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8/4/2019 CAP by Dr Sarma
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Dr. R V S N Sarma., MD., MSc., (Canada)
Consultant Physician & Chest Specialist
visit us at: www.drsarma.in
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The New Treatment Paradigm –
Selecting Appropriate Empiric Antibiotics
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Pneumonias – Classification
• Community Acquired
CAP
• Health Care Associated
HCAP
• Hospital Acquired
HAP
• ICU Acquired
ICUAP
• Ventilator Acquired
VAP
Nosocomial Pneumonias
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Community Acquired Pneumonia (CAP)
Definition
… an acute infection of the pulmonary parenchyma
that is associated with some symptoms of acute
infection, accompanied by the presence of an acute
infiltrate on a chest radiograph, or auscultatory
findings consistent with pneumonia, in a patient not
hospitalized or residing in a long term care facility
for > 14 days before onset of symptoms.
Bartlett. Clin Infect Dis 2000;31:347-82.
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Guidelines for CAP
American Thoracic Society (ATS)
Guidelines - Management of Adults with CAP (2001)
Infectious Diseases Society of America (IDSA)
Update of Practice Guidelines Management of CAP
in Immuno-competent adults (2003)
ATS and IDSA joint effort (we will follow this)
IDSA/ATS Consensus Guidelines on the
Management of CAP in Adults (March 2007)
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Evidence-based practice Best outcome for patients
Best use of resource
Restricts idiosyncratic behaviour
Legal protection
Identify research needs
A tool for education
Gain public confidence
Why Guidelines?
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CAP – The Two Types of Presentations
Classical
• Sudden onset of CAP
• High fever, shaking chills
• Pleuritic chest pain, SOB
• Productive cough
• Rusty sputum, blood tinge
• Poor general condition• High mortality up to 20% in
patients with bacteremia
• S.pneumoniae causative
• Gradual & insidious onset
• Low grade fever
• Dry cough, No blood tinge
• Good GC – Walking CAP
• Low mortality 1-2%; except
in cases of Legionellosis• Mycoplasma, Chlamydiae,
Legionella, Ricketessiae,
Viruses are causative
Atypical
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CAP – Pathogenesis
Inhalation
Aspiration
Hematogenous
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Age
Obesity; Exercise is protective
Smoking, PVD Asthma, COPD
Immuno-suppression, HIV
Institutionalization, Old age homes etc Dementia
CAP – Risk Factors for Pneumonia
ID Clinics 1998;12:723. Am J Med 1994;96:313
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Community Acquired Pneumonia (CAP)
Epidemiology
4-5 million cases annually
~500,000 hospitalizations – 20% require admission
~45,000 deaths
Fewest cases in 18-24 yr group
Probably highest incidence in <5 and >65 yrs
Mortality disproportionately high in >65 yrs
Over all mortality is 2-30%; Hospitalized Pt mort
<1% for those not requiring hospitalization
Bartlett. CID 1998;26:811-38.
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CAP – The Pathogens Involved
56%
10%
6%
6%
5%
4%
4%
9%
S.pneumoniae
H.influenza
Chlamydia
Legionella spp
S.aureus
MycoplasmaGram Neg bacilli
Viruses
40-60% - No causative agent identified
2-5% - Two are more agents identified
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Streptococcus pneumonia(Pneumococcus)
Most common cause of CAP
About 2/3 of CAP are due to S.pneumoniae
These are gram positive diplococci
Typical symptoms (e.g. malaise, shaking chillsfever, rusty sputum, pleuritic chest pain, cough)
Lobar infiltrate on CXR
May be Immuno suppressed host
25% will have bacteremia – serious effects
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CAP – Special Features – Pathogen wise
Typical – S.pneumoniae, H.influenza, M.catarrhalis – Lungs
Blood tinged sputum - Pneumococcal, Klebsiella, Legionella
H.influenzae CAP has associated of pleural effusion
S.Pneumoniae – commonest – penicillin resistance problemS.aureus, K.pneumoniae, P.aeruginosa – not in typical host
S.aureus causes CAP in post-viral influenza; Serious CAP
K.pneumoniae primarily in patients of chronic alcoholismP.Aeruginosa causes CAP in pts with CSLD or CF, Nosocom
Aspiration CAP only is caused by multiple pathogens
Extra pulmonary manifestations only in Atypical CAP
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S. aereus CAP – Dangerous
This CAP is not common; Multi lobar Involvement
Post Influenza complication, Class IV or V
Compromised host, Co-morbidities, Elderly
CA MRSA – A Problem; CA MSSA also occurs
Empyema and Necrosis of lung with cavitations
Multiple Pyemic abscesses, Septic Arthritis Hypoxemia, Hypoventilation, Hypotension common
Vancomycin, Linezolid are the drugs for MRSA
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CAP – Age wise Incidence
0
200
400
600
800
1000
1200
1400
<5 5 to 17 18-24 25-44 45-64 >65
# of cases
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CAP – Age wise Mortality
0
10
20
30
40
50
60
70
80
<4 5 to 14 15-24 25-44 45-64 >65
0 0 02
5.7
74.9
# of deaths
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Older, Unemployed, Unmarried
Recurrent common cold
Asthma, COPD; Steroid or bronchodilator use Chronic diseases, Diabetes, CHF, Neoplasia
Amount of smoking
Alcohol is NOT related to increased risk for hospitalization
CAP – Risk Factors for Hospitalization
ID Clinics 1998;12:723. Am J Med 1994;96:313
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Age > 65
Bacteremia (for S. pneumoniae)
S. aureus, MRSA , Pseudomonas
Extent of radiographic changes
Degree of immuno-suppression
Amount of alcohol consumption
CAP – Risk Factors for Mortality
ID Clinics 1998;12:723. Am J Med 1994;96:313
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CAP – Bacteriology in Hospitalized Pts
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CAP – Evaluation of a Patient
Hx. PE, CXR
No Infiltrate
Alternate Dx.
Infiltrate or Clinical
evidence of CAP
Evaluate needfor Admission
PORT &CURB 65
OutPatient
MedicalWard
ICU Adm.
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CAP – Management Guidelines
Rational use of microbiology laboratory
Pathogen directed antimicrobial therapy
whenever possible Prompt initiation of Antibiotic therapy
Decision to hospitalize based on
prognostic criteria - PORT or CURB 65
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PORT Scoring – PSI
Clinical Parameter Scoring
Age in years Example
For Men (Age in yrs) 50
For Women (Age -10) (50-10)
NH Resident 10 points
Co-morbid Illnesses
Neoplasia 30 points
Liver Disease 20 points
CHF 10 points
CVD 10 points
Renal Disease (CKD) 10 points
Clinical Parameter Scoring
Clinical Findings
Altered Sensorium 20 points
Respiratory Rate > 30 20 points
SBP < 90 mm 20 points
Temp < 350 C or > 400 C 15 points
Pulse > 125 per min 10 points
Investigation Findings
Arterial pH < 7.35 30 points
BUN > 30 20 points
Serum Na < 130 20 points
Hematocrit < 30% 10 points
Blood Glucose > 250 10 points
Pa O2 10 points
X Ray e/o Pleural Effusion 10 points
Pneumonia Patient Outcomes
Research Team (PORT)
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Classification of Severity - PORT
Predictors Absent
ClassI
70
ClassII
71 – 90
ClassIII
91 - 130
Class
IV> 130
Class
V
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CAP – Management based on PSI Score
PORT Class PSI Score Mortality % Treatment Strategy
Class I No RF 0.1 – 0.4 Out patient
Class II 70 0.6 –
0.7 Out patient
Class III 71 - 90 0.9 – 2.8 Brief hospitalization
Class IV 91 - 130 8.5 –
9.3 Inpatient
Class V > 130 27 – 31.1 IP - ICU
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CURB 65 Rule – Management of CAP
CURB 65
Confusion
BUN > 30
RR > 30
BP SBP <90
DBP <60Age > 65
CURB 0 or 1 Home Rx
CURB 2 Short Hosp
CURB 3 Medical Ward
CURB 4 or 5 ICU care
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Algorithmic Approach
CAP Patient
< 50 YearsNo
Co-morbidity
No CURB
Class I
Only OP
CURB +
OP / IP/ICU
Class II-V
Co-morbidity
Present
50 Years
PORT
Step 1Step 2 Step 3
Step 4
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Who Should be Hospitalized?
Class I and II Usually do not require hospitalization
Class III May require brief hospitalization
Class IV and V Usually do require hospitalization
Severity of CAP with poor prognosis
RR > 30; PaO2/FiO2 < 250, or PO2 < 60 on room air
Need for mechanical ventilation; Multi lobar involvement
Hypotension; Need for vasopressors
Oliguria; Altered mental status
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CAP – Criteria for ICU Admission
Major criteria
Invasive mechanical ventilation required
Septic shock with the need of vasopressors
Minor criteria (least 3)
Confusion/disorientation
Blood urea nitrogen ≥ 20 mg%
Respiratory rate ≥ 30 / min; Core temperature < 36ºC
Severe hypotension; PaO2/FiO2 ratio ≤ 250
Multi-lobar infiltrates
WBC < 4000 cells; Platelets <100,000
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CAP – Laboratory Tests
• CXR – PA & lateral
• CBC with Differential
• BUN and Creatinine
• FBG, PPBG
• Liver enzymes
• Serum electrolytes
• Gram stain of sputum
• Culture of sputum
• Pre Rx. blood cultures
• Oxygen saturation
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CAP – Value of Chest Radiograph
• Usually needed to establish diagnosis
• It is a prognostic indicator • To rule out other disorders
• May help in etiological diagnosis
J Chr Dis 1984;37:215-25
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Infiltrate Patterns and Pathogens
CXR Pattern Possible Pathogens
Lobar S.pneumo, Kleb, H. influ, Gram Neg
Patchy Atypicals, Viral, Legionella
Interstitial Viral, PCP, Legionella
Cavitatory Anerobes, Kleb, TB, S.aureus, Fungi
Large effusion Staph, Anaerobes, Klebsiella
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CAP – Gram’s Stain of Sputum
Efficiency of test S. pneumoniae H. influenza
Sensitivity 57 % 82 %
Specificity 97 % 99 %
Positive Predictive Value 95 % 93 %
Negative Predictive Value 71 % 96 %
Good sputum samples is obtained only from 39%
83% show only one predominant organism
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Pathogens Retrieved from Blood Culture
68%
16%
11%5%
S.pneumoniae
Enterobacteria
Staph.aureus
Others
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Mortality of CAP – Based on Pathogen
P. aeruginosa - 61.0 %
K. pneumoniae - 35.7 %
S. aureus - 31.8 % Legionella - 14.7 %
S. pneumoniae - 12.0 %
C. pneumoniae - 9.8 %
H. influenza - 7.4 %
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Traditional Treatment Paradigm
Conservative start with ‘workhorse’ antibiotics
Reserve more potent drugs for non-responders
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New Treatment Paradigm
Hit hard and early with appropriate antibiotic(s)
Short Rx. Duration; De-escalate where possible
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Objective 2Objective 1
Avoid emergence
of
multidrug resistant
microorganisms
Immediate Rx.
of patients with
serious sepsis
The Therapy Conundrum
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Inappropriate therapy (%)
0
30
50
10
CAP
20
40
HAP HAP on CAP
17
34
45
Kollef, et al. Chest 1999;115:462 –474
The Effect of the Traditional Approach
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New data – Don’t Wait for Results !
Switching after
susceptibility results
p<0.001
Adequate treatment
within „a few hours‟
Mortality (%) n=75
Tumbarello, et al. Antimicrob Agents Chemother 2007;51:1987 –1994
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Risk assessment approach
Early Antibiotic selection
Change treatment driven by localsurveillance
Hit hard and hit early
As short a duration as possible De-escalate when and where possible
CAP Treatment Consensus
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OPAT – OP Parenteral Antimicrobial Therapy
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Antibiotics of choice for CAP
Macrolide -M
• Azithromycin
• Clarithromycin
• Erythromycin
• Telithromycin
• Doxycycline
Fluroquinolone-FQ
• Levofloxacin• Moxifloxacin
• Gatifloxacin
• Trovafloxacin
Betalactum -
B
• Ceftriaoxone
• Cefotaxime
• B Inhibitor -
BI• Sulbactam
• Tazobactam
• Piperacillin
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Antibiotic Dosage, Route, Frequency and Duration
Doxyclycline 100-200 mg PO/IV BID for 7 to 10 days
Azithromycin 500 mg OD IV –3 days + 500 mg OD PO for 7-10 daysClarithromycin 250 – 500 mg BID PO for 7 – 14 days
Telithromycin 800 mg PO OD for 7 – 10 days
Levofloxacin 750 mg PO/IV OD for 5 days
Gatifloxacin 400 mg PO or IV OD for 5 to 7 days
Moxifloxacin 400 mg PO or IV OD for 5 to 7 days
Gemifloxacin 320 mg PO OD for 5 – 7 days
Amoxyclav 2 g of Amoxi +125 mg of Clauv PO BID for 7 to 10 days
Ceftriaxone 2 g IV BID for 3 to 5 days + PO 3G CS
Ertapenum 1 g OD IV or IM for 7 to 14 days
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Empiric Treatment – Outpatient
Healthy and no risk factors for DR S.pneumoniae1. Macrolide or Doxycycline
Presence of co-morbidities, use of antimicrobials
within the previous 3 months, and regions with a
high rate (>25%) of infection with Macrolide
resistant S. pneumoniae
1. Respiratory FQ – Levoflox, Gemiflox or Moxiflox
2. Beta-lactam (High dose Amoxicillin, Amoxicillin-Clavulanate is preferred; Ceftriaxone, Cefpodoxime,
Cefuroxime) plus a Macrolide or Doxycycline
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Empiric Treatment – Inpatient – Non ICU
1. A Respiratory Fluoroquinolone (FQ) Levo or
2. A Beta-lactam plus a Macrolide (or Doxycycline)
(Here Beta-lactam agents are 3 Generation
Cefotaxime, Ceftriaxone, Amoxiclav)
3. If Penicillin-allergic Respiratory FQ or
Ertapenem is another option
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Empiric Treatment: Inpatient in ICU
1. A Beta-lactam (Cefotaxime, Ceftriaxone,
or Ampicillin-Sulbactam) plus
either Azithromycin or Fluoroquinolone
2. For penicillin-allergic patients, a respiratory
Fluoroquinolone and Aztreonam
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Empiric Rx. – Suspected Pseudomonas
1. Piperacillin-Tazobactam, Cefepime, Carbapenums
(Imipenem, or Meropenem) plus either Cipro or Levo
2. Above Beta-lactam + Aminoglycoside + Azithromycin
3. Above Beta-lactam + Aminoglycoside + an
antipseudomonal and antipneumococcal FQ
4. If Penicillin allergic - Aztreonam for the Beta-lactam
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Empiric Rx. – CA MRSA
For Community Acquired Methicillin-Resistant
Staphylococcus aureus (CA-MRSA)
Vancomycin or Linezolid
Neither is an optimal drug for MSSA For Methicillin Sensitive S. aureus (MSSA)
B-lactam and sometimes a respiratory
Fluoroquinolone, (until susceptibility results). Specific therapy with a penicillinase-resistant
semisynthetic penicillin or Cephalosporin
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Duration of Therapy
• Minimum of 5 days
• Afebrile for at least 48 to 72 h
• No > 1 CAP-associated sign of clinical instability
• Longer duration of therapy
If initial therapy was not active against the identified
pathogen or complicated by extra pulmonary infection
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New data – The Speed of Delay ! (Class 4,5)
0
10
20
30
40
50
60
70
80
90
0.5 1 2 3 4 5 6
Delay in treatment (hours) from hypotension onset
S u r v i v a l ( % )
Each hour of delay carries
7.6% reduction in survival
Kumar, et al. Crit Care Med 2006;34:1589 –1596
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CAP – Summary of Empiric Treatment
Outpatient Rx – any one of the three
• Macrolide or Doxycycline or Fluoroquinolone
Patients in General Medical Ward
• 3rd Generation Cephalosporin + Macrolide• Betalactum / B-I + Macrolide or B / B-I + FQ
• Fluroquinolone alone
Patients in ICU• 3GC + Macrolide or 3GC + FQ
• B/B-I + Macrolide or B/B-I + FQ
IDSA guidelines: Clin Infect Dis 2000;31:347-82
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CAP – Treatment Summary
CAP Class Site of Care Treatment 1 Treatment 2 Treatment 3
Class I OP AZ CLR ER / Doxy
Class II OP FQ B + M B + Doxy
Class III OP + IP FQ IV I V - B + AZ Aztreo + FQ
Class IV Med Ward FQ + AZ B 3G + AZ Etrap + M
Class V ICU B 3G + AZ B 3G + FQCarbepenum
Sulbac ,Tazob
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Strategies for Prevention of CAP
• Cessation smoking
• Influenza Vaccine (Flu shot – Oct through Feb)
It offers 90% protection and reduces mortality by 80%
• Pneumococcal Vaccine (Pneumonia shot)
It protects against 23 types of Pneumococci
70% of us have Pneumococci in our RT
It is not 100% protective but reduces mortality
Age 19-64 with co morbidity of high for pneumonia
Above 65 all must get it even without high risk
• Starting first dose of antibiotic with in 4 h & O2 status
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Switch to Oral Therapy
Four criteria Improvement in cough, dyspnea & clinical signs
Afebrile on two occasions 8 h apart
WBC decreasing towards normal
Functioning GI tract with adequate oral intake
If overall clinical picture is otherwise favorable,
hemodynamically stable; can switch to oral
therapy while still febrile.
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Management of Poor Responders
Consider non-infectious illnesses
Consider less common pathogens
Consider serologic testing Broaden antibiotic therapy
Consider bronchoscopy
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CAP – Complications
Hypotension and septic shock
3-5% Pleural effusion; Clear fluid + pus cells
1% Empyema thoracis pus in the pleural space
Lung abscess – destruction of lung - CSLD
Single (aspiration) anaerobes, Pseudomonas
Multiple (metastatic) Staphylococcus aureus
Septicemia – Brain abscess, Liver Abscess
Multiple Pyemic Abscesses
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Pneumocystis carinii (PCP)
Important cause of pneumonia in the severely
immuno-compromised, i.e. not a “primary atypical
pneumonia”.
Classically PCP pneumonia presents with slight fever,
dyspnea and non-productive cough
Diagnosis – usually histological (silver staining).
Treatment – Co-trimoxazole or Pentamidine.
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Viruses and Pneumonia
Pneumonia in the normal host
• Adults or Children
• Influenza A and B, RSV, Adenovirus Para Influenza
Pneumonia in the immuno-compromised• Measles, HSV, CMV, HHV-6, Influenza viruses
• Can cause a primary viral pneumonia. Cause partial
paralysis of “mucociliary escalator” - increased risk of
secondary bacterial LRTI. S.aureus pneumonia is a
known complication following influenza infection.
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CAP – So How Best to Win the War?
Early antibiotic administration within 4-6 hours Empiric antibiotic Rx. as per guidelines (IDSA / ATS)
PORT – PSI scoring and Classification of cases
Early hospitalization in Class IV and V
Change Abx. as per pathogen & sensitivity pattern
Decrease smoking cessation - advice / counseling
Arterial oxygenation assessment in the first 24 h Blood culture collection in the first 24 h prior to Abx.
Pneumococcal & Influenza vaccination; Smoking X
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Normal CXR & Pneumonic Consolidation
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Lobar Pneumonia – S.pneumoniae
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CXR – PA and Lateral Views
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Lobar versus Segmental - Right Side
b P i
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Lobar Pneumonia
S i l f f C lid ti
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Special forms of Consolidation
R d P i C lid ti
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Round Pneumonic Consolidation
S i l F f P i
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Special Forms of Pneumonia
S i l F f P i
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Special Forms of Pneumonia
C li ti f P i
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Complications of Pneumonia
E
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Empyema
M l P i
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Mycoplasma Pneumonia
M l P i
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Mycoplasma Pneumonia
Chl di T h ti
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Chlamydia Trachomatis
Rare T pes of Pne monia
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Rare Types of Pneumonia
शोम शतेनैव न कडऱेन
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शोम ् श ुतनव न क ु डऱन दानेन पािणर ् नत ु किकेन वभात कायः किा पिराा परोपकारेि न चदनेन
shrothram shruthae naiva na kundalaena
dhaanaena paanir na thu kankanaena
vibhaathi kaayah karunaa paraanaam
paropakaaraena na chandanaena
BHARTHRU HARI
Hearing science glorifies the ears, nay diamond ear-rings
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Hearing science glorifies the ears, nay diamond ear rings Giving to the needy enriches the hand, nay golden bangles
To be kind and sympathetic and helping in all possible ways
Enriches the beauty of our body, nay perfume or sandal paste
shrothram shruthae naiva na kundalaena
dhaanaena paanir na thu kankanaena
vibhaathi kaayah karunaa paraanaam
paropakaaraena na chandanaena