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Abstract
Pneumonia is a serious infection and inflammation of the small air sacs of the lung (alveoli) and the tissues around them. The air sacs in the lungs fill with pus and other liquid resulting in impaired gas exchange . Pneumonia affects lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchopneumonia affects patches throughout both lungs.
Elderly patients are affected predominantly by LRTI like acute bronchitis, exacerbations of pre-existent chronic obstructive pulmonary disease (COPD) or, less often, pneumonia , The more serious is pneumonia, which necessitates hospitalization for many elderly patients . The second is non-pneumonic LRTI, which is much more common but has a much more benign clinical course.
The annual incidence of pneumonia in those aged over 60 years has been estimated to be between 25 and 44 cases per 1000, with a rate varying from two to eight times greater than this in subjects of similar age but living in institutions such as residential or nursing homes. Elderly patients are also much more likely to acquire pneumonia in hospital than are those belonging to younger age groups due to many factors including malnutrition, immunosenescence and anatomic and physiological modifications with ageing process.
Community acquired pneumonia remains a leading cause of morbidity and mortality worldwide and has significant financial implication for health care systems, and remains a major reason for admission to hospital and a common cause of death.
Moreover, it was found that in COPD patients, bacterial infections are judged to cause at least half of exacerbations, and it is advised that the choice of antibiotic is important because the rise in bacterial resistance has made older agents less effective.
On the other hand, Nosocomial pneumonia remains one of the most common hospital infections and the most common infection in critically-ill patients. The clinical and economic consequences are considerable, especially in ventilated patients. the incidence of VAP was found to range from about 30%.
Antimicrobial resistance is common and significant among the common pathogens that have been isolated. This alarming situation is due to widespread confusion over the difference between viral and bacterial respiratory infection and use of suboptimal and long duration regimens, which increase the resistant strains.
In this work, two hundred and ten patients were studied in Ain Shams University Hospitals in the period from October 2009 to April 2010 , and they were divided into 4 groups:
GROUP1: Community acquired pneumonia (CAP)
49 patients 23%
GROUP2: Hospital acquired pneumonia(HAP)
42 patients 20%
GROUP3: Ventilator associated pneumonia(VAP)
60 patients 29%
GROUP4: Non pneumonic lower respiratory tract infection
59patients 28%
All patients had sputum culture and sensitivity for aerobic bacteria, identification of cultured organism using standard techniques, and antibiotic sensitivity testing of the isolated pathogens was done by agar disc diffusion method.
Patients with ventilator associated pneumonia were subjected to endotracheal aspiration and or bronchoalveolar lavage by fiberoptic bronchoscopy.
Co-morbid diseases were taken into consideration to detect any possible relation between causative organisms and co-morbidities.
In conclusion, the main results of this work were:
Regarding GROUP1: Community acquired pneumonia (CAP)
* Forty nine patients(23% of studied group) with mean age of 64.88 ±4 years .
* The most common pathogen found was H. Influenza and TB each 18.3% of CAP cases
* The other pathogens includes klebsiella pneumonia and H1N1(16.3%) , pseudomonas aeroginosa(12.2%), streptococcus pneumonia(8%) , E-coli and proteus are (4%) each then Enterobacter(2%).
* The isolated pathogens in CAP group were found to be more sensitive to Macrolides , amoxicillin+clavulonate, co-trimoxazole ,3rd generation cephalosporines and quinolones
* Tuberculous patients received Anti tuberculous chemotherapy.
Regarding GROUP2: Hospital acquired pneumonia(HAP)
* Forty two patients (20% of studied cases) with mean age of 70 ±8years .
* The most common pathogen found was klebsiella pneumonia 24.4% of HAP cases
* The other pathogens includes Acinetobacter (21.8%) , Pseudomonas aeroginosa(19%), MRSA(6.6%), Staphylococcus coagulase positive(9.3%), E-coli (7.1%) finally Enterobacter(4.7%) .
* The isolated pathogens in HAP group were found to be more sensitive to Aminoglycosides in combination with other group of antibiotics, 3rd generation cephalosprines in combination with other antibiotics, Imipenem and Quinolones in combination with other group of antibiotics.
Regarding GROUP3: Ventilator associated pneumonia(VAP)
* Sixty patients( 29% of studied cases) with mean age of 74 ±8years .
* The most common pathogen found was klebsiella pneumonia 25% of VAP cases
* The other pathogens includes Acinetobacter(23.3%), Pseudomonas aeroginosa (21.6%),MRSA (8.3%), E-coli(8.3%), Candida (8.3%) , Staphylococcus coagulase positive (6.6%) and finally proteus(3.3%).
* The isolated pathogens in VAP group were found to be sensitive to Tazobactam+pipercillin, Aminoglycosides, Imipenem, Vancomycin and 3rd generation cephalosporines all were in in combination to other antibiotic group
Regarding GROUP4: Non pneumonic lower respiratory tract infection
* Fifty nine patients (28% of studied cases) with mean age of 67 ± 3years.
* There were 26 cases received empirical antibiotics prior to culture and sensitivity representing 48% of Non pneumonic lower respiratory tract infection. The most common organism found was Streptococcus pneumonia(16% )
* The other pathogens include H.influenza (15.2%), pseudomonas aeroginosa(5%) , acinetobacter(5%) , klebsiella(3.3%), Enterobacter (3.3%) then Proteus, E-coli and H1N1 (1.4%)each .
* The isolated pathogen were found to be sensitive to Macrolides either alone or in combination to other group, also sensitive to amoxicillin +clavulonate and 3rd generation cepahlosporines and Quinolones.
*H1N1 patients received Oseltamivir (Tamiflu).
In this work there were an association between co-morbidities with microorganisms:
* Post-operative patients with pneumonia were 25 patients(11.9% of studied cases). They were mostly infected by gram negative organisms. 28% of post-operative cases were infected by Klebsiella pneumonia followed by Pseudomonas 24% .
* Thirty two patients(15%) showed renal impairment while 28 patients(13%) were in failure and on regular hemodialysis. The microbiological results of the patients with renal impairment showed mainly Klebsiella pneumonia in 28% of patients followed by Acinetobacter in 18% were infected by Acinetobacter , 15.6% were infected by Pseudomonas, and 6% were infected by H1N1. MRSA, E-Coli, TB and candida were found to be (3%)each.
In renal failure patients ,the microbiology of patients showed Staphylococcus coagulase positive in28.5% of renal failure patients followed by gram negative organisms 21.4% , followed by streptococcus Pneumonia in 7%of cases.
* In this study,18 patients had a recent cerebrovascular stroke representing (8.5%)of total cases. The microbiology results in stroke patients was Klebsiella pneumonia representing (43.3%) of stroke patients, Pseudomonas(29.7%) and Acinetobacter(16.6%).
* In this study, there were 102 diabetic patients(48.5%) of studied group. 59 patients (28%) were not controlled . 12 cases (20.3%) of non-controlled patients showed klebsiella pneumonia followed by pseudomonas aeroginosa in 11 cases(18.4%) followed by tuberculosis in 9 cases(15.2%).