2011-10-17 Dr.HU Bijie 1
Respiratory Diseases
Pneumonia
Dr,Bijie HU（胡必杰）
Zhongshan Hospital of Fudan University
Shanghai
2011-10-17 Dr.HU Bijie 2
2011-10-17 Dr.HU Bijie 3
Semin Respir Infect 9(3):140-52,1994
mortality (per10 000)
Mortality Trends with Pneumonia from 1900 to 1990 in USA
0
20
40
60
80
100
120
140
160
180
200
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
2011-10-17 Dr.HU Bijie 4
2011-10-17 Dr.HU Bijie 5
1990 2020
Cardiovascular disease
Cerebrovascular diseases
Lower respiratory infections
Diarrhea
Perinatal disease
COPD
Tuberculosis
Morbilli
Traffic accidents
Lung cancer
Gastric cancer
HIV
suicide
Editorial,Lancet,1997,349,1263,
Mortality Forecast by WHO
2011-10-17 Dr.HU Bijie 6
Epidemiology
? 6th leading cause of death in U.S,
? Number one Among the infectious
diseases
? 5.6 million patients annually in US
? Incidence 5~10/1,000/year
? Mortality in OPD patients 1-5 %,but
Inpatients 25%,ICU 50-60%
2011-10-17 Dr.HU Bijie 7
Definition
? Pneumonia is the
inflammation of lower
respiratory tracts including
alveoli,interstitial tissues,
and broncioles by the
microorganisms,chemical
irritations or by an
immunological process
2011-10-17 Dr.HU Bijie 8
Classifications & Terminology
? Mild,moderate,severe
? Lobar vs interstitial
? Infections vs,noninfections
? Bacterial,viral,fungal,parasitic
? Primary vs,Secondary
? Community Acquired Pneumonia
Nosocomial Pneumonia
Ventilator Associated Pneumionia
? Typical vs,Atypical
? Immune compromised vs,Normal immunity
2011-10-17 Dr.HU Bijie 9
Key Bacterial Pathogens of CAP,
A Global Meta-Analysis
Fine MJ et al,JAMA 1996; 275(2):134-41,
? Study cohorts,N = 127
? Total patients,N =
33,148
? Total patients reporting
data,N = 6866
S,pneumoniae
66%
Other
12%
Legionella spp,
4%
M,pneumoniae
7%
H,influenzae
12%
2011-10-17 Dr.HU Bijie 10
Causative pathogens in 5,961 adults admitted to hospital with CAP
identified in 26 prospective studies from 10 European countries
0 5 10 15 20 25 30
S pneumoniae
C pneumoniae
Viral
Mycoplasma pneumoniae
Legionella sp
H influenzae
G-neg enterobacteria
C psittacii
Coxiella burnetii
Staph aureus
M catarrhalis
Other
Woodhead M,Chest 1998;183S-187S
2011-10-17 Dr.HU Bijie 11
Pathogens of Hospital Acquired Pneumonia (HAP)
? Mild to moderate HAP or early severe HAP
– Streptococcus pneumoniae
– Haemophilus influenza
– MSSA
– Klebsiella Pneumoniae
– Enterobacter,E coli,Proteus,Serratia
? Severe HAP
– Pseudomonas
– Acinetobacter
– MRSA
2011-10-17 Dr.HU Bijie 12
Pneumococcal Pneumonia
2011-10-17 Dr.HU Bijie 13
Etiology,S,pneumonia
? Gram-postive coccus
? most common identifiable cause of bacterial pneumonia
and accounts for 2/3 of bacteremic CAP
? Pneumococcal pneumonia generally occurs
sporadically but most frequently in winter
? It occurs most commonly in persons at age extremes,
? 5 to 25% of healthy persons are carriers of
pneumococci,with the highest rates noted in winter for
children and parents of young children,
? There are > 80 serotypes (based on antigenically
distinct capsular polysaccharides),
2011-10-17 Dr.HU Bijie 14
Pathogenesis
? Host defenses impaired
? Inoculum sufficient to cause infection enters
lower respiratory tract
? Virulent organism
2011-10-17 Dr.HU Bijie 15
Pathogenesis
? Pneumococci usually reach the lungs by inhalation
or aspiration,(Routes of entry for nosocomial pneumonia,
Microaspiration,Inhalation,Hematogenous spread,Direct extension,
Via ET tube)
? They lodge in bronchioles,proliferate,and initiate
an inflammatory process that begins in alveolar
spaces with an outpouring of protein-rich fluid,
? The fluid acts as culture medium for the bacteria
and helps spread them to neighboring alveoli,
typically resulting in lobar pneumonia,
2011-10-17 Dr.HU Bijie 16
Pathology
? Congestion,earliest stage of lobar pneumonia,
extensive serous exudation,vascular engorgement,and
rapid bacterial proliferation,
? Red hepatization,consolidated lung,Airspaces are
filled with polymorphonuclear cells,vascular congestion
occurs,and extravasation of RBCs causes a reddish
discoloration on gross examination,
? Gray hepatization,accumulation of fibrin,associated
with inflammatory WBCs and RBCs in various stages of
disintegration,and alveolar spaces are packed with an
inflammatory exudate,
? Resolution,characterized by resorption of the exudate
2011-10-17 Dr.HU Bijie 17
Manifestation
? Systematic
– often preceded by a URI
– sudden onset,shaking chill,Fever
– other,nausea,vomiting,malaise,and myalgias
? Local
– pain with breathing on the affected side (pleurisy)
– Cough,(dry initially but usually becomes productive,
dyspnea,and sputum production）
? Sign
– T,38° ~ 40.5° ; pulse is usually 100 to 140 beats/min;
respirations accelerate to 20 to 45 breaths/min,
– lobar consolidation； crackles ;pleural effusion
2011-10-17 Dr.HU Bijie 18
Severe Pneumonia
? Respiratory rate > 30/min
? PaO2/FiO2 ratio < 250mmHg
? Need for Mechanical Ventilation
? Diffuse bilateral involvement or multiple lobes,
incresing infiltration > 50% within 48 hours
? B.P,< 90systolic or 60 mmHg diastolic
? Need for vasopressors
? Renal failure
2011-10-17 Dr.HU Bijie 19
Complications,Serious and potentially lethal
? progressive pneumonia
? ARDS
? septic shock
? Special infections,empyema or purulent pericarditis
? Pleural effusions are found in about 25% of patients by
chest x-ray,but < 1% have empyema
? Bacteremia,including septic arthritis,endocarditis,
meningitis,and peritonitis (in patients with ascites),
? superinfections,temporary improvement during
treatment followed by deterioration,with recurrence of
fever and worsening pulmonary infiltrates
2011-10-17 Dr.HU Bijie 20
Lab and X-ray
Examinations
? General Lab
– Blood tests,leukocytosis with a shift to the left
– hypoxemia ＋ respiratory alkalosis
? Microbiologic Test
– Gram stain of sputum typically shows gram-positive
lancet-shaped diplococci in short chains
– Positive blood cultures
? CXR
– pulmonary infiltrate（ bronchopneumonia are most
common； dense consolidation confined to a single lobe with
typical air bronchograms is most specific for S,pneumoniae）
2011-10-17 Dr.HU Bijie 21
Lobar pneumonia
2011-10-17 Dr.HU Bijie 22
Diffuse interstitial pneumonia
2011-10-17 Dr.HU Bijie 23
Diagnosis
? Suspected
– acute febrile illness with chest pain,dyspnea,
and cough
? Presumptive
– history,changes on CXR,culture and Gram
stains of sputum
? Definitive
– demonstration of S,pneumoniae in pleural fluid,
blood,lung tissue,or transtracheal aspirate (At
least half of sputum cultures are falsely negative)
2011-10-17 Dr.HU Bijie 24
Prognosis
? poor prognosis factors
– age extremes,especially < 1 yr or > 60 yr;
– positive blood cultures;
– involvement of > 1 lobe;
– a peripheral WBC count < 5000/μL;
– associated disorders
? Cirrhosis
? heart failure
? ICH
? Agammaglobulinemia
? anatomic or functional asplenia
? uremia
– certain serotypes (especially 3 and 8);
– extrapulmonary complications,meningitis or endocarditis
2011-10-17 Dr.HU Bijie 25
? Mildly ill,defervesce during the first 24 to 48 h;
? Seriously ill,>= 4 days to become afebrile (Therapy
should not be modified if there is gradual clinical
improvement and the etiology is confirmed)
? Factors associated with not improvement
– wrong etiologic diagnosis
– adverse drug reaction
– far-advanced disease (most common)
– superinfection
– inadequate host defenses due to associated conditions
– noncompliance with the drug regimen by outpatients
– antibiotic resistance of the involved strain of S,pneumoniae
– Complications
? empyema requiring drainage
? metastatic foci of infection requiring a higher dosage of penicillin (eg,meningitis,endocarditis,or septic arthritis)
2011-10-17 Dr.HU Bijie 26
Prophylaxis
? Vaccine
– containing the 23 specific polysaccharide
antigens of the pneumococcus types
(account for 85 to 90%)
– recommended for children > 2 yr and
adults at increased risk for pneumococcal
disease or its complications; older adults
– duration of protection,5 yr (revaccinated in
< 5 yrs tend to have a more intense local reaction)
2011-10-17 Dr.HU Bijie 27
Associated Mortality
by Age and Treatment
Age Mortality
18-64 yr 10% - 15%
65-74 yr 20%
75-84 yr 30%
> 85 yr 40%
Untreated 50% - 90%
2011-10-17 Dr.HU Bijie 28
Treatment
? penicillin G 500,000 to 2 million U IV q 4 to 6 h
? cephalosporins,erythromycin,clindamycin
? Alternative drugs (25% of strains resistant to penicillin,
Many penicillin-resistant strains are also resistant to other
antibiotics)
– high doses of penicillin (not highly resistance),cefotaxime,
or ceftriaxone,
– The newer quinolones (levofloxacin,moxifloxacin,
gatifloxacin)
– Vancomycin,preferred for severely ill in areas with high
rates of resistance
– meningitis suspected,cefotaxime 2 g IV q 4 to 6 h,or
ceftriaxone 1 to 2 g IV q 12 h,plus vancomycin 1 g IV q 12
h with or without rifampin 600 mg/day po
2011-10-17 Dr.HU Bijie 29
Penicillin-Nonsensitive Streptococcus Pneumoniae in USA
0%
10%
20%
30%
40%
50%
60%
1979 1981 1983 1985 1987 1990 1995 1998 2000
2011-10-17 Dr.HU Bijie 30
2011-10-17 Dr.HU Bijie 31
? Supportive measures
– bed rest
– Fluids
– analgesics for pleuritic pain
– O2,significant hypoxemia,severe dyspnea,circulatory
disturbances,or delirium（ In those with chronic lung
disease,O2 must be given cautiously with frequent
monitoring of blood gases）
? Follow-up x-rays
– advised for pts > 35 yr,resolution of the infiltrate may
take several weeks,Persistent infiltration >= 6 wk after
therapy suggests the possibility of an underlying
bronchogenic neoplasm or TB
2011-10-17 Dr.HU Bijie 32
Risk-Class Mortality Rates for
Patients with Pneumonia
Risk No,of Mortality Recommendations
class No,of points patients (%) for site of care
I No predictors 3,304 0.1 Outpatient
II < 70 5,778 0.6 Outpatient
III 71- 90 6,790 2.8 Inpatient (briefly)
IV 91 - 130 13,104 8.2 Inpatient
V > 130 9,333 29.2 Inpatient
Fine MJ,et al,NEJM 1997;336(4)243-250
2011-10-17 Dr.HU Bijie 33
Main points of Staphylococcal Pneumonia
? Pathogens,
? Risk Factors,ICH,hospitalized,skin infections
? Symptoms,suddenly onset,severe toxic,purulent sputum
? Lab Exam,leukocytosis with a shift to the left
? CXR,
? Microbiologic Exam,
? Antibiotic Therapy,
– CAP,Penicillin？
– HAP and CAP,Oxicillin,1st cepholasporins,
Augmentin,ampicillin/sulbactam
– MRSA,Vancomycin,RFP,SMZ Co,Fluroquinolone,amikacin
2011-10-17 Dr.HU Bijie 34
Main points of Klebsiella Pneumonia
? Pathogens,
? Risk Factors,elderly,mulnutrition,CB,hospitalized
? Symptoms,suddenly onset,severe condition,sputum
? Lab Exam,leukocytosis with a shift to the left
? CXR,
? Microbiologic Exam,
? Antibiotic Therapy,
– Cephalosporin (2nd or nonpsuedomonal 3rd generation)
– Or plus aminoglycoside
– Beta lactam/lactamase inhibitor
– Fluroquinolone
– Or carbepenem alone
2011-10-17 Dr.HU Bijie 35
Pathogens of Atypical Pneumonia
? Legionella spp
? Mycoplasma pneumoniae
? Chlamydia pneumoniae
? Chlamydia psittaci 鹦鹉热衣原体
? Coxiella burnetii 伯氏考克斯体（ Q热立克次体）
? Francisella tularensis土拉杆菌（兔热病菌）
? PCP Pneumocystis carinii pneumonia 卡氏肺孢子虫
? Influenza A/B 流感病毒 A/B
? RSV respiratory syncytial virus 呼吸道合胞病毒
? CMV cytomegalovirus 巨细胞病毒
? Adenovirus 腺病毒
? SARS Coronavirus SARS冠状病毒
File TM Jr,et al,Infect Dis Clin North Am,1998;12:572,
Levison ME,Harrison’s Principles of Internal Medicine,McGraw-Hill; 1998:1439,
Bartlett JG,et al,Clin Infect Dis,1998;26:821,Table 9,
2011-10-17 Dr.HU Bijie 36
Main points of Mycoplasma Pneumonia
? Pathogens,
? Risk Factors,
? Symptoms,
? Lab Exam,
? CXR,
? Microbiologic Exam,
? Antibiotic Therapy,
– Macrolide
– Fluroquinolone
– Doxycycline
2011-10-17 Dr.HU Bijie 37
Main points of Legionella Pneumonia
? Pathogens,
? Risk Factors,
? Symptoms,
? Lab Exam,
? CXR,
? Microbiologic Exam,
? Antibiotic Therapy,
– Macrolide
– Fluroquinolone
– Doxycycline
2011-10-17 Dr.HU Bijie 38
Rx for AP,In Vitro Activity MIC Ranges (?g/mL)
File TM Jr,et al,Infect Dis Clin North Am,1998;12:585,Table 7,
M,pneumoniae C,pneumoniae L,pneumophila
Azithromycin <0.001-0.004 0.06-0.25 0.25
Clarithromycin <0.004-0.125 0.004-0.03 0.06
Erythromycin <0.002-0.004 0.06-0.25 0.25
Doxycycline 0.25 0.06-0.25 0.8
Tetracycline 0.25 0.06-0.125 —
Ciprofloxacin 2.0 1.0 0.12-0.5
Ofloxacin 2.0 1.0 0.06-0.25
Levofloxacin 0.5 0.5 0.125
Grepafloxacin 0.25 0.5 0.016
Sparfloxacin 0.06 0.25 0.06
2011-10-17 Dr.HU Bijie 39
Other infectious pneumonia
? Psuedomonas aeroginosa 绿脓杆菌
? Acinetobacter 不动杆菌
? Haemophilus influenza 流感杆菌
? Anaerobic bacteria 厌氧菌
? Chlamydia Pneumoniae 肺炎衣原体
? Virus 病毒
2011-10-17 Dr.HU Bijie 40
Symptoms,Signs,CXR,
Antibiotic Selection for
Several Types of Pneumonias
2011-10-17 Dr.HU Bijie 41
谢谢大家
Thank you
Respiratory Diseases
Pneumonia
Dr,Bijie HU（胡必杰）
Zhongshan Hospital of Fudan University
Shanghai
2011-10-17 Dr.HU Bijie 2
2011-10-17 Dr.HU Bijie 3
Semin Respir Infect 9(3):140-52,1994
mortality (per10 000)
Mortality Trends with Pneumonia from 1900 to 1990 in USA
0
20
40
60
80
100
120
140
160
180
200
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
2011-10-17 Dr.HU Bijie 4
2011-10-17 Dr.HU Bijie 5
1990 2020
Cardiovascular disease
Cerebrovascular diseases
Lower respiratory infections
Diarrhea
Perinatal disease
COPD
Tuberculosis
Morbilli
Traffic accidents
Lung cancer
Gastric cancer
HIV
suicide
Editorial,Lancet,1997,349,1263,
Mortality Forecast by WHO
2011-10-17 Dr.HU Bijie 6
Epidemiology
? 6th leading cause of death in U.S,
? Number one Among the infectious
diseases
? 5.6 million patients annually in US
? Incidence 5~10/1,000/year
? Mortality in OPD patients 1-5 %,but
Inpatients 25%,ICU 50-60%
2011-10-17 Dr.HU Bijie 7
Definition
? Pneumonia is the
inflammation of lower
respiratory tracts including
alveoli,interstitial tissues,
and broncioles by the
microorganisms,chemical
irritations or by an
immunological process
2011-10-17 Dr.HU Bijie 8
Classifications & Terminology
? Mild,moderate,severe
? Lobar vs interstitial
? Infections vs,noninfections
? Bacterial,viral,fungal,parasitic
? Primary vs,Secondary
? Community Acquired Pneumonia
Nosocomial Pneumonia
Ventilator Associated Pneumionia
? Typical vs,Atypical
? Immune compromised vs,Normal immunity
2011-10-17 Dr.HU Bijie 9
Key Bacterial Pathogens of CAP,
A Global Meta-Analysis
Fine MJ et al,JAMA 1996; 275(2):134-41,
? Study cohorts,N = 127
? Total patients,N =
33,148
? Total patients reporting
data,N = 6866
S,pneumoniae
66%
Other
12%
Legionella spp,
4%
M,pneumoniae
7%
H,influenzae
12%
2011-10-17 Dr.HU Bijie 10
Causative pathogens in 5,961 adults admitted to hospital with CAP
identified in 26 prospective studies from 10 European countries
0 5 10 15 20 25 30
S pneumoniae
C pneumoniae
Viral
Mycoplasma pneumoniae
Legionella sp
H influenzae
G-neg enterobacteria
C psittacii
Coxiella burnetii
Staph aureus
M catarrhalis
Other
Woodhead M,Chest 1998;183S-187S
2011-10-17 Dr.HU Bijie 11
Pathogens of Hospital Acquired Pneumonia (HAP)
? Mild to moderate HAP or early severe HAP
– Streptococcus pneumoniae
– Haemophilus influenza
– MSSA
– Klebsiella Pneumoniae
– Enterobacter,E coli,Proteus,Serratia
? Severe HAP
– Pseudomonas
– Acinetobacter
– MRSA
2011-10-17 Dr.HU Bijie 12
Pneumococcal Pneumonia
2011-10-17 Dr.HU Bijie 13
Etiology,S,pneumonia
? Gram-postive coccus
? most common identifiable cause of bacterial pneumonia
and accounts for 2/3 of bacteremic CAP
? Pneumococcal pneumonia generally occurs
sporadically but most frequently in winter
? It occurs most commonly in persons at age extremes,
? 5 to 25% of healthy persons are carriers of
pneumococci,with the highest rates noted in winter for
children and parents of young children,
? There are > 80 serotypes (based on antigenically
distinct capsular polysaccharides),
2011-10-17 Dr.HU Bijie 14
Pathogenesis
? Host defenses impaired
? Inoculum sufficient to cause infection enters
lower respiratory tract
? Virulent organism
2011-10-17 Dr.HU Bijie 15
Pathogenesis
? Pneumococci usually reach the lungs by inhalation
or aspiration,(Routes of entry for nosocomial pneumonia,
Microaspiration,Inhalation,Hematogenous spread,Direct extension,
Via ET tube)
? They lodge in bronchioles,proliferate,and initiate
an inflammatory process that begins in alveolar
spaces with an outpouring of protein-rich fluid,
? The fluid acts as culture medium for the bacteria
and helps spread them to neighboring alveoli,
typically resulting in lobar pneumonia,
2011-10-17 Dr.HU Bijie 16
Pathology
? Congestion,earliest stage of lobar pneumonia,
extensive serous exudation,vascular engorgement,and
rapid bacterial proliferation,
? Red hepatization,consolidated lung,Airspaces are
filled with polymorphonuclear cells,vascular congestion
occurs,and extravasation of RBCs causes a reddish
discoloration on gross examination,
? Gray hepatization,accumulation of fibrin,associated
with inflammatory WBCs and RBCs in various stages of
disintegration,and alveolar spaces are packed with an
inflammatory exudate,
? Resolution,characterized by resorption of the exudate
2011-10-17 Dr.HU Bijie 17
Manifestation
? Systematic
– often preceded by a URI
– sudden onset,shaking chill,Fever
– other,nausea,vomiting,malaise,and myalgias
? Local
– pain with breathing on the affected side (pleurisy)
– Cough,(dry initially but usually becomes productive,
dyspnea,and sputum production）
? Sign
– T,38° ~ 40.5° ; pulse is usually 100 to 140 beats/min;
respirations accelerate to 20 to 45 breaths/min,
– lobar consolidation； crackles ;pleural effusion
2011-10-17 Dr.HU Bijie 18
Severe Pneumonia
? Respiratory rate > 30/min
? PaO2/FiO2 ratio < 250mmHg
? Need for Mechanical Ventilation
? Diffuse bilateral involvement or multiple lobes,
incresing infiltration > 50% within 48 hours
? B.P,< 90systolic or 60 mmHg diastolic
? Need for vasopressors
? Renal failure
2011-10-17 Dr.HU Bijie 19
Complications,Serious and potentially lethal
? progressive pneumonia
? ARDS
? septic shock
? Special infections,empyema or purulent pericarditis
? Pleural effusions are found in about 25% of patients by
chest x-ray,but < 1% have empyema
? Bacteremia,including septic arthritis,endocarditis,
meningitis,and peritonitis (in patients with ascites),
? superinfections,temporary improvement during
treatment followed by deterioration,with recurrence of
fever and worsening pulmonary infiltrates
2011-10-17 Dr.HU Bijie 20
Lab and X-ray
Examinations
? General Lab
– Blood tests,leukocytosis with a shift to the left
– hypoxemia ＋ respiratory alkalosis
? Microbiologic Test
– Gram stain of sputum typically shows gram-positive
lancet-shaped diplococci in short chains
– Positive blood cultures
? CXR
– pulmonary infiltrate（ bronchopneumonia are most
common； dense consolidation confined to a single lobe with
typical air bronchograms is most specific for S,pneumoniae）
2011-10-17 Dr.HU Bijie 21
Lobar pneumonia
2011-10-17 Dr.HU Bijie 22
Diffuse interstitial pneumonia
2011-10-17 Dr.HU Bijie 23
Diagnosis
? Suspected
– acute febrile illness with chest pain,dyspnea,
and cough
? Presumptive
– history,changes on CXR,culture and Gram
stains of sputum
? Definitive
– demonstration of S,pneumoniae in pleural fluid,
blood,lung tissue,or transtracheal aspirate (At
least half of sputum cultures are falsely negative)
2011-10-17 Dr.HU Bijie 24
Prognosis
? poor prognosis factors
– age extremes,especially < 1 yr or > 60 yr;
– positive blood cultures;
– involvement of > 1 lobe;
– a peripheral WBC count < 5000/μL;
– associated disorders
? Cirrhosis
? heart failure
? ICH
? Agammaglobulinemia
? anatomic or functional asplenia
? uremia
– certain serotypes (especially 3 and 8);
– extrapulmonary complications,meningitis or endocarditis
2011-10-17 Dr.HU Bijie 25
? Mildly ill,defervesce during the first 24 to 48 h;
? Seriously ill,>= 4 days to become afebrile (Therapy
should not be modified if there is gradual clinical
improvement and the etiology is confirmed)
? Factors associated with not improvement
– wrong etiologic diagnosis
– adverse drug reaction
– far-advanced disease (most common)
– superinfection
– inadequate host defenses due to associated conditions
– noncompliance with the drug regimen by outpatients
– antibiotic resistance of the involved strain of S,pneumoniae
– Complications
? empyema requiring drainage
? metastatic foci of infection requiring a higher dosage of penicillin (eg,meningitis,endocarditis,or septic arthritis)
2011-10-17 Dr.HU Bijie 26
Prophylaxis
? Vaccine
– containing the 23 specific polysaccharide
antigens of the pneumococcus types
(account for 85 to 90%)
– recommended for children > 2 yr and
adults at increased risk for pneumococcal
disease or its complications; older adults
– duration of protection,5 yr (revaccinated in
< 5 yrs tend to have a more intense local reaction)
2011-10-17 Dr.HU Bijie 27
Associated Mortality
by Age and Treatment
Age Mortality
18-64 yr 10% - 15%
65-74 yr 20%
75-84 yr 30%
> 85 yr 40%
Untreated 50% - 90%
2011-10-17 Dr.HU Bijie 28
Treatment
? penicillin G 500,000 to 2 million U IV q 4 to 6 h
? cephalosporins,erythromycin,clindamycin
? Alternative drugs (25% of strains resistant to penicillin,
Many penicillin-resistant strains are also resistant to other
antibiotics)
– high doses of penicillin (not highly resistance),cefotaxime,
or ceftriaxone,
– The newer quinolones (levofloxacin,moxifloxacin,
gatifloxacin)
– Vancomycin,preferred for severely ill in areas with high
rates of resistance
– meningitis suspected,cefotaxime 2 g IV q 4 to 6 h,or
ceftriaxone 1 to 2 g IV q 12 h,plus vancomycin 1 g IV q 12
h with or without rifampin 600 mg/day po
2011-10-17 Dr.HU Bijie 29
Penicillin-Nonsensitive Streptococcus Pneumoniae in USA
0%
10%
20%
30%
40%
50%
60%
1979 1981 1983 1985 1987 1990 1995 1998 2000
2011-10-17 Dr.HU Bijie 30
2011-10-17 Dr.HU Bijie 31
? Supportive measures
– bed rest
– Fluids
– analgesics for pleuritic pain
– O2,significant hypoxemia,severe dyspnea,circulatory
disturbances,or delirium（ In those with chronic lung
disease,O2 must be given cautiously with frequent
monitoring of blood gases）
? Follow-up x-rays
– advised for pts > 35 yr,resolution of the infiltrate may
take several weeks,Persistent infiltration >= 6 wk after
therapy suggests the possibility of an underlying
bronchogenic neoplasm or TB
2011-10-17 Dr.HU Bijie 32
Risk-Class Mortality Rates for
Patients with Pneumonia
Risk No,of Mortality Recommendations
class No,of points patients (%) for site of care
I No predictors 3,304 0.1 Outpatient
II < 70 5,778 0.6 Outpatient
III 71- 90 6,790 2.8 Inpatient (briefly)
IV 91 - 130 13,104 8.2 Inpatient
V > 130 9,333 29.2 Inpatient
Fine MJ,et al,NEJM 1997;336(4)243-250
2011-10-17 Dr.HU Bijie 33
Main points of Staphylococcal Pneumonia
? Pathogens,
? Risk Factors,ICH,hospitalized,skin infections
? Symptoms,suddenly onset,severe toxic,purulent sputum
? Lab Exam,leukocytosis with a shift to the left
? CXR,
? Microbiologic Exam,
? Antibiotic Therapy,
– CAP,Penicillin？
– HAP and CAP,Oxicillin,1st cepholasporins,
Augmentin,ampicillin/sulbactam
– MRSA,Vancomycin,RFP,SMZ Co,Fluroquinolone,amikacin
2011-10-17 Dr.HU Bijie 34
Main points of Klebsiella Pneumonia
? Pathogens,
? Risk Factors,elderly,mulnutrition,CB,hospitalized
? Symptoms,suddenly onset,severe condition,sputum
? Lab Exam,leukocytosis with a shift to the left
? CXR,
? Microbiologic Exam,
? Antibiotic Therapy,
– Cephalosporin (2nd or nonpsuedomonal 3rd generation)
– Or plus aminoglycoside
– Beta lactam/lactamase inhibitor
– Fluroquinolone
– Or carbepenem alone
2011-10-17 Dr.HU Bijie 35
Pathogens of Atypical Pneumonia
? Legionella spp
? Mycoplasma pneumoniae
? Chlamydia pneumoniae
? Chlamydia psittaci 鹦鹉热衣原体
? Coxiella burnetii 伯氏考克斯体（ Q热立克次体）
? Francisella tularensis土拉杆菌（兔热病菌）
? PCP Pneumocystis carinii pneumonia 卡氏肺孢子虫
? Influenza A/B 流感病毒 A/B
? RSV respiratory syncytial virus 呼吸道合胞病毒
? CMV cytomegalovirus 巨细胞病毒
? Adenovirus 腺病毒
? SARS Coronavirus SARS冠状病毒
File TM Jr,et al,Infect Dis Clin North Am,1998;12:572,
Levison ME,Harrison’s Principles of Internal Medicine,McGraw-Hill; 1998:1439,
Bartlett JG,et al,Clin Infect Dis,1998;26:821,Table 9,
2011-10-17 Dr.HU Bijie 36
Main points of Mycoplasma Pneumonia
? Pathogens,
? Risk Factors,
? Symptoms,
? Lab Exam,
? CXR,
? Microbiologic Exam,
? Antibiotic Therapy,
– Macrolide
– Fluroquinolone
– Doxycycline
2011-10-17 Dr.HU Bijie 37
Main points of Legionella Pneumonia
? Pathogens,
? Risk Factors,
? Symptoms,
? Lab Exam,
? CXR,
? Microbiologic Exam,
? Antibiotic Therapy,
– Macrolide
– Fluroquinolone
– Doxycycline
2011-10-17 Dr.HU Bijie 38
Rx for AP,In Vitro Activity MIC Ranges (?g/mL)
File TM Jr,et al,Infect Dis Clin North Am,1998;12:585,Table 7,
M,pneumoniae C,pneumoniae L,pneumophila
Azithromycin <0.001-0.004 0.06-0.25 0.25
Clarithromycin <0.004-0.125 0.004-0.03 0.06
Erythromycin <0.002-0.004 0.06-0.25 0.25
Doxycycline 0.25 0.06-0.25 0.8
Tetracycline 0.25 0.06-0.125 —
Ciprofloxacin 2.0 1.0 0.12-0.5
Ofloxacin 2.0 1.0 0.06-0.25
Levofloxacin 0.5 0.5 0.125
Grepafloxacin 0.25 0.5 0.016
Sparfloxacin 0.06 0.25 0.06
2011-10-17 Dr.HU Bijie 39
Other infectious pneumonia
? Psuedomonas aeroginosa 绿脓杆菌
? Acinetobacter 不动杆菌
? Haemophilus influenza 流感杆菌
? Anaerobic bacteria 厌氧菌
? Chlamydia Pneumoniae 肺炎衣原体
? Virus 病毒
2011-10-17 Dr.HU Bijie 40
Symptoms,Signs,CXR,
Antibiotic Selection for
Several Types of Pneumonias
2011-10-17 Dr.HU Bijie 41
谢谢大家
Thank you
