Submitted to- DR.

SHACHI
SHRIVASTAVA
submitted by - TRISHA GARG
ROLL NO. 135 (batch 2022)
PATHOLOGY SEMINAR
What is Pneumonia?
Pneumonia
is an an acute infection of the pulmonary
parenchyma .
alveolar infection leading to consolidation of the
greater part or one or more lobes,. resulting in

alveolar filling with fluid causing Air space

disease (consolidation and exudation).
It is a common and potentially serious illness
with considerable morbidity and mortality,
particularly in :
1) Older adult patients .
2) Patients with significant comorbidities.
CLASSIFICATION
Practical classification
Community Acquired Pneumonia (CAP)
Hospital Acquired Pneumonia (HAP)
Ventilator Associated Pneumonia (VAP)
Health Care Associate Pneumonia (HCAP)
Aspiration Pneumonia
Pneumonia in the Immunocompromised
Patients
Pneumonia: Definitions
Community Acquired Pneumonia (CAP)
Infection is acquired in the community.

Hospital Acquired Pneumonia (HAP)

Pneumonia > 48 hours after admission which was
not
incubating at the time of
admission.
A) Ventilator Associated Pneumonia
(VAP) pneumonia > 48 hours after intubation.
B) Health Care Associate Pneumonia
(HCAP)
Health Care Associate
Pneumonia (HCAP)

Pneumonia that occurs in a

nonhospitalized patient with extensive
healthcare contact:
Intravenous therapy, wound care, or intravenous
chemotherapy within the prior 30 days
Residence in a nursing home or other long-term
care facility
Hospitalization in an acute care hospital for two or
more days within the prior 90 days
Attendance at a hospital or hemodialysis clinic
within the prior 30 days
 Pathogenesis
1) Inhalation,
2) aspiration and
3) hematogenous spread
4)

Primary inhalation:
Organisms bypass normal respiratory
defense mechanisms or
when the Pt inhales aerobic GN organisms
that colonize the upper respiratory tract or
respiratory support equipment
 Pathogenesis
Aspiration:
when the Pt aspirates colonized upper
respiratory tract secretions
Stomach: reservoir of GNR that can ascend,
colonizing the respiratory tract.
Hematogenous:
Originate from a distant source and reach
the lungs via the blood stream.
Pathogenesis
Microaspiration
from nasopharynx:
S. Pneumonia
Inhalation:
S. Pneumonia , TB, viruses, Legionella
Aspiration:
anaerobes
Bloodborne:
Staph endocarditis, septic emboli
 Community acquired pneumonia
Pathogens
Usually caused by a single organism .
S. pneumoniae is the most common cause of
community-acquired pneumonia (CAP),
isolation of the organism in only 5 to 18 percent of
cases.
Many culture-negative cases are caused by
pneumococcus:
1) sputum culture is negative in about 50 percent of
patients with concurrent pneumococcal bacteremia.
2) majority of cases of unknown etiology respond to
treatment with penicillin
Caused by a variety of Bacteria, Viruses, Fungi
 Pneumococci are acquired by aerosol
inhalation, leading to colonization of the
nasopharynx.

Colonization is present in 40-50 percent of

healthy adults and persists for four to 6
weeks.(carriage is more common in
children and smokers )
Risk factors
Influenza infection
Alcohol abuse
Smoking
Hyposplenism or splenectomy
Immunocompromise due to :
a) Multiple myeloma
b) Systemic lupus erythematosus
c) Transplant recipients
Aspiration Pneumonia
Common pathogens
Mixed flora
Mouth anaerobes
Peptostreptococcus spp, Actinomyces spp.
Stomach contents
Chemical pneumonitis
Enterobacterium
 TYPICAL Clinical presentation
Symptomes:
Sudden onset
Fever with chills.
Productive cough, Mucopurulent sputum
Pleuritic chest pain
Signs:
Breath sound: Auscultatory findings of rales
and bronchial breath sounds are localized to
the involved segment or lobe.
Consolidation is signs:
Dullness on percussion.

Bronchial breath sounds.

Egophony
Whispered pectoriloquy (whispers, are
transmitted clearly ).
Pneumococcal pneumonia may present
atypically, especially in older adults where
confusion or delirium may be an initial
manifestation.
 Atypical pneumonia:Clinical
presentation
Atypical
Gradual onset
Afebrile
Dry cough
Breath sound: Rales
Uni/bilateral patchy, infiltrates
WBC: usual normal or slight high
Sore throat, myalgia, fatigue, diarrhea
Common etiology
Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella pneumophilla
Mycobactria
Virus
Investigations
CXR :
CBC with diff.
Sputum gram stain, culture susceptibility
Blood Culture
ABG
Urea / Electrolytes
 DIAGNOSIS
Chest x ray:
Demonstre infiltrate.
Establish Dx
To detect the presence of complications such as
:
pleural effusion (Parapneumonic effusion).
multilobar diseaseas
 32 Y/O male
Cough for 1
wk
Fever for 2
days
Rales over LLL
Pneumonia
Diagnosis
Sputum gram stain and culture
Good specimen
PMN’s>25/LPF
Few epithelial cells<10/LPF
Single predominant organism
Pneumonia
Common organisms
Gram positive: diplococci (pairs and chains)
Gram positive: clusters, ie staphylococcal
pneumonia
Gram negative: coccobacillary, ie K.P.
Gram negative: rods
Gram stain
Organisms not visible on gram stain
M. pneumonia, Chlamydia
Legionella pneumophila
Viruses
Mycobacterium
Empiric outpt Management in Previously
Healthy Pt
No comorbidities, no recent antibiotic use,
and low rate of resistance:
Azithromycin – 500 mg on day one followed by four
days of 250 mg a day or 500 mg daily for
three days

Clarithromycin – 500 mg twice daily for five days

Doxycycline – 100 mg twice daily

IDSA/ATS Guidelines
2007
/
Comorbidities, recent antibiotic use, or
high rate of resistance:
A respiratory fluoroquinolone :
levofloxacin 750 mg daily, or

moxifloxacin 400 mg daily, or

gemifloxacin 320 mg daily for five days ….OR

Combination therapy : a beta-lactam AND
macrolide.
amoxicillin, 1 g three times daily or

amoxicillin-clavulanate 2 g twice daily

cefuroxime 500 mg twice daily.

Pathogen-directed therapy
Empiric Inpt Management-Medical Ward
Organisms: all of the above plus
polymicrobial infections (+/- anaerobes),
Legionella
Recommended Parenteral Abx:
Respiratory fluoroquinolone, OR
Advanced macrolide plus a beta-lactam
Recent Abx:
As above. Regimen selected will depend on
nature of recent antibiotic therapy.

IDSA/ATS Guidelines
2007
Complications of Pneumonia
Bacteremia
Respiratory and circulatory failure
Pleural effusion (Parapneumonic effusion),
empyema, and abscess
Pleural fluid always needs analysis in setting of
pneumonia (do a thoracocentisis)
needs drainage if empyema develop: Chest
tube, surgical
 Streptococcus pneumonia
Most common cause of CAP
Gram positive diplococci
Symptoms : malaise, shaking chills, fever,
rusty sputum, pleuritic chest pain, cough
Lobar infiltrate on CXR
25% bacteremic
Risk factors for S.pneumonia
Splenectomy (Asplenia)
Sickle cell disease, hematologic diseases
Smoking
Bronchial Asthma and COPD
HIV
ETOH
S. Pneumonia Prevention
Pneumococcal conjugate vaccine (PCV) is a
vaccine used to protect infants and young
children
7 serotypes of Streptococcus
Pneumococcal polysaccharide vaccine (PPSV)
23 serotypes of Streptococcus

PPSV is recommended (routine vaccination) for

those over the age of 65
VACCINATION
For both children and adults in special risk
categories:
Serious pulmonary problems, eg. Asthma,
COPD
Serious cardiac conditions, eg., CHF
Severe Renal problems
Long term liver disease
DM requiring medication
Immunosuppression due to disease (e.g. HIV or
SLE) or treatment (e.g. chemotherapy or radio
therapy, long-term steroid use
Asplenia
Haemophilus influenzae

Nonmotile, Gram negative rod

Secondary infection on top of Viral
disease, immunosuppression,
splecnectomy patients
Encapsulated type b (Hib)
The capsule allows them to resist phagocytosis
and complement-mediated lysis in the
nonimmune host

Hib conjugate vaccine

Specific Treatment
Guided by susceptibility testing when available
S. pneumonia:
β-lactams Cephalosporins, eg Ceftriaxone,
Penicillin G
Macrolides eg.Azithromycin
Fluoroquinolone (FQ) eg.levofluxacin
Highly Penicillin Resistant: Vancomycin
H. influenzae:
Ceftriaxone, Amoxocillin/Clavulinic Acid
(Augmentin), FQ, TMP-SMX
CAP: Atypicals
Mycoplasma pneumoniae, Chlamydophila pneumoniae,
Legionella; Coxiella burnetii (Q fever), Francisella
tularensis (tularemia), Chlamydia psittaci (psittacosis)
Approximately 15% of all CAP
‘Atypical’: not detectable on gram stain; won’t grow on
standard media
ATYPICAL
Unlike bacterial CAP, often extrapulmonary
manifestations:
Mycoplasma: otitis, nonexudative pharyngitis, watery
diarrhea, erythema multiforme, increased cold agglutinin
titre
Chlamydophila: laryngitis

Most don’t have a bacterial cell wall Don’t respond to

β-lactams

Therapy:
macrolides, tetracyclines, quinolones (intracellular
penetration, interfere with bacterial protein synthesis)
Remember these associations:
Asplenia: Strep pneumo, H. influ

Alcoholism: Strep pneumo, oral anaerobes, K.

pneumo, Acinetobacter, MTB

COPD/smoking: H. influenzae, Pseudomonas,

Legionella, Strep pneumo, Moraxella catarrhalis,
Chlamydophila pneumoniae

Aspiration: Klebsiella, E. Coli, oral anaerobes

HIV: S. pneumo,
H. influ, P. aeruginosa,
MTB, PCP, Crypto,
Histo, Aspergillus, atypical mycobacteria

Recent hotel, cruise ship: Legionella

Structural lung disease (bronchiectasis):
Pseudomonas, Burkholderia cepacia, Staph
aureus

ICU, Ventilation: Pseudomonas, Acinetobacter

Pneumonia: Outpatient or Inpatient?
CURB-65
5 indicators of increased mortality: confusion,
BUN >7, RR >30, SBP <90 or DBP <60, age
>65
Mortality: 2 factors9%, 3 factors15%, 5
factors57%
Score 0-1outpt. Score 2inpt. Score >3ICU.
Pneumonia Severity Index (PSI)
20 variables including underlying diseases;
stratifies pts into 5 classes based on mortality
risk
No RCTs comparing CURB-65 and PSI

IDSA/ATS Guidelines 200

Pneumonia: Medical floor or ICU?
1 major or 3 minor criteria= severe CAPICU
Major criteria:
Invasive ventilation, septic shock on pressors
Minor criteria:
RR>30; multilobar infiltrates; confusion; BUN
>20; WBC <4,000; Platelets <100,000; Temp
<36, hypotension requiring aggressive fluids,
PaO2/FiO2 <250.
No prospective validation of these criteria

IDSA/ATS Guidelines 20
CAP Inpatient therapy
General medical floor:
Respiratory quinolone OR
IV β-lactam PLUS macrolide (IV or PO)
β-lactams: cefotaxime, ceftriaxone, ampicillin; ertapenem
May substitute doxycycline for macrolide (level 3)
ICU:
β-lactam (ceftriaxone, cefotaxime, Amox-clav) PLUS
EITHER quinolone OR azithro
PCN-allergic: respiratory quinolone PLUS aztreonam
Pseudomonal coverage :
Antipneumococcal, antipseudomonal β-lactam (pip-
tazo, cefepime, imi, mero) PLUS EITHER (cipro or
levo) OR (aminoglycoside AND Azithro) OR
(aminoglycoside AND respiratory quinolone)
CA-MRSA coverage: Vancomycin or Linezolid
CAP Inpatient Therapy: Pearls
Give 1st dose Antibiotics in ER (no specified time
frame)
Switch from IV to oral when pts are
hemodynamically stable and clinically improving

Discharge from hospital:

As soon as clinically stable, off oxygen therapy, no active
medical problems
Duration of therapy is usually 7-10 days:
Treat for a minimum of 5 days
Before stopping therapy: afebrile for 48-72 hours,
hemodynamically stable, RR <24, O2 sat >90%, normal
mental status
Treat longer if initial therapy wasn’t active against
identified pathogen; or if complications (lung abscess,
empyema)
CAP: Influenza
More common cause in children
RSV, influenza, parainfluenza
Influenza most important viral cause in adults,
especially during winter months

Inhale small aerosolized particles from

coughing, sneezing1-4 day incubation
‘uncomplicated influenza’ (fever, myalgia,
malaise, rhinitis)Pneumonia
Adults > 65 account for 63% of annual
influenza-associated hospitalizations and 85%
of influenza-related deaths

.
CAP: Influenza
Recent worlwide pandemic of H1N1 Influenza A
(2009-2010)
Current epidemic in Saudi Arabia (2010-2011)
H1N1 risk factors
pregnant, obesity, cardipulmonary disease,
chronic renal disease, chronic liver disease
CXR findings often subtle, to full blown ARDS
Respiratory (or Droplet) isolation for suspected or
documented influenza (Wear mask and gloves)
NP swab for, Rapid Ag test Influ A,B. H1N1 PCR
RNA
Current Seasonal Influenza Vaccine prevents
disease (given every season)
Bacterial pnemonia (S. pneumo, S. aureus) may
follow viral pneumonia
Influenza: Therapy

H1N1 resistant to Adamantanes

Neuraminidase inhibitors:
70-90% effective for prophylaxis
Give within 48h of symptom onset to reduce
duration/severity of illness, and viral shedding
Osteltamivir dose in severe disease 150mg bid