PNUEMONIA

Infection of pulmonary parenchyma

Classified as
A. Community Acquired Pneumonia
B. Hospital Acquired Pneumonia
C. Ventilator-Associated Pneumonia
D. Health Care Associated Pneumonia

Pathophysiology
Results from the proliferation of microbial pathogens at the alveolar level and the host' s response to those pathogens.
Microorganisms gain access to the lower respiratory tract in several ways.
Most common is by aspiration from the oropharynx.
Pathology
Pathological changes
I. Edema: presence of a proteinaceous exudates in the alveoli
II. Red Hepatization: presence of erythrocytes in the cellular intraalveolar exudate
III.Gray Hepatization: No new erythrocytes are extravasating and those already present have been lysed and
degraded. Neutrophil is the predominant cell, fibrin deposition is abundant, and bacteria have disappeared.
corresponds with successful containment of the infection and improvement in gas exchange.
IV.Resolution: Macrophage reappears as the dominant cell type in the alveolar space, and the debris of neutrophils,
bacteria and fibrin has been cleared, as has the inflammatory response.

Community Acquired Pneumonia

lower respiratory tract infection acquired in the community within 24 hours to less than 2 weeks. It commonly presents with an acute cough,
abnormal vital signs of tachypnea (respiratory rate >20 breaths per minute), tachycardia (cardiac rate >100/minute), and fever (temperature
>37.8C) with at least one abnormal chest finding of diminished breath sounds, rhonchi, crackles, or wheeze.
Etiology: Streptococcus pneumoniae is most common
A. Typical: S. pneumoniae, Haemophilus influenzae, Staphylococcus aureus and gram-negative bacilli (Klebsiella pneumoniae and
Pseudomonas aeruginosa)
B. Atypical: Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella species (in patients) and Respiratory Viruses Influenza Viruses,
Adenoviruses, Human Metapneumovirus and Respiratory Syncytial Viruses.
. Intrinsically resistant to all -lactam agents
. Must be treated with a Macrolide, Fluoroquinolone, or Tetracycline
Health Care Associated Pneumonia
. Associated with hospitalization for 48 h, hospitalization for 2 days in the prior 3 months, residence in a nursing home or extended-care
facility, antibiotic therapy in the preceding 3 months, chronic dialysis, home infusion therapy, home wound care, and contact with a family
member who has a multidrug-resistant (MDR) infection

Ventilator Acquired Pneumonia

Highest hazard ratio in the first 5 days of mechanical ventilation.
Factors important in the pathogenesis are colonization of the oropharynx with pathogenic microorganisms,
aspiration of these organisms to the lower respiratory tract, and compromise of normal host defense mechanisms.

Risk factors: alcoholism, asthma, immunosuppression, institutionalization, age of 70 years

Pneumococcal Pneumonia: dementia, seizure disorders, heart failure, cerebrovascular disease
alcoholism, tobacco smoking, chronic obstructive pulmonary disease and HIV infection.
CA -MRSA pneumonia: skin colonization or infection with CA-MRSA.
Enterobacteriaceae: recently been hospitalized and/or received antibiotic therapy, alcoholism, heart
failure, renal failure.
P. aeruginosa: severe structural lung disease such as bronchiectasis, cystic fibrosis, severe chronic
obstructive pulmonary disease.
Legionella: diabetes, hematologic malignancy, cancer, severe renal disease, HIV infection, smoking
male gender and a recent hotel stay or ship cruise

 Clinical Diagnosis:
fever, chills, sweats, cough (either nonproductive or productive of mucoid, purulent, or blood-tinged sputum),
pleuritic chest pain, and dyspnea.
Other common symptoms include nausea, vomiting, diarrhea, fatigue, headache, myalgia, and arthralgias.
Elderly pts may present atypically, with confusion but few other manifestations.
Physical examination often reveals tachypnea; increased or decreased tactile fremitus; dull or flat percussion
reflecting consolidation and pleural fluid, respectively; crackles; bronchial breath sounds; or a pleural friction rub.
Both confirmation of the diagnosis and assessment of the likely etiology are required.
Chest radiography is often required to differentiate CAP from other conditions
Pneumatoceles = S. aureus, upper-lobe cavitating lesion = tuberculosis
CT of the chest may be helpful for pts with suspected post-obstructive pneumonia.
Sputum samples must have >25 WBCs and <10 squamous epithelial cells per high-power field to be appropriate
for culture.
Urine antigen tests for S. pneumoniae and Legionella pneumophila type 1 can be helpful.
Serology: A fourfold rise in titer of specific IgM antibody can assist in the diagnosis of pneumonia due to some
pathogens
Differential Diagnosis: acute bronchitis, acute exacerbations of chronic bronchitis, heart failure, pulmonary embolism
hypersensitivity, pneumonitis and radiation pneumonitis

Urinary Tract Infection

Most common manifestation of UTI is acute cystitis

Nitrofurantoin: first tolerable and effective agent for the treatment of UTI
Classified as:
A. Asymptomatic bacteriuria (ASB)
B. Cystitis: symptomatic infection of the bladder
C. Prostatis: symptomatic infection of the prostate gland
D. Pyelonephritis: Symptomatic infection of the kidneys
. Uncomplicated UTI: acute cystitis or pyelonephritis in nonpregnant outpatient women without anatomic abnormalities or
instrumentation of the urinary tract
. Complicated UTI
. Occurs more commonly in females than in males
. Neonatal period: slightly higher among males than among females because male infants more commonly have congenital
urinary tract anomalies.
. After 50 years of age: obstruction from prostatic hypertrophy becomes common in men
. Between 1 year and -50 years of age, UTI and recurrent UTI are predominantly diseases of females.
. Independent risk factors for Acute Cystitis: Recent use of a diaphragm with spermicide, frequent sexual intercourse and a
history of UTI
. Healthy postmenopausal women: Sexual activity, diabetes mellitus and incontinence
. Factors independently associated with pyelonephritis in young healthy women include frequent sexual intercourse a new
sexual partner, UTI in previous 1 2 months, maternal history of UTI, diabetes and incontinence
Pathophysiology:
. Bacteria establish infection by ascending from the urethra to the bladder. Continuing ascent up the ureter to the kidney is the
pathway for most renal parenchymal infections. Introduction of bacteria into the bladder does not inevitably lead to sustained
and symptomatic infection. The interplay of host, pathogen and environmental factors determines whether tissue invasion and
symptomatic infection will ensue.
. Bacteria can also gain access to the urinary tract through the bloodstream. Hematogenous spread accounts for <2% of
documented UTIs and usually results from bacteremia caused by relatively virulent organisms (Salmonella and S. aureus)

Etiologic Agent: E. coli (75-90%) most common cause of UTI, Staphylococcus saprophyticus (5 - 1 5 %) younger
women and Klebsiella, Proteus, Enterococcus, Citrobacter species along with other organisms (5 - 1 0%)
Asymptomatic Bacteruria
patient does not have local or systemic symptoms referable to the urinary tract.
clinical presentation is usually that of a patient who undergoes a screening urine culture for a reason unrelated to the
genitourinary tract and is incidentally found to have bacteriuria.

CYSTITIS
Symptoms of dysuria, urinary frequency and urgency
Nocturia, hesitancy, suprapubic discomfort and gross hematuria are often noted as well.
Unilateral back or flank pain is generally an indication that the upper urinary tract is involved.
Fever also is an indication of invasive infection of either the kidney or the prostate.
PYELONEPH RITIS
Mild pyelonephritis can present as low-grade fever with or without lower-back or costovertebral-angle pain
Severe Pyelonephritis: high fever, rigors, nausea, vomiting, flank and/or loin pain.
Fever is the main feature distinguishing cystitis and pyelonephritis.
exhibits a high spiking "picket-fence" pattern and resolves over 72 h of therapy
Papillary necrosis may also be evident in some cases of pyelonephritis complicated by obstruction, sickle cell disease
analgesic nephropathy
A rapid rise in the serum creatinine level may be the first indication
Emphysemaus Pyelonephritis: severe form of the disease that is associated with the production of gas in renal and
perinephric tissues and occurs almost exclusively in diabetic patients
Xanthogranulomatous Pyelonephritis: chronic urinary obstruction (often by stag horn calculi), together with chronic
infection, leads to suppurative destruction of renal tissue On pathologic examination, residual renal tissue frequently has
a yellow coloration with infiltration by lipid-laden macrophages.
PROSTATITIS
Includes both infectious and noninfectious abnormalities of the prostate gland.
Infections can be acute or chronic and are almost always bacterial in nature, and far less common than the noninfectious
entity Chronic Pelvic Pain Syndrome (Chronic Prostatitis) .
Acute Bacterial Prostatitis: dysuria, frequency and pain in the prostatic pelvic or perineal area. Fever and chills are
usually present and symptoms of bladder outlet obstruction are common.
Chronic Bacterial Prostatitis: presents more insidiously as recurrent episodes of cystitis, sometimes with associated
pelvic and perineal pain. Men who present with recurrent cystitis should be evaluated for a prostatic focus.
COMPLICATED UTI
Presents as a symptomatic episode of cystitis or pyelonephritis in a man or woman with an anatomic predisposition to
infection, with a foreign body in the urinary tract, or with factors predisposing to delayed response to therapy.
Diagnostics
Urine dipstick test positive for nitrite or leukocyte esterase can confirm the diagnosis of uncomplicated cystitis.
Detection of bacteria in a urine culture is the diagnostic gold standard for UTI.
Colony count threshold of >102 bacteria/ml is more sensitive (95%) and specific (85%) than a threshold of 105/ml for
the diagnosis of acute cystitis in women with symptoms of cystitis.