Bacterial Pneumonia

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Epidemiology of pneumonia:

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*PNEUMONIA IS THE MOST COMMON CAUSE OF DEATH DUE TO INFECTIOUS DISEASES
*TOGETHER WITH INFLUENZA,- THE 5TH LEADING CAUSE OF DEATH IN THE USA
*THE FINAL “COMMON PATHWAY”

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What host defenses normally protect us against pneumonia?

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*Anatomical Barriers
*Normal Oral Flora
*Coughing and the Mucociliary Elevator
*Cellular and Humoral Immunity

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Normal Flora on Buccal Cells

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Tracheal Lining Cells

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TEM of Alveolus pointing to alveolar macrophage.

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Describe what alveolar macrophages do:

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*First line of defense in lower respiratory tract
*Able to kill intracellular organisms
*Present antigens to T-cells
*Source of many cytokines that initiate the inflammatory response

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Routes of Spread leading to pneumonia and common bugs involved in each:

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*Aspiration of Oropharyngeal Secretions (Streptococcus pneumoneae)

*Inhalation of Aerosolized Droplets (Mycobacteria tuberculosis)

*Hematogenous Spread (Staphylococcus aureus)

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Risk factors to acquisition of pneumonia:

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*Occupational or avocational
*Hypoventilation
*Endotracheal intubation
*Inhibition of epiglottal reflex --> aspiration
*Inhibition of mucocilliary transport
*Hospitalization or debilitating illness
*Impairment of host defenses
*Travel history --> cocci in SW, etc.

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Common bugs implicated in pneumonia:

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Streptococcus pneumoniae
Haemophilus influenzae
Gram-negative rods
Staphylococcus aureus
Legionella pneumophila
Mycoplasma pneumoniae
Chlamydia species
Anaerobes
Mycobacteria tuberculosis
Unusual organisms

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Gram pos diplococci visible; chains visible
-Strep. pneumoniae

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-s. pneumoniae in the lung
-note neutrophil infiltrate
-lung architecture is preserved.

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*an alveoli filled with neutrophils
*s. pneumoniae infection

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-gram neg coccobacilli visible
-h. flu

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Who do you see H. flu in now?

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-adults who smoke or have underlying disease, like emphysema.

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Gram negative rods that cause pneumonia:

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Klebsiella pneumonaie
Pseudomonas aeruginosa
E. coli

*these are nosicomial-->elderly, immune compromised
*Cause total destruction of the lung, necrotizing (pictured)

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total destruction of the lung architecture from a gram neg rod.

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*sputum gram stain showing s. aureus (often acquired 2˚ to influenza)

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*acute necrotizing pneumonia from s. aureus
*destructive --> abscesses, empyema

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Describe legionella pneumonia:

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-Accounts for ~5% of pneumonias
-Often other symptoms like confusion

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How do people get pneumonia from mouth anaerobes?

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-usually from aspiration
-look for poor dentition --> indicator of anaerobic bacteria
*prevotella, fusobacterium, peptostreptococcus; usually a mixture of these

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Mycoplasma pneumoniae pneumonia:

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-"walking" pneumonia
-less severe
-often occurs in young adults

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Describe chlamydia pneumonia:

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*psittaci causes parrot fever
*trachomatos is an STI; can pass to babies' lungs in delivery
*c. pneumoniae causes a less severe outpatient pneumonia.

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What are the atypical pneumonias and how significant are they?

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*Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydia species.
*Overall about 10% of pneumonias.

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Describe M. TB pneumonia:

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*Cause chronic granuloma and lung cavities.
*AIDS patients won't show cavernous spaces in lungs b/c their immune system is weak.

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Describe the unusual causes of pneumonia:

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*Anthrax --> gram pos rod, inhale spores, activate in lymph nodes to form a bad toxin, released in bloodstream

*Brucellosis-->unpastuerized dairy

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Clinical features of pneumonia:

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1. Infection
-Fever, chills, Malaise
-Leukocytosis with left shift

2. Respiratory tract irritation
-Cough with purulent sputum (yellow or green)
-Hemoptysis (bloody or rusty-colored; suspect TB)

3. Parenchymal Inflamation
-Respiratory distress
-Pleuritic chest pain

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PE features of pneumonia:

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*Rales or crackles– popping opening sounds when collapsed small airways open
*Pleural Rubs
*Evidence of consolidation (fluid filled avleoli)
-Dullness to percussion over airless area
-Increased tactile fremitus, whispered pectoriloquy and “E to A change”

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Radiographic appearance of pneumonia:

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*"ground glass" appearance of pneumonia

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*air bronchogram indicating bacterial pneumonia
*black arrows indicating air

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*CT scan
*air bronchogram; showing air in the airways that aren't involved in the infection.

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*Xray showing interstitial pneumonia.

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*summation of linear densities. associated with viral pneumonia

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*summation of linear densities. associated with viral pneumonia

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What are "lobar" and "broncho" pneumonia?

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*consolidation= change in sound when percussing on PE

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Define Community acquired, healthcare acquired, and ventilator associated pneumonia:

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*Community Acquired Pneumonia (CAP)
pneumonia developed in an ambulatory setting.
Most common organisms are S. pneumoniae, mycoplasma, chlamydophilia, H. influenza and viruses.

*Healthcare Acquired Pneumonia (HCAP)
develops in a hospital setting or nursing home.
S. aureus, GNB more common. Frequently resistant.

*Ventilator Associated Pneumonia (VAP)
Usually caused by highly resistant organisms, e.g, pseudomonas, Acinetobacter.

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Decribe the significance of pleural effusions and abscesses related to pneumonia:

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*ask pt to lie on side--> if fluid laters out, it's a pleural effusion!

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*pleural effusion!
*layers of fluid

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Abscess with cavitary lesion --> fluid inside abscess

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Describe diagnostic testing in pneumonia pts:

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What are some advanced, special diagnostic tests you can perform for pneumonia pts?

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*if pt doesn't cough up enough phlegm.
*urine antigen tests for strep pneumonia and legionella

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How do you manage the treatment of pneumonia pts?
How do you decide to hospitalize someone?

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Describe treatment of pneumonia pts.

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*Empiric antibiotic choice is governed by the most likely pathogens for the specific situation
*Antibiotics should be given early – preferable within 4-6 hours of presentation
*High dose, broad spectrum antibiotics should be de-escalated once patient is stable and cause is known.

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Most common causes of community-acquired pneumonia?

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Summary table of treatment for pneumonia 1:

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Summary table of treatment for pneumonia 2:

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Talk about the pneumonia vaccine:

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