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??? ???

• ???? ??
• ? ? ?

2
??? ???

• ??? ??
• ??? ??
• ?? ?????? / ????
• ????? ???

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Pneumonia

• The most widespread and fatal of all acute
  disease, pneumonia, is now Captain of the Men of
  Death. - William Osler, 1901
• ??? ?? 4.1?/10??(95? ???)
• ?? 4???/?, ??? 4-20

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?????

• ????, ??, ?? ??? ???? ??? ??? ??

6
Classification of pneumonia

• Pathogenesis Inhalation vs Aspiration vs
  Bacteremia
• Etiology Various
• Anatomy Lobar vs Interstitial
• Diffuse vs Circumscribed
• Epidemiology Community-acquired vs
  Hospital-acquired
• Immunity Immunocompetent vs Immunocompromised
• Time course Acute vs Chronic

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??? ??
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??(Expectorated sputum)

• ??? ??? ??? ?? ???? ?? ??
• ??? ???? ???? ?? ?? ??? 1-5??? ???? ???? ????
  ???? ??? ???
• ?? ?? ??? ? ??? ???? ?? ???? ??
• ???? ??
• ????, ????, ?? ? ??? ??? ??, ?? ??? ?? PAS ??,
  Giemsa ??, Penumocystis carinii? ?? Silverman
  methenamine stain ?

9
??? ??? ??

• ??? ?? ??? ??
• Group No. of cells/low-power field
• WBCs SECs
• 5 gt25 lt10
• 4 gt25 10-25
• 3 gt25 gt25
• 2 10-25 gt25
• 1 lt10 gt25

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(No Transcript)
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??? ???? ??? ??
13
Community-acquired pneumonia

• ??
• ????? ??????? ?? ???? ???? ??? ?? ??? ?? ??
• ??? ???? 7? ??? ????? ???? ??? ??
• cf. Hospital-acquired pneumonia
• ??? 48??? ??? ???? ??

14
CAP ??? ?? ??

• ??? CAP? ????
• ??? CAP? ?? ??? ?????
• ? ??? ?? ?? ?????
• ??? ?? ??
• ???? ??? ?? ???? ??
• ??

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Etiology of CAP

• Outpatient
• Admittance
• ICU

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Etiology of CAP in 149 Ambulatory Patients in
Canada

• Agents Number()
• Undetermined 72(48.3)
• Mycoplasma pneumoniae 34(22.8)
• Chlamydia pneumoniae 16(10.7)
• M. pneumoniae C. pneumoniae 5(3.4)
• Influenza A 4(2.7)
• Coxiella burneii 4(2.7)
• Adenovirus 3(2.0)
• Influenza B 3(2.0)
• Others 8(5.4)

Marrie TJ. Am J Med, 1996
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??? ??? ??- ??? -

• Etiology Patients with etiology()
• USA(n2776)1 Spain(n90)2 Argentina(n346)3
• S. pneumoniae 12.6 30 10
• M. pneumoniae 32.5 22 5
• C. pneumoniae 8.9 13 3
• H. Infulenzae 6.6 7 6
• S. aureus 3.4 0 2
• M. catarrhalis 0.76 0 2
• Legionella spp. 3.0 0 1
• Enterobacteriaceae 2.8 1 3
• Pseudomonas spp. 1.7 0 2
• Anaerobes 0 0 0
• Virus 12.7 6 7
• M. tuberculosis 1.4 4 2
• Other 1.9 11 6
• Unknown 55.7 17 48

1Marston BJ, 1997 2Ruiz-Gonzalez A, 1999
3Luna CM, 2000
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??? ??? ??- ??? -

• Etiology Patients with etiology()
• Korea(n250-562) Japan(n200) Malaysia(n127)
• S. pneumoniae 26.8 20.5 5.5
• H. Infulenzae 5.0 11.0 5.5
• M. pneumoniae 9.2 9.5 3.9
• C. pneumoniae 13.2 7.5
• S. milleri 5.5 2.0 1.6
• Anaerobes 4.0 0
• K. pneumoniae 18.1 2.5 10.2
• S. aureus 11.4 5.0 1.6
• Pseudomonas spp. 11.8 2.0 3.9
• M. catarrhalis 3.0
• Legionella spp. 2.3 1.0
• Virus 3.0
• M. tuberculosis 4
• Other 18.2 1.5 2.8
• Unknown 55.7 41.5 58.3

Adopted from Matsushima T, 2002
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??????? ????? ???
Organism Positivity / Total() M.
pneumoniae 7 / 81 (8.6) C. pneumoniae 10
/ 81 (12.3) C. psittasi 0 / 81 (0) Legionella
spp. 0 / 81 (0) C. burnetti 1 / 81 (1.2)

• Two coinfected with M. pneumoniae, one coinfected
  with C. burnetti
• (??? ?. Japan J Infect Dis, 55, 157-159, 2002)

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Etiology causing severe CAP

• S. pneumoniae
• Legionella sp.
• Aerobic G(-) bacilli
• M. pneumoniae
• Respiratory viruses
• Miscellaneous
• H. infulenzae, M. tb, endemic fugi

ATS, 1993
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Etiology of CAP in Korea

• ???? ??? ??
• ??? ??? ??? ???
• ?? Strep. pneumoniae? ?? ? ??
• Atypical agent? ??? ???? ????

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Underlying conditions related to specific
pathogens in CAP

• Alcoholsim S. Pneumoniae, anaerobe, G(-) bacilli
• COPD S. Pneumoniae, H. influenzae, M.
  catarrhalis,
• Legionella spp.
• Poor dental hygene Anaerobe
• HIV infection S. Pneumoniae, H. influenzae, M.
  tuberculosis
• Aspiration anaerobe, chemical pneumonitis
• Bronchiectasis Peudomonas Spp., S. aureus
• Drug abuse S. Aureus, anaerobe, M. tuberculosis
• Airway obstruction Anaerobe

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Hospital Admittance Criteria

• Age gt 65 yrs
• Coexistence of a chronic debilitating disease
• COPD, CHF, Chronic liver disease, CRF, DM,
  Alcoholism, Immunodeficiencies(including HIV)
• No responses to a prior antibiotic treatment
  after 3 days
• Confusion or decreased level of consciousness
• Possible aspiration
• RR gt 30/min
• Hemodynamic instability
• Sepsis or metastatic infection
• Multilobar involvement
• Significant pleural effusion
• Cavitation
• Leukopenia(lt 4,000) or severe leukocytosis(gt
  20,000)
• Anemia(Hb lt 9.0)
• Acute renal failure
• Social disarray

Huchon G, 1998
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ICU Admittance Criteria

• Severe respiratory failure
• PaO2/FiO2 lt250
• Evident diaphragmatic fatigue
• Need of mechanical ventilation
• Severe hemodynamic instability
• Shock(SBP lt90 or DBP lt60 mmHg)
• Need of vasoactive drugs for gt4h
• Urine output lt20 mL/h(in the absence of
  hypovolemia)
• Acute renal failure requiring dialysis
• Severe disseminated intravascular coagulation
• Meningitis
• Coma

Huchon G, 1998
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??? ???????? ?? ??

• Societe de Pathologic Infectieuse de Langue
  Francaise, 1991
• Spanish Thoracic Society, 1992
• Canadian Infectious Disease Society Canadian
  Thoracic Society, 1993
• American Thoracic Society, 1993
• British Thracic Society, 1993
• Italian Society of Pneumology, Italian Society of
  Respiratory Medicine and Italian Society of
  Chemotherapy, 1995
• Infectious Diseases Society of America, 1998
• European Respiratory Society, 1998

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CAP? ?? ??
ATS (2001)
IDSA (2000)
CDC (2000)
Risk factors (-) macrolide Doxycycline
Macrolide Doxycycline FQs moxifloxacin
levofloxacin gatifloxacin
Macrolide Doxycycline Cefuroxime
Amoxicillin Amox/clav
Risk factors () ?-lactam macrolide or
doxy FQs
Amox/clav 2nd cephalosporin cefuroxime
cefpodoxime cefprozil
FQs (reserved)
DRSP? Risk factors age gt65yr, ?-lactam therapy
within 3 mon, alcoholism, immune-suppressed,
multiple Medical comorbidities
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CAP? ?? ??
ATS (2001)
IDSA (2000)
CDC (2000)
Risk factors (-) Macrolide IV Doxy
?-lactam FQs
ceftriaxone Macrolide IV FQs
moxifloxacin levofloxacin, gatifloxacin
?-lactams (IV) Macrolide IV FQs (reserved)
Risk factors () IV ?-lactam Macrolide
IV or doxycyline FQs (IV)
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??? ?? ??(????)
ATS (2001)
IDSA (2000)
CDC (2000)
Pseudomonas risk (-) ?-lactams (IV)
Macrolide IV FQs (IV)
?-lactams (IV) Macrolide IV FQs
?-lactams (IV) Macrolide IV FQs (reserved)
Pseudomonas risk () AP ?-lactams (IV) IV
ciprofloxacin AP ?-lactams (IV)
aminoglycoside Macrolide IV
Pseudomonas? risk factors structural lung
diseases, steroid therapy(gt10mg pd/day),
broad-spectrum antib, malnutrition
29
???? ?
?? , ?? ??... .
??? ???. ??? .
?? ?? ??
30
???? ??

• ???? ?????
• ? ? ?

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Definition

• Pneumonia occurring ?48h after admission and
• excluding any infection that is incubating at the
  time of admission(ATS 1995)
• Def of VAP
• Pneumonia occurring ?48h of MV
• Early onset vs Late onset
• Early onset HAP lt5 d of admission
• Late onset HAP ?5 d of admission

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Incidence

• SENIC study (Study on the Efficacy of Nosocomial
  Infection Control) CDC (1975-1976)
• retrospective study of 338 U.S. hospitals
• 1.1 of all hospitalized patients
• (Haley RW, et al. Am J Med 1980 70947)
• NNIS (National Nosocomial Infection Surveillance)
  project CDC (1980-1982)
• 0.6 of all hospitalized patients
• (Haley RW, et al. Am J Epidemiol 1985 121159)

(Weinstein RA. Nosocomial infection update. Emerg
Infect Dis 1998 4416)
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Hazard rate for VAP during the stay in ICU
34
Commonly reported pathogens from patients in
adult MICU (NNIS 1992-1997)
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Pathogen of HAP in 1998(CSHH)
S. aureus 35.1 P. aerosinosa 33.8 A.
baumani 19.5 Enterococcus spp. 6.5 E.
coli 1.3 Other 2.6
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Diagnostic Approaches of HAP(IDSA, 1998)
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Antibiotic treatment(1996, ATS)

• Classification of patients with HAP
• ? Assessement of disease severity
• ? The presence of risk factors for specific
  organisms
• ? Time of onset of HAP
• early onset(within lt5d of admission) or late
  onset(?5d of admission)

Definition of severe HAP
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Algorithm for classifying patients with HAP
(ATS. AJRCCM 1531711, 1996)
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Group 1 Mild-to-moderate HAP, No unusual risk
factors, Onset any time or Severe HAP, early
onset
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Group 2 Mild-to-moderate HAP, Risk factors,
Onset any time
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Group 3 Severe HAP, Risk factors, Early onset
or Severe HAP, Late onset
42
Opportunistic Infection of the Lung

• Dept of Internal Med
• College of Med
• Kangwon National Univ
• Lee Seung-Joon

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??

• ?? ??
• ?????? ??? ???? ?? ???? ?? ??. ???? ????? ??
• ???? ??
• ??? ?? ???? ??? ?? ??? ??? ??? ?? ?? ??

44
???? ??? ?? ??
45
???? ??? ???

• ????? ???
• ????? ?? ???
• CHF, pulmonary infarction, alveolar hemorrhage,
  ARDS, pulmonary edema, leukostasis, spread of
  underlying tumor
• ??? ?? ???
• ????? ????
• ??? ??? ??

46
????? ???? ??

• ???? ??
• ??? ??? ???
• ?? ???
• ???? ???? ?? ??
• ????? ??
• ??? ???? ??

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48
?? ??

• ??
• ?? ??, ?? ??, ??, ?? ?
• ??? ??
• ????
• ????
• ??? ??
• BAL, TBLB, PCNA, OLB etc

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??? ??
50
?? ??

• Sputum Analysis
• adequacy lt10 epithelial cells, gt25 WBC (100X)
• Useful in acute bacterial, pneumocystis,
  mycobacterial
• limitation in viral, fungal
• ????
• CMV, herpes simplex, toxoplasma etc
• ???? ??

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?? ??

• ??? ???
• BAL, PSB, TBLB etc
• Pneumocystis, Tb, nocardia, fungi
• ?????(PCNA B)
• Nodular or cavitary lesion
• ?????
• Diagnostic standard

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??? ???
Chest infiltraion
Initiate empiric therapy
Normal coagulation
Abnormal coagulation
BAL TBLB
BAL
Nondiagnostic
Diagnostic
Diagnostic
Specific Tx
Specific Tx
OLB
Diagnostic
Nondiagnostic
Continue empiric Tx
Specific Tx
Consider OLB again
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Bacterial pneumonia

• ?? ??
• Pseudomonas? ??? G(-) rod
• S. aureus? ??? G() cocci
• ???? ???? ? ??? ??? ??

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Cytomegalovirus(CMV)

• ???
• ????? ?? ??
• ?????, ?? ???, AIDS
• ???? ??, ??? ?? ?? ?? ???? ?? ????? ???
• Fever, tachypnea, hypoxia, nonproductive cough,
  fatigue, night sweat
• ??? ??
• Bilateral interstitial or reticulonodular
• ??
• OLB, BAL - virus culture, inclusion body
• Serologic diagnosis
• PCR
• ??
• Gancyclovir
• CMV immunoglobulin
• foscarnet

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Pneumocystis carinii(PCP)

• Fungal kingdom
• Life cycle

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Pneumocystis carinii(PCP)

• Clinical features
• Insidious onset of fever, dry cough, dyspnea,
  hypoxia in CD4 count lt200 cells/mm3
• tachycardia, tachypnea, cyanosis, few abnormal
  lung sound
• extrapulmonary infection lt 3
• Dx
• sputum exam
• GMS stanin for cyst, WG stain for nuclei
• IF stain with monoclonal antibody
• FOB with BAL mainstay of DX
• TBLB OLB

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Pneumocystis carinii

• CXR findings
• diffuse opacity, often finely reticular to
  consolidation
• perihilar accentuation
• focal parenchymal opac in UL if aerolized
  pentamidine
• pneumatocele in apices
• pneumothorax relatively common
• pleural effusion adenopathy rare
• HRCT
• bilateral ground-glass opacity, thickened
  interlobular septa
• sparing subpleural lung
• Tx
• TMP-SMX for 3wk ( pd if PaO2 lt70mmHg)
• Pentamidine
• Steroid PaO2 lt 70mmHg
• clinical response 1wk later

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Fungal pneumonia

• Aspergillosis
• ??? ??? ??? ?? ??
• ??? ??, ??? ??, ??, ??? ??
• ?? ??? ?? ???, ???
• ?? OLB, TBLB, PCNB
• ?? amphotericin B
• Candidiasis
• Hematologic malignancy, neutropenia
• Route of infection catheter or GI mucosa
• ???? ???? ??? ?? colonizer
• ?? ?? ??, ??? ??
• ?? amphotericin B, 5-fluorocytosine

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66/male, Fever with productive cough

• ?? 2?? ????? ????? ???

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???? ??? ???

• ??(lt1?)
• ???? ??
• Bacteria(Staph, Strep, E.coli, G(-) rod)
• ??
• ??? ????, ?? ??? ??
• CMV, PCP, Aspergillosis, Legionella
• ??(gt6?)
• Nocardia, Aspergillosis, Mucormycosis

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HIV disease, Natural History
64
AIDS ??? ???

• CD4 gt 500/mm3
• CD4 200-500/mm3
• CD4 lt 200/mm3
• CD4 lt 50/mm3

Kaposis sarcoma
Tb, oral candidiasis
PCP, Cryptococcosis
CMV, NTM, Toxo
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??? ??Upper Respiratory Tract Infection

• ????? ????
• ??? ??
• ? ? ?

66
??? ?? ???

• Common cold
• Pharyngotonsilitis
• Croup
• Epiglottitis
• Tracheobronchitis
• Influenza

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?????? ??

• ?? ????? ??? ???
• ??? ???? ??? ????? ??
• ????? ???? ? ? ??
• ?? ?? ???
• ??? ?? ?? ?? ??
• ??? ?? ???? ??? ???
• ?? peritonsillar abscess, epiglottitis,
  Ludwigs angina, invasive fungal sinusitis,
  invasive otitis externa

68
Common cold(Coryza)

• Mild, self-limited URI
• Incidence 2-4 /adult/year
• ???
• rhinorrhea sneezing
• sore throat, nonproductive cough
• ??? ??, ????? ??
• ?? 5-7?? ??
• ???? ?????? ??
• ??
• rhinovirus 30-50, coronavirus, respiratory
  syncytial virus, parainfluenza virus etc
• ????
• aerosol, secretion(hand to hand)

69
Common cold

• ??
• ??, ??, ??? ??
• ? ???? ?? ???? ??
• ?? ??????? ??
• ?? ??? ???? ??? ??
• ???
• otitis media, acute sinusitis, pneumonia
• ??
• symptomatic analgesics, nasal decongestant,
  antihistamine,
• antibiotics ???(?? ???? ????? ??? ??)
• ??
• ???

70
Pharyngitis, Pharyngotonsilitis

• ???
• virus adenovirus, coronavirus, rhinovirus,
  enterovirus, RSV, herpesvirus
• bacteria group A streptococcus, mycoplasma
• exudative pharyngitis
• Group A beta-hemolytic streptococcus(20-40),
  Neisseria gonorrhea, Corynebacterium diphteriae,
  Mycoplasma, Chlamydia, EBV, etc
• nonexudative pharyngitis
• RSV, parainfluenza, influenza etc

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Pharyngitis, Pharyngotonsilitis

• ???
• sore throat, pharyngeal injection, hypertrophy of
  tonsil
• ??
• throat swab Group A beta-hemolytic
  streptococcus? ??
• ??
• ????
• Group A beta-hemolytic streptococcus? ?? ??
  rheumatic fever? ?? (PCN G)

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Pharyngitis, Pharyngotonsilitis? ??

• Rest
• Adequate fluid
• Antipyretic
• Gargling with warm salt water
• Local anesthetics
• Antibiotics bacterial

• Indication of antiB
• ¾ ()
• Fever, tonsillar exudate, tender anterior
  cervical lymphadenitis, absence of cough

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Influenza

• ??
• Influenza virus? ?? ?? ?????
• ?/??? ??? ??? ??? ? ??
• Influenza virus
• Influenza A, B, C
• Influenza A? subtyping(B, C? ?? ??)
• Influenza A/Johannesburg/33/94(H3N2)
• Surface hemagglutinin(H), neuraminidase(N)
• Epidemiology(Influenza A)
• Antigenic shift major antigenic variation(????
  ??)
• Antigenic drift minor variation
• ???? 10-15? ???, ???? 1-3? ???

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Emergence of antigenic subtypes of Influenza A
virus with pandemic or epidemic disease in USA

• Year Subtype Extent of Outbreak
• 1889-90 H2N8 Severe pandemic
• 1900-03 H3N8 ?Moderate epidemic
• 1918-19 H1N1 Severe pandemic
• 1933-35 H1N1 Mild epidemic
• 1946-47 H1N1 Mild epidemic
• 1957-58 H2N2 Severe pandemic
• 1968-69 H3N2 Moderate pandemic
• 1977-78 H1N1 Mild pandemic

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???

• ??? 1-3?
• ?? ????? ??? ?? ??, ??, ??(38-41C), ???, ???
• ????? ????? ??? ??? ?? ?? ??, ??? ?
• ????? ?? ??, ?? ??? ? ??? ??? ??? ??
• ????, ???, ??? ??? ?? ???? ??? ??
• ?? ????? ???.

76
???

• ??
• primary viral pneumonia least common, most
  severe
• secondary bacterial pneumonia S. pneumoniae, S.
  aureus, H. influenza etc
• mixed pneumonia most common
• Reyes syndrome
• Myositis, rhabdomyolysis, myoglobulinuria
• Myocarditis, pericarditis

77
??

• ??? ??? ??
• antipyretics relief of headache, myalgia,
  fever
• acetaminophen in
  children below 18 years of age
• antitussive rarely indicated
• rest hydration
• antiviral agent
• amantadine, rimantadine
• ?? ??? 48??? ???? ?? ? ??? ??? ??? 50???? ???
• antibiotics only secondary bacterial infection
  combined
• ??
• vaccine
• ??? chronic cardiovascular or pulmonary
  disorder
• over 65 years of age
• DM, CRF, other
  immunosuppressed state