1 pneumoniile
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PNEUMONIILEPNEUMONIILE
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Infamatia plamanului distal=ciInfamatia plamanului distal=ci
aeriene terminale,alveole, interstitiuaeriene terminale,alveole, interstitiu Prima cauza de deces dintre bolilePrima cauza de deces dintre bolile
inectioase,inectioase,
aa cauza de moarte incauza de moarte in lumelume
PNEUMONIILEPNEUMONIILE
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PPneumonianeumonia aparapareecand mecanismelecand mecanismelede aparare nu acde aparare nu ac ataataataculuiatacului
bacterianbacterian !acteriile patrund in plaman pe " cai#!acteriile patrund in plaman pe " cai#
microaspiratiemicroaspiratie
in$alarein$alare cale san%uinacale san%uina e&tensie directae&tensie directa''rararara
PNEUMONIILEPNEUMONIILE(iziopatolo%ie(iziopatolo%ie
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PNEUMONIILEPNEUMONIILE(iziopatolo%ie(iziopatolo%ie
)i recvente de inoculare#)i recvente de inoculare#
I. Aspiratia:I. Aspiratia:
mec cel mai importantmec cel mai important creste in somncreste in somn **nivel scazut al constienteinivel scazut al constientei bacterii aerobbacterii aerobeesi &+ anaerobsi &+ anaerobe'e'micimici
cantitati de seccantitati de secretieretieoroarin%ieneoroarin%ieneproducproducpneumoniipneumonii
bacteriile adera la receptorii super-cialibacteriile adera la receptorii super-cialicelularicelulari
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II.II. Inhalare:Inhalare:
Microbi oarte virulentiMicrobi oarte virulenti
M tuberculosisM tuberculosis .irus.irusuriuri /%ripa0/%ripa0
Le%ionellLe%ionellaa
)iuma)iuma 1ntra&1ntra&
PNEUMONIILEPNEUMONIILE(iziopatolo%ie(iziopatolo%ie
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PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICA
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Cea mai frecventaCea mai frecventa
SSTREPTOCOCUSTREPTOCOCUSPNEUMONIPNEUMONIAAEE --Coc incapsulat gram pozitiv, apare in lanturi siCoc incapsulat gram pozitiv, apare in lanturi si
perechiperechi
Capsula:Capsula:PZHPZH complex-variaza in grosime sicomplex-variaza in grosime sicompozitiecompozitie
Capsula nu se vede in col GramCapsula nu se vede in col Gram Se recunoste cu o coloratie negativa cu cernealaSe recunoste cu o coloratie negativa cu cerneala
de India, alastru de metilende India, alastru de metilen Pe agar sange: alfa hemolizaPe agar sange: alfa hemoliza
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICA
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!irulenta este data de complexul PZH!irulenta este data de complexul PZH
capsular "capsular " #$#$ serotipuri% care inhiaserotipuri% care inhia
fagocitoza&fagocitoza&
Pn neincapsulat-avirulentPn neincapsulat-avirulentii
'ipurile:'ipurile:
(,)$,)#,)*,+-sugari si copii(,)$,)#,)*,+-sugari si copii
),+,,,#-adulti),+,,,#-adulti
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICA
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In colectivitate boala sporadica in timpulIn colectivitate boala sporadica in timpulierniiiernii
epidemii rare la alcoolici,epidemii rare la alcoolici, imunoimunodeprimatideprimati
1spirarea sec1spirarea secrroroarin%oroarin%dedettincapacitateincapacitatede clearance al secretiilorde clearance al secretiilor
.accinarea.accinarea/23 serotipuri0/23 serotipuri0
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICAEpidemiologiaEpidemiologia
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P4 neimunizati,P4 neimunizati,netratatinetratati
11ccanti )psanti )ps/ I% M si I% 50/ I% M si I% 50lala6'+ zile dupa inectie6'+ zile dupa inectie
.IN7E)18E4.IN7E)18E4
)ontact cupneumococ
a%ocitoza si omorareaa%ocitoza si omorareapneumpneumdede catrecatre PMN si M41lv4PMN si M41lv4
de-cit de I% M, I% 5, I%de-cit de I% M, I% 5, I%11susceptibili la P4Pn4susceptibili la P4Pn4
1c antic1c anticpsps
speci-cispeci-cipersista toatapersista toata
MMccdin si spldin si splmobilizeaza pnmobilizeaza pn
din san%edin san%e
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICAImunologieImunologie
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PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICA
Patogenea si patologiePatogenea si patologie1spiratia1spiratiamat4mat4 oroarin%oroarin%
pn inpn in alveolealveoledetdetatelectatelect
si incap de cl alsi incap de cl albactbact
refe& epi%loticrefe& epi%lotic
eesscacallator ciliarator ciliar
patura de mucuspatura de mucus
I% secretoriiI% secretorii
Mecde
Mecde
aparar
e
aparar
e
PNPNEUMONIAEUMONIA
virulentavirulentamicrobianamicrobianaMaterial aspiratMaterial aspiratnocivnociv)antit cres)antit cresccdedepneumpneum
Me
cdeinducereainf
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7ilatatie capilara si7ilatatie capilara si edem in alveoleedem in alveole )$emota&ic pt PMN)$emota&ic pt PMN 1lveolele cu lic$id'bacteriile prin porii lui1lveolele cu lic$id'bacteriile prin porii lui
9o$n si in bron$iolele terminale'ariile de9o$n si in bron$iolele terminale'ariile deconti%uitateconti%uitate
Mecanismele de aparareMecanismele de aparare''adecvate'inectia se rezolvaadecvate'inectia se rezolva''neadecvate'inectia a:un%e in pleura si -surineadecvate'inectia a:un%e in pleura si -suri
interlobareinterlobare**condensarecondensare
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICA
PatologiePatologie
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P lobaraP lobara
P multilobaraP multilobara
P se%mentareP se%mentare
P parcelare'pneumonitaP parcelare'pneumonita
!PN'inectia'concentric de la!PN'inectia'concentric de labron$iibron$ii
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICATopogra!e:Topogra!e:
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.ariabile.ariabile/usoare/usoare**rapid letale0rapid letale0
7ebut brusc7ebut brusc
;use #;use #
''productiva initial,productiva initial,
'lab'lab MP cu striatii de sin%eMP cu striatii de sin%e
'';ardiv/2"'">$0 %roasa, purulenta, ru%inie,ranc;ardiv/2"'">$0 %roasa, purulenta, ru%inie,rancsan%uinolentasan%uinolenta
''sputa %elatinoasa cu striatii de sinsputa %elatinoasa cu striatii de sin%e%e
PNEUMONIA PNEUMOCOCICAPNEUMONIA PNEUMOCOCICA
Mani"estari #lini#eMani"estari #lini#e
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PNEUMONIA PNEUMOCOCICAPNEUMONIA PNEUMOCOCICA
Mani"estari #lini#eMani"estari #lini#e
(ebra "?)(ebra "?)
Mial%iiMial%ii
;a$ipnee, resp super-cial;a$ipnee, resp super-cial 7urere pleuritica7urere pleuritica
1nore&ie, %reata, varsaturi1nore&ie, %reata, varsaturi
!acteriemie persistenta!acteriemie persistenta''risoane , soc,risoane , soc,)I7, detresa respiratorie)I7, detresa respiratorie**decesdeces
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;ranspiratii;ranspiratii**7es$idratare7es$idratare @ipotensiune@ipotensiune
;a$icardie;a$icardie )iano)ianozaza )onuz)onuzie*delirie*delir ;a$ipne;a$ipneee (oloseste mm resp accesori(oloseste mm resp accesori oc/rar0oc/rar0**)I7)I7 Netratata#pn lobara'pn multilobaraNetratata#pn lobara'pn multilobara
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICAE$amen !i#:E$amen !i#:
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1uscultatie#1uscultatie#A ufu tubarufu tubar
A 8aluri crepitante8aluri crepitante
A Lic$id pleural'M vez*vibratii vocale'Lic$id pleural'M vez*vibratii vocale'absenteabsente
A (recatura pleurala localizata(recatura pleurala localizata
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICAE$amen !i#:E$amen !i#:
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PNEUMONIA PNEUMOCOCICAPNEUMONIA PNEUMOCOCICA
E$amen !i#:E$amen !i#:
1lte semne1lte semne Ileus paraliticIleus paralitic''durere abd,distdurere abd,distensens,scad z,scad z%%
iintestntest Icter usor#Icter usor#$epatita$epatitareactiva*reactiva*$emora%ii$emora%ii
intrapulmonareintrapulmonare
ococ Purpura/)I70Purpura/)I70
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Leucocitoza#2'3Leucocitoza#2'3&N *&N * alcoolici#N*scazutalcoolici#N*scazutee )I)I7 '7 ';r scazute,;r scazute,
''pleomor-smpleomor-sm$ematii'sc$istocite,$ematii'sc$istocite,
'';;P,P7( crescute;;P,P7( crescute ''$ipo-brino%enemi$ipo-brino%enemiee
$ipovolemia$ipovolemia##@b,@t,Na@b,@t,Na !;!; *citoliza*citoliza 5azele san%uine5azele san%uine
@ipocarbie@ipocarbie @ipo&emie@ipo&emie 1lcaloza1lcaloza p@BC4"p@BC4"
oc ranc p@DC4"oc ranc p@DC4"
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICA%a&orator%a&orator
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NeutropeniciNeutropenici**des$idratatides$idratati**imunode-cienti'imunode-cienti'
normalanormala
dupa $idratare apare condensaredupa $idratare apare condensare
aa
lobaralobara**scizuri interlobare bombatescizuri interlobare bombate
)azuri severe'pneumonia multilobara)azuri severe'pneumonia multilobara 3'lic$id pleural3'lic$id pleural
teril*inectatteril*inectat
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICA
R$ pulmonaraR$ pulmonara
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pacientii asplenici'rotiu PMNpacientii asplenici'rotiu PMN'pneumococi'pneumococi
nu se asteaptanu se asteapta+>'+>'2" $ ptr4 $emoculturi2" $ ptr4 $emoculturi
sstudii de $ibridizare 7N1#tudii de $ibridizare 7N1# sputasputa
necesita nr crescut de bacterii ptr a -necesita nr crescut de bacterii ptr a -
pozitivpozitiv P)8 ampli-ca 7N1 pneumococicP)8 ampli-ca 7N1 pneumococic
8ez als F8ez als F
PNEUMONIA PNEUMOCOCICAPNEUMONIA PNEUMOCOCICA
e$amen &a#teriologi#e$amen &a#teriologi#
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1lti microbi#1lti microbi#A @ infuenzae#@ infuenzae#!P)O si umatori!P)O si umatori
A ta auriu#ta auriu#)omunitare dupa episod de %ripa)omunitare dupa episod de %ripa
Inectie nosocomiala recventInectie nosocomiala recvent
1bcedeaza recvent1bcedeaza recventA tr4 Pio%enestr4 Pio%enes 7upa scarlatina7upa scarlatina**arin%itaarin%ita
streptococicastreptococica
PNEUMONIA PNEUMOCOCICAPNEUMONIA PNEUMOCOCICA'g di"erential'g di"erential
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!acilii %ram!acilii %ram//''00 E )oli, 9lebsiella,E )oli, 9lebsiella,ProteusProteus
Pacienti debilitati*institutionalizatiPacienti debilitati*institutionalizati
Pn nososcomialePn nososcomiale
Le%ionellaLe%ionella;o&icitate sistemica;o&icitate sistemica
(umatori*lucratori in constructii(umatori*lucratori in constructii 1% urinar1% urinar
Pneumonia ;bcPneumonia ;bc
PNEUMONIA PNEUMOCOCICAPNEUMONIA PNEUMOCOCICA'g di"erential'g di"erential
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PNEUMONIA PNEUMOCOCICAPNEUMONIA PNEUMOCOCICA'g di"erential'g di"erential
)181);E8;I)1)181);E8;I)1 PNEUMONI1PNEUMONI1
PNEUMO)O)I)1PNEUMO)O)I)1
PNEUMONIIPNEUMONII.I81LE *.I81LE *MG)OPL1M1MG)OPL1M1
7ebut7ebut
(rison(rison
(ebra(ebra
;a$icardie;a$icardie
;a$ipnee;a$ipnee
7urere toracica7urere toracica
putaputa
)ondensare')ondensare'lobara*se%mentaralobara*se%mentara
Lic$id pleuralLic$id pleural
Leucocitoza cu PMNLeucocitoza cu PMN
!rusc!rusc
(recvent(recvent
MareMare
(recvent(recvent
(recvent(recvent
(recvent(recvent
PurulentaPurulenta
(recvent(recvent
8elativ recvent8elativ recvent
(recvent(recvent
5radat5radat
8ar8ar
MicaMica
8ar8ar
8ar8ar
8ar8ar
MucoasaMucoasa
8ar8ar
8ar8ar
8ar8ar
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PNEUMONIA PNEUMOCOCICAPNEUMONIA PNEUMOCOCICA)OMPLI)1;II
PULMONAREPULMONARE PlPleurezieeurezie pparaparapnn Abcesul pulmonarAbcesul pulmonar Empiemul-15-25%Empiemul-15-25%
drenajdrenaj BronsiectaziiBronsiectazii AtelecAtelecttazieazie
Rezolutia lentaRezolutia lenta
EXTRAPULMONAREEXTRAPULMONARE MeningitaMeningita Abces cerebralAbces cerebral
PericarditaPericardita EndocarditaEndocardita ArtritaArtrita PeritonitaPeritonita
Conjunctiita piogenicaConjunctiita piogenica !tita medie!tita medie
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)at mai rapid inceput)at mai rapid inceput
Nu se asteapta culturileNu se asteapta culturile;ratament empiric;ratament empiric
3 zile de aebrilitate3 zile de aebrilitate (ebra persistenta(ebra persistentadupa "'6 ziledupa "'6 zile## Empiem pleuralEmpiem pleural*1lte complicatii*1lte complicatii
(ebra medicamentoasa(ebra medicamentoasa
PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICA
TratamentTratament
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PNEUMONIAPNEUMONIA
PNEUMOCOCICAPNEUMOCOCICA
TratamentTratamentempiri#empiri#60 ani cu
comorbiditatcomorbiditat
CCE!ALO"PE!ALO"P d #n II saud #n II sauT"M sauT"M sauAU$UMENTINAU$UMENTIN %M%MACROLIDACROLID
IntrnatIntrnat CCE!OLA"PE!OLA"PIIII &&IIIIIIsausauIN'I(ITOR DE (ETAIN'I(ITOR DE (ETALACTAMA)ALACTAMA)A %%MMACROLIDACROLID
Intrnat sauIntrnat sau
s*r+s*r+AATI,TI,
CCE!ALO"PE!ALO"PIIIIIIsausauc-i*a.ntc-i*a.nt ANTIP"EUDOMONALANTIP"EUDOMONALEE+Imi/nmc+Imi/nmci/roi/ro,,
%A%AMINOMINO$$LICO)IDLICO)ID
FM1)8OLI7
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Netratati'26 mortalitateNetratati'26 mortalitate ;ratatiD6;ratatiD6
(actori de pro%nostic prost#(actori de pro%nostic prost#A !acteriemia!acteriemiaA NeutropeniaNeutropenia **asplenismulasplenismulA MultilobaraMultilobaraA !oli asociate!oli asociate
A E&tremele de varstaE&tremele de varstaA oculoculA ;ipul 3;ipul 3A 8ezistenta la antibiotice8ezistenta la antibiotice
A Intarzierea terapieiIntarzierea terapiei
PNEUMONIA PNEUMOCOCICAPNEUMONIA PNEUMOCOCICAPrognosti#Prognosti#
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Oprirea umatuluiOprirea umatului
.accinarea#.accinarea#
A 23 serotipuri23 serotipuriA La cei peste 6 aniLa cei peste 6 ani
A !oli cronice!oli cronice
A Protectie 6 aniProtectie 6 aniA . anti%ripalaB6 ani. anti%ripalaB6 ani
PNEUMONIA PNEUMOCOCICAPNEUMONIA PNEUMOCOCICAPro!la$iaPro!la$ia
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7upa ep7upa epidemiiidemiide %ripade %ripa
E&tremE&tremeele varsteile varstei
E&amen -zic'pneumonie lobaraE&amen -zic'pneumonie lobara
**!PN!PN
tare %en to&ica cu risoanetare %en to&ica cu risoane**ebra $ecticaebra $ectica
oc si embolii septice la distantaoc si embolii septice la distanta
1bces pulmonar'piopneumotora&1bces pulmonar'piopneumotora& )$iste aeriene'pneumatocele'copii)$iste aeriene'pneumatocele'copii
PNEUMONIA STA(I%OCOCICAPNEUMONIA STA(I%OCOCICA
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;ratament#;ratament#A Nacilina '>%Nacilina '>%
A O&acilina 2% iv la " oreO&acilina 2% iv la " ore 8aspunsul este lent'+" zile de8aspunsul este lent'+" zile de
aebrilitateaebrilitate
Mortalitate "'6Mortalitate "'6
PNEUMONIA STA(I%OCOCICAPNEUMONIA STA(I%OCOCICA
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7upa arin%ita streptococica*%ripa7upa arin%ita streptococica*%ripa
tare to&ica,risoane, (@,tare to&ica,risoane, (@,
Lic$id pleural/bilateral0 rapidLic$id pleural/bilateral0 rapid 1ectarea v1ectarea vv4v4limatice#opacitatilimatice#opacitati
liniareliniare
(orma#L(orma#Lobaraobara*!P*!P Penicilina 2'" milPenicilina 2'" milU la " oreU la " ore
PNEUMONIA STREPTOCOCCICAPNEUMONIA STREPTOCOCCICA
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PNPNEEUMONII%E 'ETERMINATE 'EUMONII%E 'ETERMINATE 'E
)ERMENI)ERMENI )RAM)RAMNE)ATI*INE)ATI*I
@aemop$ilus infuenzae@aemop$ilus infuenzae
9lebsiella pneumonie9lebsiella pneumonie Pseudomonas aeru%inosaPseudomonas aeru%inosa 1lti 5ram1lti 5ram//''00 E coli, ProteusE coli, Proteus
)OMUN I; *NOO)O
NOO)OM
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serotipuri PH@ capsular serotipuri PH@ capsular
5reu de distins de Pneumonia5reu de distins de Pneumonia
pneumococicca#pneumococicca#;ratament#;ratament#
A 1mpicilina1mpicilina rezrezististentaenta
A Macrolide recenteMacrolide recenteA )$inolone)$inolone*cealosp*cealosp
+aemophilus in,uenae+aemophilus in,uenae
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le&siella pneumoniele&siella pneumonie
1lcoolici, diabetici,cardiaci,1lcoolici, diabetici,cardiaci,pulmonari,ventilatipulmonari,ventilati
1ectare lobara*!P1ectare lobara*!P 8 scizuri bombate8 scizuri bombate Evolutie subacutaEvolutie subacuta1bcedare1bcedare**cicatrizarecicatrizare
severasevera
))$inolone$inolone**)( I./ceepim0)( I./ceepim0F15F15
+" zile dupa deervescenta+" zile dupa deervescenta
Mortalitate peste 6Mortalitate peste 6
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spitalizatispitalizati**ventilativentilati**primesc 1;!primesc 1;!
Lobii inLobii ineeriori, bilateralriori, bilateral'!P'!P
1bcedeaza recv1bcedeaza recv 8olul stomacului'creste p@ %astric'creste nr de8olul stomacului'creste p@ %astric'creste nr de
5ram5ramne%ne%
))ealospealospIIII**IIIIII**I.I.FF1515**c$inolonec$inolone**IMPIMP
E #oli ProteusE #oli Proteus
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Pseudomonas aeruginosaPseudomonas aeruginosa
PN PRIMARAPN PRIMARA(nebacteriemici)(nebacteriemici)
aspiratieaspiratie
1;I1;I**comorbiditatecomorbiditate 8
A !PN!PNA lic$id pleural'lic$id pleural'
recventrecventA empiemempiem
PN BACTERIEMICAPN BACTERIEMICA
NeutropeniNeutropeniee
8& !PN necrotizanta'8& !PN necrotizanta'abceseabcese !eta lactam!eta lactam
antipseudom ivantipseudom iv/cee&im* piperacilin'/cee&im* piperacilin'
tazobactam*tazobactam*carbapenem0 F ()@carbapenem0 F ()@sausau
!eta lactam!eta lactamantipseudom iv Fantipseudom iv FML iv F 15ML iv F 15
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2 s2 sinindr clinice#dr clinice#
A !oala le%ionarilor'!oala le%ionarilor'PneumoniePneumonie
A (E!81 PON;I1)(E!81 PON;I1)'acuta,'acuta,autolimitataautolimitata
)reste in apa)reste in apa**aer conditionat,aer conditionat,
sauna, dusuri,sauna, dusuri,
IN(ECTIA CU %E)IONE%%AIN(ECTIA CU %E)IONE%%A
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PnPneumoniaeumoniadin &oaladin &oala
legionarilorlegionarilor
Maniestari severeManiestari severe 'i'in%ri:in%ri:irerein 1;Iin 1;I (ebra mare(ebra mare**;use neproduc;use neproduct*t*product*san%product*san%
rarrarpurulentapurulenta **7iaree7iaree Neutro-le crescute ara microbi in sputaNeutro-le crescute ara microbi in sputa @iponatremieD+3+mE*l@iponatremieD+3+mE*l
8&8#!PN si aectare multilobara, lic$id pleural!PN si aectare multilobara, lic$id pleural Nu raspund la betalactamine si 15Nu raspund la betalactamine si 15 1pare in locuri cu apa potabila1pare in locuri cu apa potabila
contaminatacontaminata
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)ol 5ram a sputei#)ol 5ram a sputei#
''leucocite ara microbileucocite ara microbi
'')and sunt vizibili sunt mici, pleomor-, bacili 5')and sunt vizibili sunt mici, pleomor-, bacili 5'
)ultura#)ultura#A )oloniile cresc 3'6 zile)oloniile cresc 3'6 zile
1nticorpi1nticorpicresc de " ori*cresc de " ori*la un titrula un titru'+#+2>'+#+2> 1nti%en urinar1nti%en urinar
''8apid, ietin,usor de realizat8apid, ietin,usor de realizat
PnPneumoniaeumoniadin &oaladin &oala
legionarilorlegionarilor
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7e electie7e electie macrolide#azitromicina 6'+ zile saumacrolide#azitromicina 6'+ zile sau c$inolonec$inolone EEritromicinaritromicina''E secundE secund
A Ototo&icOtoto&icA %astro'intestinale%astro'intestinale
terapie ivterapie iv**;erapie orala ult;erapie orala ulterer
+'+" zile+'+" zile'' 2+2+ MortalitateMortalitate'> imunosupre'> imunosupressati si netratatiati si netratati''La imunocompetenti si tratati mortalitateLa imunocompetenti si tratati mortalitate
++**
PnPneumoniaeumoniadin &oaladin &oala
legionarilorlegionarilor
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PNEUMONII%E NE/ACTERIENEPNEUMONII%E NE/ACTERIENE
!acterii!acteriiatipiceatipice
.irusuri.irusuri (un%i*Protozoa(un%i*Protozoarere
MJcoplasmaMJcoplasmapneumoniaepneumoniae
)o&iela)o&ielaburnetii/ebra K0burnetii/ebra K0
)$lamidia)$lamidia
pneumoniaepneumoniae)$lamidia)$lamidiapsitaccipsitacci
%ripale si%ripale sipara%ripalepara%ripale
sincitial respiratorsincitial respirator
adenovirusiadenovirusi
ru:eolaru:eola
varicelo'zosterianvaricelo'zosterian)M.)M.
pneumocJstispneumocJstiscarinicarini':iroveci':iroveci
$istoplasmoza$istoplasmoza
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;eoretic alveolele nu au e&udat;eoretic alveolele nu au e&udat
Leziunile pulmonare sunt lobulare,Leziunile pulmonare sunt lobulare,
se%mentare, lobare,se%mentare, lobare, diuzediuze e&amen -zic sarace&amen -zic sarac
puta'putine leucocite, $ematiiputa'putine leucocite, $ematii
Nr leucocite'normalNr leucocite'normal
PNEUMONII%E NE/ACTERIENEPNEUMONII%E NE/ACTERIENE
AnatomopatologieAnatomopatologie
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Intre 2'" zileIntre 2'" zile
umbraumbra$iliu%a'sticla mata$iliu%a'sticla mata
)ordoane nere%ulate de la $il la)ordoane nere%ulate de la $il laperierieperierie
8ar lic$id pleural8ar lic$id pleural
PNEUMONII%E NE/ACTERIENEPNEUMONII%E NE/ACTERIENE
E$amenul radiologi#E$amenul radiologi#
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(ebra(ebra**tusetuse** 8&8&
1bsenta leucocitozei si sdr de1bsenta leucocitozei si sdr de
condensarecondensare Pro%nostic bun/+Pro%nostic bun/+ mormor0 cu0 cu
e&ceptia %ripei si ornitozeie&ceptia %ripei si ornitozei
PNEUMONII%E NE/ACTERIENEPNEUMONII%E NE/ACTERIENE
'g poiti0'g poiti0
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PNEUMONII%E NE/ACTERIENEPNEUMONII%E NE/ACTERIENE'g di"erential'g di"erential
'g etiologi#'g etiologi#
'g di"erential'g di"erential
Pneumonii bacterienePneumonii bacteriene
;bc pulmonar;bc pulmonar'g etiologi#'g etiologi#
6 cazuri6 cazuri
1nc$eta epidemiolo%ica1nc$eta epidemiolo%ica Laborator'izolarea virusului*r deLaborator'izolarea virusului*r de
imunitateimunitate
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M1COP%ASMA PNEUMONIAEM1COP%ASMA PNEUMONIAE
)el mai mic or%anism viu cunoscut')el mai mic or%anism viu cunoscut'proariote incon:urate de mproariote incon:urate de mbbplasmplasm
Lipsa peretelui celular determinaLipsa peretelui celular determinapleomor-sm celular si rez lapleomor-sm celular si rez la)(*peniciline)(*peniciline
MP evoca auto'ac I%M careMP evoca auto'ac I%M carea%lutineaza $ematiile umane la "?)'a%lutineaza $ematiile umane la "?)'anemiaanemia
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)opii si tineriD36 ani)opii si tineriD36 ani
1pare sporadic1pare sporadic**epidemiiepidemii
Incubatie 2'3 saptamaniIncubatie 2'3 saptamani;ropism pt tract respirator#;ropism pt tract respirator#
A uperior#C'> ;!uperior#C'> ;!
A Inerior +Inerior +
M1COP%ASMA PNEUMONIAEM1COP%ASMA PNEUMONIAE
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(ebra, cealee, tuse uscata, sputa(ebra, cealee, tuse uscata, sputamucoasa*striatii san%uinemucoasa*striatii san%uine
tare %enerala relativ bunatare %enerala relativ buna (arin%ita(arin%ita Mirin%ita buloasaD6Mirin%ita buloasaD6
Lipsa sdr de condensare lic$idLipsa sdr de condensare lic$idpleuralD2pleuralD2
M1COP%ASMA PNEUMONIAEM1COP%ASMA PNEUMONIAE
Mani"estari #lini#eMani"estari #lini#e
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Leucocitoza usoaraLeucocitoza usoara
)ol %ram a sputei'leucocite ara)ol %ram a sputei'leucocite aramicrobimicrobi
8% pulmonara#8% pulmonara#
A In-ltrate liniare uni*bilaterale in lobiiIn-ltrate liniare uni*bilaterale in lobiiinerioriineriori
)rioa%lutininele B)rioa%lutininele B+*+*32 primele + zile32 primele + zile
;est -&are complement'mai speci-c;est -&are complement'mai speci-c
M1COP%ASMA PNEUMONIAEM1COP%ASMA PNEUMONIAE
'iagnosti#'iagnosti#
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)omplicatii#)omplicatii#
1par prin mecanisme imune1par prin mecanisme imune
Eruptii cutanate/MP,EN0Eruptii cutanate/MP,EN0 @emoliza intravasculara@emoliza intravascularasi coa%ulopatiisi coa%ulopatii Neurolo%ice/ME,5uillain !arrNeurolo%ice/ME,5uillain !arr, ata&ie, ata&ie
cerebeloasa, psi$oza0cerebeloasa, psi$oza0 Miocardita, pericarditaMiocardita, pericardita
M1COP%ASMA PNEUMONIAEM1COP%ASMA PNEUMONIAE
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;ratament#;ratament# ;ra$eobronsita nu necesita tratament 1!;ra$eobronsita nu necesita tratament 1!
Pneumonie +"'2+ zile#Pneumonie +"'2+ zile#;etracicline#do&i + m%2*zi;etracicline#do&i + m%2*zi Eritromicina#6 m%"*ziEritromicina#6 m%"*zi
)laritromicina + m%2*zi)laritromicina + m%2*zi
1zitromicina 6m%*zi1zitromicina 6m%*zi
Levo 6m%*ziLevo 6m%*zi 5ati "m%*zi5ati "m%*zi
Mo&ifo&acina "m%*ziMo&ifo&acina "m%*zi
M1COP%ASMA PNEUMONIAEM1COP%ASMA PNEUMONIAE
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CC+%AM1'IA+%AM1'IAPNEUMONIPNEUMONIAAEE
;ineri#;! si pneumonie;ineri#;! si pneumonie crupcrupadultadult
!atranii# spitalizare si suport!atranii# spitalizare si suportrespiratorrespirator
;rat;rat
eritro*tetra 2%*zi +'+"zile saueritro*tetra 2%*zi +'+"zile saulevofo&acinlevofo&acin
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contact cu pasari'papa%alicontact cu pasari'papa%ali
(ebra, risoane,cealee, otoobie,(ebra, risoane,cealee, otoobie,redoare de ceaa/menin%ita0redoare de ceaa/menin%ita0,tuse ucata,tuse ucata
puta redusaputa redusa **striatii de san%estriatii de san%e )repitatii -ne localizate sau diuze)repitatii -ne localizate sau diuze 8& umbre d8& umbre discreteiscrete /un sin%ur se%ment0/un sin%ur se%ment0 8eactia de -&are a )B+*+8eactia de -&are a )B+*+ ;etra 6m% la ore 2+ zile;etra 6m% la ore 2+ zile
PNEUMONIA ORPNEUMONIA ORNNITO2ICAITO2ICA
In"e#tia #u #hlam3diaIn"e#tia #u #hlam3dia
psitta#ipsitta#i
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mic %ermen 5ram'Hoonozamic %ermen 5ram'Hoonoza## vite,oi,iezivite,oi,iezi !oala proesionala!oala proesionalaManiestari clinice#Maniestari clinice#
!oala sistemica/cealee, mial%ii0!oala sistemica/cealee, mial%ii0 PneumoniePneumonie**$epatita$epatita**endocarditaendocardita** 7%7%pozitivpozitiv# -&area# -&area )) crestecrestedede"&"&titrul actitrul ac
;ratament#;ratament# do&iciclina + m%2*zido&iciclina + m%2*zi **c$inoc$inolonelone +" zile+" zile
(E/RA 4(E/RA 4
In"e#tia #u CIn"e#tia #u Co$iellao$iella&urnetii&urnetii
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PNEUMONIA )RIPA%APNEUMONIA )RIPA%A
0irusurile gripale A5/- epidemii-A- 675an5 6-0irusurile gripale A5/- epidemii-A- 675an5 6-8ani8ani
*irulenta mare*irulenta mare
Clini#5Compli#atiiClini#5Compli#atii
Gripa aviara-Gripa aviara-tulpina de 0A-+9N-pasaritulpina de 0A-+9N-pasarisal&atsal&at
-+- ;
-insu" resp se0era5mortalit ridi#ata?8@-insu" resp se0era5mortalit ridi#ata?8@
- inhi&itor de neuraminidaa- OSE%TAMI*IR SI- inhi&itor de neuraminidaa- OSE%TAMI*IR SI
2ANAMI*IR2ANAMI*IR
PNEUMONIA )RIPA%APNEUMONIA )RIPA%A
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PNEUMONIA )RIPA%APNEUMONIA )RIPA%A
#ara#ter#ara#ter PN )RIPA%A PRIMARAPN )RIPA%A PRIMARA PN /ACTERIANAPN /ACTERIANA
'E'ESUPRAIN(ECTIESUPRAIN(ECTIE
'e&ut'e&ut Pre#o#erapid progresi0Pre#o#erapid progresi0 %a #ate0a ile%a #ate0a iledupa de&utuldupa de&utulgripeigripei
E$ !i# siE$ !i# siR$R$ In!ltrate di"ueIn!ltrate di"ue Sdr deSdr de#ondensare#ondensare
SputaSputa SanguinolentaSanguinolenta
/a#terii si leu#o#ite rare/a#terii si leu#o#ite rare
PurulentaPurulenta
/a#terii si leu#/a#terii si leu#
numnum
neutro!leneutro!le Normale5leu#openie #uNormale5leu#openie #u%im"o#itoa%im"o#itoa ?9.@@@5mmB #u?9.@@@5mmB #uPMNPMN
PrognostiPrognosti##
Mortalitate mareMortalitate mare Relati0 &unRelati0 &un
TratamenTratamentt
inhi&itor de neuraminidaa-inhi&itor de neuraminidaa-OSE%TAMI*IR SI 2ANAMI*IR OSE%TAMI*IR SI 2ANAMI*IR
Raspunde la AT/Raspunde la AT/
S S O C SS'R RESPIRATOR ACUT SE*ER
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)oronavirus)oronavirus
)azul initial')azul initial'5uandon%5uandon%
)onta%ios si rapid pro%resiv)onta%ios si rapid pro%resiv (ebra(ebra**risoanerisoane**tuse uscatatuse uscata
8 in-ltrate alveolare8 in-ltrate alveolare
Insu respiratorie severaInsu respiratorie severa;erapie intensiva#23;erapie intensiva#23
Nu e&ista terapie speci-ca sau vaccinNu e&ista terapie speci-ca sau vaccin
S'R RESPIRATOR ACUT SE*ERS'R RESPIRATOR ACUT SE*ERSARSSARS
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+ANTA*IRUSURI:+ANTA*IRUSURI:
.irusul in Nombre/.irusul in Nombre/soarecsoarecele de cerbi0ele de cerbi0
.irusul !lac )ree )anal.irusul !lac )ree )anal
.irusul !aJo.irusul !aJouu prodrom boalaprodrom boala
viralavirala**cealeecealee**mial%iimial%ii**ebraebra apar ta$ipnee si $ipotensiuneapar ta$ipnee si $ipotensiune
edem intedem inteerstitialrstitial**edem alveolaredem alveolarbilateralbilateral
7eces 3'" prin I87eces 3'" prin I8
;rat #intubatie, trat soc;rat #intubatie, trat soc
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PNEUMONIA %A PACIENTIPNEUMONIA %A PACIENTI
IMUNO'E(ICITARIIMUNO'E(ICITARI
7E(E);7E(E); 1(E);IUNE11(E);IUNE1 E;IOLO5 PNE;IOLO5 PN
NeutropenNeutropeniaia
Leucemii*c$imioteraLeucemii*c$imioterapiepie
5ne%*sta*candi5ne%*sta*candidada
)$emota&i)$emota&iss
7H7H ta* 5ne%ta* 5ne%
7is L;7is L; )orticoterap)orticoterap Micobact* vir*Micobact* vir*(un%i oport(un%i oport
7is L;7is L; I71I71 Pneumocistis*toPneumocistis*to&oplasma* )M.*&oplasma* )M.*un%i oportun%i oport
7is L!7is L! Mielom multipluMielom multiplu Pneumococ*$aePneumococ*$ae
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Unicelular, motilUnicelular, motil**(un%(un% Ma: copiiilor/3'" ani0 inectati'clinic silentiosMa: copiiilor/3'" ani0 inectati'clinic silentios )ea mai recv in 1I7'in latenta)ea mai recv in 1I7'in latenta
redesteptatredesteptat
aa
tuse uscatatuse uscata**ebraebra**ta$ipneeta$ipnee**insu respiratorieinsu respiratorie 8% pulmonara#8% pulmonara#
A NormalaNormalaA In-ltrate alv bilateralIn-ltrate alv bilateral
A 5eam mat5eam mat E& sputa'col 5iemsa* ar%entica#troozoitii de P)E& sputa'col 5iemsa* ar%entica#troozoitii de P) Lava: bron$oalveolarLava: bron$oalveolar E& microscopic de tesut pulmonarE& microscopic de tesut pulmonar
PNEUMOC1STIS CARINIIPNEUMOC1STIS CARINII
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A )otrimo&azolB"ori doza)otrimo&azolB"ori dozaNN/3/3saptamani0 eecte secsaptamani0 eecte sec
A Pentamidina iv' to&icaPentamidina iv' to&ica**
dabsona*clindamicina*primauinadabsona*clindamicina*primauina
A Pro-lactic#Pro-lactic#
;MP'M + tb po;MP'M + tb po Pentamidina 3m% prin in$alare lunaraPentamidina 3m% prin in$alare lunara
PNEUMOC1STIS CARINIIPNEUMOC1STIS CARINII
TRATAMENTTRATAMENT
PNEUMONIAPNEUMONIA
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PNEUMONIAPNEUMONIA
COMUNITARA 0sCOMUNITARA 0s
NOSOCOMIA%ANOSOCOMIA%A 1par la persoane1par la persoane
care nu au nici uncare nu au nici uncontact cucontact cu
institutiileinstitutiilemedicalemedicale
Pneumococ*$aemPneumococ*$aem
op$ilus*atipicaop$ilus*atipica Pro%n bunPro%n bun
1pare la pacienti1pare la pacientiinternati la celinternati la celputin ">$ de laputin ">$ de lainternareinternare
5ne%*sta-lococ*b5ne%*sta-lococ*b
act rezistact rezist Pro%n prostPro%n prost
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ETIO%O)IA PNEUMONII%ORETIO%O)IA PNEUMONII%OR
COMUNITARE %A A'U%TCOMUNITARE %A A'U%T
D@ 5"ara "a#toriD@ 5"ara "a#toriagra0antiagra0anti
PneumococPneumococ
MJcoplasmaMJcoplasma
)$lamidia)$lamidia
@aemop$ilus@aemop$ilus
.irusuri.irusuri
?@ani5"a#tori?@ani5"a#toriagra0antiagra0anti
PneumococPneumococ
@aemop$ilus@aemop$ilus
)$lamidia)$lamidia
Mora&ellaMora&ella
.irusuriFbacterii.irusuriFbacterii
MJcoplasmaMJcoplasma
(ACTORI A)RA*ANTI
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(ACTORI A)RA*ANTI(ACTORI A)RA*ANTI
impli#ati in dg etiologi#impli#ati in dg etiologi#
8isc crescut de8isc crescut de
pneumococ rezistentpneumococ rezistent
1lcoolism1lcoolism
1! recentD3luni1! recentD3luni
ImunosupresieImunosupresie
)omorbiditati)omorbiditati8isc crescut de 5 ne%8isc crescut de 5 ne% 1! recentD3luni1! recentD3luni
1ect cardiopulmonare1ect cardiopulmonare
institutionalizatinstitutionalizat
8isc crescut de8isc crescut dePseudomonasPseudomonas
1! recentBCz*luna1! recentBCz*luna
)orticost)orticost
MalnutrMalnutr
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ETIO%O)IA PNEUMONII%ORETIO%O)IA PNEUMONII%OR
COMUNITARE %A COPIICOMUNITARE %A COPII
Nastere'3 saptNastere'3 sapt Listeria monocito%enesListeria monocito%enes!acili 5ne%!acili 5ne%
)M.)M.
3 sapt'" ani3 sapt'" ani PneumococPneumococ.irusi.irusi
!ordetella!ordetella
MJcoplasmaMJcoplasma"'+6 ani"'+6 ani PneumococPneumococ
MJcoplasmaMJcoplasma
)$lamidia)$lamidia
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SCORU% 'E RISC INSCORU% 'E RISC IN
PNEUMONII COMUNITAREPNEUMONII COMUNITARE
factorfactor scorscor FactorFactor scosco
rr
FactorFactor scorscor
.arsta (.arsta ( aniani mentalmental 22 p@ C436p@ C436 33
.arsta !.arsta ! ani'+ani'+ (8(8 22 UreeUreeBB3m%3m% 22InstutionalInstutional ++ ;1;1 22 NaD+3mENaD+3mE 22
NeoplasmNeoplasm 33 ;; +6+6 5licB26m%5licB26m% ++
! $ep! $ep 22 1.1. ++ @tB3@tB3 ++
I)I) ++ PaDPaD ++
! cerebr! cerebr ++ 8ev pl8ev pl ++
! ren! ren ++
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SCORU% 'E RISC INSCORU% 'E RISC IN
PNEUMONII COMUNITAREPNEUMONII COMUNITARE
punctepuncte mortalitatmortalitat recomandrecomand
DCDC ++ Nu se internNu se intern
C'QC'Q D6D6 Nu se internNu se intern
Q'+3Q'+3 6'+66'+6 InternareInternare
B+3B+3
B+6B+6
InternareInternare
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ETIO%O)IA PNEUMONII%ORETIO%O)IA PNEUMONII%OR
NOSOCOMIA%E %A A'U%TNOSOCOMIA%E %A A'U%T
Pacienti internati ara actPacienti internati ara acta%ravanti*cu actoria%ravanti*cu actoria%ravanti'nu 1;Ia%ravanti'nu 1;I
ta-lococ aur4ta-lococ aur4
5 Ne%5 Ne%
'@aemop$ilus'@aemop$ilus
'9lebsiella'9lebsiella
%erm%ermrezistentirezistenti
Pacienti internati in 1;IPacienti internati in 1;I PseudomonasPseudomonas(un%i(un%i
erratiaerratia
1cinetobacter1cinetobacter
(ACTORI 'E RISC AI(ACTORI 'E RISC AI
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(ACTORI 'E RISC AI(ACTORI 'E RISC AI
PNEUMONII%OR NOSOCOMIA%EPNEUMONII%OR NOSOCOMIA%E
%A A'U%T%A A'U%T
intubatia tra$eala cu ventilatie mec'intubatia tra$eala cu ventilatie mec'2323
1b recent1b recent Pro-la& %astr de stresPro-la& %astr de stres I)* I@* I8en* I8I)* I@* I8en* I8 Postop#'BCaniPostop#'BCani
'c$ir abd*toracica'c$ir abd*toracica
'status ct'status ct
SCORU% 'E RISC INSCORU% 'E RISC IN
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SCORU% 'E RISC INSCORU% 'E RISC IN
PNEUMONII NOSOCOMIA%EPNEUMONII NOSOCOMIA%E
factorfactor scorscor factorfactor scorscor
tD3>4"tD3>4" In-ltr diuzIn-ltr diuz ++
tD3>4QtD3>4Q ++ )ondens r&)ondens r& 22
tB3QtB3Q 22 Pro%resie r&Pro%resie r& 22
LD++miiLD++mii !act in!act inaspirataspirat
++
LB++miiLB++mii ++
B pneumB pneumnosocomnosocomecr tra$ nepurulecr tra$ nepurul ++
ecr tra$ purulecr tra$ purul 22
187187
(ara 187(ara 187 22
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PRO(I%A7IA PNEUMONII%ORPRO(I%A7IA PNEUMONII%OR
NOSOCOMIA%ENOSOCOMIA%E
.entilatia neinvaziva cu pres.entilatia neinvaziva cu prescontinua pozcontinua poz
Pozitia mai ridicata a pacientuluiPozitia mai ridicata a pacientului 1spiratia continua a secr sub%lotice1spiratia continua a secr sub%lotice
7econtaminarea selectiva a7econtaminarea selectiva a
oroarin%elui'%enta*colistin*vancooroarin%elui'%enta*colistin*vancolocallocal
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