1 Pneumoniile

7/26/2019 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


3/72

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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)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&



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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



8/72

!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



9/72

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


10/72

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


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


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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(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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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


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


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



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)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


TratamentTratament


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PNEUMONIAPNEUMONIA


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


38/72

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


40/72

)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




41/72

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

++**




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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


43/72

;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


AnatomopatologieAnatomopatologie


44/72

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


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


'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 +



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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




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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


'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



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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



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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



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#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


(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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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


)$lamidia)$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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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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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



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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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