pneumonii bacteriene - varianta scurta
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Pneumonii bacteriene
Asist.Univ.Dr.Boroghina Steluta,M.D.
I.C.Fundeni, Clinica Pediatrie 201!201"
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Pneumonii-Def
Pneumoniile reprezinta un ansamblu de leziuni ale parenchimului pulmonar produse prin actiunea unor factori :infectiosi (virusuri, bacterii, rickettsii, fungi ,
protozoare) fizici ( iradiere, soc termic, barotrauma)
chimici ( inhalare de : pulberi, substante
volatile, fluide )
imunologici
Actiunea acestor factori produce leziuni predominant la
nivelul alveolar (alveolita) si al interstitiului pulmonar,
uneori cu afectarea simultana abronsiilor
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Etiologie varsta Nou-nascut 1-3luni 3luni -5ani > 5ani
Stre#tococ grB
Chla$%dia trach
Stre#tococ grB
Chla$%dia trach &#neu$oniae
Stre#tococ grB
Chla$%dia#neu$oniae
'.Coli (ae$o#hilus in) (I (I
*le+siella Stalococ auriu Stalococ auriu Stalococ auriu
Pneu$ococ Pneu$ococ Pneu$ococ
M%co#las$a M%co#las$a M%co#las$a
Urea#las$a
-.res#iratorii -.es# / -S -.es#/-S -.ri#ale
'ntero- 'ntero- Adeno-
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!lasificare Pneumonii
"# Etiologica : virala, bacteriana, fungica, parazitara $# Clinico-radiologic : % &ecomplicata:
PA'
Pneumonie lobara
ronhopneumonie
- !omplicata : Pleurezie
Abces
# Imunologic : Pn primitive
Pn secundare : Pn carinii ,!*+, ++,
!andida , Aspergillus (rganism cu handicap biologic)
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Pneumonia cu Pneumococ Infectia parenchimului pulmonar produsa de pneumococi
Stre#tococcus #neu$oniae3 are ur$atoarele caracteristici :
1)Infectie acuta, 4recvent nesupurativa di4era de/ Sta4, *le+silla,anaero+i3
2)Distributie lobarase!mentara in #ediatria clasica5Pn 4ranca, lo+ara3
63"linic/ de+ut +rusc, caracteristic, evocator
#$I%D%: &'($%in platou 3*-+"
&$I.N unic, /solemn
0NI #.$%"I"
Cel $ai 4recvent agent etiologic 708 ca9uri! se9onul rece
Incidenta 6luni!ani er$ene &, ca#sulat5:se o#une 4agocitarii
Agca#sular5:s#ecicitate de ti#
e;ista <= de seroti#uri 5: 1, ",1=,26 la co#ii
';ista #urtatori sanatosi de #neu$ococ5: rol $inor in dise$inareain4ectiei
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Pneumonia pneumococica
&actori de risc /
disfunctie imunolo!ica
de4cit de sintea de %c / #ri$arhi#oagammaglobulinemie
secundar
.'+,/eucemie
neutropenie disfunctie splenica: asplenie, sicklemie, talasemie
patologie cronica: D, '!!, oala pulm cr
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Pneumonie pneumococica-!linic DEBUT sugar % prodrom 'A!0123 bronhopneumonie
scilatii mari febra, frisoane multiple, alterarea starii
generale , obnubilare, coma, convulsii4- manifestari
e5trarespiratorii : refuzul alimentatiei, varsaturi, tulburari de
tranzit intestinal)
copil mareadult23 60'ADA(febra, frison, 7unghi)
4- tuse
E5amrn fizic: facies 8vultuos9: hiperemia obra7ilor, intens
hiperemici fata de restul tegumentelor faciale, doar un
pomete omonim hiperemic2 semnul accoud
la nivelul buzelor4narinelor se obsv herpes nazolabial, iar limba2 depozit sabural
important
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Pneumonie pneumococica-!linic
6eriada de stare : cu#rinde manifestari de disfunctieventilatorie:
tuse #roductiva cu s#uta ruginie, dis#nee cu gea$at e;#irator scurt,tahi#nee, #oli#nee, +atai #reins#iratorii ari#i na9ale, tira> su+ siintercostal
7 emne 4ice de condensare pulmonara
-di$inuare a$#liatii costale in (? a4ectat, Bronho4onie
vocea@ #lansul se trans$it $ai usor #rin 9ona de
condensare3 $atitate la #ercutie, M- inas#rit 5:su)u
tu+ar , raluri cre#itante ne, in 4ocar
7 emnele !enerale 7 e8trapulmonare
&ebra /in platou, astenie, alterarea starii !enerale,
anore8ie, !returi varsaturi, convulsii, obnubilare9> coma
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Pneumonie pneumococica-!linic Defervescenta !ziua ; de boala ( dupa "<-"= zile)
Ameliorare clinica si paraclinica
1caderea febrei, ameliorarea starii generale,
1caderea leucocitozei si a reactantilor de faza acuta
Complicatii
Infectiaose septicemie , meningita, endocardita, miocardita,pericardita purulenta,
artrita, peritonita, nefrita intrainfectioasa- mai ales la pacientii "plenectomizati,
#I$%,&eutropenici
#emodinamice '!!, !olaps, 6ulburari de ritm cardiac, 1top cardiac
'espiratorii abces pulmonar, fistula bronhopulmonara,, pleurezie parapneumonica,
empiem pleural, ' 0esp 0estrictiva
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Pneumonie pneumococica-
Paraclinic
( / leucocito9a& neutrolie eactanti de 4a9a acuta&&/ CP, -S(, F+ Astru#/ acido9a res#iratorie5: $eta+olica (e$ocultura& 608 din ca9uri
Biochi$ie 'lectro4ore9a #roteine serice/ $ globuline > 1puta?? 1@
0adiologic: opacitate triunghiulara, cu margini nete, bazala periferie si vf in hil, intensitate subcostala, omogena,fara caracter retractil de impingere contralaterala amediastinului
- 0areori asociaza pleurezie parapneumonica
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Pneumonie pneumococica 05
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Pneumonie pneumococica
Dia!nostic poitiv:
CIIC / De+ut evocator4e+ra, 4rison, >unghi3&tuse cu e;#ectoratie ruginiela un +olnav cu se$ne 9ice de condensare #ul$onara
PAACIIC/ in)a$atie acuta, he$oculturi #o9itive, ; #ul$onar/condensare lo+ara@ $ultilo+ara
'-U?I' /
Buna, vindecarea se #roduce du#a a#ro; 6!= as#ta$ani cu Erestitutio inintegru$
Factorii de #rognostic ne4avora+il/
In4ectia cu seroti# 6, +acterie$ie&, s#lenecto$ie@as#lenie
4unctionala, icterul, 4o$a $ultilo+ara, hi#o?A &
co$#licatii e;tra#ul$onare/ $eningita,endocardita,artrita
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Pneumonie pneumococica-6ratament Internare
Igienodietetic /
egi$ ali$entar cores#un9ator varstei@ re#aus digestiv total& nutritie #arenterala! daca ave$ detresa res#
P'- #t ('
;igenotera#ie
Drena> #ostural G #rin schi$+area #o9itiei la ecare 2 ore
Po9itie se9anda@ #e (? cu #leure9ie
'tiolo!ic: AB! Pneu$ococul nu are re9istenta #rin #rocesul de sinte9a a+etalacta$a9elor
Pen D9/ 200000 UI@Hg@9i I- la " h 5: esec tera#eutic U Alte B lacta$ine#t ca #neu$ococul5 re9istenta $ediata cro$o9o$ial
Ce4uro;i$@Ce4tria;on 100$g@Hg@9i la 12 ore &@!
-anco$icina =0$g@Hg@9i la " ore
?iena$teico#lanina!cilastatin3 #acienti riguros selectati
Durata 10!1= 9ile
imptomatic : antitermice, anal!eice, sedative, antitusive
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Pneumonie pneumococica
Prola;ie/
#acientii cu risc crescut/ sindroa$e cu as#lenie
S#lenecto$i9ati Dre#anocito9a
I$unodeciente etc
-accinare anti#neu$ococica #neu$o26
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Pneumonia stafilococica
Pneu$onia cau9ata de staloccus aureus este o a4ectiune grava,cu evolutie ra#ida
Frecvent in anoti$#ul rece
608 6 luni , J08 :1an
Precedata adesea de IACS
S aureus! in $od nor$al loc #e #iele si $ucoase, #urtatoriisanatosi5 sursa de conta$inare a $ediului 20!608 adulti, 60!08dintre co#ii "ani35:Boala a#are la #ersoanele conta$inateatunci cand are loc Krezistentei organismului
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Pneumonie stafilococica Stalococii /
Coci &, i$o+ili, aero+i
As#ectul culturilor5: 2 gru#e/ Coagula9o !@&
Sta4 auriu / coagula9o & #roduce o serie de en9i$e3 5:#roducnecro9a tisulara, distructie leucocite, he$oli9a eritrocite
?o;ina e;4oliativa care este #rodusa de unele tul#ini #roduce +oalaitterEscalded sHin s%ndro$3 sindro$ul #ielii o#arite
Unele tul#ini #roduc enteroto;ine5: $ani4estari garstro!intestinalesi de hi#o?A #ro4unda
?SS?!1 to;ic shocH s%ndro$ to;in1! codicata genetic
Stalococii coagula9o ! 5: in4ectii gravese#tice$ia3 la nou!nascut&
i$unoco$#ro$isi
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1calded 1kin 1ndrom (111)
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Pneumonie stafilococica
actori favorizanti
acient anterior sanatos, dupa *oli anergizante 0u7eola, +aricela, Bripa, 6use
!onvulsiva
acienti cu *oli pree+istente
eucemii, i*roza chistica, Colagenoze, 'munodeficiente(in special .iper
'gE4deficit functional granulocite)
Distrofia, C
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Pneumonie stafilococica
AAM'LA /
Uneori istoric de le9iuni stalococice cutanate lasugar@$e$+rii 4a$iliei
APP recente IACS!in ur$a cu o sa#ta$ana
CIIC /
De+ut/ +rusc cu 4e+ra inalta, alterare stare generala,tuse, instalare ra#ida a detresei res#iratorii si
insucienta circulatoricola#s3
i fil i if i
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Pneumonie stafilococica-*anifestari 'N'$%;' :
Stare generala grava, as#ect to;ic
Fe+ra inalta@ hi#oter$ie & 4risoane
?egu$ente #elid!cenusii! ciano9a
Perioade de letargie! alternand cu agitatie
$'6I$%#.$II:
Sugar@co#il $ic/ ?use, ?ahi#nee, ea$at e;#irator, Batai ari#ina9ale ,tira> IC, SC, ciano9a
Co#il $are/ >unghi toracic, s#uta #iosangvinolenta
IND$.< D' ".ND'N%$' 6;<
Su+$atitate, res#iratie su)anta, +ronho4onie, raluri cre#itante
locali9ate
IND$.< 6;'$'#I" :
Matitate 4ranca,a+olirea vi+ratii vocale si a M-, su)u #leuretic,a$ liatii ul$ K (? a4ectat, e$9e$ cutanat! cre itatii la
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Pneumonie stafilococica !linic
MAIF'S?AI ''A'
MAIF'S?AI 'SPIA?II /
!SD D' CD'SA' PUM
!SD P'U'?IC
&
S'M' D' ICC@hi#odiastolica
S'M' D' CAPS
MAIF'S?AI DI'S?I-' / ina#etenta,varsaturi, diaree, $eteoris$
a+do$inal
Pulso;i$etriahi#o;e$ia se corelea9a cu gravitatea #neu$oniei
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Pneumonie stafilococica-Paraclinic
( / eucocito9a cu neutrolie, ane$ie leuco#enie! se$n de #rognostic grav
eactanti de 4a9a acuta &
(e$ocultura& in 20!=08 ca9uri
Culturi +acteriene din as#irat
Pctie Pleurala/ #uroi gros, gal+ui, lichid #iosanguinolent
'co a+d
; #ul$onar /
In stadiile initiale $odicarile sunt necaracteristice ?oracocente9a! PP! lichid citologie, chi$ie, +acteriologie
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Pneumonie stafilococica Evolutie
Sta4 5: Bronho#neu$onia con)uenta, adesea unilaterala5:4ocarele de condensare a+cedea9a5: A+ces5: #er4orare&#atrundere aer in t con>unctiv su+#leural5: #neu$atocele5:e4ractie5: #io#neu$otora;
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Pneumonie stafilococica- Dg4 Diagnostic #o9itiv / 13Ancheta e#ide$iologica/
! s#itali9are recenta #t o in4ectie e;trares#iratorie
! #ioder$ita in APP recente
23Clinic
!ta+lou de Pneu$onie severa, cu stare to;ica, ane$ie
! 'volutia ra#ida a si$#to$elor
63 adiologic
! Progresivitatea le9iunilor radiologice
! Modicari ; de ti#/ evarsat #leural,
Pio#neu$otorace
Pneu$atocele
DIAS?ICU D' C'?I?UDI'
! Cultura din lichid #leural
! (e$ocultura
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Pneumonie stafilococica
Diagnostic di4erential /
Cu / Pneu$onii co$#licate cu #leure9ie
Pneu$onii a+cedate
Pn cu Stre#tococcus #neu$oniae
Pn cu Stre#tococ gru# A
Pn cu *le+siella
Pn cu (ae$o#hilus in)uen9ae
?BC #ul$onar
Pneumonie stafilococica 6ratament
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Pneumonie stafilococica-6ratament
1. Functie de gravitatea +olii5: Monot@Bi@?ritera#ie
2. Ad$inistrare I-
6. Initial e$#iric, se continua daca du#a J2 ore de laintroducere se o+tine a4e+rilitate@ se schi$+a 4unctie
de re9ultatul culturii si A+gra$a
=.Pri$a intentie / M'?ICIIA @ AFCIIA,
CIDAMICIA,
CS I C'FALI3,
AMIICLID'
. Pt tul#ini $eticilino!re9istente / -ACMICIA@
?'ICPAIA
". U 'ste ecient daca nu se drenea9a conco$itent cavitatea #leurala
J.For$e usoare@ $edii Monotera#ie ACIIA
D9 / 100!200$g@Hg@9i la "h
For$e severe @$eticilinre9istente
-ACMICIA =0$g@Hg@9i la "h &@!'?AMICIA $g@Hg@9i
la 12h
<.Durata , 4 de evolutia clinico!radiologica, a#ro; 6!"sa#ta$ani
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Pneumonie stafilococica
Evolutie,!omplicatii,Prognostic Pneumonie stafilococica2 A/A 1E+E0ACC
Evolutie indelungata
Prognostic imprevizibil
0ata mortalitate "$-"
!omplicatii:
6F'!E: Anemie hemolitica, !'D, .epatita reactiva to5ica, &efropatie to5ica
1EP6'!E: 1epticemie, Pericardita, Endocardita, Artrita,steomielita, *eningita, Abces cerebral, Abces subcutanat
*E!A&'!E (P&E@*60A!E)
'! hipodiastilica
Pahipleurita
i hil i fl
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Pneumonia cu .aemophilus influenzae
elativ 4recventa la varste $ici J08din tot Pn +acteriene 2ani3
De+utea9a cu si$#to$e de IACS
Clinic 5 ase$anator cu Pn #neu$ococica, dar de+ut $ai #utin+rusc si si$#to$atologie cu evolutie $ai lenta
08 se co$#lica cu Pleure9ie
In evolutie #oate asocia alte detre$inari/ Meningita
'#iglotita
?rata$ent de #ri$a intentie/ ce4uro;i$ 100$g@Hg@9i la 12 ore
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Pneumonia cu Pneumocstis
carinii In4ectia #ul$onara cu Pneu$oc%stis >iroveci este cea $ai 4recventa in4ectie cu
agenti o#ortunisti la #acientii cu SIDA
Anali9a +iochi$ica a secventei aci9ilor nucleici5 4ung u din 4a$ #roto9oare
A#are si la i$unode#ri$atii #rin alte $ecanis$e decat in4ectia (I-/
Boli oncologice ?rata$ent i$unosu#resiv de e;/#osttrans#lant3
I$unodeciente #ri$are
i$4o$ (odHin
PM cu varsta gestationala 4oarte $ica
Sugari atre#sici
In SUA incidenta anuala PCP la #acientii cu SIDA este de 60!=08
A4ectiune e;tre$ de severa , rata de deces la ecare nou e#isod ind de 208, in ca9ul#acientilor cu in4ectie (I-
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Pneumonia cu Pneumocstis carinii
Clinic / discre#anta intre Esaracia ano$aliilor o+tinute la e;a$enulclinicii 4ara raluri, M- #re9ent, cel $ult di$inuat3 si Edra$atis$uldetresei res#iratorii / tahi#nee severa, +alans toraco!a+do$inal, +ataiari#i na9ale, gea$at e;#irator scurt, $iscari a$#le de #iston ale ca#ului,tuse ne#roductive
';a$enul radiologic / ano$alii severe, +ilaterale di4u9e, i$agini$icro@$acronodulare la i$agini o#ace con)uente de gea$ E$at,regiunile a#icale #ul$onare sunt in general ulti$ele a4ectate
Unii #acienti ano$alii radiologice date de co$#licatii $ecanice /
Pneu$otora; cu s#ect de Eca#atana de 9ahar+ontul #ul$onar nu ecola+at in hil,datorita induratiei e;tre$e3
Pneu$o$ediastin aer 4u9at in tesutul celular su+cutanat de la +a9a gatului3
P i P i i ii
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Pneumonia cu Pneumocstis carinii
Di!anostic de certitudine/ #e +a9a i9olarii din/As#iratul +ronsicBA5+ronchoalveolar lavage3 Bio#sie trans+ronsica +ronhosco#ica
Punctie #ercutana transtoracica Bio#sie #ul$onara deschisa
& CA?II SP'CIFIC' ie$sa, Al+astru de toluidina, i$#regnare argentica
?ehnica $ai ela+orata de Dg& / 4olosirea Ac $onoclonali #entru $icrosco#ia c
P i
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Pneumocistoza
1. Co$+aterea hi#o;e$iei e;tre$e
2. ?rata$ent etiologic
C?IMAL SM@?MP3
Considerat de FDA5 trata$ent de electie3
D9/ 20$g@Hg@9i I- ?MP 3 divi9at in = #ri9e
&@! DAPSA, A?-ANUA
PIMANUIA& CIDAMICIA
sau P'?AMIDIA
6.Prola;ie /
C?IMAL $g@Hg@9i 9ilnic@ la 2 9ile
J$g@Hg@9i la 6 9ile
DAPSA #o 9ilnicP'?AMIA 600$g@"cc SF ;1@luna
!#rola;ia va continuata atata ti$# cat #acientul are i$unode#resie severa cuniveluri de CD=&200@$$6
Daca CD=&:600@$$6 se $entin #e o durata #este 6luni se #oate o#ri #rola;ia
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-A MU?UM'SC
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'nsuficienta respiratorie acuta
CI?'II
(i#o;e$ie Po2 "0$$(g sau Sat 2 728
(i#erca#nie Pco2: 0$$(g
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'nsuficienta respiratorie acuta
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