Pneumonia

PNEUMONIA
CONTENTS:
• What is pneumonia
• Pathophysiology
• Classification
• Etiology
• Complications
• Diagnosis
• Prognosis
• Treatment
• Follow up
• Prevention of pneumonia
Pneumonia
• Pneumonia is defined as
inflammation of the lung
parenchyma, that is, of
the alveoli rather than
the bronchi or
bronchioles, of infective
origin and characterised
by consolidation.
Pathophysiology
Due to etiological factors
Microbes enter respiratory tract
Activation of immune response (mucus production , cough etc)
penetrate to lower respiratory trac (terminal, bronchioles alveoli)
Vasodilation & increased blood flow

Consolidation of leukocytes &fibrin
Congestion (alveoli filled with fluid)
Consolidation of lungs (pneumonia)

Sign and symptoms
• Typical pneumonia:
• Tachycardia
• Tachypnea
• Fever
• Cough with sputum
• Fatigue
• Dyspnea
Atypical pneumonia:
• Headache
• Nausea
• Vomiting
• Diarrhea
• Malaise
• Low grade fever
• Dry cough
• Hyponatremia
• Biochemical abnormalities in liver enzymes
• Signs of inappropriate antidiuretic hormone secretion, which show up as low
plasma sodium.
Classification
Pneumonia is class classified into three types according to its origin:
• Community-acquired pneumonia (CAP) :
Pneumonia that is acquired outside the hospital.
• Hospital-acquired pneumonia (HAP):
Pneumonia which can be acquired while in a hospital or healthcare facility for
another illness or procedure.
• Aspiration Pneumonia
When solid food, liquids, spit or vomit go down your trachea (windpipe) and into
your lungs. If you can’t cough these up, your lungs can get infected.
Classification
Clinically pneumonia is classified into

two types:
• Bronchopneumonia (atypical
pneumonia)
Affects patches throughout both lungs
• Lobar pneumonia
Affects a section (lobe) of lung
Etiology:
 Community-acquired pneumonia (CAP) :
Infection with Streptococcus pneumoniae is the most common cause of CAP.
Mycoplasma pneumoniae bacteria causes atypical pneumonia. Other bacteria that
cause CAP include Haemophilus influenza, Chlamydia pneumoniae and Legionella.
Viruses that cause the common cold, the flu (influenza), COVID-19 and respiratory
syncytial virus (RSV) can sometimes lead to pneumonia.
Fungi, like Cryptococcus, Pneumocystis jirovecii and Coccidioides, are uncommon
causes of pneumonia.
Protozoa like Toxoplasma cause pneumonia.
Etiology
 Hospital-acquired pneumonia (HAP):
• Common organisms:
1. Gram-negative bacteria: Pseudomonas aeruginosa, E. coli, Klebsiella spp.
2. Gram-positive bacteria: S. pneumoniae, S. aureus including MRSA
• Less common organisms:
1. Anaerobic bacteria : Klebsiella pneumoniae
2. Fungi: Candida albicans (and other species), Aspergillus fumigatus (particularly
following prolonged episodes of neutropenia)
3. Viruses: Cytomegalovirus, Herpes simplex virus
Etiology
• Aspiration Pneumonia
Aspiration pneumonia is caused
by food going down the wrong
way, or inhaling vomit, a foreign
object or harmful substance.
PNEUMONIA: COMPLICATIONS
 respiratory failure
 shock
 multiorgan failure
 Coagulopathy
 Metastatic infection
 lung abscess
 complicated pleural effusion
 Empyema
Diagnosis
The diagnosis of pneumonia involves a combination of medical history, physical examination, and
diagnostic tests. Here are the steps usually taken in the diagnosis of pneumonia:
Medical history: The doctor will ask about your symptoms, including when they started, how severe they
are, and whether you have any other medical conditions that might put you at risk for pneumonia.
Physical examination: The doctor will listen to your lungs with a stethoscope to check for abnormal
breathing sounds, such as crackles or wheezes. They may also check your temperature and other vital
signs.
Chest X-ray: This is a common test used to diagnose pneumonia. It can show areas of the lung that are
inflamed or filled with fluid.
Blood tests: These can help determine the type of infection causing the pneumonia and how severe it is.
Blood tests may also help identify any underlying medical conditions that could be contributing to the
pneumonia.
Sputum culture: This involves collecting a sample of mucus from your lungs and testing it for the presence
of bacteria, viruses, or fungi.
Bronchoscopy: In some cases, the doctor may use a thin, flexible tube with a camera on the end
(bronchoscope) to look inside your lungs and collect samples of lung tissue or fluid.
Chest x -rays
Brochopneumonia Lobar pneumonia

PNEUMONIA: PROGNOSIS
depends on:
• Patient’s age,
• comorbidities,
• site of treatment (inpatient or outpatient)
• Young patients without comorbidity do well and usually recover fully
after ~2 weeks
• Older patients and those with comorbid conditions can take several
weeks longer to recover fully.
• The overall mortality rate for the outpatient group is <5%.
• For patients requiring hospitalization, the overall mor-
tality rate ranges from 2 to 40%, depending on the category of patient
and the processes of care.
CAP: Treatment for Out-Patients
Status Regimen
Previously healthy and no antibiotics in past 3 • A macrolide [clarithromycin (500 mg PO bid) or

months azithromycin (500 mg PO once, then 250 mg qd)]
• Doxycycline (100 mg PO bid)
Comorbidities or antibiotics in past 3 months: select • A respiratory fluoroquinolone [moxifloxacin (400
an alternative from a different class mg PO qd), gemifloxacin (320 mg PO qd), levofloxacin
(750 mg PO qd)] or
• A β-lactam [preferred: high-dose amoxicillin (1 g
tid) or amoxicillin/ clavulanate (2 g bid); alternatives:
ceftriaxone (1–2 g IV qd), cefpodoxime (200 mg PO
bid), or cefuroxime (500 mg PO bid)] plus a macrolide
CAP: Treatment for In-Patients
Status Regimen
ICU • A β-lactam [e.g., ceftriaxone (2 g IV qd), ampicillin-

sulbactam (2 g IV q8h), or cefotaxime (1–2 g IV q8h)]
plus either azithromycin or a fluoroquinolone (as
listed above for inpatients, non-ICU)
Non-ICU • A respiratory fluoroquinolone [e.g., moxifloxacin

(400 mg PO or IV qd) or levofloxacin (750 mg PO or IV
qd)] OR
A β-lactam [e.g., ceftriaxone (1–2 g IV qd), ampicillin
(1–2 g IV q4–6h), cefotaxime (1–2 g IV q8h),
ertapenem (1 g IV qd)] plus a macrolide [e.g., oral
clarithromycin or azithromycin as listed above or IV
azithromycin (1 g once, then 500 mg qd)]
CAP: Treatment Special Concerns
which Organisms involved Ragimen
Pseudomonas • An antipseudomonal β-lactam [e.g.,

piperacillin/tazobactam (4.5 g IV q6h), cefepime (1–2 g
IV q12h), imipenem (500 mg IV q6h), meropenem (1 g
IV q8h)] plus either ciprofloxacin (400 mg IV q12h) or
levofloxacin (750 mg IV qd)
• The above β-lactams plus an aminoglycoside
[amikacin IV (15 mg/kg qd) or tobramycin IV (1.7
mg/kg qd)] plus azithromycin
The above β-lactam plus an aminoglycoside plus an
antipneumococcal fluoroquinolone
CA-MRSA Add linezolid (600 mg IV q12h) or vancomycin (15
mg/kg q12h initially, with adjusted doses) plus
clindamycin (300 mg q6h)
Empirical Antibiotic Treatment of
Hospital-Acquired
Categories Treatment
NO RISK FACTORS FOR RESISTANT GRAM NEGATIVE Piperacillin-tazobactam (4.5 g IV q6h )OR
PATHOGEN Cefepime (2 g IV q8h)OR
Levofloxacin (750 mg IV q24h)
RISK FACTORS FOR RESISTANT GRAM-NEGATIVE Piperacillin-tazobactam (4.5 g IV q6hb ) PLUS
PATHOGEN amikacin(15-20 mg/kg IV qd) or
Cefepime (2 g IV q8h) Plus Gentamicin (5-7 mg/kg IV
qd) OR
Ceftazidime (2 g IV q8h) plus tobramycin (5-7 mg/kg IV
qd ) OR
Imipenem (500 mg IV q6hb ) plus ciprofloxacin (400
mg IV q8h)
Meropenem (1 g IV q8h) plus levofloxacin (750 mg qd
IV)
Risk Factors for MRSA (Add to above) Linezolid (600 mg IV q12h) or Adjusted-dose
vancomycin (trough level, 15–20 mg/dL)
PNEUMONIA: FOLLOW UP
• Fever and leukocytosis usually resolve within 2–4 days in otherwise
healthy patients with CAP, but physical findings may persist longer.
• Chest radiographic abnormalities are slowest to resolve (4–12 weeks),
with the speed of clearance depending on the patient’s age and
underlying lung disease.
• For a hospitalized patient, a follow-up radiograph ~4–6 weeks later is
recommended.
• If relapse or recurrence is documented, particularly in the same lung
segment,
the possibility of an underlying neoplasm must be considered
Prevention of Pneumonia
Prevention of CAP
All those at risk of infection should be given;
1. The main preventive measure is vaccination
• pneumococcal polysaccharide vaccine (PPSV23
• protein conjugate pneumococcal vaccine (PCV13)
2. Influenza vaccine.
3. Smokers should be strongly encouraged to stop smoking.
Prevention of HAP
General measures for reducing the occurrence of HAP includes;
1. Most important preventive intervention is to avoid intubation or
minimize its duration.
2. Minimize the duration of ventilation through daily holding
of sedation
3. Short-course antibiotic prophylaxis can decrease the risk of VAP in
comatose patients requiring intubation
REFERENCES
• Roger-Walker-Clinical-Pharmacy-and-Therapeutics
• Harrison’s Principle of Internal Medicine

Pneumonia

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PNEUMONIA

Microbes enter respiratory tract

Activation of immune response (mucus production , cough etc)

penetrate to lower respiratory trac (terminal, bronchioles alveoli)

Vasodilation & increased blood flow

Congestion (alveoli filled with fluid)

Consolidation of lungs (pneumonia)

Clinically pneumonia is classified into

Brochopneumonia Lobar pneumonia

Previously healthy and no antibiotics in past 3 • A macrolide [clarithromycin (500 mg PO bid) or

ICU • A β-lactam [e.g., ceftriaxone (2 g IV qd), ampicillin-

Non-ICU • A respiratory fluoroquinolone [e.g., moxifloxacin

Pseudomonas • An antipseudomonal β-lactam [e.g.,

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