Viral/ pneumonia

infection/ inflammation of the alveoli, distal airways, and interstitium of the lung

• Lobar Pneumonia
• -Entire lung lobe

• Bronchopneumonia
• - Patchy consolidation involving one or several lobes

• Interstitial Pneumonia
• -Patchy or diffuse inflam. Process involving the interstitium, including the alveolar walls and connective tissue around the bronchovascular tree

• Miliary pneumonia
• -Numerous discrete lesions that are diffusely distributed

• Upper resp tact (nose to larynx)
• -Curved to prevent things from going down into lungs
• (Anatomical structure, nonpathogenic bacteria, glottis (valve))
• -Lower resp tract (below trachea)
• (Coughing)
• -Mucocilary transport system w mucus layer
• (Mucins trap microorganizms, decrease mucosal pH, secretory IgA, shedding of epithelial cells)

• Macrophages
• Fibronectin
• Lysozymes
• Lactoferrin
• IgG
• Defensins
• Cathelicidins
• Collectins
• Complement¨
• Surfactant

• Microaspiration- most common
• Gross aspiration- postoperative/swallowing disorder
• Aerosolization
• -M. tuberculosis
• -Fungi
• -Legionella
• -Resp virus
• Hematogenous spread
• -Endocarditis
• -Iv catheter infection
• -UTI

• >70 y/o
• m>f
• African>caucasions
• Alcoholism
• -They tend to change diet.. mal nourish
• -Tend to replace healthy meals with alcohol
• - More at risk for aspiration pneumonia
• Asthma/COPD, CF
• CHF, CAD
• Diabetes
• -And infection rate are high bc sugar levels are high.. pathogens like sugar and have kidney damage
• Dementia, stroke, altered level of consciousness
• -Mental status change.. have a hard time swallowing
• Immunosuppresion
• -Solid organ transplants
• -HIV/AIDS
• -Asplenia
• Renal failure, chronic liver disease
• Smoking

• Advanced age
• Comobidities- ex cardiopulmonary disease
• Poor nutritional status
• Hyponaturemia
• Azotemia
• High fever
• Bacteremia
• Immunosuppression
• Acoholism
• Staph. Aureus pneumonia (MRSA)
• Ø High mortatlity
• G- bacilli pneumonia
• Ø Pseudomonas
• Ø High mortality rate
• Aspiration pneumonia

• Fever
• Cough
• Pleuritic
• Chest pain
• Chills
• Rigors
• SOB
• Headache
• N/V/D
• Myalgia
• Fatigue

• Tachypnea
• Tachycardia
• Hypotension
• Poor o2 saturation
• Dullness to percussion
• Increase tacile
• Increase tacile
• Vocal fremits
• Egophony/bronchophony
• Whispering pectoriloquy
• Crackles/rales/diminished breath sounds
• Pleural friction rub
• Radiographic evidence
• Elevated wbc w “left shift”

• Screeen tools
• -Chest radiography
• -CT
• Blood culture**
• Sputum sample
• Urine antigen (Elisa)

• Strep pneumoniae-- common**
• Mycoplasma pneumoniae--common atypical
• Haemophilus influenzae--big in the out pt setting*
• Chlyamydia pneumoniae
• Resp virus (Influenza A/b, Adenovirus, Resp syncytial virus (RSV)- parainfluenza)

• S. pneumoniae
• M. pneumoniae
• C. pneumoniae
• H. influenzae
• Legionella epp.
• Resp. virus

• S. pneumoniae
• Staph aureus *MRSA
• Legionella spp.
• G- bacilli
• H. influenzae

• P. aeruginosa
• K. pneumoniae
• S. aureus

• Age <5 or >65 y/o
• Beta-lactam therapy within the last 3 months
• Alcoholism
• Immunocompromised pts
• Multiple comorbidities
• Exposure to a child in daycare

• PCN sensitive
• IV/PO PCN
• PO amoxicillin
• ALT: Macrolides, cephalosporin’s, clindamycin, doxycycline, fluroquinolones

• PCN resistant
• Fluroquinoloes
• Doxycycline
• Clindamycin
• Cefepime
• Imipenem/ meropenems
• Linezolid
• Vanco

• -Common from a cold
• -Invasive disease in children and adults
• -Common organism that colonizes the upper resp tract (Pathogenic in pt with COPD/ smoker)

• Treatment:
• 2nd or 3rd gen cephalosporin’s
• -Cefuroxime, ceftriaxone, cefotaxime, ceftizoxime, cefixime
• -Amoxilicillin/ clavulanate
• -Alt: doxy, fluroquinolones, azith

• Mycoplasma and Chlamydia pneumonia
• Doxycyline
• Macrolides
• Alt: Fluroquinolones

• Legionella
• -Azith
• -Fluroquinolones
• -Alt: Doxy

• PORT severity index (PSI)
• CURB-65
• CRB-65
• Social circumstances
• Comorbid medical conditions

• Pt have pre- existing conditions that may compromise safety at home
• Pt have hypoxemia.. low o2
• Pt are unable to tolerate oral med
• Pt has psychosocial factors that may impact treatment
• Pt have poor mortality predictors

• Class 1- out pt <1% mortality
• Class 2- out pt <1% mortality
• Class 3- out pt/ observation until/ short hospital stay <5% mortality
• Class 4- hospital stay 8-30% mortality
• Class 5- hospital 8-30% mortality, require icu care

• Includes 20 variables
• -Scored based on age, comorbid conditions, s/s
• -Impracticable in busy ED

• Confusion
• Specific mental test
• Disorientation to person/place/time
• Uremic
• BUN>7 mmol/L (20mg/dL)..To see if they are dehydrated
• Respiration Rate
• RR >30 breaths/min
• BP (hypotensive)
• Systolic <90 mmHg or diastolic <60mmHg
• Age >65

• 0- out pt treatment
• 1- hospital admin
• >2 - hospitalization, possible ICU admin

-coverage: typical and atypical (S. pneumoniae, H. influenzae- prefer azith, M. pneumoniae, C. pneumoniae)

• Macrolides and Doxycycline
• Erythromycin: 250-500mg po q6h or 1g IV q6h

• Clarithromycin: 500mg po q12h
• **Azith: 500mg po, then 250 po qd x4days or 2g po x 1dose (suspension) or 500mg IV x2 days, then 500mg po q24h for 5-8 more days... longest 1/2 life
• Doxycycline: 100mg po q 12 h or 100mg IV q 12h

-Need to treat with more broad sprectrum

• Resp fluroquinolones OR Beta-lactam+macrolides
• -Doxycycline is a alt for macrolides

• Fluroquinolones
• -Levofloxacin- 750mg po q24h
• -Moxifloxacin- 400mg po q24h
• -Gemifloxacin- 320mg po q24 h

• Beta-lactam + macrolides (erithy, clarith, azith) for broader spectrum
• -high dose amox- 1g po q8h
• -Aug- 2g po q12h
• -Ceftriaxone- 1-2g IV q24 h
• -Cefpodoxine-200mg po q12h
• -Cefuroxime- 500mg po q12h

• if fail with macrolides give doxycycline
• NO FLUROQUINOLONES for kids

Fluroquinolone or Beta-lactam

if they have PCN allergy can give

• -resp fluroquinolone (same ones)
• or
• -beta-lactam + macrolide (Eryth, clarith, azith)
• -Etrapenem (for selected pt)
• -Doxycycline (alt for macrolide)
• -Fluroquinolone (pcn allergy)

• -Cefotaxime- 1-2g IV q6-8h
• -Ceftriaxone- 1-2g IV q24h
• -Ampicillin- 500mg po QID or 1-2g IV q6h
• -Ertapenem- 1g IM/IV q24h
• --For highly immunosuppressed pt but contraindicated in seizures, or a lot of comorbidity

• -5th generation cephalosporin
• -prodrug

For: CAP, SSTIs (Skin and Soft Tissue infection)

• active against (bacterialcidal)
• -G+ (VISA, VRSA, MRSA), strep pneumonia
• -G- Moraxella catarrhalis, h. influenzae

no better than ceftriaxone

• ***IV
• Beta-lactam + azith OR Fluroquinolone
• -Cefotaxime
• -Ceftriaxone
• -Ampicillin-sulbactam
• -same Azith and fluroquinolone doses
• -For PCN allergy: Fluroquinolones + aztreoman (no cross sens.) is recc

give cipro?? NO its not a resp

• Cefotaxime- 1-2g IV q6-8h
• Ceftriaxone- 1-2g IV q24h
• Ampicillin/Sulbactam 1.5-3g IV q6h
• Aztreonam 1-2g IV q8-12h or 2g IV q6-8h

• Psuedomonas Infection (double coverage)
• Antipsuedomonas beta lactam+cipro or levofloxacin
• Antipsuedomonas beta lactam+ aminoglycoside + azith
• Antipsuedomonas beta lactam+ aminoglycoside + fluroquinolone
• Beta-lactam allergy
• Aztreonam
• .
• .Piperacillin/tazo- 3.375-4.5g IV q4-8h
• .Cefepime-1-2g IV q12h
• .Imipenem- 500-1000mg IV q6-8h
• .Meropenem- 500-1000mg IV q8h
• .Cipro- 500-750 po q12h or 200-400mg IV q12h

• add vanco 1g IV q12h or per hospital guidlines
• -dosing adjustments per therapeutic levels OR
• add linezolid 600mg IV/PO q12h

Organism has been ID-ed, antimicrobial therapy should be directed at that pathogen (we want a narrow spectrum to prevent resistance)

• Min of 5 days, up to 7-14 days
• -fever for 48-72 hours
• -CAP associated s/s improve (hr, rr, sbp, o2 stat, tolerating orals, normal mental status)
• ->5 days may be necessary if therapy was ineffective or extrapulmonary infection occur
• IV to PO switch: >24h before discharge must swtich over**
• -hemodynamically stable and improving
• -tolerating orals (meds or food)

• Supplemental oxygen
• fluid hydration
• fever control
• nutritional support
• -Septic shock despite fluid resuscitation
• -hypotensive, fluid resuscitated pt w severe CAP should be screened for adrenal insufficieny
• -hypoxemia or repiratory distress

• Influenza Virus vaccines
• Pneumococcal vaccine
• smoking cessation
• proper hygiene

• Clinical Features: Severity of illness, treat t as out/in pt
• exposures and comorbidities
• pt's age
• previous or concurrent meds
• major organ function
• sputum gram stain
• resistance patter
• drug allergy and intolerances
• SE and potential interactions
• Cost

Pneumonia that is a result of abnormal entry significant volumes (via macroaspiration) of oropharyngeal or gastrointestinal contents into the lower resp tract

- need to think about GUT FLORES ANAEROBES** (flagyl, clindamycin)

• Aspiration pneumonia vs pneumonitis
• -pneumonitis= sequelae from sterile gastric contents; noninfectious

• Presents similar to any other pneumonia
• -can progress into ling absesses, empyema, or lung necrosis
• -CXR indicate infiltrates in dependent pulmonary segments of the lungs

• Conditions of decreased consciousness
• -Alcoholics
• -Seizure disorders (harder to swallow)
• -Head trauma (have low seizure threshold)
• -Sedation or anesthesia
• Neurologic disorders: dysphasia
• -stroke
• -Parkinson's disease
• GERD or vomiting
• Instrumentation of the airway
• -Intubation
• -Bronchoscopy
• -NG Tube

• Anaerobic bacterial from gingival crevices and GI flora
• -peptostreptococcus
• -Bacteroides
• -Fusobacterium

• target: anaerobes
• -clindamycin
• -metronidazole + pcn
• -beta-lactam/beta-lactamase inhibitor combo