PneumoniaPneumonia

Definition: pulmonary inflammatory D Definition: pulmonary inflammatory D of terminal bronchioles, alveoli and of terminal bronchioles, alveoli and interstitia. interstitia.

PathogensPathogens Microbial, physiochemical, Microbial, physiochemical,

immunological, allergic or drugsimmunological, allergic or drugs Bacterial pneumonia is most commonBacterial pneumonia is most common

Prevalence and etiologyPrevalence and etiology Almost most commonAlmost most common Risk factorsRisk factors1.1. Genetic variance and antigen driftGenetic variance and antigen drift2.2. Increased poor population, and aging Increased poor population, and aging

populationpopulation3.3. SmokingSmoking4.4. Increased nosocomial pneumoniaIncreased nosocomial pneumonia5.5. Unsuitable use of antibiotics Unsuitable use of antibiotics →bacterial →bacterial

multiple-drug resistancemultiple-drug resistance6.6. Complicated with severe systemic DComplicated with severe systemic D7.7. Dysfunction of immune system: Dysfunction of immune system:

administration of immunosuppressive administration of immunosuppressive agents, tumor, DM, Uremia, AIDS, etcagents, tumor, DM, Uremia, AIDS, etc

ClassificationClassification

In light of anatomy, etiology, or In light of anatomy, etiology, or environmentsenvironments

In terms of etiology or In terms of etiology or pathogenpathogen

Bacterial: typical bacterial include Bacterial: typical bacterial include pneumococcus, streptococcus, staphylococcus, pneumococcus, streptococcus, staphylococcus, haemophilus, type A hemolytic streptococcus, haemophilus, type A hemolytic streptococcus, Klebsiella, pseudomonas aeruginosa, etcKlebsiella, pseudomonas aeruginosa, etc

Atypical pathogen: including mycoplasma, Atypical pathogen: including mycoplasma, Chlamydia, legionella, etcChlamydia, legionella, etc

Viral: cytomegalovirus, respiratory syncytial Viral: cytomegalovirus, respiratory syncytial virus, measles virus, varicella-zoster virus, & virus, measles virus, varicella-zoster virus, & havtairus, etchavtairus, etc

Fungal: histoplasma, coccidioides & BlastomyFungal: histoplasma, coccidioides & Blastomyces spp., etcces spp., etc ( ( 白色念珠菌 、曲菌 、 放线菌等白色念珠菌 、曲菌 、 放线菌等 )) Other pathogenic microbesOther pathogenic microbes: : carinii, etccarinii, etc Physiochemical or allergen induced pnePhysiochemical or allergen induced pneumoniae: radiation related, inhalation rumoniae: radiation related, inhalation related, etcelated, etc

In terms of environmentsIn terms of environments

Community acquired pneumonia Community acquired pneumonia (CAP)(CAP)

Infected out of the hospital, including Infected out of the hospital, including those onset in hospital, but infected out those onset in hospital, but infected out of hospital in terms of latent periodof hospital in terms of latent period

Common pathogens: streptococcus Common pathogens: streptococcus pneumoniae, haemophilus influenza, etcpneumoniae, haemophilus influenza, etc

EvidenceEvidence1.1. Recent occurrence of cough, sputum or Recent occurrence of cough, sputum or

aggravated on the basis of previous aggravated on the basis of previous presentationspresentations

2.2. Fever, purulent sputum, chest painFever, purulent sputum, chest pain3.3. Dullness and/or moist rales,Dullness and/or moist rales,4.4. WBC>10X109/L or <4X109/L, WBC>10X109/L or <4X109/L,

hyposegmentationhyposegmentation5.5. X-ray examine show laminar infiltrated X-ray examine show laminar infiltrated

shadow or interstitial changes, with or shadow or interstitial changes, with or without pleural effusionwithout pleural effusion

Diagnosed by any one of items 1-4 + item Diagnosed by any one of items 1-4 + item 55

Hospital-acquired pneumonia Hospital-acquired pneumonia (HAP)(HAP)

Not infected out of hospital or not in the Not infected out of hospital or not in the latent period, but infected within 48 Hrs after latent period, but infected within 48 Hrs after admission to hospitaladmission to hospital

Nosocomial infectionNosocomial infection EvidenceEvidence Similar with CAPSimilar with CAP Common pathogens: Common pathogens: streptococcus streptococcus

pneumoniae, haemophilus influenza, S. aureus, pneumoniae, haemophilus influenza, S. aureus, enteric aerobic G- bacilli, klebsiella, etc enteric aerobic G- bacilli, klebsiella, etc

1.1. Lobar pneumonia –Lobar pneumonia –termed as alveolar termed as alveolar pneumoniapneumonia

2.2. Foliolar pneumonia – Foliolar pneumonia – termed as bronchial termed as bronchial pneumoniapneumonia

3.3. Interstitial pneumoniaInterstitial pneumonia

According to anatomyAccording to anatomy

Lobar pneumonia– Lobar pneumonia– termed as alveolar termed as alveolar pneumoniapneumonia

1.1. Alveolar inflammation of one lobe or Alveolar inflammation of one lobe or segment, parenchymal inflammation, segment, parenchymal inflammation, bronchi is not involved bronchi is not involved

2.2. Pathogens: Pathogens: streptococcus pneumoniae, streptococcus pneumoniae, infiltrated via blood circulationinfiltrated via blood circulation

3.3. X-ray: dullness shadow in a lobe or X-ray: dullness shadow in a lobe or segmentsegment

Foliolar pneumonia—bronchial Foliolar pneumonia—bronchial pneumoniapneumonia

1.1. Inflammation ofInflammation of bronchiole, terminal bronchiole, terminal bronchiole, respiratory bronchiole & alveolarbronchiole, respiratory bronchiole & alveolar

2.2. Pathogens: Pathogens: streptococcus pneumoniae, S. aureus, streptococcus pneumoniae, S. aureus, virus, mycoplasma, legionella, etc. infiltrated via virus, mycoplasma, legionella, etc. infiltrated via bronchibronchi

3.3. Often secondary Often secondary to other D such as bronchitis, to other D such as bronchitis, bronchiectasis, viral infection of upper R tractbronchiectasis, viral infection of upper R tract

4.4. Moist rales Moist rales is audible, but no dullness signsis audible, but no dullness signs5.5. X-ray: irregular lamellar shadow X-ray: irregular lamellar shadow distributed distributed

along bronchi with foggy margin, no dullnessalong bronchi with foggy margin, no dullness

Foliate pneumonia on R inferior lung

Interstitial pneumoniaInterstitial pneumonia1.1. Interstitial inflammation: involve bronchial Interstitial inflammation: involve bronchial

wall & their peripheral tissue, hyperplasia of wall & their peripheral tissue, hyperplasia of alveolar wall, edematous changes in interstitiaalveolar wall, edematous changes in interstitia

2.2. Pathogens: bacteria, mycoplasma, viruses or Pathogens: bacteria, mycoplasma, viruses or cariniicarinii

3.3. Mild symptom, few abnormal signs Mild symptom, few abnormal signs 4.4. X-ray: unilateral or bilateral irregular stripe or X-ray: unilateral or bilateral irregular stripe or

net-like shadow on inferior field, stretched net-like shadow on inferior field, stretched from hilus, accompanied with small piece of from hilus, accompanied with small piece of atelectasisatelectasis

Clinical manifestationsClinical manifestations Various with different pathogensVarious with different pathogens Determined by the status both of Determined by the status both of

host & pathogenshost & pathogens Pay much attention to signs of Pay much attention to signs of

dullness and signs of pleural effusiondullness and signs of pleural effusion

Diagnosis & Diagnosis & Differentiation DiagnosisDifferentiation Diagnosis

ProcedureProcedure1.1. Make sure of diagnosis of pneumoniaMake sure of diagnosis of pneumonia2.2. Esp. distinguish from upper R. infectionEsp. distinguish from upper R. infection3.3. Distinguish from other D such as TB, Distinguish from other D such as TB,

LC, acute lung abscess, lung LC, acute lung abscess, lung thromboembolic disease, or non-thromboembolic disease, or non-infectious lung infiltrationinfectious lung infiltration

X-ray film

CT, MRI

Scintigraphic Imaging

Severity evaluationSeverity evaluation

Which is determined by 3 factorsWhich is determined by 3 factors1.1. local inflammationlocal inflammation2.2. Generalized or notGeneralized or not3.3. Inflammatory reaction as wholeInflammatory reaction as whole

Risk factorsRisk factors Factors indicate: Factors indicate: severity and severity and

mortalitymortality1.1. History: History: >age of 65, with severe diseases >age of 65, with severe diseases

such as COPD, DM, chronic heart or kidney such as COPD, DM, chronic heart or kidney failurefailure

2.2. PE: PE: R>30 tpm, P>120tpm, T>40R>30 tpm, P>120tpm, T>40ººC, or <35C, or <35ººC, C, BP<90/60mmHg, abnormal consciousness, BP<90/60mmHg, abnormal consciousness, accompanied with infection in other organ or accompanied with infection in other organ or system such as meningitis, sepsis, etcsystem such as meningitis, sepsis, etc

3.3. Lab test & imaging: Lab test & imaging: WBC>20WBC>20×10×1099/L/L<4<4×10×1099/L, /L, NN<1<1×10×1099/L; /L; PaO2<60mmHgPaO2<60mmHg ，， PaCO2>50mmHg; PaCO2>50mmHg; Cr>106mol/LCr>106mol/L ，， BUN>7.1mmol/L; toxic BUN>7.1mmol/L; toxic symptoms or evidence of DIC; X-ray: over 1 symptoms or evidence of DIC; X-ray: over 1 lobe involved, cavity, dispersed quickly, or lobe involved, cavity, dispersed quickly, or pleural effusionpleural effusion

Standard for severe Standard for severe pneumoniapneumonia

In China, severe pneumonia is In China, severe pneumonia is determined by series of indicatorsdetermined by series of indicators

1.1. Abnormal consciousnessAbnormal consciousness2.2. R>30tpmR>30tpm3.3. PaO2<60mmHg, PaOPaO2<60mmHg, PaO22/FiO/FiO22<300, <300,

mechanical ventilation requiredmechanical ventilation required4.4. BP<90/60mmHgBP<90/60mmHg5.5. X-ray: bilateral or multiple lobes X-ray: bilateral or multiple lobes

involved, or pathological region involved, or pathological region dispersed rapidly>50% 48 Hrs after dispersed rapidly>50% 48 Hrs after admission admission

6.6. Oligouria <20ml/h or <80ml/4hOligouria <20ml/h or <80ml/4h→ acute → acute kidney failure when dialysis requiredkidney failure when dialysis required

Detection of pathogenDetection of pathogen MethodsMethods SamplingSampling1.1. SputumSputum2.2. Bronchoscopy-based techniques: airway Bronchoscopy-based techniques: airway

aspiration, brushing sample, alveolar lavageaspiration, brushing sample, alveolar lavage3.3. Subcutaneous needle aspirationSubcutaneous needle aspiration ExaminationExamination1.1. Directly examinationDirectly examination2.2. Culture + drug sensitivity test of sputum, Culture + drug sensitivity test of sputum,

Effusion or bloodEffusion or blood

TreatmentTreatment AntibioticsAntibiotics—most important—most important Experience is important—on the Experience is important—on the

basis of epidemiologic databasis of epidemiologic data More reliable if selection is based More reliable if selection is based

results from culture + sensitivity testresults from culture + sensitivity test

Antibiotics selection on patients Antibiotics selection on patients statusstatus

1.1. The youth or patients without basic The youth or patients without basic diseases: macrolides, penicillin, diseases: macrolides, penicillin, quinolones or 1quinolones or 1stst generation generation cephalosporin is selectablecephalosporin is selectable

2.2. The elder, or those with basic The elder, or those with basic diseases: 2nd or 3rd cephalosporins diseases: 2nd or 3rd cephalosporins and/or and/or -lactamase inhibitors, -lactamase inhibitors, quinolones, and/or macrolidesquinolones, and/or macrolides

Principles for severe pneumoniaPrinciples for severe pneumonia1.1. Broad-spectrum, sufficiency & combination Broad-spectrum, sufficiency & combination

with 2 or more with 2 or more 2.2. CAP: 3rd generation cephalosporin + CAP: 3rd generation cephalosporin +

macrolide + macrolide + -lactamase inhibitors -lactamase inhibitors 3.3. If hypersensitive to penicillin: quinolone + If hypersensitive to penicillin: quinolone +

aminoglycosideaminoglycoside4.4. Combining with norvancomycin if necessaryCombining with norvancomycin if necessary

Situations for changing Situations for changing antibioticsantibiotics

No improvement 72Hrs after useNo improvement 72Hrs after use Possible reasonsPossible reasons1.1. Pathogen is resistant or not overlapped Pathogen is resistant or not overlapped 2.2. Special pathogen: TB, fungus, or virusSpecial pathogen: TB, fungus, or virus3.3. Influenced by complication or Influenced by complication or

immunosuppressive statusimmunosuppressive status4.4. Diagnosis is wrong, e.g.Diagnosis is wrong, e.g. non-infected D, non-infected D,

or drug-induced feveror drug-induced fever

Family careFamily care

Enhance basic status by appropriate Enhance basic status by appropriate exerciseexercise

Reduce risk factors such as smoking Reduce risk factors such as smoking and alcohol abuseand alcohol abuse

Administration of vaccines to prevent Administration of vaccines to prevent influenza and pneumonia, esp. for influenza and pneumonia, esp. for the elder, those with basic D or the elder, those with basic D or administration of suppressive agentsadministration of suppressive agents

Streptococcus pneumoniaStreptococcus pneumonia(( 肺炎链球菌肺炎肺炎链球菌肺炎 ) )

Natural historyNatural history Half of patients with CAPHalf of patients with CAP Pathogen: S. pneumoniae—G+Pathogen: S. pneumoniae—G+ Capsular polysaccharide: main Capsular polysaccharide: main

pathogenic factorpathogenic factor Natural course:1—2 WeeksNatural course:1—2 Weeks 。 。 T T 5—10 days later spontaneously 5—10 days later spontaneously T normalized by administration of T normalized by administration of

effective antibiotics within 1-3 dayseffective antibiotics within 1-3 days

TriggersTriggers: coldness, drunkenness, : coldness, drunkenness, fatigue, viral infectionfatigue, viral infection

Abrupt onset, characterized of high Abrupt onset, characterized of high fever, rigor, cough with ferruginous fever, rigor, cough with ferruginous sputum and chest painsputum and chest pain

Pleural involvement is commonPleural involvement is common

Clinical manifestationsClinical manifestations

StagingStaging1.1. Congestion stage: Congestion stage: vascular engorgement vascular engorgement

and serous exudationand serous exudation2.2. Red hepatization stage: Red hepatization stage: reflecting reflecting

liverlike appearance of consolidated lung—liverlike appearance of consolidated lung—RBC extravasationRBC extravasation

3.3. Gray hepatization stage: Gray hepatization stage: accumulation accumulation of fibrins mixed with WBC and RBCof fibrins mixed with WBC and RBC

4.4. Resolution stage: Resolution stage: absorption of exudationabsorption of exudation

PEPE Acute feverish face, red cheeks, rapid Acute feverish face, red cheeks, rapid

respiration, dry skin, thirsty, herpes respiration, dry skin, thirsty, herpes on mouth corner or around noseon mouth corner or around nose

Cyanosis in some severe patientsCyanosis in some severe patients Bleeding in skin & sclerotic jaundice Bleeding in skin & sclerotic jaundice

in those with toxic pneumoniain those with toxic pneumonia Stiff neck + in those with meningitisStiff neck + in those with meningitis

Tachycardia or arrhythmiaTachycardia or arrhythmia Abdominal tenderness & distentionAbdominal tenderness & distention Shock, ARDS or abnormal Shock, ARDS or abnormal

consciousnessconsciousness

Signs of Lung Signs of Lung No significant signs in early stageNo significant signs in early stage Consolidation is the typical signs in red Consolidation is the typical signs in red

and grey hepatization stage: increased and grey hepatization stage: increased fremitus, dullness, bronchophony, fremitus, dullness, bronchophony, pleural friction sound may be audiblepleural friction sound may be audible

Moist rales in resolution stageMoist rales in resolution stage

Complications: rarelyComplications: rarely Infectious shockInfectious shock Pleurisy and empyema (Pleurisy and empyema ( 脓胸脓胸 )) MeningitisMeningitis PericarditisPericarditis ArthritisArthritis

Laboratory testingLaboratory testing WBC10--20x10WBC10--20x1099/L, N>80%, /L, N>80%,

hyposegmentation, toxic granuleshyposegmentation, toxic granules WBC may be lower than 4 x10WBC may be lower than 4 x1099/L in the /L in the

elder, drunk or those with immune elder, drunk or those with immune deficiency, but ratio of N/WBC is higher deficiency, but ratio of N/WBC is higher

Pathogen examinationPathogen examination Gram staining or capsule staining with Gram staining or capsule staining with

sputum precipitantsputum precipitant CultureCulture ELISA or PCR for detection of antigen or ELISA or PCR for detection of antigen or

genetic markersgenetic markers

X-rayX-ray

Typical changes: segmental or lobar Typical changes: segmental or lobar consolidation shadowconsolidation shadow

S. Pneumonia in R superior lobe (AP view)

S. Pneumonia in R superior lobe (lateral view)

S. Pneumonia in R superior lobe (lateral view)

S. Pneumonia resolution stage in R superior lobe (AP)

S. Pneumonia in R meddle lobe (AP view)

S. Pneumonia in R meddle lobe (lateral view)

Diagnosis EssentialsDiagnosis Essentials

Natural history, triggers and symptomsNatural history, triggers and symptoms SignsSigns X-rayX-ray Pathogen examination, most reliablePathogen examination, most reliable

Differentiation DiagnosisDifferentiation Diagnosis1.1. TB—liquefied pneumoniaTB—liquefied pneumonia2.2. Lung cancer– obstructive pneumoniaLung cancer– obstructive pneumonia3.3. Acute lung abscessAcute lung abscess4.4. Lung thrombemboliaLung thrombembolia5.5. Non-infectious lung infiltration such as Non-infectious lung infiltration such as

interstitial pulmonary fibrosis, interstitial pulmonary fibrosis, pulmonary edema , atelectasis, pulmonary edema , atelectasis, pulmonary infiltration of eosinophilic pulmonary infiltration of eosinophilic granulocyte and pulmonary vasculitis granulocyte and pulmonary vasculitis

TreatmentTreatment AntibioticsAntibiotics Primary: penicillin GPrimary: penicillin G AdministrationAdministration1.1. Adult mild: 2,400,000u/d, q8h im; Adult mild: 2,400,000u/d, q8h im; 2.2. Moderate: 2.4Moderate: 2.4~4.8 million ~4.8 million u/d, ivgtt, q6h u/d, ivgtt, q6h

or q8hor q8h 。 。 3.3. Severe or with meningitis: Severe or with meningitis:

1010~~30million u/d30million u/d ，， ivgttivgtt ，， q6hq6h

Hypersensitive to penicillin, or infected by Hypersensitive to penicillin, or infected by MDR strainsMDR strains

Selectable drugs: quinolones, Selectable drugs: quinolones, cephalosporins, or even norvancomycincephalosporins, or even norvancomycin

Standard course: 14d, or 3 days later after Standard course: 14d, or 3 days later after T normalizedT normalized

In some cases, oral administration may In some cases, oral administration may persist for another 2 weeks persist for another 2 weeks

Supportive treatmentSupportive treatment Sufficient rest, balanced dietSufficient rest, balanced diet In-time monitoring, prevention In-time monitoring, prevention

against shockagainst shock Painkillers used for severe chest painPainkillers used for severe chest pain

Mycoplasma pneumoniaMycoplasma pneumonia(( 肺炎支原体肺炎肺炎支原体肺炎 ))

General principlesGeneral principles

Pathogen: mycoplasma pneumoniae, Pathogen: mycoplasma pneumoniae, which exists among ciliary epithelial cellswhich exists among ciliary epithelial cells

Disseminated via respiratory tractDisseminated via respiratory tract More common in childhood or youthMore common in childhood or youth Pathology: inflammation of bronchi, Pathology: inflammation of bronchi,

bronchioles, alveolar or interstitiabronchioles, alveolar or interstitia Natural course is 4 weeks, self-limitedNatural course is 4 weeks, self-limited

Diagnostic EssentialsDiagnostic Essentials

2-3 weeks latency2-3 weeks latency Stimulant cough, some with fatigue, sore Stimulant cough, some with fatigue, sore

throat, headache, fever, dyspepsia, diarrhea, throat, headache, fever, dyspepsia, diarrhea, myalgiamyalgia

Extrapulmonary: dermatitisExtrapulmonary: dermatitis Few signsFew signs X-ray: segmental distributed polymorphic X-ray: segmental distributed polymorphic

infiltration shadow, mainly in inferior field, infiltration shadow, mainly in inferior field, disappears spontaneously 3-4 weeks laterdisappears spontaneously 3-4 weeks later

Laboratory testing: WBC counting Laboratory testing: WBC counting increase slightly, Nincrease slightly, N

2/3 patients with positive result of 2/3 patients with positive result of cold aggregation test (1:32), more cold aggregation test (1:32), more meaningful if titer meaningful if titer gradually gradually

Detection of Mycoplasma-specific IgMDetection of Mycoplasma-specific IgM

TreatmentTreatment

Administration of antibioticsAdministration of antibiotics Course: 2 weeksCourse: 2 weeks Primary: macrolides such as Primary: macrolides such as

erythromycin 2g/D, roxithromycin erythromycin 2g/D, roxithromycin 150mg po bid, azithromycin 0.5g, qd150mg po bid, azithromycin 0.5g, qd

Selectable: quinolones or tetracyclines Selectable: quinolones or tetracyclines Ineffective: penicillin and cephalosporinsIneffective: penicillin and cephalosporins

Appendices 1 –antibioticsAppendices 1 –antibiotics CephalosporinCephalosporin 44thth generation generation1.1. Wider spectrum, more effective on GWider spectrum, more effective on G＋＋ coccus, especially for penicillin-coccus, especially for penicillin-

resistant S. pneumoniaeresistant S. pneumoniae2.2. Stronger activity on GStronger activity on G-- bacilli bacilli3.3. More stable to β- lactamaseMore stable to β- lactamase

CephalosporinCephalosporin GG ＋ ＋ coccuscoccus G- bacilliG- bacilli

11stst generation generation Cephazolin Cephazolin (( 头孢唑啉头孢唑啉 )) SensitiveSensitive

22ndnd generation generation Cefuroxime Cefuroxime (( 头孢呋辛头孢呋辛 )) SensitiveSensitive Sensitive Sensitive

33rdrd generation generation Ceftriaxone Ceftriaxone (( 头孢曲松头孢曲松 )) WeakWeak StrongStrong

44thth generation generation Cefepime Cefepime （头孢吡肟（头孢吡肟 )) StrongStrong StrongStrong

CarbopenemCarbopenem Representatives: tienam composed of Representatives: tienam composed of

Imipenem and cilastatin sodiumImipenem and cilastatin sodium Most effective in the worldMost effective in the world Quite stable to β- lactamase because Quite stable to β- lactamase because

of trans structure formed by hydroxyl of trans structure formed by hydroxyl lateral chain and β-lactate looplateral chain and β-lactate loop

Cilastatin inhibit enzymes (degrade Cilastatin inhibit enzymes (degrade imipenem) in kidneyimipenem) in kidney

TienamTienam1.1. Wide spectrum—aerobic or Wide spectrum—aerobic or

anaerobic Ganaerobic G ＋ ＋ coccus and G- bacilli, coccus and G- bacilli, including those with super β-including those with super β-lactamase (ESBL), and resistant lactamase (ESBL), and resistant against 3against 3rdrd-generation cephalosporin-generation cephalosporin

2.2. Imipenem combine with PBP-2 and Imipenem combine with PBP-2 and PBP-2Ib PBP-2Ib →induce rapid resolution, →induce rapid resolution, production of endotoxinproduction of endotoxin

QuinolonesQuinolones Representative: levoflaxacin (Representative: levoflaxacin ( 左旋氧氟沙星来立信左旋氧氟沙星来立信 )) AdvantagesAdvantages1.1. No need for cutaneous sensitivity testNo need for cutaneous sensitivity test2.2. Oral administrationOral administration3.3. Wide-spectrumWide-spectrum4.4. Less side-effect on liver & kidneyLess side-effect on liver & kidney5.5. Effective on intracellular pathogens such as legionellEffective on intracellular pathogens such as legionella and mycobacterium, mycoplasma, Chlamydia, etc.a and mycobacterium, mycoplasma, Chlamydia, etc. DisadvantagesDisadvantages1.1. Weaker effective on GWeaker effective on G+ + coccuscoccus2.2. Toxic to long bones and article, not recommended tToxic to long bones and article, not recommended to be used in youth (o be used in youth (< < ageage of 16) of 16)

MacrolidesMacrolides Representative: erythromycin, Representative: erythromycin,

roxithromycin, clarithromycin, azithromycinroxithromycin, clarithromycin, azithromycin very effective on Gvery effective on G ＋ ＋ coccuscoccus Effective on atypical infectionsEffective on atypical infections

AminoglycosidesAminoglycosides Representations: kanamycin, amikacin, netimiRepresentations: kanamycin, amikacin, netimicin, etimicin (cin, etimicin ( 爱大爱大 )) G- bacilliG- bacilli Toxin injury to Ear, auditory Nerve, kidneyToxin injury to Ear, auditory Nerve, kidney Etimicin more effective than gentamicinEtimicin more effective than gentamicin Netimicin, etimicin less side-effectNetimicin, etimicin less side-effect

Anti fungus drugsAnti fungus drugs Representatives: Amphotericin B, Representatives: Amphotericin B,

ketoconazole, fluconazole ketoconazole, fluconazole Candida, cryptococcus, aspergillusCandida, cryptococcus, aspergillus Anti anaerobic bacteriaAnti anaerobic bacteria Penicillin, metronidazole, tinidazole, Penicillin, metronidazole, tinidazole,

chloromycetin, clindamycin. Erythromycin chloromycetin, clindamycin. Erythromycin is only against anaerobic coccus, is only against anaerobic coccus, metronidazole against all anaerobic metronidazole against all anaerobic bacteriabacteria

Appendices 2Appendices 2organisms & antibioticsorganisms & antibiotics

OrganismOrganism Typical Typical symptomssymptoms

Radiographic Radiographic appearanceappearance

TherapyTherapy

S. S. pneumoniaepneumoniae

Sudden onset, Sudden onset, fever, rigor, fever, rigor, chest painchest pain

Lobar Lobar pneumonia, pneumonia, pleural effusionpleural effusion

PenicillinPenicillinvancomycinvancomycin

S. AureusS. Aureus Gradual, Gradual, fever, purulent fever, purulent phlegm, phlegm, dyspneadyspnea

Multiple lobar, Multiple lobar, empyema, empyema, abscessabscess

Methicillin, Methicillin, vancomycinvancomycin

K. K. PneumoniaePneumoniae

Sudden, chest Sudden, chest pain, dyspnea, pain, dyspnea, blood phlegmblood phlegm

Multiple lobular, Multiple lobular, empyema, absceempyema, abscessssAzithromycinAzithromycinbroad -spectrum broad -spectrum cephalosporincephalosporin

H. InfluenzaeH. Influenzae Gradual, Gradual, bronchitis, bronchitis, chest pain, chest pain, dyspneadyspnea

Consolidative Consolidative or patchy or patchy lobular patternlobular pattern

Azithromycin, orAzithromycin, oramoxicillinamoxicillin

P. aeruginosaP. aeruginosa nosocomial, nosocomial, blood phlegmblood phlegm

Patchy Patchy localized localized infiltrateinfiltrate

Cefepime, imipeneCefepime, imipenem, m,

OrganismOrganism Typical Typical symptomssymptoms

Radiographic Radiographic appearanceappearance

Basic TherapyBasic Therapy

L. L. pneumophilapneumophila

Gradual, rigor, Gradual, rigor, chest pain, GI chest pain, GI disturbancedisturbance

Patchy Patchy localized localized infiltrateinfiltrate

AzithromycinAzithromycin

Anaerobic Anaerobic organismsorganisms

Gradual onset, Gradual onset, putrid phlegmputrid phlegm

Upper Seg. of lUpper Seg. of lower lobes, loower lobes, lower Seg. of Upwer Seg. of Upper lobesper lobesPenicillin, Penicillin, metronidazolemetronidazole

MycoplasmaMycoplasma Gradual onset, Gradual onset, malaise, fever, malaise, fever, headacheheadache

Patchy Patchy localized localized infiltrateinfiltrate

AzithromycinAzithromycin

ChlamydiaChlamydia Erythromycin, Erythromycin, roxithromycinroxithromycin

Fungal Fungal infectionsinfections

Gradual onset, Gradual onset, bronchitis, bronchitis, dyspneadyspnea

Bilateral Bilateral diffuse, diffuse, infiltrate with infiltrate with foggy marginfoggy margin

Amophotericin Amophotericin B, fuconazole, B, fuconazole, ketoconazoleketoconazole

Extracurricular taskExtracurricular task List the diagnostic essentials forList the diagnostic essentials for1.1. Viral pneumoniaViral pneumonia2.2. Fungal pneumoniaFungal pneumonia3.3. Staphylococcual pneumoniaStaphylococcual pneumonia4.4. Klebsiella pneumoniaKlebsiella pneumonia5.5. Pneumonia caused by gramPneumonia caused by gram- - bacillibacilli6.6. And pneumonia of legionnaires’ diseaseAnd pneumonia of legionnaires’ disease

Look for the primary antibiotics and Look for the primary antibiotics and selectable ones against pneumonia selectable ones against pneumonia listed above?listed above?

Try to make out the essentials for Try to make out the essentials for diagnosis of pneumonia?diagnosis of pneumonia?