PNEUMONIA

Pneumonia is inflammation (swelling) of the tissue in one or both of your lungs. It is usually caused by an infection. Classification and causes 1) Community-acquired is when you get pneumonia from contact with germs you encounter in the course of your normal routine May be primary, or secondary to underlying disease Streptococcus pneumoniae is the commonest cause, followed by Haemophilus influenzae and Mycoplasma pneumoniae (commonly presents as a dry cough) Staphylococcus aureus, Legionella species (via water tank) and Chlamydia (via person-person) account for most of the remainder Gram negative bacilli, Coxiella burnetii (Q-fever) and anaerobes are rare In patients with COPD, Moraxella catarrhalis and Pseudomonas infection also occur Viruses (e.g influenza) account for up to 15%

2) Hospital acquired (nosocomial) is an infection of the lungs contracted during a hospital stay 48h after hospital admission Most commonly Gram negative enterobacteria or Staphylococcus aureus Also Pseudomonas, Klebsiella, Bacteroides and Clostridia

3) Aspiration is an inflammation of the lungs and bronchial tubes caused by inhaling foreign material, usually food, drink, vomit, or secretions from the mouth into the lungs. This may progress to form a collection of pus in the lungs (lung abscess) Occurs due to the aspiration of gastriointestinal material due to an inability to protect the airway (Mendelsons syndrome), anaerobic organisms may be implicated Those with stroke, myasthenia, bulbar palsies, decreased consciousness (e.g. post-ictal or drunk), oesophageal disease (achalsia, reflux) or poor dental hygiene are at risk Most usual sites for spillage are the apical and posterior segments of the right lower lobe

4) Immunocompromised patient describes a lung infection that occurs in a person whose infectionfighting mechanisms are significantly impaired

Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, Mycoplasma pneumoniae, Gram negative bacilliand Pneumocystis carinii (e.g during HIV infection)

Community Acquired Pneumonia

Community-acquired pneumonia (CAP) is a serious illness. It is the fourth most common cause of death in the UK, and sixth in the USA. 85% of cases of CAP are caused by the typical bacterial pathogens, namely, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The remaining 15% are caused by atypical pathogens, namely Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species. Unusual aerobic gram-negative bacilli (for example, Pseudomonas aeruginosa, Acinetobacter, Enterobacter) rarely cause CAP.

Common Organisms Causing Pneumonia Community Acquired Pneumonia Streptococcus pneumoniae (gram positive) Staphylococcus aureus (gram positive) Haemophilus influenza (gram negative) Legionella pneumophila (gram negative) Mycoplasma pneumonia (smallest free-living organism) Chlamydia pneumonia (parasite)

Signs and Symptoms Symptoms of CAP commonly include:

dyspnea coughing that produces greenish or yellow sputum a high fever that may be accompanied with sweating, chills, and uncontrollable shaking sharp or stabbing chest pain rapid, shallow breathing that is often painful

Less common symptoms include:

the coughing up of blood (hemoptysis) headaches (including migraine headaches) loss of appetite excessive fatigue blueness of the skin (cyanosis) nausea

vomiting diarrhea joint pain (arthralgia) muscle aches (myalgia)

Complications Sepsis Sepsis can occur when microorganisms enter the blood stream and the immune system responds. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is the most common cause. Individuals with sepsis require hospitalization in an intensive care unit. They often require medications and intravenous fluids to keep their blood pressure from going too low. Sepsis can cause liver, kidney, and heart damage among other things. Respiratory failure Because CAP affects the lungs, often individuals with CAP have difficulty breathing. If enough of the lung is involved, it may not be possible for a person to breathe enough to live without support. Non-invasive machines such as a bilevel positive airway pressuremachine may be used. Otherwise, placement of a breathing tube into the mouth may be necessary and a ventilator may be used to help the person breathe. Pleural effusion and empyema Occasionally, microorganisms from the lung will cause fluid to form in the space surrounding the lung, called the pleural cavity. If the microorganisms themselves are present, the fluid collection is often called an empyema. If pleural fluid is present in a person with CAP, the fluid should be collected with a needle (thoracentesis) and examined. Depending on the result of the examination, complete drainage of the fluid may be necessary, often with a chest tube. If the fluid is not drained, bacteria can continue to cause illness because antibiotics do not penetrate well into the pleural cavity.

Abscess Rarely, microorganisms in the lung will form a pocket of fluid and bacteria called an abscess. Abscesses can be seen on an x-ray as a cavity within the lung. Abscesses typically occur in aspiration pneumonia and most often contain a mixture of anaerobic bacteria. Usually antibiotics are able to fully treat abscesses, but sometimes they must be drained by a surgeon or radiologist. Tests PHYSICAL EXAMINATION Physical examination may reveal dullness to percussion of the chest, crackles or rales on auscultation, bronchial breath sounds, tactile fremitus, and egophony (E to A changes). The patient also may be

tachypneic. A prospective study7 showed that patients with typical pneumonia were more likely than not to present with dyspnea and bronchial breath sounds on auscultation. RADIOGRAPHY Chest radiography (posteroanterior and lateral views) has been shown to be a critical component in diagnosing pneumonia. According to the latest American Thoracic Society (ATS) guidelines for the diagnosis and treatment of adults with CAP, all patients with suspected CAP should have a chest radiograph to establish the diagnosis and identify complications (pleural effusion, multilobar disease).Chest radiography may reveal a lobar consolidation, which is common in typical pneumonia; or it could show bilateral, more diffuse infiltrates than those commonly seen in atypical pneumonia. However, chest radiography performed early in the course of the disease could be negative. LABORATORY TESTS Historically, common laboratory tests for pneumonia have included leukocyte count, sputum Gram stain, two sets of blood cultures, and urine antigens. However, the validity of these tests has recently been questioned after low positive culture rates were found (e.g., culture isolates of S. pneumoniae were present in only 40 to 50 percent of cases). Such low positive culture rates are likely due to problems with retrieving samples from the lower respiratory tract, previous administration of antibiotics, contamination from the upper airways, faulty separation of sputum from saliva when streaking slides or plates, or viral etiology. Furthermore, sputum samples are adequate in only 52.3 percent of patients with CAP, and only 44 percent of those samples contain pathogens. Nonetheless, initial therapy often is guided by the assumption that the presenting disease is caused by a common bacterial pathogen. Prevalence and Incidence In the United States, two or four million cases of pneumonia occur each year, and it is the fifth leading cause of death. The highest incidence among adults occurs in older adults, nursing home residents, hospitalization clients and those being mechanically ventilated. Community-acquired pneumonia (CAP) is more common than nosocomial pneumonia and occurs late in fall and winter as a complication of influenza. The overall rate of community-acquired pneumonia (CAP) in adults is approximately 5.16 to 6.11 cases per 1000 persons per year; the rate of CAP increases with increasing age. There is seasonal variation, with more cases occurring during the winter months. The rates of pneumonia are higher for men than for women and for black persons compared with Caucasians. The etiology of CAP varies by geographic region; however, Streptococcus pneumoniae is the most common cause of pneumonia worldwide. In 2005, pneumonia and influenza combined was the eighth most common cause of death in the United States and the seventh most common cause of death in Canada. There were over 60,000 deaths due to pneumonia in the United States. Mortality is highest for CAP patients who require hospitalization, with a 30-day mortality rate of up to 23 percent in such patients. All-cause mortality in patients with CAP is as

high as 28 percent within one year. Given the aging population in North America, it is expected that the burden of CAP will increase International prevalence The distribution and prevalence of zoonotic CAPs is higher internationally than in the United States because of the density and distribution of zoonotic vectors. Risk Factors associated with Pneumonia Community-Acquired Pneumonia Older adult No history of pneumococcal vaccination No history of having received the influenza vaccine in the previous year Chronic or other coexisting condition Recent history of or exposure to viral or influenza infections History of tobacco or alcohol use

Prevention

Wash your hands. Your hands are in almost constant contact with germs that can cause pneumonia. These germs enter your body when you touch your eyes or rub the inside of your nose. Washing your hands often and thoroughly can help reduce your risk. When washing isn't possible, use an alcoholbased hand sanitizer.

Don't smoke. Smoking damages your lungs' natural defenses against respiratory infections. Stay rested and fit. Proper rest and moderate exercise can help keep your immune system strong. Eat a healthy diet. Include plenty of fat-free dairy products, fruits, vegetables and whole grains. Set an example. Stay home when you're sick. When you're in public with a cold, catch your coughs and sneezes in the inner crook of your elbow.