Pneumonia
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Pneumonia
is defined as inflammation
and consolidation of the
respiratory part of lung
tissue (alveoli)
due to an infectious agent.
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Community-acquired pneumonia remains a
common illness. Pneumonia is the sixth
leading cause of death in the the world and is
the most common infectious cause of death.
Pneumonia is the leading cause of death
among hospital-acquired infections, and the
mortality rates range from 20-50%.
Advanced age increases the incidence of
pneumonia and the mortality from it.
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Causes of bacterial
pneumonia
include infection with respiratory
pathogens.
Exposure to pulmonary irritants or
direct pulmonary injury causes
noninfectious pneumonitis
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Intrinsic factors that predispose
pneumonia include
1)the host's immune response,
2)the presence of comorbidities
3) aspiration of oropharyngeal
flora into the lung.
4) local lung pathologies
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Aspiration is facilitated by altered mental
status from intoxication, deranged
metabolic states, neurological causes (eg,
stroke), and endotracheal intubation.
Local lung pathologies (tumors, chronic
obstructive pulmonary disease,
bronchiectasis) are predisposing factors
for bacterial pneumonia.
Smoking impairs the host's defense to
infection by a variety of mechanisms.
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Classification
1. Community-acquired pneumonia
typical
atypical
2.Nosocomial pneumonia
3. Aspiration pneumonia.
4.Pneumonia in
immunocompromised patients.
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1. Pneumonia that develops outside
the hospital setting is considered
community-acquired pneumonia.
2. Pneumonia developing 48 hours
or more after admission to the
hospital is termed nosocomial or
hospital-acquired pneumonia.
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3. Aspiration pneumonia takes the
special place due to high risk of lung
tissue destruction and bad prognosis.
4. Pneumonia in immunocompromised
patients (those who receive
immunodepressants, such as
cytostatics or system steroids, HIVinfected persons on last stage).
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Community-acquired
pneumonia
is caused most commonly by
bacteria that traditionally
have been divided into 2
groups, typical and atypical.
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A. Typical organisms in
community-acquired pneumonia
(approximately 85%) include
Streptococcus pneumoniae
(pneumococcus),
Haemophilus influenzae (is associated
with asthma and COPD), and
Moraxella catarrhalis (in patients with
chronic bronchitis).
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S pneumoniae remains
the most common
agent responsible for
community-acquired
pneumonia.
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Rare bacterial pathogens
in community-acquired
pneumonia are
Klebsiella pneumoniae (in persons
with chronic alcoholism),
Staphylococcus aureus (in the
setting of postviral influenza),
Pseudomonas aeruginosa (in
patients with bronchiectasis).
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B. Atypical pathogens in communityacquired pneumonia
(approximately 15%) are
Legionella pneumophila,
Mycoplasma pneumoniae,
Chlamydia psittaci,
Coxiella burnetii.
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Do not mix community-acquired
pneumonia due to atypical
flora with
“atypical pneumonia” due to
virus (SARS – severe acute
respiratory syndrome)!.
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Typical (predominantly pneumococcal)
pneumonia produces the following:
a characteristic clinical pattern, with sudden
onset of fever and shaking chills, pleuritic
chest pain, and production of rust-colored
sputum and
radiological evidence of consolidation.
examination of sputum in case of
pneumococcal pneumonia shows grampositive diplococci in chains.
This clinical picture was recognized as
“typical” (classical) pneumonia.
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”Atypical" community-acquired
pneumonia
Most patients present with a gradual onset of
the disease without shaking chills.
A prodrome of it consists of headache,
photophobia, sore throat, and eventually a dry,
nonproductive cough.
Their sputum does not contain gram-positive
diplococci (pneumococci).
Although these patients were not feeling well,
they were not critically ill.
Laboratory evaluations showed white blood
cell counts to be normal.
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Hospital-acquired
(nosocomial) pneumonia
defines as pneumonia occurring
more than 48 hours after
admission to the hospital.
It is a major cause of morbidity and
mortality in hospitalized patients.
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The most common organisms responsible
for nosocomial pneumonia are
Staphylococcus aureus
Klebsiella pneumoniae
Gram-negative pathogens:
>Enterobacter,
>Pseudomonas aeruginosa, and
>Escherichia coli.
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S. aureus pneumonia generally occurs
in those who abuse intravenous drugs:
in hospitalized patients and patients
with prosthetic devices; it spreads
hematogenously to the lungs from
contaminated local sites.
Infection by Pseudomonas aeruginosa
tend to cause pneumonia in the
patients,
requiring
mechanical
ventilation.
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Essentials of diagnosis of
community-acquired pneumonia
 Occurs in healthy person
 Sudden onset of fever and shaking chills,
cough, and production of rust-colored
sputum sometimes accompanied by pleuritic
chest pain due to pleurisy
 Physical examination detects signs of
consolidation
 Crackles in auscultation
 Pulmonary infiltrate on chest x-ray.
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Essentials of diagnosis of hospitalacquired (nosocomial) pneumonia
 Occurs more than 48 hours after admission
to the hospital.
 One or more clinical findings (fever, cough,
leukocytosis, purulent sputum) in most
patients.
 Especially frequent in patients requiring
intensive care and mechanical ventilation.
 Pulmonary infiltrate on chest x-ray.
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Clinical presentation in patients
with pneumonia
varies from a mildly ill ambulatory patient to a
critically ill patient with respiratory failure or
septic shock.
Typically, patients with pneumonia present
with variable degrees of fever; they may
report rigors or shaking chills.
Pleuritic chest pain secondary to pleurisy is a
common feature of pneumococcal infection,
but these may occur in other bacterial
pneumonias.
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Clinical presentation in patients
with pneumonia
A productive cough is characteristic feature of
pneumonia. The character of sputum may
suggest a particular pathogen.
 Patients with pneumococcal pneumonia
produce rust-colored sputum.
 Infections
with
Pseudomonas
and
Haemophilus are known to expectorate green
sputum.
 Anaerobic infections produce foul-smelling
sputum.
 Currant-jelly sputum suggests pneumonia
from Klebsiella.
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Clinical presentation in patients
with pneumonia
Malaise, myalgias, and exertional dyspnea
may be observed.
Patients may complain of other nonspecific
symptoms, which include
> headaches,
> nausea, and
> vomiting.
These symptoms are accompanied by
intoxication.
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A detaled past medical history and history of
environmental and occupational exposures
should be obtained
This history should include whether the patient has
recently traveled or had contact with animals that might
serve as a source of an infectious agent.
Patients may report
exposure to turkeys, chickens, ducks in case of
Chlamydia psittaci infection
exposure to contaminated air-conditioning cooling
towers in case of Legionella pneumophila infection.
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Evaluation of host factors often provides
a clue to the bacterial diagnosis
 Diabetic ketoacidosis may lead to S. pneumoniae or S.
aureus infection.
 Alcoholism may indicate Klebsiella pneumoniae
infection.
 Chronic obstructive lung disease may lead to
Haemophilus influenzae or Moraxella catarrhalis
infection.
 HIV infection may lead to Cryptococcus neoformans,
Mycobacterium
avium-intracellulare
infection
or
Pneumocystis pneumonia.
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Precise clinical diagnosis
of nosocomial pneumonia
is much more difficult than community-acquired
pneumonia.
It is because of the absence of a typical clinical
picture against the background of the disease,
which was the reason for hospitalization.
The subclinical course without clear typical picture
is widespread.
However, one or more clinical findings (fever,
leukocytosis, purulent sputum), and a pulmonary
infiltrate on chest x-ray are present in most
patients.
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Physical
A.The common symptoms and signs (due to
intoxication and respiratory failure) are as
follows:
 Fever (temperature >38.5°C)
 Tachypnea
 Tachycardia
 Central cyanosis
These symptoms are non-specific and indicate
severity of the disease, not etiology. They
can’t help to diagnose pneumonia, but they
determine therapy and prognosis.
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Physical
B. The most important information on
physical examination is connected with
signs of lung tissue consolidation due to
local inflammation:
Dullness to percussion
Increased tactile fremitus
Decreased intensity of breath sounds
Crackles (crepitation) at the beginning and
resolving of inflammation
Local rales
Pleural friction rub
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The main doctor’s task on physical
examination
is revealing of asymmetric
pathology.
Pneumonia is local respiratory pathology.
Therefore, the presence of focal area of lung
tissue consolidation has the most diagnostic
value.
It is direct indication for chest radiograph.
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Imaging Studies
The diagnosis of pneumonia is impossible
without X-ray investigation.
Direct indication for chest X-ray is not only
focal acoustic pathology but also any
clinical situation accompanied by chronic
or prolonged cough.
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Imaging Studies
In chest medicine 80% of information is
on the developed film.
Chest radiograph findings in typical case
of pneumonia indicate a segmental or
lobar
opacity,
or
infiltration
corresponding to the impaired area.
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Left low lobe pneumonia
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Low lobe pneumonia
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Right upper lobe lobar pneumonia
secondary to Streptococcus
pneumoniae infection
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Bacterial pneumonia. Bilateral airspace
infiltration secondary to communityacquired pneumonia, subsequently
confirmed to be Legionella pneumonia
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Bacterial pneumonia. Rarely, severe
pneumococcal infection may be associated
with necrotizing pneumonia.
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Chest radiographs showing
right middle lobe pneumonia
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Hospital-acquired right lower lobe pneumonia; sputum culture
confirmed this to be secondary to gram-negative organisms
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Aspergillus pneumonia
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Pneumonia caused by Chlamydia
psittasi
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Aspiration pneumonia
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CT in case of pneumonia
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Lab Studies
Complete blood count
Leukocytosis with a left shift is commonly
observed in case of pneumonia.
These findings may be absent in elderly or
debilitated patients.
Leukopenia is an ominous sign of impending
sepsis and a poor outcome.
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Lab Studies
Sputum examination
provides an accurate diagnosis in approximately
50% of patients. A single pathogen present on
the Gram stain is typical for pneumonia.
The main value of sputum examination is to exclude
the presence of such microorganisms as
mycobacteria, fungi, Legionella, and
Pneumocystis through special smears and
cultures.
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Bacterial pneumonia. Pneumococci
on sputum Gram stain.
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Bacterial pneumonia. Histopathological
micrograph of bacterial pneumonia showing
extensive infiltration with inflammatory cells
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Bacterial pneumonia. Klebsiella
pneumoniae on sputum Gram stain
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Lab Studies
The diagnosis of pneumonia cannot
be based solely on the results of
culture of expectorated sputum.
100% sputum cultures are impossible
in most clinics. No ordinary lab can
ensure 100% etiological diagnosis
of pneumonia in time.
The standard lab limits sputum
investigation
by
Gram-stained
smear.
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Lab Studies
Additional lab tests are necessary when
diagnosis is unclear and the treatment
based on the findings of standard tests has
no effect.
Other tests may include serology, which is
essential in the diagnosis of unusual
causes of pneumonia such as Legionella,
Mycoplasma, Chlamydia, and other.
Blood cultures are of a limited value, as they
are positive only in approximately 40% of
cases.
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Other Tests
Arterial blood gas (ABG) determination:
Evaluation of the patient's gas exchange is
essential in order to decide if hospital
admission, oxygen supplementation, or
other efforts are indicated.
Pulse oximetry of less than 90% indicates
significant hypoxia; an ABG determination
should be performed in these patients.
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Procedures
Bronchoscopy
Bronchial washing specimens can be obtained. Protected
brush and bronchoalveolar lavage can be performed for
quantitative cultures.
Thoracentesis
This is an essential procedure in patients with a
parapneumonic pleural effusion.
Obtaining fluid from the pleural space for laboratory
analysis allows for the differentiation between simple and
complicated effusions. This determination helps guide
further therapeutic intervention.
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Differential diagnosis
Any case of pneumonia requires
excluding of 2 other
pulmonological problems.
They are
lung cancer and
tuberculous.
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Complications
Pleural effusion
Empyema
Pulmonary abscess
Respiratory failure
Acute heart failure
Death
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Criteria for hospitalization
The decision to hospitalize patients with
community-acquired pneumonia is
dictated by risk factors that increase
either the risk of death or the risk of a
complicated course of disease.
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Some of indications for
hospitalization include
Advanced age (over 65)
comorbidity (alcoholism, diabetes mellitus,
COPD, chronic renal or heart failure,
chronic liver disease)
suspicion of aspiration
leukopenia or marked leukocytosis
any evidence of respiratory failure
septic appearance and
absence of supportive care at home (social
indications).
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Who can be treated at home?
Only young people in case of mild
course.
If there’s the smallest sign of a
moderate course, the patient must
be directed to the in-patient
department immediately!
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Treatment
Establishing a specific etiologic diagnosis of
pneumonia is often difficult.
In most cases of both community-acquired
and hospital-acquired pneumonia no etiology
was identified.
Therefore, when organisms are not known,
therapy should be empiric.
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The initial approach to treating
patients with сommunity-acquired
pneumonia
involves a determination of 3 factors.
(1) Should the patient with pneumonia be
treated in the hospital or as an outpatient?
(2) Does the patient have a serious
coexisting illness or is the patient elderly?
(3) How severely ill is the patient at the time
of the initial evaluation?
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Community-acquired pneumonia:
treatment
Empiric therapy for pneumonia based on
recommendations by the WHO (2000).
Patients with community-acquired
pneumonia are categorized into 4 groups
because a different microbiologic
spectrum is suggested in each group to
choose the initial empiric therapy the
most effectively.
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Community-acquired pneumonia:
treatment
A. The 1st major category includes
outpatients aged 60 years or younger
without comorbidity.
Antibiotic treatment with one of
the
newer
macrolides
(clarithromycin or azithromycin) is
advised.
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Community-acquired pneumonia:
treatment
B. The 2nd group combines community-acquired
pneumonias occurring in outpatients
comorbidity or age 60 years or older.
with
The recommended therapy is
a 2nd-generation cephalosporin (cefuroxime), or
a beta-lactam + a beta-lactamase inhibitor (amoxicillinclavulanate), or
a newer fluoroquinolone (levofloxacin or moxifloxacin).
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Community-acquired pneumonia:
treatment
C.Community-acquired
pneumonia
requiring
hospitalization
The recommended therapy is
a 2nd-generation cephalosporin (cefuroxime), or
a 3rd-generation cephalosporin (ceftriaxone), or
amoxicillin-clavulanate.
Combination therapy is advised with 2nd- or 3rdgeneration cephalosporin + macrolide
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Community-acquired pneumonia:
treatment
D. Severe community-acquired pneumonia
requiring ICU care
Combination therapy is advised with
a macrolide plus a 3rd-generation
cephalosporin (eg, ceftazidime), or
triple therapy with
(1) ceftazidime or carbapenem +
(2) amikacin +
(3) macrolide or fluoroquinolone
(ciprofloxacin)
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Nosocomial pneumonia:
treatment
Nosocomial pneumonia remains a
prevalent hospital-acquired
infection.
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Severe nosocomial pneumonia:
treatment
The possible combinations are
one of the following:
(1) aminoglycoside or
ciprofloxacin +
+ (2) amoxicillin-clavulanate, or
ceftazidime, or
imipenem+vancomycin
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NB!
Pneumonia is not treated
with
gentamycin
or
penicillin!
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Telithromycin (KETEK) is first antibiotic in a new
class called ketolides.
It keeps active against gram-positive cocci in
the presence of resistance. Indicated to treat
mild-to-moderate
community-acquired
pneumonia, including infections caused by
multidrug-resistant S. pneumoniae.
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