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Pneumonia


Pneumonia is defined as inflammation and consolidation of the respiratory part of lung

tissue (alveoli) due to an infectious agent.


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.


Causes of bacterial pneumonia

include infection with respiratory pathogens.

Exposure to pulmonary irritants or direct pulmonary injury causes noninfectious pneumonitis


Intrinsic factors that predispose pneumonia include

1)1)the host's immune response,

2))the presence of comorbidities

3) aspiration of oropharyngeal flora into the lung.

4) local lung pathologies


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.


ClassificationClassification

1. Community-acquired pneumonia1. Community-acquired pneumoniatypicalatypical

2.Nosocomial pneumonia2.Nosocomial pneumonia

3. Aspiration pneumonia. 3. Aspiration pneumonia.

4.Pneumonia in immunocompromised 4.Pneumonia in immunocompromised patients. patients.


1. Pneumonia that develops outside the hospital setting is considered community-acquired pneumonia.community-acquired pneumonia.

2. Pneumonia developing 48 hours or more after admission to the hospital is termed nosocomial or hospital-acquired pneumoniahospital-acquired pneumonia..


3. 3. Aspiration pneumoniaAspiration pneumonia takes the takes the special place due to high risk of lung special place due to high risk of lung tissue destruction and bad prognosis. tissue destruction and bad prognosis.

4. 4. Pneumonia Pneumonia in immunocompromised in immunocompromised patientspatients (those who receive (those who receive immunodepressants, such as immunodepressants, such as cytostatics or system steroids, HIV-cytostatics or system steroids, HIV-infected persons on last stage).infected persons on last stage).


Community-acquired pneumonia

is caused most commonly by bacteria that traditionally have been divided into 2 groups, typical and atypical.


A. Typical organisms in community-acquired pneumonia

(approximately 85%) includeStreptococcus pneumoniae (pneumococcus), Haemophilus influenzae (is associated with asthma and COPD), and Moraxella catarrhalis (in patients with chronic bronchitis).


S pneumoniae remains the most common agent responsible for community-acquired pneumonia.


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).


B. Atypical pathogens in community-acquired pneumonia

(approximately 15%) are

Legionella pneumophila,

Mycoplasma pneumoniae,

Chlamydia psittaci,

Coxiella burnetii.


Do not mix community-acquired pneumonia due to atypical flora with

“atypical pneumonia” due to virus (SARS – severe acute respiratory syndrome)!.


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 gram-positive diplococci in chains.

This clinical picture was recognized as “typical” (classical) pneumonia.


”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.


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.


The most common organisms responsible for nosocomial pneumonia are

Staphylococcus aureusStaphylococcus aureusKlebsiella pneumoniaeKlebsiella pneumoniaeGram-negative pathogens: Gram-negative pathogens:

>Enterobacter, >Pseudomonas aeruginosa, and >Escherichia coli.


S. aureus pneumonia generally occurs S. aureus pneumonia generally occurs in those who abuse intravenous drugs: in those who abuse intravenous drugs: in hospitalized patients and patients in hospitalized patients and patients with prosthetic devices; it spreads with prosthetic devices; it spreads hematogenously to the lungs from hematogenously to the lungs from contaminated local sites. contaminated local sites. Infection by Pseudomonas aeruginosa Infection by Pseudomonas aeruginosa tend to cause pneumonia in the tend to cause pneumonia in the patients, requiring mechanical patients, requiring mechanical ventilation.ventilation.


Essentials of diagnosis of Essentials of diagnosis of community-acquired pneumoniacommunity-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.


Essentials of diagnosis of hospital-Essentials of diagnosis of hospital-acquired (nosocomial) pneumoniaacquired (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.


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.



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.



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.


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.


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.


Precise clinical diagnosis of nosocomial pneumonia

is much more difficultmuch more difficult than community-acquired pneumonia.

It is because of the absence of a typical clinical pictureabsence of a typical clinical picture against the background of the disease, which was the reason for hospitalization.

The subclinical coursesubclinical course without clear typical picture is widespread.

However, one or more clinical findingsclinical findings (fever,

leukocytosis, purulent sputum), and a pulmonary pulmonary infiltrateinfiltrate on chest x-ray are present in most patients.


PhysicalPhysical

A.The common symptoms and signs (due to due to intoxication and respiratory failureintoxication and respiratory failure) are as follows:

Fever (temperature >38.5°C) Tachypnea Tachycardia Central cyanosis

These symptoms are non-specificnon-specific and indicate severityseverity of the disease, not etiologynot etiology. They can’t help to diagnose pneumonia, but they determine therapy and prognosis.


PhysicalPhysical

B. The most important information on physical examination is connected with signs of lung tissue consolidationlung tissue consolidation due to local inflammation:Dullness to percussionIncreased tactile fremitusDecreased intensity of breath soundsCrackles (crepitation) at the beginning and

resolving of inflammationLocal rales Pleural friction rub


The main doctor’s task on physical examination

is revealing of asymmetric is revealing of asymmetric

pathology.pathology.

Pneumonia is locallocal respiratory pathology. Therefore,

the presence of focal area of lung tissue focal area of lung tissue

consolidationconsolidation has the most diagnostic value.

It is direct indication for chest radiograph.


Imaging StudiesImaging Studies

The diagnosis of pneumonia is impossible without X-ray investigation.

Direct indication for chest X-ray is not only

focal acoustic pathologyfocal acoustic pathology but also any clinical situation accompanied by chronic or prolonged cough.


Imaging StudiesImaging Studies

In chest medicine 80% of information is on the developed film.

Chest radiograph findings in typical case of pneumonia indicate a segmental or segmental or lobar opacity, or infiltrationlobar opacity, or infiltration corresponding to the impaired area.


Left low lobe pneumoniaLeft low lobe pneumonia


Low lobe pneumoniaLow lobe pneumonia


Right upper lobe lobar pneumonia Right upper lobe lobar pneumonia secondary to Streptococcus secondary to Streptococcus

pneumoniae infectionpneumoniae infection


Bacterial pneumonia. Bilateral airspace Bacterial pneumonia. Bilateral airspace infiltration secondary to community-infiltration secondary to community-acquired pneumonia, subsequently acquired pneumonia, subsequently

confirmed to be confirmed to be LegionellaLegionella pneumonia pneumonia


Bacterial pneumonia. Rarely, severe Bacterial pneumonia. Rarely, severe pneumococcal infection may be associated pneumococcal infection may be associated

with necrotizing pneumonia.with necrotizing pneumonia.


Chest radiographs showing Chest radiographs showing

right middle lobe pneumoniaright middle lobe pneumonia


Hospital-acquired right lower lobe pneumonia; sputum culture Hospital-acquired right lower lobe pneumonia; sputum culture

confirmed this to be secondary to gram-negative organismsconfirmed this to be secondary to gram-negative organisms


Aspergillus pneumoniaAspergillus pneumonia


PPneumonineumonia caused by a caused by ChlamydChlamydia ia psittasipsittasi


Aspiration pneumoniaAspiration pneumonia


CTCT in case of pneumoniain case of pneumonia


Lab StudiesLab 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.



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.


Bacterial pneumonia. Pneumococci Bacterial pneumonia. Pneumococci on sputum Gram stain. on sputum Gram stain.


Bacterial pneumonia. Histopathological Bacterial pneumonia. Histopathological micrograph ofmicrograph of bacterial pneumonia showing bacterial pneumonia showing extensive infiltration with inflammatory cellsextensive infiltration with inflammatory cells


Bacterial pneumonia. Bacterial pneumonia. Klebsiella Klebsiella pneumoniaepneumoniae on sputum Gram stain on sputum Gram stain



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.

That is why diagnosis of pneumonia is clinical-That is why diagnosis of pneumonia is clinical-radiological, not etiological.radiological, not etiological.



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 serologyserology, which is essential in the diagnosis of unusual causes of pneumonia such as Legionella, Mycoplasma, Chlamydia, and other.

Blood culturesBlood cultures are of a limited value, as they are positive only in approximately 40% of cases.


Other TestsOther Tests

Arterial blood gas (ABG) determination: Arterial blood gas (ABG) determination: Evaluation of the patient's gas exchange is Evaluation of the patient's gas exchange is essential in order to decide if hospital essential in order to decide if hospital admission, oxygen supplementation, or admission, oxygen supplementation, or other efforts are indicated. other efforts are indicated.

Pulse oximetry of less than 90% indicates Pulse oximetry of less than 90% indicates significant hypoxia; an ABG determination significant hypoxia; an ABG determination should be performed in these patients.should be performed in these patients.


ProceduresProcedures

BronchoscopyBronchoscopy

Bronchial washing specimens can be obtained. Protected Bronchial washing specimens can be obtained. Protected brush and bronchoalveolar lavage can be performed for brush and bronchoalveolar lavage can be performed for quantitative cultures. quantitative cultures.

ThoracentesisThoracentesis

This is an essential procedure in patients with a This is an essential procedure in patients with a parapneumonic pleural effusionparapneumonic pleural effusion. .

Obtaining fluid from the pleural space for laboratory analysis Obtaining fluid from the pleural space for laboratory analysis allows for the differentiation between simple and allows for the differentiation between simple and complicated effusions. This determination helps guide complicated effusions. This determination helps guide furtherfurther therapeutic interventiontherapeutic intervention..


Differential diagnosis

Any case of pneumonia requires excluding of 2 other pulmonological problems.

They are

lung cancer and lung cancer and

tuberculoustuberculous..


Complications

Pleural effusion

Empyema

Pulmonary abscess

Respiratory failure

Acute heart failure

Death


Criteria for hospitalization

The decision to hospitalize patients with

community-acquired pneumonia is

dictated by risk factorsrisk factors that increase

either the risk of death or the risk of a risk of death or the risk of a

complicated course of diseasecomplicated course of disease.


Some of indications for indications for hospitalizationhospitalization include

Advanced age (over 65)comorbidity (alcoholism, diabetes mellitus, COPD, chronic renal or heart failure, chronic liver disease)suspicion of aspiration leukopenia or marked leukocytosisany evidence of respiratory failureseptic appearance and absence of supportive care at home (social indications).


Who can be treated at home?Who can be treated at home?

Only young people in case of mild Only young people in case of mild

course. course.

If there’s the smallest sign of a If there’s the smallest sign of a

moderate course, the patient must moderate course, the patient must

be directed to the in-patient be directed to the in-patient

department immediately!department immediately!


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.


The initial approach to treating The initial approach to treating patients with patients with сommunity-acquired

pneumonia

involves a determination of 3 factors. involves a determination of 3 factors. (1)(1) Should the patient with pneumonia be Should the patient with pneumonia be

treated in the hospital or as an outpatient? treated in the hospital or as an outpatient? (2)(2) Does the patient have a serious Does the patient have a serious

coexisting illness or is the patient elderly? coexisting illness or is the patient elderly? (3)(3) How severely ill is the patient at the time How severely ill is the patient at the time

of the initial evaluation?of the initial evaluation?


Community-acquired pneumonia: treatment

Empiric therapy for pneumonia based on

recommendations by the WHO (2000).

Patients with community-acquired Patients with community-acquired

pneumonia are categorized into pneumonia are categorized into 4 groups 4 groups

because a different microbiologic because a different microbiologic

spectrumspectrum is suggested in each group to is suggested in each group to

choose the initial empiric therapy the choose the initial empiric therapy the

most effectively.most effectively.



A. TheA. The 11stst major category major category includes includes outpatients aged 60 years or younger without comorbidity..

Antibiotic treatment with one of the newer macrolides (clarithromycin or azithromycin) is advised.



B. The 2nd group combines community-acquired pneumonias occurring in outpatients with comorbidity or age 60 years or older.

The recommended therapy is

a 2nd-generation cephalosporin (cefuroxime), or

a beta-lactam + a beta-lactamase inhibitor (amoxicillin-clavulanate), or

a newer fluoroquinolone (levofloxacin or moxifloxacin).



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 3rd-generation cephalosporin + macrolide



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)


Nosocomial pneumonia: treatment

Nosocomial pneumonia remains a prevalent hospital-acquired infection.


Severe nosocomial pneumonia: treatment

The possible combinations are one of the following:

(1) aminoglycoside or ciprofloxacin +

+ (2) amoxicillin-clavulanate, or ceftazidime, or

imipenem+vancomycin


NB!

Pneumonia is not treated with gentamycin or penicillin!


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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