Pneumonia

DEFINATION OF
DIFFERENT TYPES OF PNEUMONIA
Dr. Jaydeep Hirpara
Assistant Professor,
Department Of Medicine,
Govt. Medical College, Surat

Pneumonia vs
Pneumonitis
Pneumonitis (noo-moe-NIE-tis) is a general term that refers to

inflammation of lung tissue. Although pneumonia is

technically a type of pneumonitis because the infection causes
inflammation, most doctors are referring to other causes of
lung inflammation when they use the term "pneumonitis."
Pneumonia can be generally defined as inflammation of the

lung parenchyma, in which consolidation of the affected part

and a filling of the alveolar air spaces with exudate,
inflammatory cells, and fibrin is characteristic. [1] Infection by
bacteria or viruses is the most common cause, although
inhalation of chemicals, trauma to the chest wall, or infection
by other infectious agents such as rickettsiae, fungi, and
yeasts may occur.

Community-acquired
pneumonia (CAP)
CAP is defined as pneumonia that develops in the

outpatient setting or within 48 hours of admission to

a hospital. CAP should not meet the criteria for
healthcare-associated pneumonia (HCAP).
Typical & Atypical - In the individual patient, there

are no findings from history, physical examination,

or routine laboratory studies that allow the clinician
to distinguish pneumonia caused by atypical from
typical organisms. Indeed, the term "atypical
pneumonia" should no longer be used.

The IDSA defines CAP as an acute infection

of the pulmonary parenchyma that is

associated with at least some symptoms
of acute infection, accompanied by the
presence of an acute infiltrate on a chest
radiograph or auscultatory findings
consistent with pneumonia (such as
altered breath sounds and/or localized
rales), in a patient not hospitalized or
residing in a long-term care facility for
more than 14 days before onset of
symptoms

Typical vs Atypical CAP

Bacteria are the most common cause of CAP and have

traditionally been divided into two groups: "typical"

and "atypical" agents:
"Typical" organisms include S. pneumoniae,

Haemophilus influenzae, Staphylococcus aureus,

Group A streptococci, Moraxella catarrhalis, anaerobes,
and aerobic gram-negative bacteria.
"Atypical" refers to pneumonia caused by Legionella

spp, Mycoplasma pneumoniae, Chlamydophila

(formerly Chlamydia) pneumoniae, and C. psittaci.

Hospital-acquired (or
nosocomial) pneumonia (HAP)
Pneumonia that occurs 48 hours or more after

admission and did not appear to be incubating

at the time of admission.

Early vs Late onset

The ATS subdivides nosocomial pneumonia

into early onset (usually within the first 4 d

of the hospitalization) and late onset (usually
occurring after the fifth hospital day). Early
onset nosocomial pneumonia tends to carry a
better prognosis than does late-onset
nosocomial pneumonia; the latter tends to be
associated with multidrug-resistant organisms
and so is characterized by higher mortality
rates

Ventilator-associated
pneumonia (VAP)
A type of HAP that develops more than 48 to

72 hours after endotracheal intubation.

Healthcare-associated
pneumonia (HCAP)
Pneumonia that occurs in a non-hospitalized

patient with extensive healthcare contact, as

defined by one or more of the following:
- Intravenous therapy, wound care, or
intravenous chemotherapy within the prior 30 days
- Residence in a nursing home or other longterm care facility
- Hospitalization in an acute care hospital for
two or more days within the prior 90 days
- Attendance at a hospital or hemodialysis
clinic within the prior 30 days

Aspiration Pneumonia
Aspiration is defined as the inhalation of either oropharyngeal

or gastric contents into the lower airways; that is, the act of
taking foreign material into the lungs.
Three types of material cause 3 different pneumonic syndromes.
Aspiration of gastric acid causes chemical pneumonia, which has
also been called aspiration pneumonitis (Mendelson's
syndrome)although the former is an infectious process and
the latter is a chemical injury, and both are managed differently.
[1] Aspiration of bacteria from oral and pharyngeal areas causes
bacterial pneumonia, and aspiration of oil (eg, mineral oil or
vegetable oil) causes exogenous lipoid pneumonia, a rare
form of pneumonia. In addition, aspiration of a foreign body may
cause an acute respiratory emergency and, in some cases, may
predispose the patient to bacterial pneumonia.

Risk Factors for Multidrug-Resistant

Pathogens Causing Hospital-Acquired
Pneumonia, Healthcare-Associated
Pneumonia, and Ventilator-Associated
Pneumonia
Antimicrobial therapy in preceding 90 days
Current hospitalization of 5 days or more
High frequency of antibiotic resistance in the community or

in the specific hospital unit

Presence of risk factors for HCAP: Hospitalization for 2 or
more days in the preceding 90 days
Residence in a nursing home or extended care facility
Home infusion therapy (including antibiotics)
Chronic dialysis within 30 days
Home wound care
Family member with multidrug-resistant pathogen
Immunosuppressive disease and/or therapy

Additional Risk Factors for MultidrugResistant Infections in HealthcareAssociated Pneumonia

Presence of chronic indwelling device
Prior antibiotic use in the last 3 months
Chronic and advanced pulmonary diseases

(chronic obstructive pulmonary disease,

bronchiectasis, etc.)
History of alcoholism and immunosuppression
(i.e., systemic corticosteroids,
immunosuppressive therapy, etc.)

Hypersensitivity pneumonitis (HP)

(Extrinsic allergic alveolitis)
DIAGNOSTIC CRITERIASeveral different diagnostic criteria for

HP have been proposed [9,11,12]. All have significant problems

that limit their utility:
All were developed before the common use of high resolution

CT scanning and bronchoalveolar lavage

Most apply only to typical, acute cases
No clear diagnostic criteria exist for subacute or chronic disease
All rely on the presence of an abnormal chest radiograph or

positive serum precipitins, findings which are often absent

The proposed diagnostic criteria for HP are based upon the presence of
some or all of the following :
1. Known exposure to offending antigen(s) identified by:
A. History of appropriate exposure.
B. Aerobiologic or microbiologic investigations of the environment that
confirm the presence of an inciting antigen .
C. The presence of specific IgG antibodies in serum against the identified
antigen (serum precipitins). A positive precipitin test even in the
presence of a clear history of exposure to the identified antigen is merely
suggestive of, rather than diagnostic of, a potential etiology.
2. Compatible clinical, radiographic, or physiologic findings:
A. Respiratory ( constitutional) symptoms and signs, such as crackles on
chest exam, weight loss, cough, breathlessness, febrile episodes,
wheezing, and fatigue. These findings are especially suggestive if
present, appearing, or worsening several hours after antigen exposure
[15].
B. Reticular, nodular, or ground glass opacity on chest radiograph or HRCT .
C. Altered spirometry and/or lung volumes (may be restrictive, obstructive,
or mixed pattern), reduced DLCO, altered gas exchange either at rest or
with exercise testing

3. BAL with lymphocytosis:

A. Usually with low CD4 to CD8 ratio
B. Positive specific immune response to the antigen by lymphocyte
transformation testing (currently not available in most centers)
4. Positive inhalation challenge testing by:
A. Reexposure to the environment (figure 1)
B. Inhalation challenge to the suspected antigen in a hospital
setting (figure 2)
5. Histopathology showing compatible changes:
A. Poorly formed, noncaseating granulomas OR
B. Mononuclear cell infiltrate

Definite HP

Definite HPA patient is considered to have definite HP under the following

circumstances:
Criteria 1, 2, and 3 are met Histopathologic confirmation of the diagnosis

is not needed in the majority of such cases.

Criteria 1, 2, and 4A are met BAL or histopathologic confirmation of the

diagnosis is not needed in the majority of these cases but may be important to
allow decision-making regarding management.
Criteria 1, 2A, 3, and 5 are met These patients are usually identified as

part of a case cluster. The index cases usually have more severe disease.
Criteria 2, 3, and 5 are met In these cases, the diagnosis is first suspected

after BAL or transbronchial lung biopsy. It is critical that every attempt be made
to identify the specific antigen. This often requires aggressive surveillance of
the home and work environment by an experienced industrial hygienist.
Complete removal of the patient from his or her usual environment for two to
three weeks may lead to spontaneous improvement, and reexposure may
result in acute symptoms that help identify environmental precipitants.

Probable or subclinical
HP
Probable or subclinical HPA patient is

considered to have probable HP if criteria 1,

2A, and 3 are present, and subclinical HP if
criteria 1 and 3A are present. Sensitization,
rather than HP, is present in patients who only
fulfill criterion 1.

Acute eosinophilic
pneumonia
AEP is a diagnosis of exclusion that requires :
An acute febrile illness of short duration (usually less

than one week)

Hypoxemic respiratory failure
Diffuse pulmonary opacities on chest radiograph
BAL eosinophilia >25 percent
Lung biopsy evidence of eosinophilic infiltrates (acute
and/or organizing diffuse alveolar damage (DAD) with
prominent eosinophilia is the most characteristic finding)
Absence of known causes of eosinophilic pneumonia,
including drugs, infections, asthma, or atopic disease

A 55 year old male presents to his primary care physician's office

with cough, mild dyspnea, and fever to 101 degrees. Symptoms

have been present for the past 3 days, and when over-thecounter cold medications were having no effect, he decided to
seek medical attention. On initial examination, blood pressure
was 120/73, pulse was 96 and regular, and respirations were 20.
He was febrile with a temperature of 100.9 degrees. Lung
examination revealed the presence of right lower lung crackles
with decreased breath sounds in this area as well.
Laboratory studies revealed WBC of 15.6 with a left shift, sodium
of 140, potassium of 4.5, BUN of 22 and creatinine of 1.0. Chest
x-ray revealed a right lower lobe infiltrate.
Based upon the above presentation, what is the most appropriate
course of action?
A. Admit the patient to the hospital and start intravenous
ceftriaxone and azithromycin
B. Admit the patient to the hospital and start intravenous cefipime
C. Prescribe clarithromycin, 500 mg twice daily and schedule a
follow-up in 1 week
D. Refer the patient to a pulmonary specialist for a STAT evaluation

ANSWER: C
This patient obviously has pneumonia, and according

to the lack of recent hospitalization or exposure to a

medical facility, it is acceptable to consider him as
having community-acquired pneumonia. Based upon
the presentation described, the patient does not have
severe enough illness to necessitate admission to the
hospital. Scales such as the Pneumonia Severity Index
(PSI) can be used to judge if admission is necessary,
in addition to the clinical impression of the
practitioner. In this case, based upon the information
provided, the patient can be allowed to go home and
start oral antibiotics, and then re-evaluated to see if
he is improving. Lack of improvement at the follow-up
visit would be an indication for hospitalization, as
would deterioration while being treated.

A 77 year old female presents to the emergency department

with dyspnea, fever to 103, hypotension and mental status

changes. Initial evaluation demonstrates a left lower lobe
infiltrate. Additional studies show blood pressure of 90/60,
respiratory rate of 34, and pulse of 110. Laboratory
parameters include WBC of 2.3, and BUN of 33, with creatinine
of 1.3. Pulse oximetry reveals 88% on room air, which comes
up to 99% on 4 liters.
Based upon the above presentation, which of the following is
the most appropriate course of action?
A. Discharge the patient on oral azithromycin
B. Admit the patient to the general medical ward and begin
intravenous doxycycline and azithromycin
C. Admit the patient to the intensive care unit, and begin fluid
resuscitation, and intravenous ampicillin-sulbactam and
levofloxacin
D. Admit the patient to the intensive care unit and initiate
mechanical ventilation, pressors, and intravenous piperacillintazobactam

ANSWER: C
This patient clearly has severe CAP, and

according to current recommendations, meets

criteria for ICU admission for CAP. Specifically,
the leukopenia, hypoxia, hypotension, and
mild uremia all indicate the need for closer
monitoring. Initial treatment for CAP requiring
ICU admission includes empiric therapy with a
beta-lactam + either azithromycin or a
fluoroquinolone. If pseudomonas is suspected,
an antipseudomonal, antipneumococcal betalactam is indicated, in addition to a quinolone.
Other regimens may be used as well.

Persistent Pneumonia Symptoms in

a 29-Year-Old

A 29-year-old, previously healthy woman was seen on 3

occasions by her primary care provider for upper respiratory

symptoms 2 weeks after competing in an outdoor obstacle
course that involved crawling in the dirt in the California San
Joaquin Valley. The patient denies any recent sick contacts or
travel outside of the local area. A diagnosis of communityacquired pneumonia was made and she was given 3 separate
courses of antibiotics, over the course of 6-8 weeks, without
improvement. She has presented to the urgent care clinic
today with worsening cough, production of malodorous
sputum, anorexia, fevers, chills, sweats, nausea, vomiting, and
malaise. She has lost 20 lb since the onset of symptoms.
On physical examination, the patient is mildly ill-appearing,

with a temperature of 102.4F, a heart rate of 106 bpm, a

respiratory rate of 22 breaths/min, a blood pressure of 118/64
mm Hg, and an oxygen saturation of 95% on room air. Lung
auscultation reveals coarse rhonchi in the left upper lung field.
Her heart rate is rapid, but no murmurs are appreciated. The
remainder of her physical examination is unremarkable.

Laboratory tests performed in the urgent care

clinic show a mild leukocytosis of 13.4 x

103/L WBC count, with otherwise normal
results. Chest radiography shows a 4.2-cm
diameter cavitary lesion with an air fluid level
in the left upper lobe, along with mediastinal
lymphadenopathy (see Images 1-2).

What is the diagnosis? How would you

approach this patient's treatment?

The patient was admitted to the hospital with respiratory

isolation, aggressively hydrated with 4 L of normal saline, and

started on intravenous ceftriaxone and azithromycin and 800 mg
of oral fluconazole. Her purified protein derivative (PPD) and HIV
test results were negative. Three induced sputum samples were
negative for acid-fast bacilli. Within 1 day of treatment, she
improved clinically and was discharged on oral fluconazole (800
mg daily) and amoxicillin/clavulanate (875/125 mg twice daily)
with an empiric diagnosis of coccidioidomycosis. On reevaluation,
she had almost complete resolution of her systemic symptoms.
Within 3 months of therapy on fluconazole, she was
asymptomatic and her cavitary lesion had resolved with mild
residual scarring.
Coccidioidomycosis, commonly referred to as "valley fever" or

"San Joaquin Valley fever," is a fungal infection caused by the

inhalation of the spores of Coccidioides immitis, a fungus endemic
to the semi-arid areas of the southwest United States, particularly
central California, Arizona, parts of Texas, and Mexico.

Thank You