Pneumonia (Dr. Yaman) PDF

1
DR. YAMAN WALID KASSAB

B.Pharm (AUST), Mpharm (JUST), PhD Clin Pharm (USM)
Dept. of Hospital & Clinical Pharmacy,
Faculty of Pharmacy, CUCMS
2
LEARNING OBJECTIVES
Upon the completion of the lecture, students should be able to:
✓ List the common pathogens in pneumonia

✓ Describe the signs & symptoms associated with (different
types) pneumonia
✓ Develop objective risk assessment to guide the therapeutic
plan for an individual patient
✓ Design an appropriate empiric and definite therapy based on
both patient- and organism-specific data
✓ Recommend appropriate monitoring plan.
3
INTRODUCTION
 Pneumonia is an inflammation of lung parenchyma (mainly

alveoli) usually characterized by consolidation.
What is lung consolidation ?!
 A pathological process in which the alveoli are filled with a

mixture of inflammatory exudate, bacteria & WBCs →
swelling or hardening (induration)
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INTRODUCTION …
A: Normal
B: consolidation
(white area)
5
RESPIRATORY SYSTEM'S DEFENCE
MECHANISMS
1. Mechanical and structural
✓ Nose
✓ Cough/ gag reflex
✓ Airway branching
✓ Mucociliary clearance
✓ Oro-pharyngeal flora
2. Cellular
✓ Surface epithelium → secrets antimicrobial peptides (Lactoferrin)
✓ Dual phagocytic system: alveolar macrophages & neutrophils
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RESPIRATORY SYSTEM'S DEFENCE
MECHANISMS …
3. Humoral/ Inflammatory
✓ IgG, IgA
✓ Cytokines
✓ Colony stimulating factors
Note: Large particles get trapped and removed from nasopharynx.
Small microorganisms reach alveolar sacs → INFECTIONS

7
FACTORS AFFECTING DEFENCE
MECHANISMS
Is there any factor that can impair these defence mechanisms ?!
Defence mechanism Impaired by

Coughing reflex Alcohol, Stroke, Coma
Alcohol, Smoking,
Mucociliary clearance
Kartengener’s syndrome
Alcohol, Smoking, Steroids,
Alveolar macrophages
Pulmonary edema,
Humoral Immune defence IG deficiencies
Cell-mediated Immune defence Hodgkin’s, steroids, HIV
8
ROUTES OF INFECTION
There are FOUR (4) main routs to get pneumonia infection,

those are:
1. Inhalation / person to person (most common)

 Normally through airborne route (droplets) - sneezing,
coughing, etc.....
 Incubation Period → 1-4 Weeks
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ROUTES OF INFECTION …
2. Gross aspiration → aspirational pneumonia (common)

 occurs when food, saliva, liquids, or vomit is breathed
from the mouth into the airways leading to the lungs.
3. Exogenous penetration and contamination of the lung (rare)
 occurs due to accidental trauma (car accident), surgery or
bronchoscopy.
4. Haematogenous spread to the lung from an extra-pulmonary
site of infection (uncommon)
 E.g. UTI, sepsis, endocarditis.
10
TYPES OF PNEUMONIA
What are the types of Pneumonia?!
 Pneumonia can be classified in several ways, such as:

1. Anatomical classification.
2. Etiological classification.
3. Based on location acquired.
4. Based on the presenting symptoms.
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TYPES OF PNEUMONIA …
1. Anatomical classification: depending on the extent of lesions,

pneumonia can be :
a) Lobar pneumonia involves all or part of lung’s lobe.
o often due to Streptococcus pneumoniae.
b) Bronchial pneumonia affects bronchioles
and adjacent alveoli
o Appears as scattered patches.
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Lobar pneumonia Bronchial pneumonia

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1. Anatomical classification …
c) Interstitial pneumonia (pneumonitis) where inflammatory

infiltrate involve mainly interstitial tissue between alveoli.
o more likely to be caused by viruses or by atypical
bacteria.
14
2. Based on location acquired:

 Community-acquired Pneumonia (CAP)
Acquired in the community in patients who:
➢ have not been hospitalised within 14 days prior to onset
of symptoms, OR
➢ have been hospitalised less than 48 hours prior to the
onset of symptoms.
Bartlett. Clin Infect Dis 2008;31:347-82.
 Nosocomial Pneumonia
Any types for nosocomial pneumonia ?!
15
3. Etiological classification: based on the cause

 Most cases of pneumonia are caused by microorganism
(infectious Pneumonia).
i. Bacterial ii. Viral
iii. Fungal iv. Parasitic
 Non-infectious causes include:
✓ Aspiration of food, gastric acid, or foreign bodies
(hydrocarbons or lipoid substances).
✓ Aspiration of amniotic fluid.
✓ Drug or radiation induced pneumonitis. Examples?
o Anticancer agents & Gold salts
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Infectious Pneumonia
 Results from more than 30 studies during the past decade show
that the causative agent in pneumonia is unclear about 35 to
70% of the time, even after extensive laboratory diagnostic
work-up.
Mandell LA, Bartlett JG, Dowell SF, et al: Update of practice guidelines for the management of
community-acquired pneumonia in immunocompetent adults. Clin Infect Dis. 2009, 37: 1405-1433.
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COMMUNITY ACQUIRED
PNEUMONIA (CAP)
• DEFINITION
• PATHOPHYSIOLOGY
• RISK FACTORS
• AETIOLOGY
• CLINICAL MANIFESTATION
• DIAGNOSTIC TESTs
• TREATMENT
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EPIDEMIOLOGY OF CAP
 Most common ID and is an important cause of mortality and

morbidity worldwide (6th leading cause of death worldwide).
 Highest incidence is among elderly (≥ 65 years) and the very
young (< 5 years), but still common in nonelderly adults.
 Annual death (Asia): almost 1 million adults (mainly elderly)
 Mortality is highest for CAP patients who require
hospitalisation, with a 30-day mortality rate of up to 23 % in
such patients.
Peto et al. 2015;108(6):326-37
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ETIOLOGY OF CAP
TYPICAL PNEUMONIA ATYPICAL PNEUMONIA
▪ Streptococcus Pneumoniae (20-60%) ▪ Chlamydia Pneumoniae (4-6%)

▪ Haemophilus Influenzae (3-10%) ▪ Mycoplasma Pneumoniae (1-6%)
▪ GNB – Klebsiella Pneumoniae (3-10%) ▪ Legionella species (2-8%)
▪ Pseudomonas Aeruginosa ▪ Respiratory Viruses (2-15%)
▪ Staphylococcus Aureus (3-5%)
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ETIOLOGY OF CAP…
• CAP is usually caused by a single organism, except

aspiration pneumonia, which is commonly polymicrobial.
• Atypical organisms are not revealed on ordinary Gram stain

and culture media.
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ETIOLOGY OF CAP…
Viruses
❑ Most common cause of pneumonia in children <5 years.
❑ Mild → recover within 1-2 weeks without treatment.
❑ Flu virus is the most common cause of viral pneumonia in
adults.
❑ Include respiratory syncytial virus, rhinovirus, severe
acute respiratory syndrome (SARS)
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ETIOLOGY OF CAP…
Fungi
❑ Most people exposed to fungi don’t get sick, but some do
and require treatment.
❑ Serious fungal infections are most common in immuno-
compromised patients.
❑ Examples:
✓ Pneumocystis jiroveci /carinii (PCP/PJP)
✓ Histoplasmosis
✓ Cryptococcus (in bird droppings)
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ETIOLOGY BY SEVERITY
Remains the most
common cause
(60% of cases)
1. MILD CAP
a) No comorbidity
• Streptococcus pneumoniae Comorbidities such
• Mycoplasma pneumoniae as : CHF, COPD,
• Haemophilus influenza DM or renal
• Chlamydophila pneumoniae diseases
• Klebsiella pneumoniae
b) Comorbidity or History of recent antibiotic therapy (3 months)

• Streptococcus pneumoniae
• Mycoplasma pneumoniae
• Haemophilus influenzae
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ETIOLOGY BY SEVERITY…
2. Moderate & Severe CAP (not requiring mechanical ventilation)

• Mycoplasma pneumoniae Fortunately, CAP
• Haemophilus influenzae attributable to S. aureus
• Klebsiella pneumoniae is rare (< 5 %)
• Legionella pneumophila
• Chlamydia pneumophila
• Staphylococcus aureus
• Other Gram-Negative Bacilli (Enterobacter & Escherichia coli)
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3. Severe CAP (requiring mechanical ventilation)

• Haemophilus influenzae Fortunately, CAP
• Staphylococcus aureus attributable to S. aureus
• Klebsiella pneumoniae is rare (< 5 %)
• Mycoplasma pneumoniae
• Legionella pneumophilia
• Chlamydophila pneumoniae
• Burkholderia pseudomallei
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Why to worry from S. aureus? When to suspect it?
✓ S. aureus pneumonia is usually sever & requires hospitalisation.

✓ It
causes abscesses & necrosis of the lung, therefore, has a high
mortality rate.
✓ Therapy should be continued for up to 2 weeks.
Remember: Staphylococcus aureus usually colonizes the upper

airway of asymptomatic people.
27
When to suspect MSSA? What are the risk factors for

MSSA?!
✓ Risk factors for MSSA are:

1. Prior influenza infection (most common predisposing factor).
2. Prior antibiotics use especially quinolones
3. IV drugs abuse
4. ESRF Malaysian National Antibiotic Guidelines 2014
Treatment: IV cloxacillin 2g q4h X 10-14 days

28
How to predict the risk for MRSA in pneumonia ?!

• Using a validated risk-stratification tool, Shorr Score
Shorr et al., 2013

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Underlying problem: Over-diagnosis of MRSA pneumonia

• S. aureus commonly colonises the upper airway of asymptomatic
people.
• Imagine that a person colonised with MRSA develops pneumonia
with an organism that is difficult to detect (e.g. mycoplasma or viral
pneumonia). The patient's sputum may be contaminated with MRSA
from their upper airway, leading to an incorrect diagnosis of
“MRSA pneumonia”.
• MRSA is easy to culture, so detecting MRSA contaminant may be
easier than detecting the true pathogen.
• Among pneumonia patients with sputum cultures positive for
MRSA, >80% don't appear to have a true MRSA pneumonia
Enomoto 2016, Kawanami 2016
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ETIOLOGY BY COMORBIDITY
Alcoholism ▪ Strep pneumoniae

▪ Oral anaerobes
▪ Klebsiella pneumoniae
▪ Acinetobacter spp
▪ M. tuberculosis
COPD and/or Tobacco
catarrhalis
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ETIOLOGY BY COMORBIDITY…
Alcoholism ▪ Strep pneumoniae

▪ Oral anaerobes
▪ Klebsiella pneumoniae
▪ Acinetobacter spp
▪ M. tuberculosis
COPD and/or Tobacco ▪ Haemophilus influenzae
▪ Pseudomonas aeruginosa
▪ Legionella spp
▪ S. pneumoniae
▪ Moraxella catarrhalis
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Lung Abscess ▪ Community-associated (CA-MRSA)

▪ Oral anaerobes
▪ Endemic fungi
▪ M. tuberculosis
▪ Atypical mycobacteria
Structural lung disease
(e.g. bronchiectasis)
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Lung Abscess ▪ Community-associated (CA-MRSA)

▪ Oral anaerobes
▪ Endemic fungi
▪ M. tuberculosis
▪ Atypical mycobacteria
Structural lung disease ▪ Pseudomonas aeruginosa
(e.g. bronchiectasis) ▪ Burkholderia cepacia
▪ S. aureus
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Advanced HIV ▪ Pneumocystis jirovecii (PCP)

▪ Cryptococcus
▪ Histoplasma
▪ Aspergillus
▪ Pseudomonas aeruginosa
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ETIOLOGY BY ZOONOTIC EXPOSURE
Bat or bird droppings ▪ Histoplasma capsulatum
▪ Chalmydophila psittaci
Birds
▪ Poultry: avian influenza
Rabbits ▪ Francisella tularensis
Farm animals / parturient cats ▪ Coxiella burnetti (Q fever)
Communicable disease Epidemiology and Immunization Sections

Health Advisory: Potential exposure to Avian Psittacosis from Birds, Oct 2009
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ETIOLOGY IN CHILDREN
Birth - 3 weeks Group B streptococcus, E. Coli, Strep. pneumoniae,

Haemophilus influenzae (type b)
Respiratory syncytial virus (RSV), other respiratory
3 weeks - 3 months viruses (parainfluenza viruses, influenza viruses,
adenovirus), S. pneumoniae, H. influenzae (type b)
RSV, other respiratory viruses, S. pneumoniae, H.
4 months - 4 years influenzae (type b), Mycoplasma pneumoniae, group A
streptococcus
M. pneumoniae, Strep. pneumoniae, Chlamydophila
5 years - 15 years
pneumoniae, H. influenzae (type b), influenza viruses,
other respiratory viruses, Legionella pneumophila
Kliegman RM, Marcdante KJ, Jenson HJ, et al: Nelson essentials of pediatrics, ed 5, Philadelphia, 2016, p 504.
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PREDISPOSING FACTORS
 Age: < 5 years or > 65 years.

 Co-morbidities: Chronic heart, lung, liver, or renal diseases, diabetes
mellitus, malignancies, asplenia, immunosuppressing conditions
 Other respiratory conditions: Cystic fibrosis, Bronchiectasis,
Asthma, COPD.
 Lifestyle: Malnutrition, Cigarette smoking, Alcoholism.
 Drugs:
o Immunosuppressant therapy (e.g. prolonged corticosteroids),
o Proton pump inhibitors (PPI) or H2 receptor blockers.
IDSA 2007
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PREDISPOSING FACTORS…
Why using acid-suppressive drugs increase the

risk for CAP ?!
By decreasing gastric acidity → ↑ risk of gastric bacteria

colonization → if aspirated to the lungs could cause
pneumonia.
Note: Sucralfate was not found in literature to increase the

risk of CAP.
Eom et al 2011 Use of acid-suppressive drugs and risk of pneumonia: a systematic review
and meta-analysis.
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CLINICAL MANIFESTATIONS
TYPICAL PRESENTATION ATYPICAL PRESENTATION

 Sudden onset  Gradual & insidious onset
 High fever (80%) with chills  Low grade fever / no fever
 Productive cough (90%)  Dry cough
 Poor general condition  Good general condition:
 Tachypnoea RR > 20 (70%) ‘walking pneumonia’
 Extra-pulmonary manifestations,
 Dyspnoea & SOB (66%)
EXAMPLES ??
 Pleuritic chest pain (50%),
 Low blood pressure
 Tachycardia HR >100
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CLINICAL MANIFESTATIONS…
Extra-Pulmonary Manifestations in Atypical Pneumonia:

 Erythema Multiforme: in Mycoplasma pneumonia
 Headache / mental confusion.
 Relative bradycardia.
 Abdominal pain / diarrhea.
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DIAGNOSTIC WORKUP
1. CHEST RADIOGRAPHY
• Usually needed to establish diagnosis

• It is a prognostic indicator
• To rule out other disorders
▪ Shows lung consolidation

▪ Findings do not correlate with severity
▪ Do not reliably distinguish between bacterial
and viral infection
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DIAGNOSTIC WORKUP…
LABORATORY MICROBIOLOGY
 CBC: with differential WBC  Expectorated sputum Gram stain
 Renal Profile: BUN, Cr,  Serum culture and sensitivity
electrolytes (before empiric)
 FBG  Serology
 LFT: Enzymes  Polymerase chain reaction (PCR)
 Blood gases: SpO2
43
RISK STRATIFICATION & SITE-OF
CARE DECISIONS…
Various predictive tools are used to assess mortality risk and guide
physicians in deciding the site-of-care.
Hospital admission:
1. PSI (Pneumonia Severity Index) → 20 variables
2. CURB-65
3. CRB-65
4. SMART-COP
5. Expanded-CURB-65
ICU ADMISSION:
1. ATS (American Thoracic Society) Score
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PNEUMONIA SEVERITY INDEX (PSI)
(Predicting the morbidity and mortality rate)
It consists of twenty clinical and laboratory parameters →

It is complicated to calculate → limits its clinical application
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PNEUMONIA SEVERITY INDEX (PSI)
(Predicting morbidity and mortality rates)
Low
Moderate
High
46
CURB-65
CONFUSION
UREA > 7
RR > 30
SBP < 90
DBP ≤ 60
AGE > 65
47
NEW: Expanded-CURB-65 (year 2016)
Consists of 8 parameters as follows:

1. Confusion,
2. Urea > 7 mmol/L
3. Respiratory rate ≥ 30 /min
4. Low systolic (< 90 mmHg) or diastolic (≤ 60 mmHg) BP
5. Age ≥ 65 years
6. Lactate dehydrogenase (LDH) > 230 u/L
7. Albumin < 3.5 g/dL
8. Platelet count < 100 × 109/L
The score is categorized into three classes as follows:
0–2 as low risk → treated as outpatient
3–4 intermediate risk → treated as inpatient in hospital ward
5–8 high risk → treated as inpatient in ICU
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SMART-COP
(Predicting the need for ventilatory/vasopressor support)
IRVS: intensive respiratory or vasopressor support

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ATS SCORE
Direct admission to ICU is recommended for patients with:

• 1-2 major criteria OR 3 minor criteria
50
RISK STRATIFICATION…
• These predictive tools serve only as a guide to

clinical management.
• Severity of illness is not the only factor to be considered
when deciding on admission.
• Social and home circumstances must be considered as well.
• Tools must be used in conjunction with clinical judgment
when assessing the severity of a pneumonia case.
51
GOAL OF TREATMENT
Desired outcome:
 Eradicating the causative pathogens.
 Alleviating and resolving the signs and symptoms of
pneumonia
 Preventing of complications such as sepsis, lung abscess,
and empyema.
 Minimising hospitalisation, and preventing reinfection.
52
LOCAL ANTIBIOTIC RESISTANCE
PATTERNS
A. Streptococcus Pneumonia
Malaysian National Antibiotic Guidelines 2014

53
PATTERNS…
B. Staphylococcus aureus

54
PATTERNS…
C. MRSA

55
MANAGEMENT OF CAP
Empiric & Deﬁnitive therapy for CAP
(Please refer to National Antibiotic

Guideline 2014)
56
MANAGEMENT OF CAP…

57
MANAGEMENT OF CAP…
What is the rational behind using combination therapy with ß-

lactams and macrolides in patients with moderate& severe CAP ?!
• This combination has been shown to achieve better outcomes in
patients with severe CAP.
• It also confers broader coverage as a proportion of bacteraemic
pneumococcal pneumonias have concomitant mycoplasma and
rarely legionella infections.
• ß-lactams act on the bacterial wall while macrolides inhibit protein
synthesis providing a dual mechanism of action.
• Apart from its antimicrobial activity, macrolides have anti-
inflammatory properties that result in less production of virulence
factors.
Guide to antimicrobial therapy in ICU 2017
58
DE-ESCALATION OF ANTIBIOTIC
THERAPY…
Switching from intravenous (IV) to oral (PO) therapy:
 Patients started on IV therapy should be switched to equivalent

oral therapy when possible.
 Advantages of early IV to PO switch include reduced IV line
infections, early hospital discharge and reduced cost.

59
ASPIRATION PNEUMONIA
• DEFINITION
• PATHOPHYSIOLOGY
• RISK FACTORS
• AETIOLOGY
• TREATMENT
60
ASPIRATION PNEUMONIA
 Aspiration pneumonia is a complication of pulmonary aspiration

when food, gastric acid, saliva or vomit is inhaled into the lungs.
 Risk factors for aspiration are conditions that:
✓ suppress cough and muco-ciliary clearance.
✓ impair swallowing and epiglottic closure.
Stroke, seizures, or neuromuscular diseases
 The usual causative organisms in aspiration pneumonia are those

that colonise the oropharynx.
61
ASPIRATION PNEUMONIA…
62
Classified into TWO (2) types based on location acquired:

A. Community-acquired cases
✓ Oral anaerobes are the predominant organisms (e.g.
Peptostreptococci, Fusobacterium spp & Prevotella
melaninogenica)
B. Nosocomial cases
✓ More likely due to oropharyngeal colonisation with
Gram-negative enteric bacilli and Staphylococcus aureus.
Remember: Antimicrobials are not indicated in aspiration without

evidence of infection
63
What is the antibiotic therapy recommended for aspiration

pneumonia?! and Why?!
• ß-lactam/ß-lactamase inhibitors are recommended,

because oral anaerobes are sensitive to them.
• Metronidazole can be added especially if Prevotella

melaninogenica is suspected.
64
Guide to antimicrobial therapy in the adult ICU 2017

65
NOSOCOMIAL PNEUMONIA
(HCAP/HAP/VAP)
• DEFINITION
• PATHOPHYSIOLOGY
• RISK FACTORS
• AETIOLOGY
• TREATMENT
66
NOSOCOMIAL PNEUMONIA
A. Hospital-acquired Pneumonia (HAP):

✓ Occurs ≥ 48 hours after hospital admission and not incubating
at the time of admission.
B. Ventilator-associated pneumonia (VAP):

✓ Second-most-common type and is usually bacterial in origin.
✓ Occurs 48 hours following endotracheal intubation mainly in
critically ill patients in the ICU.
C. Health care–associated pneumonia (HCAP):

✓ This term is NO LONGER USED
67
NOSOCOMIAL PNEUMONIA…
C. Health care–associated pneumonia (HCAP):

occurs in a non-hospitalised patient with extensive healthcare
contact, as defined by one or more of the following:
 Intravenous therapy, wound care, or intravenous

chemotherapy within the prior 30 days of the current
infection;
 Residence in a nursing home or other long-term care facility;
 Hospitalisation in an acute care hospital for ≥ 2 days within
the prior 90 days of the current infection;
 Attendance at haemodialysis clinic within the prior 30 days.
ACCP Updates in Therapeutics 2014
68
NOSOCOMIAL PNEUMONIA…
PREDISPOSING FACTORS for nosocomial pneumonia

 Endotracheal intubation / mechanical ventilation (MV)
 Age > 70 years
 Depressed mental status
 Underlying diseases and malnutrition
 Respiratory / Metabolic acidosis
 Trauma & Surgery
 Supine position
69
HOSPITAL-ACQUIRED PNEUMONIA
(HAP) - ETIOLOGY
ONSET OF INFECTION
EARLY ONSET (< 5 DAYS) LATE ONSET
▪ S. Pneumoniae ▪ P. Aeruginosa
▪ H. Influenzae ▪ Acinetobacter spp.
▪ S. Aureus ▪ K. Pneumoniae (ESBL)
▪ E. Coli ▪ MRSA
▪ K. Pneumoniae ▪ S. Pneumoniae
▪ Enterobacter spp. ▪ H. Influenzae
▪ Proteus spp. ▪ S. Aureus
▪ Serratia Marcescens ▪ M. Pneumoniae
70
(HAP) - ETIOLOGY
• Aerobic gram-negative bacteria account for

more than half of the cases of HAP.
• S. aureus is the most common gram-positive pathogen,

causing 13-40% of HAP
71
(HAP) - ETIOLOGY
ONSET OF HAP INFECTION
Late onset or at risk for MDR

EARLY ONSET (< 5 DAYS)
pathogens
Monotherapy Combination therapy

72
(HAP) – TREATMENT
 Early onset HAP and low risk for infection with multi-drug
resistant (MDR) organisms

73
(HAP) – TREATMENT…
 Early onset with MDR risk factors and Late onset HAP
For patients with renal

insufficiency or receiving
other nephrotoxic agents.
74
What is MDR and XDR bacteria ?!
 Multidrug-resistant bacteria (MDR): resistant to three or more

antibiotic classes
 Extremely drug resistant (XDR) is ‘susceptible only to one or
two drug classes.
European Centre for Disease Prevention and

Control (ECDC)
75
 Recent evidence has demonstrated that duration of

antibiotics could be shortened to 7 days even for MDR
Pseudomonas aeruginosa and Acinetobacter baumanii
organisms.
 Duration of treatment for MRSA Pneumonia is 10-14
days.
 Longer duration may be indicated depending upon
clinical, radiologic and laboratory parameters.

76
(HAP) – TREATMENT Outcome
Initiation of
antibiotic therapy Responding ➢ De-escalation of antibiotics
48 – 72
hours
Non-
responding ➢ Re-evaluate for non-infectious
mimics of pneumonia
➢ MDR
➢ Extra-pulmonary sites of infections
➢ Complications of pneumonia
77
Empiric & Deﬁnitive therapy for HAP
(Please refer to National Antibiotic

Guideline 2014)
78
VENTILATOR-ASSOCIATED
PNEUMONIA (VAP)
 Tracheal colonisation is common in intubated patients.
COLONISATION OR INFECTION ?
 Factors that favor infections:

✓ A new fever / worsening fever or change in fever pattern
✓ Rise in peripheral WBC count, leukocytosis
✓ Increase purulent sputum production from endotracheal tube
✓ Reduced arterial PaO2
✓ Enlarging infiltrate or newly developed infiltrate on CXR.
79
PNEUMONIA (VAP)…
The presence of a new progressive infiltrate PLUS at least 2

or 3 clinical features (fever, leukocytosis or leukopenia and
purulent secretions) is the most accurate clinical criteria for
starting empirical therapy.
Infect Dis Clin N Am 2004;18:939-962, Am J Respir Crit

Care Med 2005, in press
80
PNEUMONIA (VAP)…
 Gram -ve organisms account for 90.7% & 60% are MDR organisms.
 Staphylococcus aureus comprises 8.1% of VAP organisms, 75% being
methicillin-resistant organisms.
Malaysia Registry of Intensive Care (MRIC) Report 2015
 The risk factors for MDR VAP include:
1. prior antibiotic use within 90 days,
2. septic shock at time of VAP,
3. Acute Respiratory Distress Syndrome (ARDS) preceding VAP,
4. ≥ 5 days of hospitalisation prior to occurrence of VAP,
5. acute renal replacement therapy prior to onset of VAP.
81
PNEUMONIA (VAP)…

82
PNEUMONIA (VAP)…
 Recent evidence has demonstrated that duration of antibiotics

could be shortened to 7 days even for MDR Pseudomonas
aeruginosa and Acinetobacter baumanii organisms.
 Duration of treatment for MRSA pneumonia is 10 to 14 days.

83
PNEUMONIA (VAP)…
 Clinical pulmonary infection score (CPIS) is a tool commonly

used to facilitate diagnosis of VAP.
 CPIS > 6 suggest pneumonia
 Limited sensitivity & specificity
 CPIS should be monitored during VAP therapy → Patients
with VAP having CPIS ≤ 6 can safely discontinue antibiotics
after 3 days.
AJRCCM 2000; 162:501-511

84
PNEUMONIA (VAP)…
85
IMMUNIZATION
The pneumococcal vaccine (Streptococcus pneumoniae)

✓ age 65 or older.
✓ age 19 to 64 who smoke or have asthma.
✓ Those with a chronic (long-term) diseases including DM,
cirrhosis, lung, heart, liver, or kidney diseases.
✓ Immune system disorders or using medications that weaken the
immune system.
✓ Living in a nursing home or long-term care home.
86
IMMUNIZATION…
Influenza vaccine
✓ Chronic illness
✓ Immune system disorders
✓ Residents of nursing homes
✓ Health care workers
✓ Persons in contact with high risk patients.
Note: Healthy persons aged 2 to 64 years without contraindication are

also encouraged to receive influenza vaccine even if they are not in one
of the priority groups
87
ADDITIONAL READING &
REFERENCES
 National-antibiotic-guideline 2014
 Protocol on antimicrobial stewardship program in
healthcare Facilities 2014
 Guide to antimicrobial therapy in the adult ICU 2017
 IDSA Guidelines on the Management of CAP in Adults
 UMMC On-line Antibiotic Guideline 2017
 The Sanford Guide to Antimicrobial Therapy
88
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1

DR. YAMAN WALID KASSAB

Upon the completion of the lecture, students should be able to:

✓ List the common pathogens in pneumonia

 Pneumonia is an inflammation of lung parenchyma (mainly

What is lung consolidation ?!

 A pathological process in which the alveoli are filled with a

Note: Large particles get trapped and removed from nasopharynx.

Small microorganisms reach alveolar sacs → INFECTIONS

Is there any factor that can impair these defence mechanisms ?!

Defence mechanism Impaired by

There are FOUR (4) main routs to get pneumonia infection,

1. Inhalation / person to person (most common)

2. Gross aspiration → aspirational pneumonia (common)

What are the types of Pneumonia?!

 Pneumonia can be classified in several ways, such as:

1. Anatomical classification: depending on the extent of lesions,

Lobar pneumonia Bronchial pneumonia

c) Interstitial pneumonia (pneumonitis) where inflammatory

2. Based on location acquired:

3. Etiological classification: based on the cause

 Most common ID and is an important cause of mortality and

TYPICAL PNEUMONIA ATYPICAL PNEUMONIA

▪ Streptococcus Pneumoniae (20-60%) ▪ Chlamydia Pneumoniae (4-6%)

• CAP is usually caused by a single organism, except

• Atypical organisms are not revealed on ordinary Gram stain

b) Comorbidity or History of recent antibiotic therapy (3 months)

2. Moderate & Severe CAP (not requiring mechanical ventilation)

3. Severe CAP (requiring mechanical ventilation)

Why to worry from S. aureus? When to suspect it?

✓ S. aureus pneumonia is usually sever & requires hospitalisation.

Remember: Staphylococcus aureus usually colonizes the upper

When to suspect MSSA? What are the risk factors for

✓ Risk factors for MSSA are:

Treatment: IV cloxacillin 2g q4h X 10-14 days

How to predict the risk for MRSA in pneumonia ?!

Shorr et al., 2013

Underlying problem: Over-diagnosis of MRSA pneumonia

Alcoholism ▪ Strep pneumoniae

Alcoholism ▪ Strep pneumoniae

Lung Abscess ▪ Community-associated (CA-MRSA)

Lung Abscess ▪ Community-associated (CA-MRSA)

Advanced HIV ▪ Pneumocystis jirovecii (PCP)

ETIOLOGY BY ZOONOTIC EXPOSURE

Bat or bird droppings ▪ Histoplasma capsulatum

Rabbits ▪ Francisella tularensis

Farm animals / parturient cats ▪ Coxiella burnetti (Q fever)

Communicable disease Epidemiology and Immunization Sections

Birth - 3 weeks Group B streptococcus, E. Coli, Strep. pneumoniae,

 Age: < 5 years or > 65 years.

Why using acid-suppressive drugs increase the

By decreasing gastric acidity → ↑ risk of gastric bacteria

Note: Sucralfate was not found in literature to increase the

TYPICAL PRESENTATION ATYPICAL PRESENTATION

Extra-Pulmonary Manifestations in Atypical Pneumonia:

• Usually needed to establish diagnosis

▪ Shows lung consolidation

It consists of twenty clinical and laboratory parameters →

NEW: Expanded-CURB-65 (year 2016)

Consists of 8 parameters as follows:

IRVS: intensive respiratory or vasopressor support

Direct admission to ICU is recommended for patients with:

• These predictive tools serve only as a guide to