Pneumonia.
Pneumonia (P)
is one of the most wide-spread disease of human. In spite of wide prevalence of P, knowledge of modern methods of
diagnostics and treatment of disease are not enough.
PNEUMONIA
- is acute infectious disease, mainly bacterial etiology, which causes the
air sacs in the lungs (called the alveoli), and the smaller bronchial tubes to
become inflamed and fill with fluid. From data of official statistics in Ukraine
Etiology.
Many different organisms can cause P, including bacteria (Str. Pneumoniae, Staf. pyogenus, Staf. albus, Klebsiella pneumoniae is a pneumobacillus, Neisseria cataralis, Proteus vulgaris, Haemophilus influenzae, Psevdomonas aeruginosa, Legionella pneumophilia,, Micoplasma pneumoniae,, Bacteroides fragilis), the viruses of Citomegalovirus, and fungi of Candida albicans. Pneumonia can range from
mild to severe. The severity depends on the type of organism causing pneumonia,
as well as your age and underlying health.
The basic patogenetic links of development of pneumonia are:
- penetration of infection in pulmonary tissue (by inhalation, bronchogenic way, hematogenic way – at a sepsis, direct
distribution of infection in lungs from nearby organs, lymphogenic way).
- a change of the system of local bronchopulmonary protection -the state
of mucociliary transport, bronchopulmonary immune system, factors of unspecific
resistance (lysozyme , lactoferrin, IGA, interferon, system
of surfactant),
- development of local inflammatory process and his distribution on
pulmonary tissue , that depends on the type of infection:
Str. Pneumoniae, Klebsiella pneumoniae, Haemophilus influenzae
and E. coli producing endotoxins and during persistence in
air-cells they cause a serosal edema.
This serosal edema is their reproducing
environment and helps them to penetrate
through the Kon’s pores to nearby air-cells. In such way segmentary and
croupous pneumonias are developed.
Streptococci, staphylococcuss producing
exotoxins, which promote limitation of inflammation by fibrin, and smaller
bronchial tubes to become inflamed and
fill with fluid with formation of
microatelectasis. In such way focal pneumonia is developed.
Production by leucocytes and
epithelial cells bioactive substances
(cytokines) plays important role in development of inflammation. Cytokines
influence on chemotaxis of macrophages, neutrophils and other cells, which are
taking part in local inflammatory reaction.
Classification
Select the followings types of pneumonias:
·
community-acquired pneumonia
·
nosocomial or hospital-acquired pneumonia
·
Aspiration
pneumonia
·
Pneumonia
in an immunocompromised host
Pneumonia that develops outside the hospital setting
is considered community-acquired pneumonia. Pneumonia developing 72 hours or
more after admission to the hospital is termed nosocomial or hospital-acquired
pneumonia. Pneumonia can be mild, moderate and severe.
Severe P. is the special form of disease of different etiology, which
shows up a heavy intoxication syndrome, haemodynamic changes, expressed
respiratory insufficiency and signs of septic shock.
Recommend to select the large and small criteria of severe pneumonia.
SMALL CRITERIA :
- breathing frequency 30 in 1 mins and more,
- unconsciousness, - pressure of oxygen below 60 ,
- a systole arterial blood pressure below 90
- bilateral or polifocal defeat, cavities of disintegration, pleura
effusion.
LARGE CRITERIA:
- requirement of artificial
ventilation of lungs,
- rapid progress of focal infiltration, infiltration more
than on 50% during the nearest 2 days,
-
septic shock or necessity
of introduction of vasopressor medicines
during 4 hours and more. We can say about severe P. if we have 2 small and 1
large criteria. In such cases must be immediate hospitalization.
M. pneumoniae is a common cause of mild pneumonia that usually affects people
younger than 40. Various studies suggest that it causes 15-50% of all pneumonia
in adults and an even higher percentage of pneumonia in school-aged children.
People at highest risk for mycoplasma pneumonia include those living or
working in crowded areas such as schools and homeless shelters, although many
people who contract mycoplasma pneumonia have no identifiable risk factor.
The symptoms are generally mild and appear over a period of 1 to 3
weeks. They may become more severe in some people.
Common symptoms include the following:
Headache, fever (may be high),Chills, excessive
sweating, Cough (usually dry and without phlegm or blood), chest
pain, sore throat
Less frequently seen symptoms include:
- Skin lesions or
rash
- Eye pain or soreness
- Muscle aches and joint stiffness
- Neck lump
- Rapid breathing
- Ear pain
A physical examination may reveal enlarged
lymph nodes and inflammation of the
eardrum. An examination of the chest
with a stethoscope (auscultation) reveals crackles.
Legionella pneumophila.
Most infection occurs in middle-aged or older people, although it has
been reported in children. Typically, the disease is less severe in children.
Symptoms tend to get worse during the first 4 to 6 days. They typically improve
in another 4 to 5 days.
Symptoms may include:
- Muscle aches and stiffness
- Joint pain
- Loss of energy
- General discomfort, uneasiness, or ill feeling (malaise)
- Headache
- Fever
- Shaking chills
- Nonproductive cough
- Coughing of blood
- Shortness of breath
- Chest pain,
- Diarrhea
Chlamydophila pneumonia occurs year round and accounts for 5-15% of all pneumonias.
It is usually mild with a low mortality rate.
Community
acquired pneumonia
Community-acquired
pneumonia develops in people with limited or no contact with medical
institutions or settings. The most commonly identified pathogens are Streptococcus pneumoniae , Haemophilus influenzae , and atypical
organisms (ie, Chlamydia
pneumoniae , Mycoplasma pneumoniae , Legionella sp). Symptoms
and signs are fever, cough, dyspnea, tachypnea, and tachycardia. Diagnosis is
based on clinical presentation and chest x-ray. Treatment is with empirically
chosen antibiotics. Prognosis is excellent for relatively young and/or healthy
patients, but many pneumonias, especially when caused by S. pneumoniae and influenza
virus, are fatal in older, sicker patients.
Symptoms include
malaise, cough, dyspnea, and chest pain. Cough typically is productive in older
children and adults and dry in infants, young children, and the elderly.
Dyspnea usually is mild and exertional and is rarely present at rest. Chest
pain is pleuritic and is adjacent to the infected area. Pneumonia may manifest as upper abdominal pain when lower lobe
infection irritates the diaphragm. Symptoms become variable at the extremes of
age; infection in infants may manifest as nonspecific irritability and
restlessness; in the elderly, as confusion and obtundation.
Symptoms and signs were previously thought to differ by type
of pathogen, but presentations overlap considerably. In addition, no single
symptom or sign is sensitive or specific enough to predict the organism.
Symptoms are even similar for noninfective lung diseases such as pulmonary
embolism, pulmonary malignancy, and other inflammatory lung diseases.
The most
important diagnostic tool for pneumonia is the stethoscope. Sounds in the chest
that may indicate pneumonia include:
-
Rales, a bubbling or crackling sound. Rales on one side of
the chest or that are heard while the patient is lying down strongly suggest
pneumonia.
-
Abnormal rumblings indicating that there is sputum in the
large airways.
-
A dull thud. The physician will use a test called
percussion, in which the chest is tapped lightly. A dull thud, instead of a
hollow drum-like sound, indicates certain conditions that suggest pneumonia.
These conditions include consolidation (in which the lung becomes firm and
inelastic) and pleural effusion (fluid build-up in the space between the lungs
and the lining around it).
Diagnosis
is suspected on the basis of clinical presentation and is confirmed by chest
x-ray .Chest x-ray almost always demonstrates some degree of infiltrate;
rarely, an infiltrate is absent in the first 24 to 48 h of illness. In general,
no specific findings distinguish one type of infection from another, though
multilobar infiltrates suggest S. pneumoniae or Legionella pneumophila
infection, and interstitial pneumonia suggests viral or mycoplasma etiology.In
severe cases, a doctor needs to use invasive diagnostic measures to identify
the cause of the infection. Standard lab tests used to help diagnose pneumonia
include:
Sputum Tests. The color of the
mucus (sputum) sample coughed up from the lungs can reveal the severity of the
disease. Only a sputum sample will reveal the organism causing the
infection.The patient coughs as deeply as possible to bring up mucus from the
lungs, since a shallow cough produces a sample that usually only contains
normal mouth bacteria. Some people may need to inhale a saline spray to produce
an adequate sample. In some cases, a tube will be inserted through the nose
into the lower respiratory tract to trigger a deeper cough.
The physician will check the sputum
for:
-
Blood,
which means an infection is present.
-
Color
and consistency: If it is yellow, green, or brown, an infection is likely.
The sputum
sample is sent to the laboratory, where it is analyzed for the presence of
bacteria and to determine whether the bacteria are Gram-negative or
Gram-positive.
Blood Tests.
The following blood tests may be performed:
-
White blood cell count (WBC).
High levels indicate infection.
-
Blood cultures. Cultures are
done to determine the specific organism causing the pneumonia, but they usually
cannot distinguish between harmless and dangerous organisms. They are accurate
in only 10 - 30% of cases. Their use is generally limited to severe cases.
-
Detection of antibodies to S.
pneumoniae. Antibodies are immune factors that target specific foreign
invaders. One type of immunohistochemical test for S. pneumoniae is showing tremendous promise. The presence
of antibodies that are responding to mycoplasma or chlamydia infection are not
present early enough in the course of pneumonia to allow for prompt diagnosis
and treatment.
Patients with CAP can be categorized
into 1 of 4 groups based on information collected at the time of the initial
evaluation. The risk factors for stratification include the need for
hospitalization, the severity of illness, the presence of coexisting disease, and
the patient's age. The 4 major categories not only speculate the microbial
etiology but also predict ultimate prognosis and outcome. These categories are
(1) CAP occurring in patients aged 60 years or younger who have no evidence
of comorbidity and who can be treated in an outpatient setting,
(2) CAP occurring in patients with
evidence of comorbidity and/or who are aged 60 years or older who can be
treated in an outpatient setting,
(3) CAP requiring hospitalization but not admission to an intensive care
units (ICU),
(4) severe CAP requiring ICU care.
Treatment
Because organisms are difficult to identify, antibiotics are selected
based on likely pathogens and severity of illness
A/b for empiric treatment, divide into
medicines of the first choice (medicines of
1 choice and alternative medicines) and second row.
EMPIRIC ANTIBAKTERIAL THERAPY
PATIENTS OF CAP IN AMBULATORY
|
Group of patients
|
Possible exciter
|
Antibiotic
first row
|
Antibiotic of the second
row
|
|
|
Drugs of
choice
|
Alternative Drugs
|
|||
|
1 group
(with
the unsevere CAP, without concomitant pathology and other modifying factors
|
M. pneumoniae
S. рneumoniae
H. influenzae
|
Peroral
reception:
amoxycillin
or
macrolide
|
Peroral
reception:
fluoroquinolones
III-IV generation
|
Peroral
reception:
1.
Makrolide or doxycycline at uneffectiveness of aminopenicillin
2.
Aminopenicillin or fluoroquinolones III-IV generation at uneffectiveness
of macrolide
|
|
11 group
With the
unsevere CAP, with the presence of concomitant pathology or other modifying
factors
|
M. pneumoniae
S. рneumoniae
H.
influenzae
S.
aureus
M. catarrhalis
family
Enterobacteriaceae
|
A
peroral reception is amoxycillin or cefuroxym ethanol
|
Peroral
reception: fluoroquinolones
III-IV generation
Or
Ceftriakson
|
Peroral
reception:
To add
to в-lactam macrolide or
monotherapy
Fluoroquinolones
III-IV generation
|
Note: * - parenterally introduction of Ceftriakson is appointed at impossibility
of peroral reception of preparations of choice.
Estimation of efficiency of antibacterial
therapy is conducted in 48 hours from the beginning of treatment.
Duration of antibacterial therapy:
For patients with the unsevere CAP antibacterial therapy can be completed after achievement
of normalization of temperature during 3-5 days. As a rule in such cases
treatment takes 7-10 days.
Criteria of efficiency of antibacterial therapy
- Temperature of body below 37,5
- absence of symptoms of intoxication,
- absence of signs of respiratory failure (breathing frequency below 20
in 1 mins),
- absence of festering sputum,
- there is a less than amount of leucocytes in blood, neutrocytes less
than 80%, young forms –less 6%,
- absence of negative dynamics from data of roentgenologic research.
If patient saved high temperature
of body, intoxication or symptomatology makes progress, treatment is considered
ineffective, and it is necessary to change antibacterial therapy to the
antibiotic of the second row . U should remember some sings that are not
necessary to change therapy.
Clinical signs and
states which are not necessary to change therapy
or make
its modifications
|
Clinical sign
|
|
|
temperature of body of 37,0-37,5оС
|
In
absence of other signs of bacteria
infection can be the sign of non-bacterial inflammation, postinfectious asthenia, medicinal fever
|
|
Maintainance
of remaining changes on a x-rays (infiltration, increasing of pulmonary
vasculature)
|
Can be
saved during 1-2 months and more after carried P
(a
roentgenologic dynamics is carried out more slowly, for 60% patients regress
in the first 4 weeks. and these information can not be criteria for determination
of duration of à/b therapy)
|
|
Dry
cough
|
Can be
saved during 1-2 months.
|
|
Maintainance
of wheezes during auscultation
|
Dry
wheezes can be saved during 3-4 weeks and more
|
|
Increase
of erythrocyte sedimentation rate, ESR
|
Heterospecific
index, is not only the sign of bacteria infection
|
|
Weakness,
sweating
|
Displays
of postinfectious asthenia
|
It is necessary to conduct differential diagnosis with the empyema of
pleura, cancer of lungs, tuberculosis.
Empiric à/b therapy of patients of CAP in the hospital.
To the patients 1 and 2 groups which are hospitalized on social testimonies,
appoint the proper à/b therapy.
To the patients 3 groups must be appointed the
combined à/b therapy with the parenterally setting of preparations.
Antibacterial THERAPY OF PATIENTS with CAP IN
HOSPITAL
|
Group of patients
|
Possible exciter
|
Antibiotic
first row
|
Antibiotic of the second
row
|
|
|
Preparation
choice
|
Alternative preparation
|
|||
|
3
group
(with
the unsevere CAP)
|
S. рneumoniae
H. influenzae,
Atipichnye
exciters,
Gramnegativnye
enterobacteria
|
Application
of intravenous introduction or intramuscular introduction of: protected
aminopenicillin
+ macrolide (per os)
or cephalosporin II- IIIgenerations
+ macrolide (per os)
|
Intravenous
application: Fluoroquinolones
III-IV generation
|
Intravenous
application of Fluoroquinolones III-IV generation or carbapenems
|
|
IV
group
with severe CAP
|
S. рneumoniae
H.
influenzae
S.
aureus,
Legionella spp.,
Polimikrobnye
associations
|
intravenous introduction of protected
aminopenicillin
+ macrolide
or cephalosporin III
generations
+ macrolide
|
Intravenous
application: Fluoroquinolones
III-IV generation + в-lactam
|
Intravenous
application of Fluoroquinolones III-IV generation + carbapenems
Or carbapenems
+
Macrolide
|
|
At
suspicion on
P. aeruginosa
cephalosporin
III-IV
+ aminoglycoside + cyprofloxaciny
|
Intravenous
application: cephalosporin
III-IV generation + aminoglycoside + Macrolide
|
Intravenous
application
Meropenem
+
aminoglycoside +cyprofloxaciny
|
||
Estimation of efficiency – on those criteria in 48-72 hours from the beginning of therapy.
Duration of à/b therapy – at treatment of patients with the severe CAP–
10 days. In this term mark disappearance of leukocytosis .
For patients with an early adequate clinical answer for à/b therapy it is possible to change parenterally
injection to taking antibiotics per os..
In default of answer for treatment during the first 3 days it’s necessary make the correction of treatment and
additional inspection.
COMPLICATIONS OF NP
- pleura effusion,
- empyema of pleura,
- destruction / abscess of pulmonary tissue ,
- acute respiratory failure,
- infectious toxic shock,
- pericarditis, myocarditis..
Risk factors:
- age more 50 years
- concomitant diseases
- severe pneumonia,
-smoking.
Hospital-acquired pneumonia (HAP) or Nosocomial pneumonia
refers to any pneumonia
contracted within 48-72 hours of being admitted in hospital. In practice,
hospital-acquired pneumonia is often suspected on the basis of the appearance
of a new infiltrate on a chest x-ray.
Classification
Select:
Early HAP – arises up during the first 5 days from the moment of
hospitalization and caused by infection which patient had before
hospitalization -S. Rneumoniae , H. Influenzae, methicillinsensetive S. aureus and other representatives
of normal microflora of cavity of mouth. More frequent these agents are
sensible to antibiotic drugs, and pneumonia has more favourable prognosis.
Late – develops not earlier 6 day of hospitalization and caused
actually by hospital microflora with
more high risk of development of high-virulent and polyresistant bacterias,
such as P. Aeruginosa, Enterobacteriaceae, methicillinresistant culture of
S. aureus. Such HAP has a less
favourable prognosis.
Risk
factors:
Endotracheal
intubation with mechanical ventilation poses the greatest overall risk;
ventilator-associated pneumonia constitutes > 85%
of all cases, with pneumonia occurring in 17 to 23% of ventilated patients.
Endotracheal intubation breaches airway defenses, impairs cough and mucociliary
clearance, and facilitates microaspiration of bacteria-laden secretions that
pool above the inflated endotracheal tube cuff. In addition, bacteria form a
biofilm on and within the endotracheal tube that protects them from antibiotics
and host defenses.
In nonintubated
patients, risk factors include previous antibiotic treatment, high gastric pH
(from stress ulcer prophylaxis therapy), and coexisting cardiac, pulmonary,
hepatic, and renal insufficiency. Major risk factors for postoperative
pneumonia are age > 70, abdominal or thoracic
surgery, and dependent functional status.
