Pulmonary Infection Disease

8/14/2019 Pulmonary Infection Disease

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Pulmonary Infection Disease

Cheng Zhang Respiratory Medicine Affiliated Hospital of Jining Medicine college

23,Feb


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Pneumonia Bacterial Pneumonia


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General Consideration

Definition : location :distal airways alveoli and

interstitium of the lung .

causes : pathogenicmicroorganisms physical or chemical agents immunologic injury allergicdiseases and medicine

Bacteria Pneumonia is the commonest Pneumonia and also the one of thecommonest infection disease


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Epidemiology

In United States CAP affects 4 millionadults per year costs 9.7 billion 20% admitted

Prevalent rate :0.8~1.5% per year,highest rates at the extremes 0f age and during winter months

Mortality 1~5% in out-patients 12% inhospital 40% in ICU

.


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Aging,smoking,alcoholism,comorbid medical conditions and immunosuppression suchas

AIDS,immunodepressants,transplantation,C OPD,AIDS malignant tumor diabetesmellitus,mutation of pathogenicmicroorganisms and abusage of antibioticsand poverty are also partially responsible


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Pathogenesis

Pulmonary defence mechanismscough reflex,mucociliary clerance system,immune responses prevent aspiration of

oropharyngeal secretions(contaning bacteria or inhalation of infected aerosols) . Pneumonia occurs or not dependents on defects of

normal host defence mechanism or numbersand virulence of bacteria


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Pathogenic organisms could raech the lower respiratory tract and result in Pneumonia viathe following ways

a.Aspiration of infected aerosols b.Dissemination via blood stream c.Spreading by the adjacent organ infections

d.Aspiration of permanent planting organisms in the upper air way e.Aspiration of gastric-oesophageal reflux


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Classification

Anatomical Classification A.Lobar Pneumonia Alveolar

PneumoniaStart with alveolitis produced by bacteriaand expand to the other alveolithroughout the lobe via the pores of

Kohn and result segments or evenwhole lobe infection


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Classification

Parenchyma infection Lobe consolidation,bronchus not be involved Streptococcus pneumonia is the main

pathogen X-ray will show segment or lobar

consolidation shadow


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B.Lobular pneumonia bronchopneumonia )

Pathogens spread via bronchi and produceinfection in the bronchiole distal bronchiole and alveoli

Often secondary to some other diseases such asbronchitis bronchiectasis long-termlying in bed


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Classification Pathogens Streptococcus pneumonia

Staphylococci viruses Mycoplasma pneumonia

Rales(often heard) no signs of consolidation

X-ray the irregular patch infiltration shadows go along with the lung markingsand no appearance of consolidation

Lower lobe is easier to be involved


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Classification

C.Interstitial pneumoniaInvolving interstitium including thealveolar walls and the connective tissue

Alveoli septa infiltration of lymphocytes macrophages and plasmacells

It could be caused by infection of bacteriamycoplasma chlamydia virus pneumocystis carinii and so on


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Classification

Aetiological Classification A.Bacterial Pneumonia

Classified as Streptococcus pneumonia Staphylococci aureus Alpha hemolytis streptococcus Klebsiella pneumoniae Hemophilus influenza Pseudomonasaeruginosa pneumonia


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Classification

B.Atypical Pathogens Pneumonia Legionella Mycoplasma and Chlamydia

C.Viral pneumoniaCoronavirus adenovirus Respiratory

syncytial virus Influenza virus Measlesvirus Cytomegalovirus Herpes simplex virus


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Classification

D.Fungal pneumonia Candida albicans Aspergillus,and

Actinomycetes

E.Other Pathogens Associated Pneumonia Ricketts

organism toxoplasmosis protozoa parasite(echinococcosis,schistosomiasis)


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F.Physical and chemical Pneumonia Radiation pneumonia Chemical pneumonia Lipoid pneumonia


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Classification Classification According To TheCircumstances The Patient

Acquire Pneumonia A.Community-acquired pneumonia CAP

Occurs outside of hospital or less than 48hours after admission in a patient who is not

hospitalized or residing in a long-term care facility for more than 14 days before theonset of symptoms


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Classification

Essentials diagnosis Symptoms and signs cough with or

without purulent sputum dyspnea with

or without chest pain Fever Bronchial breath sounds or rales are freqent

auscultatory findings WBC>1010 9 /L or


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Classification Parenchymal infiltration or interstitial changes with

or without pleural effussion on chest radiograph Any one of the first four points above plus the last

one and exclude other pulmonarytuberculosis,neuoplasm,non-fectious,pulmonaryedema,atelectasis,pulmonary embolism,ILD,thediagnosis of CAP could be confirmed.

The pathogens include Streptococcus

pneumoniae Hemophilus influenza Moraxellecatarrhalis and atypical pathogens


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Classification

B.Hospital-Acquired Pneumonia HAP/Nosocomial Pneumonia NP Occurs more than 48 hours after admission tothe hospital and excludes any infection

present at the time of admission

Essentials diagnosis At least two of the following fever cough leukocyosis purulent sputum


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Classification New or progressive parenchymal infiltrate on

chest radiograph Especially common in patients requiring

intensive care or mechanical ventilation

Organisms In patients without high infection risk factors

are Streptococcus pneumoniae Hemophilusinfluenza Staphylococcus aureus,

Escherichia coli,Klebsiella pneumoniae


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Classification

In patient with high risk factors are Streptococcus pneumoniae Pseudomonasaeruginosa Enterobacter Klebsiella

pneumoniae and so forth


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Clinical Findings Pneumonia can range in severity from mild to

fulminant and fatal. The typical pneumonia is characterized by the

sudden onset of fever cough productive of purulent or bloody sputum, with or without pleuritic

chest pain, shortness of breath or distress. The physical signs associated with pneumonia are

fever tachypnea, tachycardia nasal flaring cyanosis

Dullness to percussion may be detected if a parapneumonic pleural effusion or empyema iscomplicated


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Diagnosis and Differential Diagnosis

.first upper/lower respiratory tract infections

Secondly.orther diseases that mimicthe pneumonia should be excluded


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Pulmonary tuberculosisOften have an insidious onset and general toxic

symptoms such as low-grade fever night sweat fatigue weight lost and so forth X-ray Shadows mainly located in the upper zone irregular density slow disappearancecavity formation and bronchial disseminationn

Sputum smear could get positive results Patients will not respond to the common antibiotic


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d ff l


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Lung cancer Neoplasm must be excluded in any patient who has pneumonia which clears slowly radiologically or repeats in same part of lung

Further investigations includeCT MRI,bronchoscopy and sputum cytologicexamination may help


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Di i d Diff i l


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Lung Abscess Early stage similar but large amount of purulent sputum will be coughed up while the

disease progresses X-ray shows cavity with fluid level


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Diagnosis and Differential


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pulmonary thromboembolism There are phlebothrombosis factors,such asthrombophlebitis,diseases of heart and lung,trauma,surgery,neoplasm and so forth

Hemoptysis syncope and dyspnea are thecharacteristic manifestations

X-ray lung marking decrease and sometimes awedge shadow

Hypoxemia and hypocapnia D-dimer CTPA Pulmonary arteriographyand MRI can help to differentiate


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Di i d Diff i l


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Non-Infectious Pulmonary Infiltration

Such as pulmonary interstitial fibrosis pulmonary edema pulmonaryatelectasis pulmonaryeosinophilia pulmonary vasculitis and soon


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A f P i S i


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Assessment of Pneumonia Severity

Severity evaluation is associated with treatment Pneumonia severity depends on the three factors

the extent of local inflammation thedissemination of pulmonary inflammation and the

degree of systemic inflammation response Besides the following risk factors are also

associated with the increase of pneumonia severityand mortality

History Age over 65 years old with coexisting illness

A f P i S i


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Sign Respiratory rate>30/min

Pulse rate120/min

Bp


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A f P i S i


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So far,there has not been a definition of severe pneumonia,which is recognized generally.The definition of severe pneumoniaestablished by our country is as follow:Confusion

Respiratory rate>30/min

PaO 2


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Bilateral or multilobar involvement on the X-ray film,or50% increase of the lesion within the 48hours after admission

Oliguria:urinary production


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Eti l i Di i


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Etiologic Diagnosis

Aspiration via fibrous bronchoscope or artificial airway Less chance to be polluted 10 5cfu/ml could be defined as pathogens

Protected specimen brush,PSB10 3cfu/ml could be defined as pathogens

Bronchial alveolar lavage,BAL

10 4 cfu/ml or 10 3cfu/ml in the protected BAL sample could be defined as pathogens

Eti l gi Di g i


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Etiologic Diagnosis

Percutaneous fine-needle aspiration Has good sensitivity and specificity,but has highincidence of complication

Culture of blood and pleural fluid Blood culture should be performed but positive islow(5%-20%)

T t t


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Treatment The identification of pathogens is very helpful in

guiding the treatment(target therapy) Low sensitivity and specificity and delayed results Since the etiology of pneumonia is frequently

unknown, initial antibiotic therapy is often

empirical Choice of antibiotics must modified based on

circumstances (CAP or HAP),epidemiology of community or hospital and cover most likely

pathogens


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The following conditions are also consideredin selecting the antibiotics andadministration routeage

Underlying diseaseRadiographic appearancePrior use of antimicrobialsSeverity of pneumonia

Aspirationhospitalization


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Macrolides ,penicillions,first generation of cephalosporins or quinolones are preferred for CAP in adults under age 60 and with no coexisting

illnesses For age over 60with comorbidities or reqiring

hospitalization the second or third generation of cephalosporins ,-lactams/-lactamase inhibitors or

quinolones are considered and the combination of macrolides or aminosides

Treatment


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Treatment Severe pneumonia should broad-

spectrum dosage and combination The condition of patient should be assessed 48-72

hours after the antibiotic therapy When a patient with pneumonia fails to improve 72

hours after administration the capital possibilities listed as follow The pathogens are not covered The infection of specific pathogensComplications or host factors

Non-infectious disease

Prevention


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Prevention

smoking cessation Exercise Influenza and pneumococcal vaccination

appropriately

Bacterial Pneumonia


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Bacterial Pneumonia

Streptococcus pneumonia

Staphylococcal pneumonia


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Aetiology and Pathogenesis


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Pneumococci are spherical gram-positive bacteria The bacteria are classified as 86 serotype according

to their polysaccharide capsule antigen. Pathogenicity and virulence are related toproperties

of the outer capsules and cell walls.


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Susceptible are the previously healthy young adults elderly and infants Pneumococci are aerosolized from the

nasopharynx to the alveolus and causealveolar wall adema and that followed byexudation of white blood cells and red blood cells


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Pneumococci are aerosolized from thenasopharynx to the alveolus and causealveolar wall edema and that is followed byexudation of white blood cells and redcells.the edema fluidswith bacteria spreadsrapidly throughout the lobe via the pore of cohn, resulting in a mostly lobar distributionof consolidation.Because the inflamationstarts from peripheral lung tissue,the pleuralmembrane is easy to be involved and that isrelated to the pleuritis and pleural effusion

Pathology


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Pathology

Four stagesCongestion

Red hepatisation

Gray hepatisation Resolution

Clinical Manifestations


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A. Symptoms Often have a history of cold

,fatigue,drunkness,viral infection before the

onset Sudden attack of high fever 39-40 chills myalgia cough bloody or rusty sputum dyspnea pleuritic chest pain

Nausea vomitting abdominal pain diarrhea



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Clinical Manifestations B. Signs

Flush cyanosis braeth rapidly and shallowly,alae nasi moving Moving less on the affected side,Dull to

percussion increased tactile vocal fremitusbronchial breath sounds rales pleural frictionrub

Nature history is 1-2 weeks,defervescence may occur

either gradually or dramatically 5~10 days after onset or 1~3 days with effective antibiotic therapy


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Laboratory Findings


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Laboratory Findings

WBC is increased Sputum smear Sputum culture PCR Blood culture or pleural fluid culture

Radiographic Diagnosis


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Radiographic Diagnosis

Chest radiography may confirm the diagnosis Assess severity and response to therapy over time Radiographic findingscan range from patchy

airspace infiltrates to lobar consolidation withair bronchograms. Finds pleural effusions and cavitation Clearing of pulmonary infiltrates can take 3-4

weeks


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Diagnosis and Differential


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According to symptoms signs and chest Radiographic findings

Atypical Clinical Manifestations should differentiate

Treatment


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Treatment

A. Antibiotic therapyTherapy should be initiated promptly after the diagnosis of pneumonia is established

Penicillin quinolones or third generationof cephalosporins Vancomycine

Therapy for two weeks or until the patient is

afebrile for at least 72 hours

Treatment


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Treatment

B. Treatment of complicationsTherapy according to symptoms such as torelieve chest pain thoracentesis when

pleural fluid formation



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Staphylococcal pneumonia is an acute pulmonary suppuration caused by staphylococcus It often affects persons with co-morbid illness and

usually has sudden onset of high

fever chills chest pain and purulent sputum

X-ray presents with necrotizing pneumonia suchas lung abscesses air cyst and empyema

It has a very high mortality if not being treated properly


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Staphylococci are gram-positive coccus and can beclassified as coagulase-positive Staphylococcusaureus coagulase-negative S.epidermidis and

S.saprophyticus The pathogenic materials of staphylococcus are

toxins and enzymes such ashematoxin leucocidin enterotoxin and so on

The virulence of staphylococcus can be determined by testing the coagulase



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et o ogy a d at oge es s

The coagulase-positive agent has stronger virulence Staphylococci has been implicated in 11%-25% of

CAP and there have been reports about the epidemicoutbreak of methicillin resistent

S.aureus MRSA in the hospital in the recent years

Pathology


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Pathology

S.aureus can gain access to the lung parenchyma bytwo routes aspiration of upper respiratory floraand hematogenous spread

The pneumonia associated with aspiration will

present with lobar consolidation or extensivelydistributed bronchial pneumonia

Lung abscess air cyst empyema and pyopneumothorax are the common typical pathologic changes

Pathology


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gy Hematogenous seeding of the lungs with S.aureus

follows embolization from an intravascular nidus of infection

Common settings for septic pulmonaryemboliazation are right-sided

endocarditis especially common among injectiondrug users and septicthromboophlebitis which is most often acomplication of an indwelling venous catheter

The bacterial embolus can also come fromcutaneous infections such as

furuncle carbuncle cellulites and wound infection



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Only rarely does S.aureus cause pneumonia without predisposing epidemiologic or host factors that favour colonization of the respiratory tract and/or that impair defense mechanisms

Clinical findings is characterized by sudden attack of high fever 39-40 chills chest pain cough productive of purulent sputum or blood tinged purulent sputum

Systemic toxicity includes myalgia arthralgiaand prostration



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Ciuculatory collapse can occur in early stage in casewith severe condition

The onset can be insidious in patient with HAP and temperature will go up gradually

The elderly may present atypical manifestations The patient with hematogenous spread usually has a

history of indwelling venous catheter wound infection and drug abuse by intravenous

They often strat with the symptoms of primary lesionand have less respiratory manifestations



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Few signs can be detected in early stage that is not parallel with the severe toxic symptoms Afterward the signs of pneumonia pleural

effusion or pneumothorax can be found Radiograph shows consolidation of segment or

lobar cavity formation and air cyst with fluid level

Multiple nodular or fluffy infiltrates suggest hemotogenous spread


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Diagnosis


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g The initial diagnosis can be made according to the

systemic toxicity produtive cough with blood stained purulent sputum increase of WBC and radiographic changes

Aetiological evidence can confirm the diagnosiswhich can obtain from the culture of

sputum pleural fluid and blood


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Documents

Pulmonary Infection Disease