Community Acquired Pneumonia

The Doctor said What We should know in this lecture is just basics for Medicine as a Dentist; to know how to act with our patients in any case .. *ex: we dont give penicillin to a patient who has allergy to penicillin. Today our lecture is about Community Acquired Pneumonia

Types of Pneumonia
Community Acquired Pneumonia (CAP) Hospital Acquired Pneumonia Pneumonia in Immune-compromised Host Pneumonia in Patients with HIV What is the difference between Hospital Acquired Pneumonia and Community acquired Pneumonia? -Hospital Acquired Pneumonia is the Pneumonia you develop after 48 Hours of entering th0e Hospitals, this means the patient enters the Hospital without any symptoms of Pneumonia then after 48 hours the symptoms appear on the patient, (he caught the disease from the Hospital) but Community Acquired Pneumonia is the Pneumonia developed before 48 Hours of admission the Hospital /or the symptoms appear outside the hospital in the community . Epidemiology Common and a serious illness (not an Easy one). The most common infectious cause of death. The sixth leading cause of death. 6th
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Mortality < 1% in the outpatient setting. 5-12% for patients requiring hospital admission. 22-50% for patients requiring ICU admission. - So it is a death causing disease, so when you face a case of Pneumonia, dont hesitate to take it to a specialist. Microbiology Variety of bacterial and viral pathogens. Bacteria are the most common cause of Pneumonia. Streptococcus pneumonia is the most common organism. Anaerobic infection is more common in patient with dental caries and bad oral hygiene.(Anaerobic Aspiration Pneumonia) *Anaerobic Aspiration Pneumonia: caused Due to Dental caries and bad oral hygiene, and most of the organisms that cause this in the oral cavity are Anaerobic, and the treatment is different from other Pneumonias. Risk factors related to specific pathogens in community-acquired pneumonia such as Alcoholism, Aspiration, lung abscess and exposure to bats and birds droppings, exposure to rabbits etc Table in slide 6 is not required -Scientists used to categorize Pneumonia into 1. Typical S. pneumoniae H. influenzae S. aureus Gram ve bacilli 2. Atypical a. Legionella species b. Chlamidia pneumoniae c. Mycoplasma pneumoniae
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Typical means it has the typical presentation of symptoms for Pneumonia such as cough and chest pain and fever, focal Pneumonia but the Atypical doesnt have all these symptoms like they will have shortness of breath but not fever or cough.. Each of type has its organisms causing the disease, But Scientists can't depend on this category anymore because a patient may has a typical presentation of the disease but the cause is an Atypical organisms.

Diagnostic Approach to CAP

Clinical Evaluation History. (The patient tells the doctor if he has a fever, cough ,shortness of breath) Physical exam (abnormal findings) Simple laboratory tests Radiological Evaluation Chest X-Ray CT chest Microbiological studies Clinical Evaluation Symptoms Cough 90% Purulent sputum 66% Dyspnea 66% Pleuritic chest pain 50% Fever and chills 30-40% Pleuritic chest pain means the patient feels pain while breathing, so he can't take a deep breath. Physical Signs Vital signs: Tachycardia, tachypnea, fever, hypotension Signs of consolidation: Dullness, egophony, bronchial breath sounds, crepetations Signs of pleural effusion:
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 Stony dullness, diminished breath sound

Tachycardia: Increase in the heart Rate/beats Tachypnea: Increase the breathing Rate. Consolidation: infection material caused by the infection of the chest due to Pneumonia. So we find Consolidations in the area of Pneumonia Dullness: when u put your hand, you find it dull sound. Egophony: the breath sound of the patients are not normal, u can hear crackles, weezles (abnormal sounds). pleural effusion: fluid in the chest around the Pneumonia area. Stony dullness: you find the chest dull, empty of air and diminished breath sounds.

Investigation
Outpatient vs. Inpatient Routine tests performed on admission Chest radiograph (chest X-Ray) Complete blood count (CBC): White blood cells test, platlets WBCs increase indicates an infection and not a common cold. (leukocytosis).
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 Urea, electrolytes and liver function tests indicates the severity of Pneumonia. Sever Pneumonia may cause Severe systemic manifestations and severe Electrolytes failure, Renal failure, liver failure. Oxygenation assessment: ABG SaO2 <92% on admission Hypoxia is a feature of severe pneumonia.(Low Oxygen rate) - When the doctors find chest findings, hypoxia and leukocytosis in a patient, all these indicate the patient has Pneumonia.

Radiological Evaluation
By definition, Pneumonia requires the finding of infiltrate on chest radiograph, this means if there isn't infiltrate this is not Pneumonia The presence of infiltrate on CXR is the gold standard for diagnosing pneumonia. The findings we should look for in patients: Lobar infiltrate: One lobe or multi-lobar

- Human body has two lungs, each lung consist of lobes, the right one consists of three lobes (upper,middle,lower), the left one consists only from two lobes (upper, lower). - When one lobe is involved in Pneumonia it's called lobar Pneumonia, but if more than one lobe is involved it's called Multi-lobar Pneumonia. Interstitial infiltrate: when all the lungs are involved it is called Intersitial

Infiltrate. Pleural effusion: Parapneumonic or empyema Lung abscess: people with Anaerobic Infection associated with Gram Negative Infection, but we treat it as Anaerobic Infection.

Right Upper Lobe

Right lower + middle Lobes

Pleural Effusion

Sharp parts of the lung shows that there is a pleural infusion.

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Lung Abscess

Infiltrate with consolidation and air fluid level, this is called a Cavity lesion. Many diseases cause the cavity lesion, but most common is Anaerobic Infection with Pneumonia.

Microbiologic Diagnosis
Doctors always search for the Micro-organisms causing the disease ;to know how to Treat patients. Not sensitive cause Pneumonia is caused by Multi Micro-organisms. It is not necessary to perform a full range of microbiological investigations on every patient. Should be guided by: i. The severity of pneumonia ii. Epidemiological risk factors iii. The response to treatment From Where we can take the specimen ?! 1) Sputum culture 2) Blood Culture
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 It is recommended for all patients admitted with CAP, preferably before antibiotic treatment 3) Pleural fluid 4) Invasive Techniques Bronchoscopy (BAL, PB) If Pneumonia is Severe or Immune-compromised,We cant wait, we can go inside the Air-ways and take a good specimen of culture. Serology Legionella urinary antigen Pneumococcal urinary antigen Routine serologic testing is not recommended It takes 4-6 weeks to get the results

a. b.

Treatment
Where to treat? Outpatient Inpatient Hospital ward ICU Admission How do we decide? We have criteria to decide How we treat patients. Pneumonia Severity Index (PSI) This index has scores, when the score increases, the severity increases CURB-65

C Confusion Metal status. U Urea > 7 mmol/l R Respiratory rate > 30/min B
BP: Systolic < 90 mm Hg Diastolic < 60 mm Hg (Hypotensive).

65 Age > 65 Years, patients older than 65 years, have more tendency
for Pneumonia.

Minor Criteria 3 Respiratory rate > 30/min PaO2 / FIO2 < 250 Multi-lobar infiltrates Confusion Uremia (BUN > 20 mg/dl) Neutropenia Thrombocytopenia Hypothermia CAP Treatment

Criteria for Sever Pneumonia ICU Admission

Major Criteria Any Invasive mechanical ventilation Septic shock requiring vasopressors

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 Initial therapy is empirical Microbiological DX unknown in up to 50% Outpatient Treatment i. Previously healthy + No antimicrobials within the previous 3 months Macrolide: eryhthromycin, Clarithromycin, Azithromycin ii. Comorbidities or antimicrobials within the previous 3 months: Respiratory fluoroquinolone: levofloxacin (we can use them even for patients with penicillin allergy). -lactam + macrolide Conclusion: if the patient has simple Pneumonia, we gave him Macrolide,but if it's severe either Levoflxacin or a compination between -lactam + macrolide. Inpatient Treatment According to the Doctor it is the same to outpatient .

In cases of aspiration and lung abscess pneumoniae where anaerobic infection is suspected: Clindamycin (first-line therapy) we also can use it for people with Penicillin allergy. Amoxicillin-clavulanate , (can't use by penicillin allergic patients) Metronidazole + Amoxicillin/Penicillin G Prevention strategies A. Pneumococcal Vaccine B. Influenza virus Vaccine

Dental Pneumonia

Good luck Done By Maher.Khatib

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