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Pneumonia. Dr Andrew Dodgson Consultant Microbiologist. Terminology. Histological/Radiological Lobar vs bronchopneumonia Lobar vs. interstitial Microbiological Bacterial, viral, fungal Clinical/ Microbiological Atypical vs. typical Clinical/epidemiological

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pneumonia

Pneumonia

Dr Andrew Dodgson

Consultant Microbiologist

terminology
Terminology
  • Histological/Radiological
    • Lobar vs bronchopneumonia
    • Lobar vs. interstitial
  • Microbiological
    • Bacterial, viral, fungal
  • Clinical/ Microbiological
    • Atypical vs. typical
  • Clinical/epidemiological
    • Community acquired vs. nosocomial
  • All have clinical relevance though none is absolute
terminology1
Terminology
  • Histological/Radiological
    • Lobar vs bronchopneumonia
    • Lobar vs. interstitial
  • Microbiological
    • Bacterial, viral, fungal
  • Clinical/ Microbiological
    • Atypical vs. typical
  • Clinical/epidemiological
    • Community acquired vs. nosocomial
  • All have clinical relevance though none is absolute
importance
Importance
  • “the most widespread and fatal of all acute diseases, pneumonia is now Captain of the Men of Death” Osler, 1901 (Principles and Practice of Medicine, 4th Ed.)
  • Pneumonia is 6th leading cause of death in US
  • Leading infectious cause of death
  • 5 million deaths/year worldwide
  • High mortality rate
    • Outpatient: 5%
    • Inpatient: 12%
    • ITU: 40%
clinical presentation
Clinical Presentation
  • Cough (productive vs. non-productive)
  • Fever
  • Dyspnoea
  • Fatigue
  • Headache
  • Nausea, vomiting, diarrhoea
  • Myalgia
predisposing factors
Predisposing factors
  • Age
  • COPD
  • Diabetes
  • Heart failure
  • Immunocompromised states
  • Alcoholism
  • Smoking
  • Travel/occupational/recreational exposure
physical signs
Physical signs
  • Tachycardia
  • Tachypnoea
  • Hypotension
  • Creps
  • Bronchial breathing
  • Fever
physical signs1
Physical signs
  • Physical exam has a sensitivity of 47-60% and specificity of 50-75%
  • However in pt’s with creps, fever, cough and tachycardia the possibility of pneumonia increases from 18 to 42%
  • Also, pt’s with none of RR>20, HR>100 and temp>37.8ºC have a <1% chance of having pneumonia
investigation
Investigation
  • Chest X-ray
  • FBC
  • CRP
  • U&E’s
  • ABG’s
  • Sputum culture
  • Blood culture (+ve in 1-16% of pt’s requiring admission)
  • Serology/PCR/antigen
severity assessment
Severity assessment
  • CURB-65
    • Confusion
    • Urea >7mmol/L
    • Respiratory rate >30
    • Blood pressure diastolic <60mmHg or systolic <90
    • ≥65 years old
  • 0-1-may be suitable for outpatient Rx
  • 2 Hospital Rx, consider other features too (e.g. PaO2)
  • ≥3 Severe disease
pneumonia aetiology

0

5

10

15

20

25

30

Percentage of Cases

PNEUMONIA AETIOLOGY

S pneumoniae

C pneumoniae*

Viral

M pneumoniae

Legionella spp

H influenzae

G- Enterobacteria

C psittaci

Coxiella burnetii

S aureus

M catarrhalis

Other

Data from 26 prospective studies (5961 adults) from 10 countries. *Data from 6 studies.

Woodhead MA. Chest. 1998;113:183S-187S.

aetiology
Community Acquired

S. pneumoniae

H. influenzae

Atypicals

S. aureus

Kleb. pneumoniae

Hospital Acquired

Gram negatives

E.g. E.coli, Klebsiella, Pseudomonas

S. aureus

Atypicals infrequent

S. pneumoniae rare

Aetiology
pathogens
S. pneumoniae

Gram +ve diplococci

Almost all S to penicillins, cephalosporins (R more common is southern Europe and S. Africa)

Most S to erythromycin

H. influenzae

G –ve cocco-bacilli

S to amoxycillin

25% produce B-lactamase, thus Amoxy R.

S to Co-Amoxyclav, ceph’s, Ciprofloxacin

R Eryth

Pathogens
pathogens1
S. pneumoniae

Gram +ve diplococci

Almost all S to penicillins, cephalosporins (R more common is southern Europe and S. Africa)

Most S to erythromycin

H. influenzae

G –ve cocco-bacilli

S to amoxycillin

25% produce B-lactamase, thus Amoxy R.

S to Co-Amoxyclav, ceph’s, Ciprofloxacin

R Eryth

Pathogens
pathogens2
Pathogens
  • S. aureus
  • Seen classically after flu
  • Severe necrotising pneumonia in young adults seen in PVL (toxin) producing strains-emerging pathogen
  • Rx flucloxacillin, eryth.
  • Vancomycin, linezolid for MRSA
atypical pneumonia
Atypical pneumonia
  • Caused by organisms that will not grow under routine culture conditions
  • Non-productive cough
  • Negative culture
  • Clinical signs often do not match severity of clinical (and radiological) presentation
  • Legionella, Mycoplasma, C. psittacci, C. pneumoniae, C. burnetii, viruses (esp. influenza)
aspiration pneumonia
Aspiration pneumonia
  • Occurs in patients with abnormal gag reflex (altered consciousness, CVA…)
  • Combination of chemical (acid) injury, bronchial obstruction and bacterial infection.
  • Bacteria involved will reflect oropharyngeal flora-anaerobes and Streps & haemophilus (community) or gram neg’s (nosocomial)
  • Rx often broad spectrum B-lactam e.s. co-amoxyclav or pipperacillin/tazobactam +/- metronidazole
sputum culture
Sputum culture
  • Interpretation
    • Macroscopic appearance
      • Mucoid or purulent?
    • Presence of leukocytes
    • Organism isolated
      • Pure culture or mixed?
      • Amount?
      • Likely pathogen given the situation?
    • What’s happening to the patient?
diagnosing atypical pneumonia
Diagnosing Atypical Pneumonia
  • Clinically
  • Laboratory:
    • Culture-not likely to be useful
    • Serology-detects antibody response
      • Usually take time
      • Requires demonstration of a single high level or 4-fold rise (after 10-14 days)
      • Immunocompromised patients?
    • Antigen detection
      • Good strategy but only available for Legionella
    • PCR
      • Detects DNA/RNA of organism
      • Potentially excellent strategy
      • Only available in reference centres currently
      • Will likely be method of choice in future
diagnosis of legionella am j med 2001 110 41 48
Diagnosis of LegionellaAm J Med, 2001; 110:41-48

Sputum culture

Selective media

Results in 2 -7 days

10% sensitivity vs serology

61% sensitivity vs DFA

Better if endotracheal/BAL

Urine antigen

Results in 1 -6 hours

Can take ~ 5 days to turn pos

Can remain pos for up to 6 wk

Inexpensive

Serogroup 1 specific

70-80% sensitivity

100% specificity (serogrp 1)

Direct Fluorescent Antibody Stain (DFA) of sputum

Need large numbers of orgs.

Sensitivity approx 50%

60 - 70% specificity for particular serotypes

Serology - ELISA

Acute & convalescent samples needed

4-12 weeks for AB response

Single titre of 1:256 = disease

20% have no AB response

PCR

Fast – sensitivity of ~ 70%

Can be used for sputum

Currently research use only

treatment
Treatment

Need to consider:

  • Setting
    • Community or hospital
  • Severity
    • CURB-65 score
treatment community acquired
Treatment-Community acquired

CURB65 0-1

  • Amoxycillin 500-1g TDS

CURB65 2

  • Amoxycillin AND Clarithromycin 500mg BD

CURB65 ≥3

  • Co-amoxyclav 1.2g TDS AND Clarithromycin 500mg BD-Both given IV
treatment nosocomial
Treatment-Nosocomial

Occurring ≥48 hrs post admission

Usually

  • Co-amoxyclav

However if severe or recently on ITU or recent Abx

  • Piperacillin/tazobactam
treatment specific organisms
Treatment-Specific organisms

S. pneumoniae

  • Benzylpenicillin or amoxycillin

S. aureus

  • Flucloxacillin

Legionella

  • Clarithromycin (or a quinolone e.g. Cipro)

Psitacosis or Q fever

  • Doxycycline

Mycoplasma

  • Clarithromycin

C. pneumoniae

  • Clarithromycin
other aetiologies
Other aetiologies
  • TB
  • Viral
  • Fungal
  • Pneumocystis