Pneumonia
MAE KRISTINE CEVANTES
POST GRADUATE INTERN
General Data
• JJ
• 29 / male
• Filipino
• single
• a returning seafarer
• currently resides in Dasmarinas Cavite
Chief Complaint
• Shortness of Breath
History of Present Illness
• 10 days prior to admission, he arrived in Manila and meet up with friends &
family. He stayed there for 5 days.
• 7 days prior to admission, he arrived at Dasmarinas Cavite.
• 5 days prior to admission, he started to have headache. He took paracetamol-
ibuprofen 1 tablet once only thinking that this is due to exhaustion.
• 4 days PTA, he had undocumented fever, and persistence of headache. He
took Paracetamol-ibuprofen1 tablet 3x a day.
History of Present Illness
• 3 days PTA, aside from headache, non-productive cough started. He
was advised to seek consult but self medicated with “ Lola Remedios”
cough remedy and attended a friend’s son baptism wherein he is a
godfather.
• 1 day PTA he had fever at 38.5OC. He continued taking paracetamol
and lola remedios 3x a day. He called his friend, a nurse, who advised
him to go to the emergency room. But because of fear to be confined
he did not comply with.
• On the day of admission, he had cough with white mucoid sputum,
accompanied with some shortness of breath, prompted consult
Past Medical History
• He has no known comorbidities and no previous hospital admission
or surgery.
• He does not have any known allergy to food and drugs.
Family History
• Hypertension on both sides of the family.
Personal and Social History
• He lives in a private subdivision in Dasmarinas Cavite.
• Together with his mother- 65 year old, father 70 year old, and a
helper .
• He is an occasional smoker and consumes 1-2 standard drinks of
alcohol on occasions.
• He is a seafarer since he was 25 years old.
• Denies use of illicit drugs.
Vital Signs
• BP: 120/80 mmHg
• CR: 110 beats/minute
• RR: 31 breaths per minute
• Temp: 38.5OC
• O2 sat: 94% at room air
Physical Examination
• General survey: awake, conversant, coherent, ambulatory, tachypneic
• HEENT: Anicteric sclerae; Pinkish conjunctiva; moist lips and mucosa; non erythematous tonsils
and pharynx; No neck vein engorgement; No palpable neck or supraclavicular lymphadenopathies.
• Chest: There are no lesions or masses on the anterior and posterior chest; symmetrical chest
expansion; vilateral tactile fremitus crackles heard on right lung fields; tachycardic but normal
rhythm without appreciable murmur
• Abdomen: Abdomen was flabby; Normoactive bowel sounds; Soft and nontender.
• Genito-urinary: Grossly normal
• Extremities: no synovitis, No lesions, atrophy.
Neuro exam
• Cranial nerves intact
• Awake, oriented to time, place and person, coherent. No lateralizing
signs; ; No Babinski sign; Negative meningeal signs; Intact cerebellar
reflexes.
• Motor: No fasciculation or tremors; Good muscle tone and muscle
strength on both distal upper and lower extremities.
• Normal reflexes, 2+ on all extremities.
• Sensory: no sensory deficit; good vibration and position sense.
Salient Features
• 29/M seafarrer • febrile
• fever • tachycardic
• productive cough • tachypneic
• shortness of breath • coarse crackles on right lung field
• +travel history in the past week
At the ER
• Patient was seen and examined
• O2 at 2lpm was started
• Labs requested:
• CBC, ABG, UAT, Sputum Gram Stain and Culture, COVID RT- PCR, CRP
• Imaging Requested:
• Chest X-ray PAL
ABG at O2 2 LPM NORMAL VALUES Complete Blood Count Result
pH 7.47 7.35-7.45 Hgb 14.9
Hct 0.40
pCO2 31 35-45 mmHg RBC 4.01
WBC 13.1
HCO3 26 22-26 mEq/L Segmenter 0.70 0.80
PO2 87 80-100 mmHg Lymphocytes 0.20 0.16
O2 Sat 95 95-100 % Eosinophils 0.01
Monocytes 0.08 0.03
Basophils 0.00
Urine antigen test Result Platelets 212,000
Pneumococci POSITIVE
Legionella NEGATIVE
Chest X-ray (PAL)
• Meds:
• Ampicillin-Sulbactam 1.5 gm q6h IV
• Azithromycin 500mg/tab 1 tab OD PO
• Paracetamol 500mg/tab 1 tab q4h PRN for T >38oC PO
• Patient was then transferred to isolation room with negative pressure.
• Admitting diagnosis
• Community - Acquired Pneumonia - Moderate Risk
• Covid suspect
What is Pneumonia?
• Pneumonia is an infection of the pulmonary parenchyma
• Classified by the specific etiologic agent, which determines the treatment, or,
if no pathogen can be isolated, by the clinical setting in which the infection
occurs
Classification by acquisition:
Community Acquired Hospital Acquired Ventilator Associated
Pneumonia (CAP) Pneumonia (HAP) Pneumonia (VAP)
Epidemiology
• Most common type of Lower Respiratory Tract Infection
• Major cause of morbidity and mortality in adults worldwide
• In the Philippines
• Top 2 leading cause of morbidity in the Philippines in 2014 (DOH)
• Top 4 leading cause of mortality in the Philippines in 2013 (DOH)
Etiology
Etiology
Typical Bacterial Pathogens Atypical Organisms
S. pneumoniae Mycoplasma pneumoniae
Haemophilus influenzae Chlamydia pneumoniae
S. aureus Legionella species
Klebsiella pneumoniae respiratory viruses
(influenza viruses, adenoviruses, human
metapneumovirus, and respiratory
syncytial viruses)
Pseudomonas aeruginosa
Pathophysiology
nasal hairs and turbinates
gag and cough reflexes
mucociliary clearance and local antibacterial factors
branching architecture of the tracheobronchial tree
normal flora
Organism enters alveolar
level Cough
Macrophages
Capacity to kill exceeded
Inflammatory response initiated
Chemokines (IL-8, G-
IL1, TNF a
CSF)
Fever Neutrophils
Peripheral Leukocytosis, Inc.
Purulent Secretion
Hemoptysis Capillary Leak Hypoxemia, decreased
Radiographic compliance
infiltrate Alveolar increased respiratory
crackles Filling drive, increased
secretions, infection-
Dyspnea related bronchospasm
Location
LOBAR
PNEUMONIA
LOBULAR
BRONCHOPNEUMONIA Consolidation of a large
portion of a lobe or of an
Patchy consolidation of the entire lobe
lung
4 stages of the
inflammatory response
CONGESTION
RED HEPATIZATION
GRAY HEPATIZATION
RESOLUTION
Pathology of Classic Lobar Pneumonia
Clinical Manifestation
FEBRILE PLEURITIC CHEST PAIN NAUSEA
TACHYCARDIA TACHYPNEA VOMITING
INC/DEC TACTILE
CHILLS/SWEAT DIARRHEA
FREMITUS
COUGH DULL PERCUSSION FATIGUE
SHORTNESS OF
CRACKLES HEADACHE
BREATH
PLEURAL FRICTION
RUB MYALGIA/ARTHRALGIA
Diagnosis
SPUTUM URINARY BIOMARKERS
GS/CS ANTIGEN
TEST
Blood
CHEST culture RT-PCR SEROLOGY
X-RAY
Risk Stratification
LOW RISK CAP MODERATE RISK CAP HIGH RISK CAP
VITAL SIGNS Stable Unstable
RR<30/minute RR > 30/min
PR<125/min PR > 125/min Any of the criteria
SBP> 90 mm Hg Temp < 36C or > 40C under CAP- MR, PLUS
DBP > 60 mm Hg SBP<90 mmHg any of the following:
Temp >36C or <40C DBP <60 mmHg
FEATURES No altered mental state of Altered mental state of acute • Severe Sepsis and
acute onset onset septic shock, or
No suspected aspiration Suspected aspiration • Need for
No or stable comorbids Decompensated comorbids mechanical
ventilation
CHEST X RAY Localized infiltrates Multilobar infiltrates
No pleural effusion Pleural effusion
No abscess Abscess
DISPOSITION Outpatient Ward admission ICU Admission
TREATMENT
When should antibiotics be initiated for the empiric
treatment of community-acquired pneumonia (CAP)?
Antibiotics
• the mainstay for the treatment of pneumonia
• initiated as soon as the diagnosis of CAP is made.
POTENTIAL PATHOGEN EMPERIC THERAPY
Streptococcus pneumoniae Without co-morbid illness LOW RISK
Haemophilus influenzae Amoxicillin 1 gm TID
Chlamydophila pneumoniae OR
Extended macrolides:
Mycoplasma pneumoniae Azithromycin 500 mg OD
Moraxella catarrhalis OR
Enteric Gram-negative Clarithromycin 500 mg BID
bacilli
(among those with co- With stable co-morbid illness
β-lactam/β-lactamase inhibitor
morbid illness) combination (BLIC) OR 2nd gen oral
Cephalosporin +/- extended Macrolides
Co-amoxiclav 1 gm BID OR
Sultamicillin 750 mg BID OR
Cefuroxime axetil 500 mg BID
+/-
Azithromycin 500 mg OD OR
Clarithromycin 500 mg BID
POTENTIAL PATHOGEN EMPERIC THERAPY
MODERATE
Streptococcus pneumoniae
Haemophilus influenzae
IV non-antipseudomonal β-lactams
(BLIC, cephalosporin)
RISK
Chlamydophila pneumoniae + extended macrolides or
Mycoplasma pneumoniae respiratory fluoroquinolones (PO)
Moraxella catarrhalis
Enteric Gram-negative bacilli Ampicillin-Sulbactam 1.5 gm q6h IV OR
Legionella pneumophila Cefuroxime 1.5 g q8h IV OR
Anaerobes (among those Ceftriaxone 2 g OD
with risk of aspiration +
Azithromycin 500 mg OD PO
OR
Clarithromycin 500 mg BID PO
OR
Levofloxacin 500 mg OD PO
OR
Moxifloxacin 400 mg OD PO
POTENTIAL PATHOGEN EMPERIC THERAPY
MODERATE
Streptococcus pneumoniae
Haemophilus influenzae
If aspiration pneumonia is suspected
and, a regimen containing
RISK
Chlamydophila pneumoniae ampicillin/sulbactam and/or
Mycoplasma pneumoniae moxifloxacin is used, there is no need
Moraxella catarrhalis to add another antibiotic for
Enteric Gram-negative bacilli additional anaerobic coverage.
Legionella pneumophila
Anaerobes (among those If another combination is used may
with risk of aspiration add clindamycin to the regimen to
cover microaerophilic streptococci.
Clindamycin 600 mg q8h IV
OR
Ampicillin-Sulbactam 3 g q6h IV
OR
Moxifloxacin 400 mg OD PO
POTENTIAL PATHOGEN EMPERIC THERAPY
HIGH RISK
Streptococcus pneumoniae No risk for P. aeruginosa
Haemophilus influenzae IV non-antipseudomonal
Chlamydophila pneumoniae β-lactams + IV extended macrolides
Mycoplasma pneumoniae or IV respiratory
Moraxella catarrhalis Fluoroquinolones
Enteric Gram-negative bacilli
Legionella pneumophila Ceftriaxone 2 gm OD OR
Anaerobes (among those with Ertapenem 1 gm OD
risk of aspiration) +
Staphylococcus aureus Azithromycin dihydrate
Pseudomonas aeruginosa 500 mg OD IV
OR
Levofloxacin 500 mg OD IV
OR
Moxifloxacin 400 mg OD IV
EMPERIC THERAPY (Risk for P. auruginosa) HIGH
IV antipneumococcal antipseudomonal IV antipneumococcal antipseudomonal RISK
β lactams β-lactams (BLIC, cephalosporin or
(BLIC, cephalosporin or carbapenem) + carbapenem)
IV extended macrolides + + IV ciprofloxacin / high dose levofloxacin
aminoglycosides
Piperacillin-tazobactam 4.5 gm q6h OR
Piperacillin-tazobactam 4.5 gm q6h OR Cefepime 2 gms q8-12h OR
Cefepime 2 gm q8-12h OR Meropenem 1 Meropenem 1 gm q8h
gm q8h +
+ Levofloxacin 750 mg OD IV OR
Azithromycin dihydrate 500 mg OD IV Ciprofloxacin 400 mg q8-12h IV
+
Gentamicin 3 mg/kg OD OR Amikacin 15 If MRSA pneumonia is suspected, add
mg/kg OD Vancomycin 15 mg/kg q8-12 h
OR
OR Linezolid 600 mg q12h IV
OR
Clindamycin 600 mg q8h IV
How can response to initial therapy be assessed?
• Vital signs monitoring
• Response to therapy is expected within 24-72 hours of initiating
treatment
• Failure to improve after 72 hours of treatment is an indication to repeat the
chest radiograph
• Follow-up cultures of blood and sputum are not indicated for patients
who are responding to treatment
When should de-escalation of empiric antibiotic therapy be done?
1. Resolution of fever for > 24 hours
2. Less cough and resolution of respiratory distress
3. Improving white blood cell count, no bacteremia.
4. Etiologic agent is not a high-risk (virulent/resistant) pathogen
5. No unstable comorbid condition or life-threatening complication
6. No sign of organ dysfunction
7. Patient is clinically hydrated, taking oral fluids and is able to take oral
medications
Which oral antibiotics are recommended for de-escalation or
switch therapy from parenteral antibiotics?
How long is the duration of treatment for CAP?
ETIOLOGIC AGENT DURATION IN DAYS
Most bacterial pneumonias except enteric 5-7 days
Gramnegative pathogens S. aureus (MSSA and MRSA), 3-5 (azalides) for S. pneumoniae
and P. aeruginosa
Enteric Gram-negative pathogens, S. aureus (MSSA and MSSA community-acquired pneumonia
MRSA), and P. aeruginosa a. non-bacteremic - 7-14 days
b. bacteremic - longer up to 21 days
MRSA community-acquired pneumonia
a. non-bacteremic - 7-21 days
b. bacteremic - longer up to 28 days
Pseudomonas aeruginosa
a. non-bacteremic - 14-21 days
b. bacteremic - longer up to 28 days
Mycoplasma and Chlamydophila 10 - 14 days
Legionella 14-21; 10 (azalides)
What should be done for patients who are not improving
after 72 hours of empiric antibiotic therapy?
• Complete reappraisal
• Reassess patient for possible resistance to the antibiotics being given
or for the presence of other pathogens.
• Follow-up CXR is recommended.
• Additional specimens for microbiologic testing should be considered.
Reasons for lack of response
• Correct organism but inappropriate antibiotic choice or dose
• Resistance of organism to selected antibiotic
• Wrong dose (e.g., in a patient who is morbidly obese or has fluid overload)
• Antibiotics not administered
• Correct organism and correct antibiotic but infection is loculated (e.g., most commonly empyema)
• Obstruction (e.g., lung cancer, foreign body)
• Incorrect identification of causative organism
• No identification of causative organism and empirical therapy directed toward wrong organism
• Non-infectious cause
• Drug-induced fever
• Presence of an unrecognized, concurrent infection
When can a hospitalized patient with CAP be discharged?
• In the absence of any unstable coexisting illness, the patient may be
discharged once clinically stable and oral therapy is initiated.
• A repeat CXR prior to hospital discharge is not needed in a patient
who is clinically improving.
• A repeat CXR is recommended during a follow-up visit, approximately
4 to 6 weeks after hospital discharge.
Recommended Discharge Criteria
During the 24 hours before discharge, the patient should have
the following characteristics:
1. Temperature of 36-37.5oC
2. Pulse < 100/min
3. Respiratory rate between 16-24/minute
4. Systolic BP >90 mmHg
5. Blood oxygen saturation >90%
6. Functioning gastrointestinal tract
What other information should be discussed with the patient?
1 week: fever should have resolved
4 weeks: chest pain and sputum production should have substantially reduced
6 weeks: cough and breathlessness should have substantially reduced
3 months: most symptoms should have resolved but fatigue may still be present
6 months: most people will feel back to normal.
Prognosis
• Depends on the patient’s age, comorbidities, and site of treatment
• Young patients without comorbidity do well and usually recover fully
after ~2 weeks.
• Older patients and those with comorbid conditions can take several
weeks longer to recover fully.
Prevention
• VACCINATION is the main preventive measure
• PPSV23 (23 pneumococcal serotypes)
• PCV13 (13 pathogens common in children)
• Influenza (Inactivated or Recombinant)
VENTILATOR-ASSOCIATED PNEUMONIA
HOSPITAL-ACQUIRED PNEUMONIA
Ventilator Associated Pneumonia
• Most common complication among patients needing mechanical
ventilation
• Clinical manifestations are generally the same in VAP as in all other
forms of pneumonia
VAP Etiology
VAP Pathogenic Mechanism
• oropharyngeal colonization with pathogens
• cross infection from other patients
• large volume aspiration
• microaspiration around endotracheal tube
• altered lower respiratory host defense
Hospital Acquired Pneumonia
• Pneumonia acquired in the hospital that is not associated with mechanical
ventilation
• Higher frequency of non-MDR pathogens
• Anaerobic pathogens are more common
• Diagnosis using Lower respiratory tract samples appropriate for culture are
considerably more difficult to obtain
• Generally, host has better immunity/defense
• Antibiotic failure is lower
Diagnosis
• No single set of criteria is reliably diagnostic of pneumonia in a
ventilated patient
• Quantitative Culture Approach
• Culture and additional tests (Gram’s staining, differential cell counts,
gram-staining)
• Clinical Approach
Risk Factors for Multidrug Resistant Pathogens
DISEASE RISK FACTORS
MDR VAP • Prior IV antibiotics use within 90 days
• Septic shock at time of VAP
• ARDS preceding VAP
• >5 days of hospitalization prior to
occurrence of VAP
• Acute renal replacement therapy
prior to VAP onset
MDR HAP
MRSA VAP/HAP
• Prior antibiotic use within 90 days
MDR Pseudomonas
VAP/HAP
Treatment
PATIENTS WITH OUT RISK FACTORS FOR PATIENTS WITH RISK FACTORS FOR MDR PATHOGENS
MDR PATHOGENS
Majority can be treated with a single agent Standard recommendation is treatment with 3 antibiotics: 2
directed at P. aeruginosa and one at MRSA
• Ceftriaxone 2g IV q24 A beta lactam:
• Moxifloxacin 400mg IV q24 • Ceftazidime 2g IV OR Cefepime 2g IV q8-12
• Ciprofloxacin 400mg IV q8 • Imipenem 500mg IV q6 or 1g IV q8 or Meropenem 1g IV q8
• Levofloxacin 750mg IV q24 • Aztreonam 2g IV q8
• Ampicillin/Sublactam 3g IV q6
• Ertapenem 1g IV q24 A 2nd agent active against Gram negative pathogens:
• Piperacillin- tazobactam 4.5g IV q6 • Gentamicin or Tobramycin 7mg/kg IV q24 or Amikacin
• Cefepime 2g IV q8 20mg/kg IV q24 or
• Imipenem 500mg IV q6 • Ciprofloxacin 400mg IV q8 or Levofloxacin 750mg IV q24
• Cefepime 2g IV q8
• Imipenem 500mg IV q6 An agent active against Gram positive pathogens:
• Meropenem 1g IV q8 • Linezolid 600mg IV q12 or
• Vancomycin 15mg/kg up to 1g IV q12
Course in the wards - Day 2
S Awake, alert, febrile, no headache, still with productive cough white mucoid sputum, no
shortness of breath, good appetite
O T:37.9 RR:22 CR:90 BP: 120/80 O2sat: 97%
Crackles noted at right middle lung field
CRP: 14.2mg/dl
A CAP-MR, Covid suspect
P Continue medications
• Ampicillin-Sulbactam 1.5 gm q6h IV
• Azithromycin 500mg/tab 1 tab OD PO
• Paracetamol 500mg/tab 1 tab q4h PRN for T >38oC PO
O2 at 1lpm
Follow-up Covid RT-PCR
Course in the wards - Day 3
S Awake, alert, afebrile in the last 12 hours, no headache, with nonproductive cough, no
shortness of breath, good appetite
O T:36.9 RR:17 CR:83 BP: 120/70 O2sat: 97%
Crackles on the right lung field
Sputum Culture: (+) S. pneumoniae; SARS CoV2 RTPCR: negative
A CAP-MR
P Continue medications
Discontinue O2
Transfer to regular room
Course in the wards - Day 4
S Awake, alert, afebrile, no headache, with nonproductive cough, no shortness of breath,
good appetite
O T:36.8 RR:18 CR:74 BP: 120/80 O2sat: 99%
Fine crackles on the right lung field
CRP: 8mg/dl
A CAP-MR
P Discontinue Ampicillin-Sulbactam IV and Azithromycin PO
Start Amoxicillin-Clavulanic Acid 625mg TID PO
Course in the wards - Day 5
S Awake, alert, afebrile, no headache, with nonproductive cough, no shortness of breath,
good appetite
O T:37.1 RR:18 CR:78 BP: 110/80 O2sat: 99%
fine crackles on the right lung field
CBC: hgb 14.3/ hct 0.42
WBC 9.7 (13.1) /N 0.68 (0.80)/ L 0.19 /E 0.03 /M 0.07/ B 0.01
A Community Acquired Pneumonia - Moderate Risk
P May go Home
Take Home Meds:
Amoxicillin-Clavulanic Acid 625mg TID PO for 3 more days
Ascorbic Acid 500mg/tab 1 tab OD PO
Follow up after 3 days or anytime if with problems
Final Diagnosis
• Community Acquired Pneumonia - Moderate Risk
References
• Kasper DL., et al. Harrison’s Principles of Internal Medicine, 20 th
edition
• Philippine CPG of the Diagnostics, Empiric Management, and
Prevention of Community Acquired Pneumonia; 2016
