PNEUMONIA

Michael Angelo Z. Delgado, M.D.

PNEUMONIA
Inflammation of the parenchyma of the lungs Usually caused by microorganisms Noninfectious causes include aspiration of food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity reactions, and drug- or radiationinduced pneumonitis Causes of lung infection in neonates and immunocompromised hosts are distinct from those affecting otherwise normal infants and children.

PNEUMONIA
The cause of pneumonia in an individual is often difficult to determine because direct culture of lung tissue is invasive and rarely performed. Cultures performed on specimens obtained from the upper respiratory tract or sputum generally do not accurately reflect the cause of lower respiratory tract infection. Using state-of-the-art diagnostic testing, a bacterial or viral cause of pneumonia can be identified in 4080% of children with community-acquired pneumonia. Immunization status is relevant Children fully immunized against H. influenzae type b and S. pneumoniae are less likely to be infected with these pathogens. Children who are immunosuppressed or who have an underlying illness may be at risk for specific pathogens, such as Pseudomonas spp. in patients with cystic fibrosis.

PNEUMONIA
The lower respiratory tract is kept sterile by physiologic defense mechanisms Mucociliary clearance Properties of normal secretions secretory immunoglobulin A (IgA) clearing of the airway by coughing Macrophages present in alveoli and bronchioles

PNEUMONIA: BACTERIAL
Bacterial Pneumonia Symptoms Shaking chill High fever Chest pain Brief upper respiratory tract illness Drowsiness with intermittent periods of restlessness Rapid respirations; Dry, hacking, unproductive cough; anxiety; and, occasionally, delirium. Circumoral cyanosis Pleuritic pain

PNEUMONIA: BACTERIAL CAUSES

Common Streptococcus pneumoniae Group B streptococci Group A streptococci Mycoplasma pneumoniae[*] Chlamydia pneumoniae[*] Chlamydia trachomatis Mixed anaerobes Gram-negative enteric Adolescents;summer-fall epidemics Adolescents Infants Aspiration pneumonia Nosocomial pneumonia Neonates

PNEUMONIA: BACTERIAL CAUSES

Uncommon Haemophilus influenzae type B Staphylococcus aureus Moraxella catarrhalis Neisseria meningitides Francisella tularensis Nocardia species Chlamydia psittaci[*] Yersinia pestis Legionella species[*] Animal, tick, fly contact Immunosuppressed persons Bird contact Plague Exposure to contaminated water; nosocomial Unimmunized Pneumatoceles;infants

PNEUMONIA: BACTERIAL
M. Pneumoniae attaches to the respi epith and inhibits ciliary action cellular destruction and inflammation airway obstruction S. pneumoniae local edema; focal lobar involvement S. pyogenes diffuse infection with interstitial PN; necrosis of tracheobronchial mucosa; extension into the interalveolar septa and pleural involvement S. aureus confluent BPN, often unilateral; hemorrhagic necrosis and cavitation

PNEUMONIA: BACTERIAL
Pneumococcal Organism Clinical Manifestation S. pneumonia Infants: - mild URTI - Abrupt high fever & resp. distress Child/Ado: - brief mild URTI - shaking chill, high fever, chest pain Streptococcal Grp A Strep - sudden onset - chills, high fever, resp. distress - (occ) insidious, mildly ill Staphylococcal H. influenzae S. aureus - infant <1 yr - 1 wk URTI - abrupt high fever, cough, resp. distress H. inf. type b - similar to pneumococcal - more often insidious & course is prolonged

PNEUMONIA: BACTERIAL
Pneumococcal Organism P.E. Findings S. pneumonia Infant: - grunting - RR - alar flare - retractions - rales - PE change little during course Child & Ado: - same; fremiti - BS - PE change during course Streptococcal Grp A Strep - febrile - RR - similar to pneumococcal Staphylococcal H. influenzae S. aureus - febrile - RR - grunting - retractions - alar flare - cyanosis - rales / rhonchi - if w/ complications: dull percussion BS vocal fremiti H. inf. type b - febrile - RR - alar flare - retractions - localized dullness to percussion - rales

PNEUMONIA: BACTERIAL
Pneumococcal Organism Lab. Findings S. pneumonia -WBC (15-40) (15- PMNs - ABGs hypoxemia - Isolate org from nasopharyngeal secretions - Bacteremia in 30% (c/s of bld & pleural fluid) Streptococcal Grp A Strep - WBC - Anti strepstreptolysin titer - Isolate org: throat swab, NP secretions, sputum - Bacteremia in 10% - c/s of PF, bld, lung aspirate Staphylococcal H. influenzae S. aureus - WBC (> 20) - PMNs - Dxic cultures: tracheal asp, pleural tap, blood - G/S gm+ cocci in clusters H. inf. type b - mod. WBC - lymphopenia - Dxic cultures: blood, pleural fluid, lung aspirate

PNEUMONIA: BACTERIAL
Pneumococcal Organism CX Ray S. pneumonia -Lobar consolidation (not common in infants & young child) - pleural fluid common - Resolution: several weeks Streptococcal Grp A Strep - Diffuse BPN - Large pleural effusion often - Resolution: up to 10 wks Staphylococcal H. influenzae S. aureus - nonspecific H. inf. type b - usually lobar BPN (early) but no char. - patchy / lobar CXR later - lung involved - segmental infiltrates in 65% - Pleural effusion - pleural / empyema effusion - PneumaPneumapneumatocoeles common - pneumatocoeles - pyopneumopyopneumothorax in 25% -Rapid progression -Resolution: weeks (pneumatocoeles mos.)

PNEUMONIA: BACTERIAL
Pneumococcal Organism Complications (Rare after antibiotic tx) S. pneumonia - Empyema (> in infants) Streptococcal Grp A Strep - Empyema in 20% - septic foci in bones or joints Staphylococcal H. influenzae S. aureus - septic lesions outside RT, rare except in young infant heart, meninges, bone, soft tissue H. inf. type b - freq. in young infant bacteremia, pericarditis, cellulitis, empyema, meningitis

PNEUMONIA: BACTERIAL

Pneumococcal Organism S. pneumonia Treatment - Penicillin (supportive (100 TuKD) measures in all)

Streptococcal Grp A Strep - Penicillin G (100 TuKD) * 2-3 wk 2course

Staphylococcal H. influenzae S. aureus - drainage of pus collection - semisemisynthetic penicillinase resistant pen (Nafcillin 200 MKD) H. inf. type b - Ampicillin (100 MKD) - Chloro (100 MKD) - Ceftriaxone (100 MKD) * 10-14 days 10tx

PNEUMONIA: BACTERIAL TREATMENT

OPD Amoxicillin 80-90 mkd Alternatives: Cefuroxime or Coamoxiclav School age: Macrolide antibiotic Adolescent: Respiratory Fluoroquinolone Hospitalized patients IV Cefuroxime 75-150 mkd, Cefotaxime or Ceftriaxone Staphylococcal PN Vanco or Clinda

PNEUMONIA: VIRAL
RSV most common during infancy Peak age: 2 3 yrs Clin Manifestations : prodrome of rhinitis & cough, fever (low temp) P.E.: RR, alar flare, retractions, rales, wheezes CXR: hyperinflation with bilateral interstitial infiltrates and : peribronchial cuffing

PNEUMONIA: VIRAL CAUSES

Common Respiratory synctial virus Parainfluenza types 13 Influenza A, B Adenovirus Metapneumovirus Bronchiolitis Croup High fever; winter months Can be severe; 1st quarter of the year Similar to RSV

PNEUMONIA: VIRAL CAUSES

Uncommon Rhinovirus Enterovirus Herpes simplex Cytomegalovirus Measles Varicella Hantavirus SARS agent Rhinorrhea Neonates Neonates Infants, immunosuppressed persons Rash, coryza, conjunctivitis Adolescents Southwestern United States, rodents Asia

PNEUMONIA: VIRAL
DIagnosis: - WBC (N) or slightly elevated (<20,000); lymphocyte predominance - Viral studies Treatment: - supportive measures - Influenza A: Oseltamivir (2mg/kg/dose BID for 5 days) or oral Amantadine (4.4-8.8 mg/dg/day for 3-5 days) - RSV: aerosolized Ribavirin

PNEUMONIA: FUNGAL
Histoplasma capsulatum Cryptococcus neoformans Aspergillus species Mucormycosis Coccidioides immitis Blastomyces dermatitides Geographic region; bird, bat contact Bird contact Immunosuppressed Immunosuppressed Geographic region Geographic region

PNEUMONIA: OTHER CAUSES

Rickettsial Coxiella burnetii[*] Rickettsia rickettsiae Q fever, animal (goat, sheep, cattle) exposure Tick bite

Mycobacterial Mycobacterium tuberculosis Mycobacterium avium-intracellulare Developing countries Immunosuppressed persons

Parasitic Pneumocystis carinii Eosinophilic Immunosuppressed, steroids Various parasites (e.g., Ascaris Strongyloides species)

PNEUMONIA: ETIOLOGIC AGENTS BY AGE

AGE GROUP Neonates (<1 mo) nontypable) 13 mo Febrile pneumonia Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza viruses, adenoviruses), S. pneumoniae, H. influenzae (type b,[*] nontypable) Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, cytomegalovir FREQUENT PATHOGENS (IN ORDER OF FREQUENCY) Group B streptococcus, Escherichia coli, other gram-negative bacilli, Streptococcus pneumoniae, Haemophilus influenzae (type b,[*]

Afebrile pneumonia

PNEUMONIA: ETIOLOGIC AGENTS BY AGE

312 mo Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza viruses, adenoviruses), S. pneumoniae, H. influenzae (type b,[*] nontypable), C. trachomatis, Mycoplasma pneumoniae, group A streptococcus

25 yr

Respiratory viruses (parainfluenza viruses, influenza viruses, adenoviruses), S. pneumoniae, H. influenzae (type b,[*] nontypable), M. pneumoniae, Chlamydophila pneumoniae, S. aureus, group A

streptococcus

PNEUMONIA: ETIOLOGIC AGENTS BY AGE

518 yr viruses 18 yr pneumophila M. pneumoniae, S. pneumoniae, C. pneumoniae, H. influenzae (type b, [*] nontypable), influenza viruses, adenoviruses, Legionella M. pneumoniae, S. pneumoniae, C. pneumoniae, H. influenzae (type b, [*] nontypable), influenza viruses, adenoviruses, other respiratory

PNEUMONIA: COMMUNITY ACQUIRED

Variables CoCo-morbid illness Compliant caregiver Ability to followfollow-up Presence of dehydration Ability to feed PCAP A Minimal none yes possible none able PCAP B Low present yes possible mild able PCAP C Moderate present no not possible moderate unable PCAP D High present no not possible severe unable

PNEUMONIA: COMMUNITY ACQUIRED

Variables Age Respiratory rate Signs of respi failure
Complications

PCAP A Minimal >11 mos

PCAP B Low > 11 mos

PCAP C Moderate < 11 mos

PCAP D High < 11 mos

2-12 mos > 50/min 1-5 y/o > 40/min >5 y/o > 30/min none none none none

2-12 mos > 60 or 70/min 1-5 y/o > 50/min >5 y/o > 35/min Irritable, (+) retractions present present present ADMIT TO ICU

ACTION PLAN

OPD; ffup at OPD; ffup in ADMIT end of tx 3 days regular ward