awaiting cultures)
 MY EMPIRICAL THERAPY OF SEVERE CAP
IN COMPROMISED HOST

Compromised host Usual pathogen Empiric therapy

Chronic alcoholics Oral anaerobes 3rd or 4th generation

and/or cephalosporin
Klebsiella spp. OR
meropenam
Postviral influenzae S. aureus Cloxacillin
OR
vancomycin
HIV S. pneumoniae new fluoroquinolone
Salmonella
Legionella
Congenital/acquired S. pneumoniae -lactam/-lactamase
asplenia or hyposplenia N. meningitidis inhibitor
H. influenzae OR
meropenam

Izham,2002
 Why is pneumonia still a leading
cause of morbidity and mortality ?
Changing pathogens
Greater diagnostic difficulties
Widespread antibiotic resistance
Survival of patients at both
extremes of ages
Larger population of
compromised hosts
More hospital-acquired
pneumonia
Despite more and better antimicrobials
What shall I do with
my next pneumonia?

Of all the diseases to which

man is heir, those known in
etiology, possible of cure,
capable of prevention, are for
the most part caused by
infectious agents -therefore

Choose the right antibiotic.

Choose the right physician!!!!!!!!