Pneumonia

Disease
 contents

overview
Community acquired pneumonia
Hospital acquired pneumonia
Suppurative pneumonia
Aspiration pneumonia
Pulmonary abscess
Pneumonia in immunocompromised patients
 Community acquired
pneumonia
Most cases are spread by droplet
infection, and while CAP may occur in
previously healthy individuals, several
factors may impair the effectiveness of
local defences and predispose to CAP.
Streptococcus pneumoniae remains the
most common infecting agent, and
thereafter the likelihood that other
organisms may be involved depends on
the age of the patient.
Viral infections are recognised as
important causes of CAP in children
and their contribution to adult CAP is
increasingly recognized.
 CLINICAL
FEATURES
Pneumonia , particularly lobar pneumonia, usually presents as an acute illness
SYSTEMIC FEATURES: FEVER, RIGORS, SHIVERING AND MALAISE,
PREDOMINATE AND DELIRIUM may be present. The APPETITE IS
INVARIABLY LOST AND HEADACHE frequently reported.
PULMONARY SYMPTOMS: COUGH characteristic which is short, painful and
dry, but later is accompanied by the EXPECTORATION OF
MUCOPURULENT SPUTUM.
RUST-COLOURED SPUTUM may be produced by patients with STREP.
PNEUMONIAE INFECTION and the occasional patient may report
haemoptysis.
PLEURITIC CHEST PAIN may be a presenting feature and on occasion may be
referred to the shoulder or anterior abdominal wall.
UPPER ABDOMINAL TENDERNESS is sometimes apparent in patients with
 Organisms causing community acquired
pneumonia

Bacteria: Viruses:
Streptococcus pneumoniae  Influenza
Mycoplasma pneumoniae  Measles 
Legionella pneumophila Herpes simplex 
Chlamydia pneumoniae Varicella 
Haemophilus infuenzae  Adenovirus 
Staphylococcus aureus  Cytomegalovirus 
Chlamydia psittaci  Coronaviruses (SARS-CoV-2 and MERS-CoV
Coxiella burnetii (Q fever) 
Klebsiella pneumoniae (Freidländer’s bacillus)
 CURB-65
score
 CURB-65 score
The CURB-65 score, which takes into account both examination and
investigation
Chest signs vary, depending on the inflammatory response, which proceeds
through
Stages :
ACUTE EXUDATION
RED HEPATISATION
GREY HEPATISATION
RESOLUTION
When consolidated the lung is TYPICALLY DULL TO PERCUSSION
and as conduction of sound is enhanced AUSCULTATION REVEALS
BRONCHIAL BREATHING AND WHISPERING CRACKLES are
heard throughout.
 INVESTIGATION
blood
S
FULL BLOOD COUNT
Very high (>20 X 10*9/L) or low (4 X 10*9/L) WBC marker severity
Neutrophils leucocytosis >15 X 10*9/L suggest bacterial aetiology
Hemolytic anemaia : complication of mycoplasma
UREA and ELECTROLYTES
Urea >7mmol/L
Hyponatremia
LIVER FUNCTION TESTS
Abnormal if basal pneumonia inflames liver
Hypoalbuminemia:marker of severity
PROCALCITONIN
A high procalcitonin suggest it is a bacterical than viral infection
 INVESTIGATION
S
C-REACTIVE PROTEIN/ESR
Non specifically elevated
BLOOD CULTURE
Bacteraemia:marker or severity
ARTERIAL BLOOD GAS
Measure spo2 <93% or when clinical features are severe to assess ventilatory
failure or acidosis
SPUTUM
Sputum samples
Gram stain culture tryptic soy broth and antimicrobical sensitivity testing
PHARYNGEAL SWABS
NAAT for respiratory viruses and bacteria
URINE
Pneumococcal or legionella antigen
 INVESTIGATION
S X RAY
CHEST
LOBAR PNEUMONIA
Patchy opacification evolves into homogenous consolidation of affected lobe
Air bronchogram may be present
BRONCHOPNEUMONIA
Typically patchy and segmental shadowing
COMPLICATIONS
Para pneumonic effusion intrapulmonary abcess or empyema
S.AUREUS
Multilobular shadowing cavitation pneumatoceles and abscesses
PLEURAL FLIUD
Always aspirate and culture when present in more than trivial amounts
 management
oxygen
Oxygen should be administed in all paitents with tachypnoea , hypoxaemia ,
hypotension or acidosis to maintain the O2 saturations
Continuous positive airway pressure (CPAP) should be considered in those
who remain hypoxic
Mechanical ventilation is supplied
Fluid balance
Intravenous fluids should be given in severe illness
It is appropriate to discontinue hypertensive agents
temporarily particularly if there is evidence of acute kidney
injury instead adequate oral fluid encouraged
 Management Antibiotic treatment
LOW SEVERITY CAP (CURB-65 SCORE 0–1) 
Amoxicillin 500 mg 3 times daily orally (or IV if necessary)
If patient is allergic to penicillin 
Doxycycline 200 mg loading: dose then 100 mg/day orally or clarithromycin 500 mg
twice daily orally
MODERATE SEVERITY CAP (CURB-65 SCORE 2) 
Amoxicillin 500 mg–1 g 3 times daily orally (or IV if oral medication not possible) or
benzylpenicillin 1.2 g 4 times daily IV plus clarithromycin 500 mg twice daily orally/IV
If patient is allergic to penicillin 
Doxycycline 200 mg loading dose then 100 mg/day orally or levofloxacin 500 mg/day
orally
SEVERE CAP (CURB-65 SCORE 3–5) 
Co-amoxiclav 1.2 g 3 times daily IV or cefuroxime 1.5 g 3 times daily IV or ceftriaxone
1–2 g daily IV plus clarithromycin 500 mg twice daily IV or benzylpenicillin 1.2 g 4
times daily IV plus levofloxacin 500 mg twice daily IV
If Legionella is strongly suspected 
 management
Treatment of pleural pain
It is important to relieve pleural pain in order to
allow the patient breathe normally and cough
efficiently
Simple analgesia with paracetamol , co codamol or
physiotherapy
NSAID is sufficent .
It is not indicated usually in patients with CAP
but it is helpful to assist expectoration in patients
who suppress cough because of pleural pain
 management
prognosis
.
Most patients respond promptly to antibiotic therapy. Fever may persist for
several days, however, and the chest X-ray often takes several weeks or even
months to resolve, especially in old age. Delayed recovery says complication
has occurred
discharge and follow up
The decision to discharge a hospitalised patient depends on the home
circumstances and the likelihood of complications. A chest X-ray need not be
repeated before discharge in patients making a satisfactory clinical recovery.
Clinical review by general practitioner or hospital should be arranged around 6
weeks later and a chest X-ray obtained if there are persistent symptoms,
physical signs or reasons to suspect underlying malignancy, such as tobacco
exposure.
 prevention
Current smokers should be advised to stop. Influenza and pneumococcal
vaccination should be offered to patients at highest risk of pneumonia (e.g.
those over 65 or with chronic lung, heart, liver or kidney disease, diabetes or
immunosuppression).
Causes of pneumonia that have important public health implications must be
notied to the appropriate health authority
The resource-poor settings, tackling malnourishment and indoor air
pollution, and encouraging immunisation against measles, pertussis and
Haemophilus influenzae type b, are particularly important in children.
 HOSPITAL ACQUIRED
PENUMONIA
Hospital-acquired pneumonia (HAP) is defined as an episode of pneumonia that
presents at least 48 hours after admission to hospital and was not incubating at the
time of admission.

It is the second most common healthcare-associated infection (HAI) after surgical-

site infections and the leading cause of HAI-associated death. Older patients are
particularly at risk, as are patients in intensive care units.

The term ventilator-associated pneumonia (VAP) is used to describe pneumonia

that develops in a person who is mechanically ventilated
 CLINICAL FEATURES AND
purulent sputum (orINVESTIGATION
The diagnosis should be considered in any hospitalised patient who develops
endotracheal secretions), new radiological in ltrates, an
otherwise unexplained increase in oxygen requirement, a core temperature >38.3°C,
and a leucocytosis or leucopenia.

The clinical features and radiographic signs are variable and non-specifc, however,
raising a broad differential diagnosis that includes pulmonary embolism, ARDS,
pulmonary oedema, pulmonary haemorrhage and drug toxicity.
Therefore, in contrast to CAP, microbiological conrmation should be sought
whenever possible. Adequate sputum samples may be difficult to obtain and
physiotherapy should be considered to aid expectoration.

In patients who are mechanically ventilated, bronchoscopy-directed protected brush

specimens, bronchoalveolar lavage (BAL) or endotracheal aspirates may be
 MANAGEMENT
The principles of management are similar to those of CAP, focusing on
adequate oxygenation, appropriate fluid balance and antibiotics.
The choice of empirical antibiotic therapy is considerably more challenging,
however, given the diversity of pathogens and the potential for drug resistance.

PREVENTION
Good hygiene is paramount, particularly with regard to hand-washing and any
equipment used. Steps should be taken to minimise the chances of aspir ation
and to limit the use of stress ulcer prophylaxis with proton pump inhibitors.
Oral antiseptic (chlorhexidine 2%) may be used to decontaminate the upper
airway
 antibiotics treatment
First-choice oral antibiotic for non-severe symptoms or signs and not at higher risk of resistance
Co-amoxiclav 500/125 mg 8-hourly for 5 days
If co-amoxiclav unsuitable
Doxycycline 200 mg on 1rst day, then 100 mg daily for 4 days (5-day course)
Cefalexin (caution in penicillin allergy) 500 mg 3 times or twice daily (can be increased to 1 g to 1.5
g 4 or 3 times daily) for 5 days
Co-trimoxazole 960 mg twice daily for 5 days
Levofloxacin 500 mg daily or twice daily for 5 days
First-choice IV antibiotics if severe symptoms or signs (e.g. of sepsis) or at higher risk of resistance
Piperacillin with tazobactam 4.5 g 3 times daily (increased to 4.5 g 4 times daily if severe infection)
Ceftazidime 2 g 3 times daily
Ceftriaxone 2 g once daily
Cefuroxime 750 mg 4 or 3 times daily
Antibiotics to be added if suspected or confirmed MRSA infection
Vancomycin 15 mg/kg to 20 mg/kg 3 times or twice daily IV
Teicoplanin Initially 6 mg/kg twice daily for 3 doses, then 6 mg/kg daily
Linezolid (if vancomycin cannot be used; specialist advice only) 600 mg twice daily or IV
 suppurative pneumonia aspiration pneumonia
pulmonary abscess
Suppurative pneumonia and pulmonary abscess
. Suppurative pneumonia is characterised by destruction of the lung parenchyma

by the inflammatory process.

Suppurative pneumonia and pulmonary abscess often develop after the
inhalation of septic material during operations on the nose, mouth or throat,
under general anaesthesia, or of vomitus during anaesthesia or coma,
particularly if oral hygiene is poor
Aspiration pneumonia
Aspiration pneumonia include bulbar or vocal cord palsy, achalasia or
oesophageal reflux, and alcoholism
Aspiration tends to localise to dependent areas of the lung, such as the
apical segment of the lower lobe in a supine patient.
 suppurative pneumonia
Clinical features
SYMPTOMS 
.

Cough with large amounts of sputum, sometimes fetid and blood-stained 

Pleural pain common 
Sudden expectoration of copious amounts of foul sputum if abscess ruptures
into a bronchus
CLINICAL SIGNS 
High remittent pyrexia 
Profound systemic upset 
Digital clubbing may develop quickly (10–14 days) 
Consolidation on chest examination; signs of cavitation rarely found 
Pleural rub common 
Rapid deterioration in general health, with marked weight lossif not adequately
treated
 investigations

CHEST X RAY
.
Radiological features of suppurative pneumonia
include homogeneous lobar or segmental opacity
consistent with consolidation or collapse

Abscesses are characterised by cavitation and a

uid level. Occasionally, a pre-existing
emphysematous bulla becomes infected and appears
as a cavity containing an air–fluid level
 management
antibiotics
Aspiration
. pneumonia can usually be treated with amoxicillin and
metronidazole.

Parenteral therapy with vancomycin or linezolid can also be

considered.

treatment with intravenous or oral penicillin, or with a tetracycline in

penicillin-allergic patients

Fusobacterium necrophorum (lemirre syndrome) is highly susceptible

to β-lactam antibiotics and to metronidazole, clindamycin and third-
generation cephalosporins. Prolonged treatment for 4–6 weeks may be
 pneumonia in immunocompromised patients
Immunosuppressed patients
.
Patients immunocompromised by drugs or disease
(particularly human immunodeciency virus (HIV)
infection) are at increased risk of pulmonary
infection and pneumonia is the most common cause
of death in this group

patients with more profound immunosuppression

cause ‘opportunistic’ pathogens
 pneumonia in immunocompromised patients
Clinical features
.

Fever
Cough
Breathlessness but are influenced by the degree of
immunosuppression
The onset of symptoms tends to be swift in those
with a bacterial infection but more gradual in
patients with opportunistic organisms such as
Pneumocystis jirovecii and mycobacterial infections
 pneumonia in immunocompromised patients
investigations
.
The approach is informed by the clinical context and severity of the illness.

HRCT can be helpful:  focal unilateral airspace opacification favours bacterial

infection, mycobacteria or Nocardia 
Bilateral opacification favours P. jirovecii pneumonia, fungi, viruses and unusual
bacteria, e.g. Nocardia 
Cavitation may be seen with N. asteroides, mycobacteria and fungi 
The presence of a ‘halo sign’ (a zone of intermediate attenuation between the
nodule and the lung parenchyma) may suggest aspergillosis or other invasive
fungal infection 
Pleural effusions suggest pyogenic bacterial infections and are uncommon in P.
jirovecii pneumonia.
ß-1,3-D-glucan levels are characteristically elevated in P. jirovecii pneumonia.
 pneumonia in immunocompromised patients
managemenT
.

Treatment should be based on an established aetiological

diagnosis in practice

Broad-spectrum antibiotic therapy should be commenced

immediately, e.g. a third-generation cephalosporin, or a
quinolone, plus an antistaphylococcal antibiotic, or an
antipseudomonal penicillin plus an aminoglycoside

antifungal or antiviral therapies may be added

 COMPLICATIONS OF
PNEUMONIA
• Para-pneumonic effusion – common 
• Empyema 
• Retention of sputum causing lobar collapse 
• Deep vein thrombosis and pulmonary embolism 
• Pneumothorax, particularly with Staphylococcus aureus 
• Suppurative pneumonia/lung abscess 
• ARDS, renal failure, multi-organ failure 
• Ectopic abscess formation (Staphylococcus aureus) 
• Hepatitis, pericarditis, myocarditis, meningoencephalitis 
• Arrhythmias 
• Pyrexia due to drug hypersensitivity
 Differential
Diagnosis
• Pulmonary infarction 
• Pulmonary/pleural tuberculosis 
• Pulmonary oedema (can be unilateral) 
• Pulmonary eosinophilia 
• Malignancy: bronchoalveolar cell
carcinoma
• Cryptogenic organising
pneumonia/bronchiolitis obliterans
organising pneumonia (COP/BOOP)
 Thanks
for
attentions
From VALLARASU PG
138
 REFERENCE

Davidson's Principles and Practice of Medicine,

International Edition, 24e
Ramadas Nayak Exam Preparatory Manual for
Undergraduates: Pathology. Fourth Edition
Harrison's Principles of Internal Medicine 21e