Air born and droplet

Infections- Pneumonia
& Tuberculosis (TB)

Epidermology, Etiology, Transmission, Clinical

Presentation, and Management
Dr Avishek Reddy 2024
 Objective

•Epidemiology
•Understand the Etiology/cause:
•Comprehend the Modes of Transmission:
•Recognize the Clinical Presentation:.
•Learn about Management and Treatment:
•Appreciate the Importance of Public Health Measures:
 Pneumonia - Etiology
 Def: Pneumonia is an infection that inflames the air
sacs/alveoli in one or both lungs, which may fill with fluid or
pus.
 Caused by a variety of pathogens including:
 Bacteria (e.g., Streptococcus pneumoniae, Haemophilus
influenzae)
 Viruses (e.g., Influenza, RSV, covid)
 Fungi (e.g., Pneumocystis jirovecii)- Common in PLHIV
 •Can be classified as
 community-acquired (acquired outside health care setting (strep
p. or virus- influenza) or
 hospital-acquired. (acquired within hospital – staph or
pseudomonas a)
 Epidermology

Data source: IHME, Global Burden of Disease

 Epidemiology of Pneumonia in children
• Child Mortality:Pneumonia is the leading cause of death among
children under five (excluding neoates).
• Accounts for 14% of all deaths in this age group, killing 740,180 children
in 2019.
• Significant reduction in child deaths from 4 million in 1981 to just over 1
million in 2013.
• Further decline in annual deaths from over 1 million in 2013 to less than
750,000 in 2019.
Factors Contributing to Decline:
• Reduced Risk Factors:
• Improvements in childhood nutrition (reduced wasting).
• Better air quality and sanitation.
• Decrease in global poverty.
• Health Interventions:
• Widespread use of pneumococcal, HIB vaccines.
• Increased access to antibiotics and healthcare.
Epidemiology of Pneumonia in Adults
 Impact on the Elderly:
• Rising Mortality Among Elderly:
• Deaths among those aged 70+ increased from 600,000 in
1990 to over 1 million in 2019.
• Increase attributed to a growing and aging global
population..
Risk factor For pneumonia in children

- Including HIV and overcrowding

Data source: IHME, Global Burden of Disease (2024)
Risk factor for pneumonia in- adults
 Pneumonia - Transmission
 Spread through respiratory droplets from coughing or sneezing.
 Can also occur through aspiration of food, liquids, or vomit.
 Risk factors include weakened immune system, chronic diseases,
and smoking.
 Droplet transmission- droplets containing infectious agents are
expelled from an infected person and enter the mucous membranes
(eyes, nose, mouth) of another person. This can happen during
activities such as coughing, sneezing, talking, or even breathing.
 5 micrometers and can travel short distances, usually up to about 1 -2
meter (3 feet) before settling on surfaces.
 Eg: covid, influenza
 Can also contaminate surfaces, leading to indirect transmission if
someone touches the surface and then their face.
 Pneumonia - Clinical
Presentation
 Main Symptoms
 Cough- Often productive (producing mucus) May be dry
in some cases
 Shortness of Breath -Difficulty breathing or rapid
breathing
 Chest Pain Sharp or stabbing pain, often worsening with
deep breathing or coughing
 Confusion Particularly in older adults or those with
severe pneumonia
 Severe cases can lead to sepsis or respiratory failure.
 Constitutional Symptoms

 Definition: Constitutional symptoms are systemic signs

that indicate a general state of health, often reflecting
the body's response to infection or illness
 Fever -Typically high (above 100.4°F or 38°C)
 Chills- Shivering or shaking chills
 Fatigue- General weakness or tiredness
 Sweating- Excessive perspiration
 Headache- Commonly reported, may accompany fever
 Nausea or Vomiting- Less common but may occur,
especially in children
 Physical Exam Findings for Pneumonia
 General Appearance-
 Respiratory Examination
 Signs of respiratory distress  Auscultation:
(e.g., use of accessory muscles)
 Crackles (rales) or wheezing
 Cyanosis (bluish discoloration of
lips or fingers)
 Diminished breath sounds over
affected areas
 Vital Signs  Percussion:
 Temperature: Often elevated  Dullness over areas of
(fever)v>37.5 consolidation
 Respiratory Rate: Increased  Palpation:
(tachypnea- > 20)  Increased tactile fremitus over
 Heart Rate: Increased consolidated lung areas
(tachycardia)- >100  Cardiovascular Examination
 Blood Pressure: May be normal  Possible elevated heart rate or
or low in severe cases murmurs in severe cases
 Investigation
 Chest X-ray: Radiographic evidence of infiltrates or
consolidation.
 Laboratory Tests:
 Elevated white blood cell count (WBC)
 Sputum culture
 Blood cultures in severe cases
 Clinical criteria for admission or
outpatient treatment
 CURB-65 Score (adult only)
 The CURB-65 score is a clinical tool used to assess the severity of
pneumonia and guide treatment decisions. It helps determine whether a
patient should be treated in the hospital or can be managed as an
outpatient. The score is based on five clinical criteria:

 Confusion (new onset)

 Urea: Blood urea nitrogen (BUN) > 7 mmol/L (20 mg/dL)
 Respiratory Rate: ≥ 30 breaths per minute
 Blood Pressure: Systolic < 90 mmHg or diastolic ≤ 60 mmHg
 Age: ≥ 65 years
 Scoring: Each criterion scores 1 point. The total score ranges from 0 to 5.

 Score 0-1: Low risk; outpatient treatment.

 Score 2: Moderate risk; consider hospitalization.
 Score 3-5: High risk; likely requires hospitalization.
 CORB Score (adults only)
 The CORB score is a simpler tool for assessing pneumonia
severity, particularly in the emergency department setting. It
includes four criteria:

 Confusion (new onset)

 Oxygen saturation: < 90% on room air
 Respiratory Rate: ≥ 30 breaths per minute
 Blood Pressure: Systolic < 90 mmHg
 Scoring: Each criterion scores 1 point. The total score ranges
from 0 to 4.

 Score 0-1: Low risk; outpatient treatment.

 Score 2-4: Higher risk; consider hospitalization.
Classification in children (WHO Pocket book)
 DD
 Bronchitis: Often presents with a cough but typically
lacks the fever and consolidation seen in pneumonia.
 Pulmonary Embolism: Can cause acute respiratory
symptoms and chest pain; requires imaging for
diagnosis. (clinically-wells criteria)
 Congestive Heart Failure: May present with dyspnea and
cough; look for signs of fluid overload.
 Lung Cancer: In chronic cases, may present similarly but
often with weight loss and other systemic symptoms.
 Tuberculosis: Consider in patients with risk factors,
presenting with chronic cough, fever, and night sweats.
 Lower respiratory and pleural disea
Pneumonia -- infection of alveoli
(viral or bacterial)
vs. Pneumonitis -- immune-
mediated
Empyema: inflammation of
purulent exudate alveoli
in the pleural
cavity Bronchitis --
inflammation of
bronchi, may be
immune-mediated,
e.g. asthma, COPD, or
Abscess: infectious (usually
circumscribed viral but can be
collection of pus bacterial)
within the lung Bronchiolitis:
parenchyma inflammation of
bronchioles (often viral
but can be bacterial)
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 Pneumonia (outpatient)
 Advice
 Instruct patients to monitor their symptoms and seek medical attention if they
worsen (danger signs- worsening sob, no improvement sx in 48-72h, confusion,
cyanosis/blue discoloration of lips, palpitation)
 Encourage hydration- due to higher insensible loss , hydration also thins out mucous
 Nutriional support- balanced diet
 Smoking cessation
 ABX :
 Amoxicillin for 5-7 days or doxycycline (8y+) or
 Procaine penicillin IMI daily for 5 days (where supervised administration is preferred)
 Symptomatic Treatment:
 Encourage rest and hydration.
 Use antipyretics (e.g., acetaminophen or ibuprofen) for fever and discomfort.
 Follow up- 2-3 days
 Manage comorbid condition – asthma, copd, dm2
 Pneumonia management -Mod/Severe

 Acute Management (ABC Approach)

 Airway:- Ensure the airway is patent.
 Breathing:
 Assess respiratory rate and effort.
 Check Spo2- Administer supplemental oxygen to maintain SpO2 ≥ 95%.
 Provide bronchodilators if wheezing is present. (bronchospasm)
 Consider non-invasive ventilation (e.g., CPAP or BiPAP) in severe cases.
 Consider intubation and ventilation in impending respiratory failure
 Circulation:
 Monitor vital signs (heart rate, blood pressure).
 Establish IV access for fluids (excess loss occur in some with fever and
high rr) and medications.
 Administer IV antibiotics promptly.
 Disability - check GCS and glucose- low gcs could be due to hypoxia,
sepsis/shock or low sugars
 E- exposure and environment- ensure pt is warm, control fever
 Long term
 Antibiotic Therapy:
 Xpen/benzylpenicillin + doxycylin (8y+) 100 mg po bd (in very severe
disease with suspected sepsis- ceftri+cloxa+ azithro/erythto)
 In ICS pt- add cotrimoxazole
 Adjust based on culture results.
 Supportive Care:
 Encourage hydration and rest.
 Use antipyretics for fever control.
 Monitor for potential complications (e.g., abscess, empyema).
 Follow-up:
 Schedule follow-ups to assess recovery.
 Consider repeat imaging if symptoms persist.
 Pulmonary Rehabilitation:
 For patients with significant lung impairment, refer for rehabilitation to
improve lung function.
 Prevention
 Vaccination:
 Administer pneumococcal vaccines (PCV13 (babies)and PPSV23 (adults).
 HIB vaccine Pertussis (as DTwP-HepB-Hib at 6,10,14w)
 Pertussis (as DTwP-HepB-Hib at 6,10,14w) and measles (as MR at 1 year)
 Provide annual influenza vaccines to high-risk group.
 Smoking Cessation:
 Offer resources and support for quitting smoking.
 Hygiene Practices:
 Promote hand hygiene and respiratory etiquette to prevent infections.
 Education:
 Educate patients on recognizing early pneumonia symptoms and the
importance of seeking medical help.
 Environmental Controls:
 Reduce exposure to pollutants and allergens.
 Antibiotic
 Cotrimoxazole – for PJP prophylaxis in immunocompromised cases
 Complications of pneumonia

Pleural effusion
• inflammation leads to
exudation of fluid into pleural
space
• can compromise lung function
Empyema
• purulent exudate in pleural
space
• necrosis/breakdown of
visceral pleura and/or spread
of infection into pleura
Pleural adhesions, lung fibrosis
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 Complications of pneumonia

Abscess / cavitary lesion

• circumscribed focus of
liquefactive necrosis within
lung tissue
• associated with necrotizing
Staph or Strep infections or
Gram-neg rods (e.g.
aspiration)

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 Questions & Discussion
 .
 Reference
WHO, pneumonia in children 2022 https://www.who.int/ne
ws-room/fact-sheets/detail/pneumonia

https://ourworldindata.org/pneumonia