Pneumonia

Pneumonia is defined
as an acute respiratory
illness associated with
recently developed
radiological pulmonary
shadowing which may
be segmental, lobar or
multilobar
 Predisposing factors
 Cigarette smoking
 Upper respiratory tract infection
 Alcohol
 Corticosteroid therapy
 Old age
 Recent influenza infection
 Pre-existing lung disease
 Pneumonias are typically
classified as:

 Community-acquired
 Hospital-acquired(nosocomial)
 Anaerobic pneumonias and lung
abscess can occur in both
settings
 Community-acquired
pneumonia
Definition & Pathogenesis

Community-acquired pneumonia begins

outside of the hospital or is diagnosed
within 48 hours after admission to the
hospital in a patient who has not resided
in a long-term care facility for 14 days
or more before the onset of symptoms
Pulmonary defense mechanisms
(cough reflex, mucociliary clearance
system, immune responses) normally
prevent the development of lower
respiratory tract infections following
aspiration of oropharyngeal
secretions containing bacteria or
inhalation of infected aerosols
Community-acquired pneumonia
occurs when there is a defect in one
or more of the normal host defense
mechanisms or when a very large
infectious inoculum or a highly
virulent pathogen overwhelms the
host
Normal Lung

Lobar
Pneumonia

Alveolar air spaces

are full of PMNs as
well of
exsanguinated
RBCs
 Causative agents
There is failure to identify the cause of community-
acquired pneumonia in 40–60% of cases
 Bacterial pathogens
The most common pathogen identified in most cases
of community-acquired pneumonia is S
pneumoniae
Other bacteria are H influenzae, Mycoplasma
pneumoniae, Chlamydia pneumoniae, S
aureus, Neisseria meningitidis, M catarrhalis,
Klebsiella pneumoniae, other gram-negative rods,
and Legionella species
Streptococcus
pneumoniae
 Viral causes:
Influenza virus, respiratory syncytial virus,
adenovirus, and parainfluenza virus.

 Other causes:
Chlamydia psittaci (psittacosis), Coxiella
burnetii (Q fever), Francisella tularensis
(tularemia), endemic fungi (Blastomyces,
Coccidioides, Histoplasma), and sin nombre
virus (hantavirus pulmonary syndrome).
 Clinical Findings
Symptoms
 Acute or subacute onset of fever
 Cough with or without sputum
production
 Dyspnea
 Rigors, sweats, chills
 Chest discomfort, pleurisy
 Hemoptysis
 Fatigue
 Myalgias
 Anorexia
 Headache
 Abdominal pain
 Signs
 Fever or hypothermia
 Tachypnea
 Tachycardia
 Mild arterial oxygen desaturation
 Patients will appear acutely ill
 Chest examination is often remarkable
for altered breath sounds and rales
(crackles or crepitations )
 Dullness to percussion may be present if
a parapneumonic pleural effusion is
present
 Streptococcus pneumoniae : In winters, young to
middle aged, rapid onset, high fever, pleuritic chest
pain, rusty sputum

 Mycoplasma pneumoniae and Chlamydia

pneumoniae : Common in young adults not in elderly

 Haemophilus influenzae : Common in elderly, rarely

young

 Viral pneumonias: In younger children

 Legionella species: Foreign travel

 Klebsiella pneumoniae: Alcohol abuse, diabetes

mellitus; nosocomial
 Investigation
Laboratory Findings
 Sputum Gram stain should be attempted in all
patients with community-acquired pneumonia
and that sputum culture should be obtained for
all patients who require hospitalization

 Sputum should be obtained before antibiotics

are initiated except in a case of suspected
antibiotic failure

 The specimen is obtained by deep cough and

should be grossly purulent
 Additional testing is generally
recommended for patients who
require hospitalization
 Pre antibiotic blood cultures (at least two
sets with needle sticks at separate sites)
 Arterial blood gases
 Complete blood count with differential
 Chemistry panel (including serum glucose,
electrolytes, urea nitrogen, creatinine,
bilirubin, and liver enzymes)

Assess the severity of the disease and guide evaluation and

therapy. HIV serology should be obtained from all
hospitalized patients.
 Imaging
Chest radiography
 Radiographic findings can range from patchy
airspace infiltrates to lobar consolidation with
air bronchograms to diffuse alveolar or
interstitial infiltrates

 Additional findings can include pleural effusions

and cavitation

 No pattern of radiographic abnormalities is

pathognomonic of a specific cause of pneumonia

 Clearing of pulmonary infiltrates in patients with

community-acquired pneumonia can take 6
weeks or longer and is usually fastest in young
patients, nonsmokers, and those with only single
lobe involvement.
A: Normal
Chest X-ray
PA view
B: Lobar
Pneumonia
The chest x-ray below shows extensive
consolidation affecting more than one
lobe in the right lung
 Viral
Pneumoni
a
The chest x-ray
below is
Haemophilus
influenzae
showing a
typical
bronchopneum
onic pattern of
heterogeneous
localized
consolidation
 Special Examinations
 Sputuminduction is reserved for patients
who cannot provide expectorated sputum
samples or who may have P jiroveci or
Mycobacterium tuberculosis pneumonia

 Transtracheal aspiration, fiberoptic

bronchoscopy, and transthoracic needle
aspiration techniques to obtain samples of
lower respiratory secretions or tissues are
reserved for selected patients
 Thoracentesis with pleural fluid analysis (Gram
stain and cultures; glucose, LDH, and total
protein levels; TLC with differential) should be
performed on most patients with pleural
effusions to assist in diagnosis of the etiologic
agent and assess for empyema or complicated
parapneumonic process

 Serologicassays, polymerase chain reaction

tests, specialized culture tests, and other new
diagnostic tests for organisms such as
Legionella, M pneumoniae, and C pneumoniae
are performed when these diagnoses are
suspected
 Treatment
 General Measure:
 Rest
 Smoking cessation
 Oxygenation
 Fluid balance
 Antibiotic therapy
 Nutritional support
 Oxygen
 Pateints with tachypnea,
hypoxemia, hypotension and
acidosis require oxygen therapy
 Aim: PaO2 > 60mmHg
 Some patients require assisted
ventilation
 Fluid Balance
 Oral fluid intake is encouraged
 I/V Fluid therapy needed in
severely ill patients, elderly and
in patients with vomiting.
 Antibiotic therapy
 Antimicrobial therapy should be initiated
promptly after the diagnosis of pneumonia is
established and appropriate specimens are
obtained, especially in patients who require
hospitalization

 Choice of Antibiotic is guided by clinical

context, severity assessment, local
knowledge of antibiotic resistance pattern
 Uncomplicated Community
Acquired Pneumonia
 Amoxicillin 500 mg 8 hourly orally
 If patient is allergic to penicillin
 Clarithromycin 500 mg 12-hourly orally or
 Erythromycin 500 mg 6-hourly orally
 If staphylococcus is cultured or suspected
 Flucloxacillin 1-2 g 6-hourly i.v. plus
 Clarithromycin 500mg 12-houly i.v.
 If mycoplasma or Legionella is suspected
 Clarithromycin 500 mg 12-hourly orally or i.v. or
Erythromycin 500 mg 6-hourly orally or i.v. plus
 Rifampicin 600 mg 12 hourly i.v. in severe cases
 Severe Community Acquired
Pneumonia
 Clarithromycin 500 mg 12-hourly i.v. or
Erythromycin 500 mg 6-hourly i.v. plus

 Co-amoxiclav 1.2 g 8-hourly i.v. or

Ceftriaxone 1-2 g daily i.v. or
Cefuroxime 1.5 g 8-hourly i.v. or
Amoxicillin 1 g 6-hourly i.v. plus
flucloxacillin 2 g 6-hourly i.v.
 Treatment of pleuritic
 Allows
pain
patient to breath normally and
cough efficiently
 Adequate analgesia
 Extreme caution with opioids

Physiotherapy
 Formal physiotherapy not required
 Assisted cough needed
 Complications
 Para-pneumonic effusion
 Empyema
 Retention of sputum causing lobar collapse
 Development of thromboembolic disease
 Pneumothorax
 Suppurative pneumonia/lung abscess
 ARDS, Renal failure, End organ failure
 Ectopic abscess
 Hepatitis, pericarditis, myocarditis,
meningoencephalitis
 Pyrexia due to drug hyper-sensitivity.
 Prevention
 Polyvalent pneumococcal vaccine
Indications : Age 65 years or any chronic
illness that increases the risk of community-
acquired pneumonia Immunocompromised
patients and those at highest risk of fatal
pneumococcal infections

 The influenza vaccine

Administered annually to persons at risk for
complications of influenza infection (age 65
years, residents of long-term care facilities,
patients with pulmonary or cardiovascular
disorders, patients recently hospitalized with
chronic metabolic disorders) as well as health
care workers and others who are able to
transmit influenza to high-risk patients
 Hospital-Acquired
Pneumonia
Hospital-acquired pneumonia is
defined as pneumonia
developing more than 48 hours
after admission to the hospital
 Pathogenesis
 Colonization of the pharynx with bacteria is the
most important step in the pathogenesis of
nosocomial pneumonia

 Pharyngeal colonization is promoted by :

1. Instrumentation of the upper airway with nasogastric
and endotracheal tubes
2. Treatment with broad-spectrum antibiotics that
promote the emergence of drug-resistant organisms
3. Malnutrition
4. Advanced age
5. Altered consciousness
6. Swallowing disorders
7. Underlying pulmonary and systemic diseases
 Aspiration of infected pharyngeal or gastric
secretions delivers bacteria directly to the lower
airway

 Impaired cellular and mechanical defense

mechanisms in the lungs of hospitalized patients
raise the risk of infection after aspiration has
occurred

 Tracheal intubation increases the risk of lower

respiratory infection by mechanical obstruction
of the trachea, impairment of mucociliary
clearance, trauma to the mucociliary escalator
system, and interference with coughing

 Tight adherence of bacteria to the tracheal

epithelium and the biofilm that lines the
endotracheal tube makes clearance of these
organisms from the lower airway difficult
 Causative agents
 The most common organisms responsible for
nosocomial pneumonia are P aeruginosa, S aureus,
Enterobacter, K pneumoniae, and Escherichia
coli

 Proteus, Serratia marcescens, H influenzae, and

streptococci account for most of the remaining cases

 Infection by P aeruginosa and Acinetobacter tend

to cause pneumonia in the most debilitated patients,
those with previous antibiotic therapy, and those
requiring mechanical ventilation

 Anaerobic organisms (bacteroides, anaerobic

streptococci, fusobacterium) may also cause
pneumonia in the hospitalized patient
 Staphylococcal Pneumonia
Posteroanterior chest radiograph demonstrating right upper
lobe consolidation. Staphylococcus aureus was isolated from
blood cultures.
 The chest
radiograph
shows a right
upper lobe
pulmonary
consolidation
with central
cavitation
 Klebsiella species are associated
with hospital-acquired pneumonias
 Clinical Findings
Symptoms and Signs
 The signs and symptoms associated with
nosocomial pneumonia are non-specific

 Fever, leukocytosis, purulent sputum, and

a new or progressive pulmonary infiltrate
on chest radiograph are present in most
patients

 Other findings associated with nosocomial

pneumonia include those for community-
acquired pneumonia
 Investigations
The minimum evaluation for suspected
nosocomial pneumonia includes:

 Blood cultures from two different sites

 Arterial blood gas or pulse oximetry determination

 Blood counts and clinical chemistry tests can help define

the severity of illness and identify complications

 Thoracentesis for pleural fluid analysis (stains, cultures;

glucose, LDH, and total protein levels; leukocyte count
with differential; pH determination) should be
performed in patients with pleural effusions
 Gram stains and cultures of sputum are neither
sensitive nor specific in the diagnosis of
nosocomial pneumonia can be used to help
identify antibiotic sensitivity patterns of
bacteria and as a guide to therapy

 If nosocomial pneumonia from Legionella

pneumophila is suspected, direct fluorescent
antibody staining can be performed

 Sputum stains and cultures for mycobacteria

and certain fungi may be diagnostic.
 Radiographic Imaging
 Radiographic findings are nonspecific and can range from
patchy airspace infiltrates to lobar consolidation with air
bronchograms to diffuse alveolar or interstitial infiltrates
 Additional findings can include pleural effusions and
cavitation

Special Examinations
Patients with ventilator-associated pneumonias may require
lower respiratory tract secretions for analysis by
endotracheal aspiration using a sterile suction catheter and
fiberoptic bronchoscopy with bronchoalveolar lavage
 Treatment
 Treatment of nosocomial pneumonia, like
treatment of community-acquired
pneumonia, is usually empiric

 Therapy should be started as soon as

pneumonia is suspected because of the
high mortality rate

 Initialregimens must be broad in

spectrum and tailored to the specific
clinical setting
Adequate grame-negative coverage is usually
obtained with:

 A third generation cephalosporin (e.g.

cefotaxime) plus an aminoglycoside ( e.g.
gentamicin) or
 Meropenem or
 A monocyclic β-lactam ( e.g. aztreonam)
plus flucloxacillin
 Aspiration pneumonis is teated by co-
amoxiclav 1.2 g 8-hourly plus
metronidazole 500mg 8-hourly

Adequate oxygen therapy

Fluid support

Physiotherapy