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1、Pneumonia,Definition, Pneumonia is an acute infection of the parenchyma of the lung(肺实质), caused by bacteria, fungi(真菌）, virus, parasite（寄生虫） etc. Pneumonia may also be caused by other factors including X-ray, chemical, allergen,Epidemiology,The morbidity and mortality of pneumonia are high especial
2、ly in old people.,Etiology,There are two factors involved in the formation of pneumonia , including pathogens and host defenses.,Classification,Classification of anatomy Classification of pathogen Classification of acquired environment,.Classification by pathogen,Pathogen classification is the most
3、useful to treat the patients by choosing effective antimicrobial agents,Bacterial pneumonia,(1) Aerobic Gram-positive bacteria,such as streptococcus pneumoniae, staphy- lococcus aureus, Group A hemolytic streptococci (2) Aerobic Gram-negative bacteria, such as klebsiella pneumoniae, Hemophilus influ
4、enzae, Escherichia coli (3) Anaerobic bacteria,Atypical pneumonia,Including Legionnaies pneumonia , Mycoplasmal pneumonia ,chlamydia pneumonia.,Fungal pneumonia,Fungal pneumonia is commonly caused by candida(念珠菌) and aspergilosis(曲菌). pneumocystis jiroveci（肺孢子虫）,Viral pneumonia,Viral pneumonia may b
5、e caused by adenoviruses, respiratory syncytial virus, influenza, cytomegalovirus, herpes simplex,Pneumonia caused by other pathogen,Rickettsias (a fever rickettsia), (立克次体） parasites(寄生虫) protozoa（原虫）,.Classification by anatomy,1. Lobar（大叶性）: Involvement of an entire lobe 2. Lobular（小叶性）: Involveme
6、nt of parts of the lobe only, segmental or of alveoli contiguous to bronchi (bronchopneumonia). 3. Interstitial（间质性）,Lobar pneumonia,Lobular pneumonia,Interstitial pneumonia,Classification by acquired environment,Community acquired pneumonia，CAP （社区获得性肺炎） Hospital acquired pneumonia，HAP ，NP （医院获得性肺炎
7、） Nursing home acquired pneumonia,NHAP (护理院获得性肺炎） Immunocompromised host pneumonia,(ICAP) (免疫宿主低下肺炎）,Diagnosis（诊断步骤）,Give a definite diagnosis of pneumonia To evaluate the degree of the pneumonia To definite the pathogen of the pneumonia,Diagnosis,History and physical examination(5W) X-ray examinati
8、on Pathogen identification,Differentiation,Pulmonary tuberculosis Lung cancer Acute lung abecess Pulmonary embolism Noninfectious pulmonary infiltration,Pathogen identification,Sputum: More than 25 white blood cells (WBCs) and less than 10 epithelial cells. Nasotracheal suctioning BAL, ETA, PSB, LA
9、Blood culture or pleural effusion culture Serologic testing (immunological testing) Molecular Techniques,The principal of therapy,Select antibiotics According to guideline,Therapy,The therapy should always follow confirmation of the diagnosis of pneumonia and should always be accompanied by a dilige
10、nt effort to identify an etiologic agent. Empiric therapy,(4-8h) Combined empiric therapy to target therapy,It is important to evaluate the severity degree of pneumonia,The critical management decision is whether the patient will require hospital admission. It is based on patient characteristics, co
11、morbid illness, physical examinations, and basic laboratory findings.,The diagnostic standard of sever pneumonia,Altered mental status Pa0230/min Blood pressure90/60mmHg Chest X-ray shows that bilateral infiltration, multilobar infiltration and the infiltrations enlarge more than 50% within 48h. Ren
12、al function: U20ml/h, and 80ml/4h,CAP (社区获得性肺炎）,CAP refers to pneumonia acquired outside of hospitals or extended-care facilities . Streptococcus pneumoniae remains the most commonly identified pathogen. Other pathogens include Haemophilus influenzae, mycoplasma pneumoniae, Chlamydophilia pneumoniae
13、, Moraxella catarrhalis and ects. Drug resistance streptococcus pneumoniae(DRSP),Clinical manifestation,The onset is accute Respiratory symptoms Extrapulmonary symptoms,signs,Consolidation signs Moist rales Respiratory rate or heart rate,Laboratory examination,WBC X-ray features,Diagnosis,Clinical d
14、iagnosis Pathogen diagnosis Evaluate the severity degree of pneumonia,Therapy,Antiinfectious therapy(Combined empiric therapy to target therapy) Supportive therapy,Empiric therapy (1),Outpatient60 years old and no comorbid diseases Common pathogens: S pneumoniaes, M pneumoniae, C pneumoniae, H influ
15、enzae and viruses,A new generation macrolide A beta-lactam: the first generation cephlosporin A fluoroquinolone,Empiric therapy (2),Outpatient65 years old or having comorbid diseases or antibiotic therapy within last 3 months Common pathogens: S pneumoniae(drug-resistant), M pneumoniae, C pneumoniae
16、, H pneumoniae, H influenzae, Viruses, Gram-negative bacilli and S aureus,A fluoroquinolone A beta-lactam / beta-lactamase inhibitor The second generation cephalosporin or combination of a macrolide,Empiric therapy (3),Inpatient : Not severely ill. Common pathogen:S pneumoniae, H influenzae, polymic
17、robial, Anaerobes, S aureus, C pneumoniae, Gram-negative bacilli.,The second or third generation cephalosporin plus A macrolide A beta-lactam/betalactamase inhibitor. A newer fluoroquinolone,Empiric therapy (4),Inpatient severely ill Common pathogens:S pneumoniae, Gram-negative bacilli, M pneumoniae
18、, S aureus and viruses,The second or third generation cephalosporin plus A macrolide A beta-lactam/betalactamase inhibitor. A newer fluoroquinolone Vancomycin,Empiric therapy (5),Patients in ICU without Pneudomonas aeruginosa infection,The second or third generation cephalosporin plus A macrolide A
19、beta-lactam/betalactamase inhibitor. A newer fluoroquinolone Vancomycin,Empiric therapy (6),Patients in ICU with Pneudomonas aeruginosa infection,A antipneudomonas aeruginosa beta-lactam/betalactamase inhibitor plus fluoroquinolone,HAP（医院获得性肺炎）,HAP refers to pneumonia acquired in the hospital settin
20、g. Enteric Gram-negative organisms, S. aureus, Pneudomonas aeruginosa, ects.,The pathogen of HAP,Gram-negative bacteria (GNB) account for 55% to 85% of HAP infections gram-positive cocci account for 20% to 30% and some other pathogens.,EPIDEMIOLOGY,General risk factors for developing HAP include age
21、 more than 70 years, serious comorbidities, malnutrition, impaired consciousness, prolonged hospitalization, and chronic obstructive pulmonary diseases.,EPIDEMIOLOGY,HAP is the most common infection occurring in patients requiring care in an intensive care unit (ICU), with incidence rates ranging fr
22、om 6% up to 52%, much higher than the 0.5% to 2% incidence reported for hospitalized patients as a whole. This increased incidence is due to the fact that patients located in an ICU often require mechanical ventilation, and mechanically ventilated patients are 6 to 21 times more likely to develop HA
23、P than are nonventilated patients. Mechanical ventilation is associated,PATHOGENESIS,Aspiration :Microaspiration of contaminated oropharyngeal secretions seems to be the most important of these factors, as it is the most common cause of HAP. Inhalation Contamination,Clinical manifestations,The onset
24、 is acute or insidious Respiratory symptoms Physical signs,Laboratory examinations,Chest X-ray,diagnosis,Clinical diagnosis Pathogen diagnosis Evaluate the severity degree of pneumonia,Treatment (1),Antibiotic therapy: antimicrobial therapy begin promptly because delays in administration of antibiot
25、ics have been associated with worse outcomes. The initial selection of an antimicrobial agent is almost always made on an empiric basis and is based on factors such as severity of infection, patient-specific risk factors, and total number of days in hospital before onset.,Treatment (2),All empiric t
26、reatment regimens should include coverage for a group of core organisms that includes aerobic gram negative bacilli (Enterobacter spp, Escherichia coli, Klebsiella spp, Proteus spp, Serratia marcescens, and Hemophilus influenzae) and gram-positive organisms such as Streptococcus pneumoniae and Staph
27、ylococcus aureus.,Treatment (3),In patients with mild or moderate infections and no specific risk factors for resistant or unusual pathogens, monotherapy with a second-generation cephalosporin such as cefuroxime; a nonpseudomonal third-generation cephalosporin such as ceftriaxone; or a beta-lactam/b
28、eta-lactamase inhibitor such as ampicillin/sulbactam, ticarcillin/clavulanate, or piperacillin/tazobactam may be appropriate. For patients in this low-risk category who have an allergy to penicillin, it is appropriate to initially use a fluoroquinolone,Treatment (4),Patients with severe infections w
29、ith specific risk factors should have broadened empiric coverage. Combination therapy should be employed in these cases because of the high rate of acquired resistance among these organisms. Appropriate combinations for this group of patients include an aminoglycoside or ciprofloxacin in addition to
30、 a beta-lactam with antipseudomonal coverage. Additionally, vancomycin should be considered if the patient has risk factors that suggest methicillin-resistant Staphylococcus aureus could be a pathogen.,Prevention,Release aspiration Washing hands vaccination,ICHP (免疫低下宿主肺炎),Pneumonia in an immunocomp
31、romised host describes a lung infection that occurs in a person whose ability to fight infection is greatly impaired. (Non-HIV-ICH),Causes, incidence, and risk factors,Immunosuppression can be caused by HIV infection, leukemia, organ transplantation, bone marrow transplant, and medications to treat
32、cancer. Microorganisms include all kinds of bacteria and virus(CMV), candida(念珠菌) and aspergilosis(曲菌). pneumocystis carinii（PCP,卡氏肺孢子虫）,Symptoms,The onset is incidous , but clinical Symptoms are severe. Fever Nonproductive (dry) cough or cough with mucus-like, greenish, or pus-like sputum PCP Funga
33、l infection,Diagnosis,Earlier finding and diagnosis Pathogen diagnosis Chest x-ray Sputum gram stain, other special stains, and culture Arterial blood gases Bronchoscopy Chest CT scan, Tissue diagnosis,Treatment,Antimicroorganism therapy The goal of treatment is to get rid of the infection with anti
34、biotics or antifungal agents. The specific drug used will depend on what kind of organism is causing the problem. One drug may kill one type of organism, but not another. Respiratory treatments (to remove fluid and mucus) and oxygen therapy are often needed.,Pneumococcal pneumonia,Abstraction, Pneum
35、ococcal pneumonia is produced by streptococcal pneumoniae It is the most commonly occurring bacterial pneumonia,Etiology, Streptococcus pneumonia are encapsulated, gram-positive cocci that occur in chains or pairs The capsule which is a complex polysaccharide has specific antigenicity Type 3 is the
36、most virulent, usually causing severe pneumonia in adults, but type 6,14,19 and 23 are virulents is children,Bacteria are introduced into the lungs by the four routes,Source Route Response Outcome colonization aspiration Air inhalation Non-pulmonary blood lung pneu. infection stream defenses Contigu
37、ous direct infection extention,pathogenesis,Pneumococci usually reach the lungs by inhalation or aspiration. They lodge in the bronchioles, proliferation and initiate an inflammatory process.,Pathology,Congestion red hepatization grey hepatization resolution),Pathology,Red hepatilization, All of the
38、 four main stages of the inflammatory reaction described above may be present at the same time In most cases, recovery is complete with restoration of normal pulmonary anatomy,Clinical manifestations,Clinical manifestations (1), Many patients have had an upper respiratory infection for several days
39、before the onset of pneumonia Onset usually is sudden, half cases with a shaking chill The temperature rises during the first few hours to 39-40,Clinical manifestations (2),Typically, patients have the symptoms of high fever , shaking chill, sharp chest pain, cough, dyspnea and blood-flecked sputum.
40、 But in some cases, especially those at age extremes symptoms may be more insidious., The pulse accelerates Sharp pain in the involved hemi thorax The cough is initially dry with pinkish or blood-flecked sputum Gastrointestinal symptoms such as, anorexia, nausea, vomiting abdominal pain, diarrhea ma
41、y be mistaken as acute abdominal inflammation,Clinical manifestations (3),Signs 1, The acutely ill patient is tachypneic, and may be observed to use accessory muscles for respiration, and even to exhibit nasal flaring Fever and tachycardia are present, frank shock is unusual, except in the later sta
42、ges of infection or DIC,Signs 2, Auscultation of the chest reveals bronchovesicular or tubular breath sounds and wet rales over the involved lung A consolidation occurs, vocal and tactile fremitus are increased,Laboratory examinations,Laboratory examinations (1), The peripheral white blood cell (WBC
43、) count Before using antibiotic, the culture of blood and of expectorated purulent sputum between 24-48 hours can be used to identify pneumococci Colony counts of bacteria from bronchoalveolar lavage washings obtained during endoscopy are seldom available early in the course of illness Use of the PC
44、R may amplify pneumococcal DNA and improve potential for detection,X-ray examination, Chest radiographs is more sensitive than physical examination PA and lateral chest radiographs are invaluable to detect pneumonia,X-ray examination, Usually lobar or segmental consolidation suggests a bacterial cau
45、se for pneumonia If blunting of the costophrenic angle is noted, pleural effusion may be exist.,The features of CT,Air-bronchogram sign,Complications,In 5% to 10% of patients, infection may extend into the pleural space and result in an empyema （脓胸） In 15% to 20% of patients, bacteria may enter the
46、blood stream (bacteremia) via the lymphatics and thoracic dust. Invasion of the blood stream by pneumococci may lead to serious metastatic disease at a number of extra pulmonary sites (meningitis, arthritis, pericarditis, endocarditis, peritonitis, ostitis media etc).,Complications,sepsis （脓毒性休克） lu
47、ng abscess（肺脓疡） or empyema pleural effusion（胸腔积液） pleuritis ARDS（急性呼吸窘迫综合征） ARF（急性呼吸衰竭） pneumothorax（气胸） Extrapulmonary infections,Diagnosis,According to history, the clinical signs , physical examinations, laboratory examinations and radiographic features it is not difficult to make the diagnosis,D
48、ifferential diagnosis, pulmonary tuberculosis Other microbial pneumonias: klebsiella pneumonia, staphylococal pneumonia, pneumonias due to G (-) bacilli, viral and mycoplasmal Acute lung abscess Bronchogenic carcinoma Pulmomary infarction,Treatments,Antibiotics Support therapy Therapy of complicatio
49、ns,Antibiotic therapy (1), All patients with suspected pneumococcal pneumonia should be treated as promptly as possible with penicillin G The dose and route of delivery may have to be on the basis of patients status adverse rea- ction or complication that occur, For patients who are believed to be allergic to penicillin, one may select the first or second generation cephalosporin or advanced macrol