Professional Documents
Culture Documents
BY DR.LOKESH.L.V
MODERATORs : DR MOHAN.RAO
AND
DR UMAMAHESHWARI
DEFINITION
Pneumonia with a slow resolution of radiographic
infiltrate or clinical symptoms despite adequate
antibiotic treatment (generally 10 to 14 days).
days
Is usually due to:
Defects in immune defense mechanisms
Presence of unusual organisms
Resistant bacteria
Diseases that mimic pneumonia.
Clinics in chestmedicine 2005
ALTERNATE DEFINITION
Non-resolving pneumonia is a clinical syndrome in
which infiltrates occurring in association with acute
pulmonary infection fail to improve /worsen [despite
at least 10 days of antibiotic therapy] clinically /
radiologically (non-resolution within 12 weeks of the
onset of pneumonia.)
Problem statement
CONTD……
Problem statement
In a large US teaching hospitals study, approximately 15% of
pulmonology consultations and 10% of diagnostic
bronchoscopies were performed for NRP.
Pneumococcus
Bacteremic 3-5 mo 25%-35%
C. psittaci 1 -3 mo 10%-20%
Legionella
Mycoplasma
Staph aureus
Eosinophilic pneumonia.
Miscellaneous Noninfectious
causes
Congestive heart failure
Pulmonary embolism or infarction
Drug toxicity
Foreign body
Sarcoidosis
Radiation pneumonitis
Alveolar hemorrhage syndromes
Pulmonary alveolar proteinosis
Lipoid pneumonia
Rounded atelectasis
Drug-induced lung
disease
Nitrofurantoin crystals This drug can cause acute and
chronic pulmonary reactions that result in alveolar interstitial
pneumonitis.
Amiodarone hydrochloride Toxic levels of this drug can
present acutely as focal alveolar infiltrate.
Methotrexate. A chest radiograph usually shows bilateral
interstitial infiltrate that sometimes appears nodular or displays
an alveolar pattern.
Bleomycin sulfate A chest radiograph shows reticular-nodular
infiltrate, which can progress to diffuse interstitial infiltrate.
Mitomycin Toxic pulmonary levels of this drug usually are
observed when it is used with vinca alkaloids or cisplatin
(Platinol-AQ). A chest radiograph may show diffuse interstitial
infiltrate.
Cancers and common infectious organisms linked to immune
defects that may lead to nonresolving pneumonia
Immune Cancers linked to Common organisms linked to
defect immune defect immune defect
Local
Inflammatory
Response
• Cough
• Sputum
• SOA
• Rales
• Pulmonary
infiltrate
Pathogens In Nonresolving
Pneumonia
Mycobacterium tuberculosis
Atypical mycobacteria
Nocardia
Actinomyces israelii
Aspergillus
Coxiella burnetii
Francisella tularensis
Chlamydia psittaci
Leptospira interrogans
Burkholderia pseudomallei
Anthrax
If cultures show a resistant or
unusual pathogen, thempy can be
modified appropriately.
Sputum culture
For patients with severe CAP
Chest January 2003
Retrospective analysis of prospective data
210 pts at two teaching hospitals in Spain
106 intubated, 81 noninvasive mechanical
ventilation, median age 60 years
Microbiologic Dx pneumonia in 117 patients
Most common: S. pneumo, legionella, H. flu
Pseudomas and legionella more common with
intubation, also more lethal
41.6% patients required changes to antibiotic
regimen
Bronchoscopy
Specificity and False Positives
80
70
False Positive (%)
60
50 ETA
40 BAL
30 PSB
20
10
0
103 104 105 106
Culture Threshold
Torres et al. ARRD. 1993: 952-57.
MICROBIOLOGIC DIAGNOSIS OF VAP: TECHNIQUES
A) NONBRONCHOSCOPIC:
• Endotracheal aspirates with quantitative cultures (106
cfu/ml)
• Sampling of distal airways (mini-BAL, PTC)
B) BRONCHOSCOPIC:
• Bronchoalveolar lavage (104 cfu/ml)
• Protected specimen brushing (103 cfu/ml)
If improvement is not seen at that time
and the patient has no risk factors for
delayed resolution, further workup with a
chest CT scan, fiberoptic bronchoscopy,
and other studies should be considered.
Bacterial adherence to airway epithelium
Mechanical Obstructions – foreign body, tumors
Impaired immune defense mechanisms
• Immunoglobulins.
• Complement.
• Polymorphonuclear leukocytes.
• T cells .
• Alveolar macrophages.
The radiographic resolution of
Streptococcus pneumoniae
pneumonia. Jay SJ et al N EngI J Med 1995;293:798-
801
patients with bacteremic pneumococcal pneumonia.