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Pneumonia
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Pneumonia is defined as inflammation and consolidation of the respiratory part of lung
tissue (alveoli) due to an infectious agent.
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Community-acquired pneumonia remains a common illness. Pneumonia is the sixth leading cause of death in the the world and is the most common infectious cause of death.
Pneumonia is the leading cause of death among hospital-acquired infections, and the mortality rates range from 20-50%.
Advanced age increases the incidence of pneumonia and the mortality from it.
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Causes of bacterial pneumonia
include infection with respiratory pathogens.
Exposure to pulmonary irritants or direct pulmonary injury causes noninfectious pneumonitis
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Intrinsic factors that predispose pneumonia include
1)1)the host's immune response,
2))the presence of comorbidities
3) aspiration of oropharyngeal flora into the lung.
4) local lung pathologies
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Aspiration is facilitated by altered mental status from intoxication, deranged metabolic states, neurological causes (eg, stroke), and endotracheal intubation.
Local lung pathologies (tumors, chronic obstructive pulmonary disease, bronchiectasis) are predisposing factors for bacterial pneumonia.
Smoking impairs the host's defense to infection by a variety of mechanisms.
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ClassificationClassification
1. Community-acquired pneumonia1. Community-acquired pneumoniatypicalatypical
2.Nosocomial pneumonia2.Nosocomial pneumonia
3. Aspiration pneumonia. 3. Aspiration pneumonia.
4.Pneumonia in immunocompromised 4.Pneumonia in immunocompromised patients. patients.
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1. Pneumonia that develops outside the hospital setting is considered community-acquired pneumonia.community-acquired pneumonia.
2. Pneumonia developing 48 hours or more after admission to the hospital is termed nosocomial or hospital-acquired pneumoniahospital-acquired pneumonia..
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3. 3. Aspiration pneumoniaAspiration pneumonia takes the takes the special place due to high risk of lung special place due to high risk of lung tissue destruction and bad prognosis. tissue destruction and bad prognosis.
4. 4. Pneumonia Pneumonia in immunocompromised in immunocompromised patientspatients (those who receive (those who receive immunodepressants, such as immunodepressants, such as cytostatics or system steroids, HIV-cytostatics or system steroids, HIV-infected persons on last stage).infected persons on last stage).
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Community-acquired pneumonia
is caused most commonly by bacteria that traditionally have been divided into 2 groups, typical and atypical.
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A. Typical organisms in community-acquired pneumonia
(approximately 85%) includeStreptococcus pneumoniae (pneumococcus), Haemophilus influenzae (is associated with asthma and COPD), and Moraxella catarrhalis (in patients with chronic bronchitis).
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S pneumoniae remains the most common agent responsible for community-acquired pneumonia.
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Rare bacterial pathogens in community-acquired
pneumonia are
Klebsiella pneumoniae (in persons with chronic alcoholism),
Staphylococcus aureus (in the setting of postviral influenza),
Pseudomonas aeruginosa (in patients with bronchiectasis).
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B. Atypical pathogens in community-acquired pneumonia
(approximately 15%) are
Legionella pneumophila,
Mycoplasma pneumoniae,
Chlamydia psittaci,
Coxiella burnetii.
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Do not mix community-acquired pneumonia due to atypical flora with
“atypical pneumonia” due to virus (SARS – severe acute respiratory syndrome)!.
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Typical (predominantly pneumococcal) pneumonia produces the following:
a characteristic clinical pattern, with sudden onset of fever and shaking chills, pleuritic chest pain, and production of rust-colored sputum and radiological evidence of consolidation. examination of sputum in case of pneumococcal pneumonia shows gram-positive diplococci in chains.
This clinical picture was recognized as “typical” (classical) pneumonia.
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”Atypical" community-acquired pneumonia
Most patients present with a gradual onset of the disease without shaking chills. A prodrome of it consists of headache, photophobia, sore throat, and eventually a dry, nonproductive cough. Their sputum does not contain gram-positive diplococci (pneumococci). Although these patients were not feeling well, they were not critically ill. Laboratory evaluations showed white blood cell counts to be normal.
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Hospital-acquired (nosocomial) pneumonia
defines as pneumonia occurring more than 48 hours after admission to the hospital.
It is a major cause of morbidity and mortality in hospitalized patients.
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The most common organisms responsible for nosocomial pneumonia are
Staphylococcus aureusStaphylococcus aureusKlebsiella pneumoniaeKlebsiella pneumoniaeGram-negative pathogens: Gram-negative pathogens:
>Enterobacter, >Pseudomonas aeruginosa, and >Escherichia coli.
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S. aureus pneumonia generally occurs S. aureus pneumonia generally occurs in those who abuse intravenous drugs: in those who abuse intravenous drugs: in hospitalized patients and patients in hospitalized patients and patients with prosthetic devices; it spreads with prosthetic devices; it spreads hematogenously to the lungs from hematogenously to the lungs from contaminated local sites. contaminated local sites. Infection by Pseudomonas aeruginosa Infection by Pseudomonas aeruginosa tend to cause pneumonia in the tend to cause pneumonia in the patients, requiring mechanical patients, requiring mechanical ventilation.ventilation.
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Essentials of diagnosis of Essentials of diagnosis of community-acquired pneumoniacommunity-acquired pneumonia Occurs in healthy person Sudden onset of fever and shaking chills,
cough, and production of rust-colored sputum sometimes accompanied by pleuritic chest pain due to pleurisy
Physical examination detects signs of consolidation
Crackles in auscultation Pulmonary infiltrate on chest x-ray.
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Essentials of diagnosis of hospital-Essentials of diagnosis of hospital-acquired (nosocomial) pneumoniaacquired (nosocomial) pneumonia
Occurs more than 48 hours after admission to the hospital.
One or more clinical findings (fever, cough, leukocytosis, purulent sputum) in most patients.
Especially frequent in patients requiring intensive care and mechanical ventilation.
Pulmonary infiltrate on chest x-ray.
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Clinical presentation in patients with pneumonia
varies from a mildly ill ambulatory patient to a critically ill patient with respiratory failure or septic shock.
Typically, patients with pneumonia present with variable degrees of fever; they may report rigors or shaking chills.
Pleuritic chest pain secondary to pleurisy is a common feature of pneumococcal infection, but these may occur in other bacterial pneumonias.
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Clinical presentation in patients with pneumonia
A productive cough is characteristic feature of pneumonia. The character of sputum may suggest a particular pathogen.
Patients with pneumococcal pneumonia produce rust-colored sputum.
Infections with Pseudomonas and Haemophilus are known to expectorate green sputum.
Anaerobic infections produce foul-smelling sputum.
Currant-jelly sputum suggests pneumonia from Klebsiella.
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Clinical presentation in patients with pneumonia
Malaise, myalgias, and exertional dyspnea may be observed.
Patients may complain of other nonspecific symptoms, which include
> headaches, > nausea, and > vomiting.
These symptoms are accompanied by intoxication.
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A detaled past medical history and history of environmental and occupational exposures
should be obtained
This history should include whether the patient has recently traveled or had contact with animals that might serve as a source of an infectious agent.
Patients may report
exposure to turkeys, chickens, ducks in case of Chlamydia psittaci infection
exposure to contaminated air-conditioning cooling towers in case of Legionella pneumophila infection.
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Evaluation of host factors often provides a clue to the bacterial diagnosis
Diabetic ketoacidosis may lead to S. pneumoniae or S. aureus infection.
Alcoholism may indicate Klebsiella pneumoniae infection.
Chronic obstructive lung disease may lead to Haemophilus influenzae or Moraxella catarrhalis infection.
HIV infection may lead to Cryptococcus neoformans, Mycobacterium avium-intracellulare infection or Pneumocystis pneumonia.
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Precise clinical diagnosis of nosocomial pneumonia
is much more difficultmuch more difficult than community-acquired pneumonia.
It is because of the absence of a typical clinical pictureabsence of a typical clinical picture against the background of the disease, which was the reason for hospitalization.
The subclinical coursesubclinical course without clear typical picture is widespread.
However, one or more clinical findingsclinical findings (fever,
leukocytosis, purulent sputum), and a pulmonary pulmonary infiltrateinfiltrate on chest x-ray are present in most patients.
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PhysicalPhysical
A.The common symptoms and signs (due to due to intoxication and respiratory failureintoxication and respiratory failure) are as follows:
Fever (temperature >38.5°C) Tachypnea Tachycardia Central cyanosis
These symptoms are non-specificnon-specific and indicate severityseverity of the disease, not etiologynot etiology. They can’t help to diagnose pneumonia, but they determine therapy and prognosis.
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PhysicalPhysical
B. The most important information on physical examination is connected with signs of lung tissue consolidationlung tissue consolidation due to local inflammation:Dullness to percussionIncreased tactile fremitusDecreased intensity of breath soundsCrackles (crepitation) at the beginning and
resolving of inflammationLocal rales Pleural friction rub
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The main doctor’s task on physical examination
is revealing of asymmetric is revealing of asymmetric
pathology.pathology.
Pneumonia is locallocal respiratory pathology. Therefore,
the presence of focal area of lung tissue focal area of lung tissue
consolidationconsolidation has the most diagnostic value.
It is direct indication for chest radiograph.
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Imaging StudiesImaging Studies
The diagnosis of pneumonia is impossible without X-ray investigation.
Direct indication for chest X-ray is not only
focal acoustic pathologyfocal acoustic pathology but also any clinical situation accompanied by chronic or prolonged cough.
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Imaging StudiesImaging Studies
In chest medicine 80% of information is on the developed film.
Chest radiograph findings in typical case of pneumonia indicate a segmental or segmental or lobar opacity, or infiltrationlobar opacity, or infiltration corresponding to the impaired area.
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Left low lobe pneumoniaLeft low lobe pneumonia
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Low lobe pneumoniaLow lobe pneumonia
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Right upper lobe lobar pneumonia Right upper lobe lobar pneumonia secondary to Streptococcus secondary to Streptococcus
pneumoniae infectionpneumoniae infection
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Bacterial pneumonia. Bilateral airspace Bacterial pneumonia. Bilateral airspace infiltration secondary to community-infiltration secondary to community-acquired pneumonia, subsequently acquired pneumonia, subsequently
confirmed to be confirmed to be LegionellaLegionella pneumonia pneumonia
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Bacterial pneumonia. Rarely, severe Bacterial pneumonia. Rarely, severe pneumococcal infection may be associated pneumococcal infection may be associated
with necrotizing pneumonia.with necrotizing pneumonia.
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Chest radiographs showing Chest radiographs showing
right middle lobe pneumoniaright middle lobe pneumonia
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Hospital-acquired right lower lobe pneumonia; sputum culture Hospital-acquired right lower lobe pneumonia; sputum culture
confirmed this to be secondary to gram-negative organismsconfirmed this to be secondary to gram-negative organisms
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Aspergillus pneumoniaAspergillus pneumonia
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PPneumonineumonia caused by a caused by ChlamydChlamydia ia psittasipsittasi
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Aspiration pneumoniaAspiration pneumonia
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CTCT in case of pneumoniain case of pneumonia
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Lab StudiesLab Studies
Complete blood count
Leukocytosis with a left shift is commonly observed in case of pneumonia.
These findings may be absent in elderly or debilitated patients.
Leukopenia is an ominous sign of impending sepsis and a poor outcome.
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Lab StudiesLab Studies
Sputum examination
provides an accurate diagnosis in approximately 50% of patients. A single pathogen present on the Gram stain is typical for pneumonia.
The main value of sputum examination is to exclude the presence of such microorganisms as mycobacteria, fungi, Legionella, and Pneumocystis through special smears and cultures.
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Bacterial pneumonia. Pneumococci Bacterial pneumonia. Pneumococci on sputum Gram stain. on sputum Gram stain.
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Bacterial pneumonia. Histopathological Bacterial pneumonia. Histopathological micrograph ofmicrograph of bacterial pneumonia showing bacterial pneumonia showing extensive infiltration with inflammatory cellsextensive infiltration with inflammatory cells
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Bacterial pneumonia. Bacterial pneumonia. Klebsiella Klebsiella pneumoniaepneumoniae on sputum Gram stain on sputum Gram stain
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Lab StudiesLab Studies
The diagnosis of pneumonia cannot be based solely on the results of culture of expectorated sputum.
100% sputum cultures are impossible in most clinics. No ordinary lab can ensure 100% etiological diagnosis of pneumonia in time.
The standard lab limits sputum investigation by Gram-stained smear.
That is why diagnosis of pneumonia is clinical-That is why diagnosis of pneumonia is clinical-radiological, not etiological.radiological, not etiological.
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Lab StudiesLab Studies
Additional lab tests are necessary when diagnosis is unclear and the treatment based on the findings of standard tests has no effect.
Other tests may include serologyserology, which is essential in the diagnosis of unusual causes of pneumonia such as Legionella, Mycoplasma, Chlamydia, and other.
Blood culturesBlood cultures are of a limited value, as they are positive only in approximately 40% of cases.
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Other TestsOther Tests
Arterial blood gas (ABG) determination: Arterial blood gas (ABG) determination: Evaluation of the patient's gas exchange is Evaluation of the patient's gas exchange is essential in order to decide if hospital essential in order to decide if hospital admission, oxygen supplementation, or admission, oxygen supplementation, or other efforts are indicated. other efforts are indicated.
Pulse oximetry of less than 90% indicates Pulse oximetry of less than 90% indicates significant hypoxia; an ABG determination significant hypoxia; an ABG determination should be performed in these patients.should be performed in these patients.
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ProceduresProcedures
BronchoscopyBronchoscopy
Bronchial washing specimens can be obtained. Protected Bronchial washing specimens can be obtained. Protected brush and bronchoalveolar lavage can be performed for brush and bronchoalveolar lavage can be performed for quantitative cultures. quantitative cultures.
ThoracentesisThoracentesis
This is an essential procedure in patients with a This is an essential procedure in patients with a parapneumonic pleural effusionparapneumonic pleural effusion. .
Obtaining fluid from the pleural space for laboratory analysis Obtaining fluid from the pleural space for laboratory analysis allows for the differentiation between simple and allows for the differentiation between simple and complicated effusions. This determination helps guide complicated effusions. This determination helps guide furtherfurther therapeutic interventiontherapeutic intervention..
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Differential diagnosis
Any case of pneumonia requires excluding of 2 other pulmonological problems.
They are
lung cancer and lung cancer and
tuberculoustuberculous..
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Complications
Pleural effusion
Empyema
Pulmonary abscess
Respiratory failure
Acute heart failure
Death
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Criteria for hospitalization
The decision to hospitalize patients with
community-acquired pneumonia is
dictated by risk factorsrisk factors that increase
either the risk of death or the risk of a risk of death or the risk of a
complicated course of diseasecomplicated course of disease.
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Some of indications for indications for hospitalizationhospitalization include
Advanced age (over 65)comorbidity (alcoholism, diabetes mellitus, COPD, chronic renal or heart failure, chronic liver disease)suspicion of aspiration leukopenia or marked leukocytosisany evidence of respiratory failureseptic appearance and absence of supportive care at home (social indications).
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Who can be treated at home?Who can be treated at home?
Only young people in case of mild Only young people in case of mild
course. course.
If there’s the smallest sign of a If there’s the smallest sign of a
moderate course, the patient must moderate course, the patient must
be directed to the in-patient be directed to the in-patient
department immediately!department immediately!
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Treatment
Establishing a specific etiologic diagnosis of pneumonia is often difficult.
In most cases of both community-acquired and hospital-acquired pneumonia no etiology was identified.
Therefore, when organisms are not known,
therapy should be empiric.
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The initial approach to treating The initial approach to treating patients with patients with сommunity-acquired
pneumonia
involves a determination of 3 factors. involves a determination of 3 factors. (1)(1) Should the patient with pneumonia be Should the patient with pneumonia be
treated in the hospital or as an outpatient? treated in the hospital or as an outpatient? (2)(2) Does the patient have a serious Does the patient have a serious
coexisting illness or is the patient elderly? coexisting illness or is the patient elderly? (3)(3) How severely ill is the patient at the time How severely ill is the patient at the time
of the initial evaluation?of the initial evaluation?
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Community-acquired pneumonia: treatment
Empiric therapy for pneumonia based on
recommendations by the WHO (2000).
Patients with community-acquired Patients with community-acquired
pneumonia are categorized into pneumonia are categorized into 4 groups 4 groups
because a different microbiologic because a different microbiologic
spectrumspectrum is suggested in each group to is suggested in each group to
choose the initial empiric therapy the choose the initial empiric therapy the
most effectively.most effectively.
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Community-acquired pneumonia: treatment
A. TheA. The 11stst major category major category includes includes outpatients aged 60 years or younger without comorbidity..
Antibiotic treatment with one of the newer macrolides (clarithromycin or azithromycin) is advised.
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Community-acquired pneumonia: treatment
B. The 2nd group combines community-acquired pneumonias occurring in outpatients with comorbidity or age 60 years or older.
The recommended therapy is
a 2nd-generation cephalosporin (cefuroxime), or
a beta-lactam + a beta-lactamase inhibitor (amoxicillin-clavulanate), or
a newer fluoroquinolone (levofloxacin or moxifloxacin).
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Community-acquired pneumonia: treatment
C.Community-acquired pneumonia requiring hospitalization
The recommended therapy is
a 2nd-generation cephalosporin (cefuroxime), or
a 3rd-generation cephalosporin (ceftriaxone), or
amoxicillin-clavulanate.
Combination therapy is advised with 2nd- or 3rd-generation cephalosporin + macrolide
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Community-acquired pneumonia: treatment
D. Severe community-acquired pneumonia requiring ICU care
Combination therapy is advised with a macrolide plus a 3rd-generation cephalosporin (eg, ceftazidime), or triple therapy with
(1) ceftazidime or carbapenem + (2) amikacin + (3) macrolide or fluoroquinolone
(ciprofloxacin)
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Nosocomial pneumonia: treatment
Nosocomial pneumonia remains a prevalent hospital-acquired infection.
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Severe nosocomial pneumonia: treatment
The possible combinations are one of the following:
(1) aminoglycoside or ciprofloxacin +
+ (2) amoxicillin-clavulanate, or ceftazidime, or
imipenem+vancomycin
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NB!
Pneumonia is not treated with gentamycin or penicillin!
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Telithromycin (KETEK) is first antibiotic in a new
class called ketolides.
It keeps active against gram-positive cocci in
the presence of resistance. Indicated to treat
mild-to-moderate community-acquired
pneumonia, including infections caused by
multidrug-resistant S. pneumoniae.