PNEUMONIAS

Lecture Objectives
• Define pneumonia
• Classify and define types of pneumonia
• Describe the etiologic organisms, risk
factors for, clinical features, investigations,
treatment, complications and preventive
measures of the various types of
pneumonias
 Case 1
• JK, 70 yrs, male, admitted with 3day Hx of
cough, chest pain, fever and confusion
• Has been living at an Old People’s home
for the past 10 yrs. Hx of smoking, 5-pack
years but stopped several yrs ago
• O/E e, tachypnoeic, RR-40b/min, BP -
100/50mmHg, features of consolidation
RT middle lobe
• With reasons, what is your diagnosis?
• What investigations would you do and
why?
Case 2
• SM, 48yr old female, admitted 4 days ago
with a 1-day Hx of inability to move the LT
side of her body.
• She has difficulty keeping food in the
mouth and had NG Tube inserted for
feeding on admission.
• Today on the MWR, she is found to have
new onset cough, fever and
breathlessness.
• With reasons, what is your diagnosis?
• What investigations would you do?
Organisms
• Case 1 – What are the likely
aetiological organisms in case 1? Why?
• Case 2 – What are the likely organisms
in case 2? Why?
Pneumonia
Definition
• Acute respiratory illness associated with
recently developed radiological pulmonary
shadowing which is either segmental or
lobar

• Pneumonia may be bacterial, viral,

mycobacterial or fungal
 Classification
1) Community-acquired pneumonia
2) Hospital-acquired pneumonia
3) Aspiration pneumonia (including
suppurative pneumonia)
4) Pneumonia in the immunocompromised
host
Community-Acquired Pneumonia
(CAP)
Definition
• Pneumonia acquired in the patient’s
home or in the non-hospital environment
such as
a nursing home

• Mainly spread by inhalational

CAP - Definitions
• Lobar pneumonia - radiological and
pathological term
 – Refers to homogeneous opacification (red
hepatisation) of one or more lung lobes often
associated with pleural inflammation
• Bronchopneumonia - patchy alveolar
consolidation associated with bronchial
and bronchiolar inflammation affecting
both lower lobes
Lobar Pneumonia vs
Bronchopneumonia
 CAP – Organisms I
Etiologic Organisms
• Streptococcus pneumoniae 30%
• Chlamydia pneumoniae 10%
• Mycoplasma pneumoniae 9%
• Legionella pneumophila 5%
• Hemophilus influenza 3%
CAP – Organisms II
Etiologic Organisms
• Others – Staphylococcus aureus, Chlamydia
psittaci, Coxiella burnetti, Klebsiella
pneumoniae, Actinomyces israeli all <1%.
• Viruses – Influenza virus 7-8% of CAP
- Parainfluenza
- Measles
- Respiratory syncytial virus (RSV) in infancy
- Varicella (chicken pox)
Aetiological Organisms of CAP
 Risk Factors
• Cigarette smoking
• Alcohol intake
• Corticosteroid therapy
• Old age
• Recent influenza infection
• Preexisting lung disease
• Contact with sick birds (Chlamydia psittaci)
• Farm environments (Coxiella burnetti)
Risk Factors and Specific
Pathogens I
Risk Factors and Specific
Pathogens II
 Clinical Features - Symptoms
• Cough – productive of rust coloured
sputum
• Fever
• Malaise
• Pleuritic chest pain
• Headache
• Confusion
Clinical Features - Signs
• Fever • Signs of consolidation
• Tachycardia – dull percussion note
• Tachypnoea and bronchial breath sounds
• Hypoxemia • Crepitations
• Hypotension • Signs of a pleural
• Confusion effusion – stony
• Pleural rub dullness and absent
or reduced breath
sounds.
Pathological Basis for the Signs in
Lobar Pneumonia
 Assessment of Disease Severity I
Clinical parameters
- Age of 60yrs or older
- Respiratory rate >30/min
- Diastolic blood pressure 60mmHg or less
- Confusion
- More than 1 lobe involved in CXR
- Presence of underlying disease
Laboratory parameters
 Assessment of Disease Severity II
- Hypoxemia (PaO2 <8kPa)
- Leucopenia (<4000x109/L)
- Leucocytosis (>20000x109/L)
- Raised serum urea ≥7mmol/L
- Positive blood culture
- Hypoalbuminemia
• The 4 cardinal markers of severity are:- -
RR ≥30/ min
 Assessment of Disease Severity
III
- Diastolic BP ≤60mmHg
- Serum BUN of ≥7mmol/L
- Presence of confusion
• Patients with 2 or more of the 4 cardinal
markers of severity have a 36-fold higher
risk of dying compared with patients
without these signs
 CURB – 65 Score
• Based upon 5 easily measurable factors
– Confusion (based upon a specific
mental test or new disorientation to
person, place, or time)
– Urea (BUN) >7 mmol/L
– RR >30 breaths/minute
– BP (systolic <90 mmHg or diastolic
<60 mmHg)
 – Age >65 years
CURB -65 and Mortality Risk
Score Mortality Risk Level Site of Care
%

o 0.6 % Low Outpatient

1 2.7 % Low Outpatient

2 6.8 % Moderate Short inpatient/

Supervised
inpatient
3 14 % Moderate to High Inpatient

4 or 5 27.8 % High Inpatient/ICU

 Investigations I
1) Chest radiograph
• Homogenous opacity localised to the
affected lobe or segment
• Useful in identifying pleural effusion,
intrapulmonary abscess formation or
when empyema is suspected
 Investigations II
• Hilar lymphadenopathy is seen in
Mycoplasma pneumonia
2)Microbiological investigations
- sputum microscopy, culture and
sensitivity
- aspiration of tracheal/ bronchial
secretions during bronchoscopy for
M/C/S
 Investigations III
- Blood cultures and sensitivity patterns
3) Arterial blood gas measurement for
assessment of disease severity
4) Complete blood count
- Neutrophil leucocytosis suggests
bacterial pneumonia

- Leucopenia suggests viral etiology

Investigations IV
 Treatment
• Supportive and specific treatment
• Good response to antibiotic therapy
• When there is delayed recovery suspect:-
- complications
- wrong diagnosis
- proximal bronchial obstruction
- recurrent aspirate
 Supportive Treatment
• Oxygen- for all hypoxemic patients. Use
concentrations ≥35% in those without
advanced COPD or hypercapnia
• IV fluids
• Physiotherapy
• Pain relief with paracetamol or if severe
then with pethidine or morphine
 Empiric Treatment
• Pretreatment specimen samples (blood
cultures and expectorated sputum) should
be obtained for microbiological evaluation
before starting empirical therapy

• Combination empirical treatment is

recommended
Empiric Antibiotic Use for CAP I
Empiric Antibiotic Use for CAP II
 Specific Treatment
• Antibiotic therapy – given after specimens
have been obtained for microbiological
evaluation
– S. pneumoniae - B-lactam antibiotic eg
ceftriaxone
– C. pneumoniae/ C.psitacci - macrolide
or tetracycline (doxycycline)
– M. pneumoniae – Macrolide or
tetracycline
Specific Treatment II
– L. pneumophila – Fluoroquinolone or
macrolide
– H. influenza – B-lactam antibiotic,
ciprofloxacin
– Klebsiella pneumoniae - gentamicin and
ceftazidime
– Actinomycosis – benzyl penicillin
– Varicella pneumonia – acyclovir
Pathogen Specific Therapy I
Pathogen Specific Therapy II
Indicators of Improvement
 Complications
• Parapneumonic effusions
• Empyema
• Sputum retention
• Pneumothorax

Patterns of Delayed Response and

Causes I
Patterns of Delayed Response and
Causes II
 Prevention of CAP
• Immunization with influenza A/B for all people
>50yrs
• Immunization with 23 polyvalent pneumococcal
and H. influenza type B vaccines for all
susceptible people e.g.
– elderly>65yrs
– Co-morbidities like diabetes, immunocompromised,
sickle cell disease or asplenia.
• Treatment of water sources to prevent
Legionella pneumophila
Vaccine Recommendations I
Vaccine Recommendations II
 Serotypes in Available
Pneumococcal Vaccines
• PPV-23 – 1,2,3,4,5,6B,7F,8,9N,9V,10A,11A,12F,
14,15B,17F,18C,19F,19A,20,22F,23F and 33F
– (23-valent pneumococcal polysaccharide vaccines
for adults and children < 2years)

• PCV-13 – 1,3,4,5,6A,6B,7F,9V,14,18C,19A,19F
and 23F
– (Polysaccharide-protein conjugate vaccines, better
tolerated in children and induce an immune response)

• PCV-10 – 1,4,5,6B,7F,9V,14,18C,19F and 23F

 Hospital Acquired Pneumonia
(HAP)
• Nosocomial pneumonia
Definition
• A new episode of pneumonia occurring at
least 2 days (48hrs) after admission to
hospital
• Occurs in 2-5% of all hospital admissions
• Mortality is high ≈ 30%
 HAP
Etiologic Agents (Organisms)
• Gram negative bacteria
-Escherichia coli
-Pseudomonas
-Klebsiella species
• Staph aureus including methicillin resistant
staph aureus (MRSA)
• Anaerobic organisms
 Risk Factors I
• Reduced host defences against bacteria
- Reduced immune defences e.g. diabetes
, malignancy
- Reduced cough reflex( Post-operative)
- Disordered mucociliary clearance
- Bulbar or vocal chord palsy
 Risk Factors II
• Aspiration of nasopharyngeal or gastric
secretions
- Immobility or reduced level of
consciousness
- Vomiting, dysphagia, achalasia, severe
reflux
- Nasogastric intubations
 Risk Factors III
• Bacteria introduced into the lower respiratory
tract
- Endotracheal intubation/ tracheostomy
- Infected ventilators, nebulisers, bronchoscopes.
- Dental or sinus infections
• Bacteremia
- Abdominal sepsis
- Intravenous cannula infections
 Risk Factors IV
- Infected emboli
 Clinical Features
• Cough
• Fever
• Sputum purulence
• Breathlessness
• Central cyanosis
• Crepitations
 Investigations
1) Chest radiograph – mottled
appearance in both lung fields in the lower
zones
2) Complete blood counts – neutrophil
leucocytosis
3) Tracheal aspirates 4) Blood cultures
Treatment
Supportive treatment
- Physiotherapy
- Oxygen therapy
 - Fluid support and monitoring
Specific therapy
• IV antibiotics guided by culture results.
• Gram negative coverage which includes
-3rd generation cephalosporin + an aminoglycoside
or
- imipenem
or
- a monocyclic β-lactam + flucloxacillin

Prevention of HAP
• Improved pulmonary toilet in post-op patients
through frequent suctioning, incentive spirometry
and non-cough suppressant analgesia
 • Handwashing
• Appropriate sterilization and handling of devices
and respiratory equipment
• Proper placement of NG tubes
• Appropriate volume and rate of oral and enteral
feeding
• Elevation of head of bed to 30 -450
Aspiration Pneumonia /
Suppurative Pneumonia
Definition
• Pneumonia resulting from introduction of
foreign objects or substances into the
 lower respiratory tract
Etiologic Agents (Organisms)
- Enterobacteriaceae
- Staphylococcus aureus
- Streptococcus pneumoniae
- Haemophilus influenza

Mechanisms for Aspiration and

Suppurative Pneumonia
1) Primary bacterial pneumonias with
pulmonary suppuration due to Staph.
 aureus and Klebsiella pneumoniae
2) Inhalation of septic material during
operations on the nose, mouth or throat
under general anaesthesia
3) Inhalation of vomitus
4) Bacterial infection of a pulmonary infarct
or of a collapsed lobe

Risk Factors
• Gross oral sepsis • Achalasia
• Bulbar palsy • Oesophageal reflux
• Vocal chord palsy disease
• Alcoholics associated with
• IVDU – at risk of endocarditis
lung abscesses affecting the
pulmonary and
tricuspid valves
Clinical Features - Symptoms
• Cough – productive of large amounts of
sputum, fetid and bloodstained
• Chest pain (pleuritic)
• Sudden expectoration of copius amount of
foul sputum occurs if abscess ruptures into
a bronchus
Clinical Features - Signs
• High fever
• Digital clubbing may develop quickly in
10-14 days
• Signs of consolidation
• Pleural rub is common
• Weight loss
Investigations
1)Chest radiograph
• Homogenous lobar or segmental opacity
consistent with consolidation or collapse
• Large, dense opacity which may later cavitate
and show a fluid level is the characteristic
finding when a frank lung abscess is present
• A preexisting emphysematous bulla may
become infected and appears as a cavity
containing an air-fluid level
2) Sputum examination and culture

Treatment
1) Supportive treatment – Physiotherapy to assist
in drainage of large cavities
2) Specific treatment
• Ceftriaxone(gram positive+ negative) +
clindamycin (anaerobic)
• Modify treatment according to microbiology
results
• Treat for 4-6 weeks
• Removal of any obstructing endo-bronchial
lesion is essential
• Surgical intervention for abscesses that fail to
resolve despite optimal medical therapy
Complications
• Fibrosis
• Bronchiectasis

Prevention
• Good oral hygiene
• Assess patients at risk of aspiration and
nurse them with head of bed elevated
between 30 – 450
Pneumonia in The
Immunocompromised Host
Defined as:-
• Pneumonia in patients receiving
immunosuppressive drugs and in those with
diseases causing defects in cellular or humoral
immune mechanisms
Etiologic Agents( Organisms)
• Gram negative bacteria especially P. aeruginosa
• Unusual organisms normally considered to be of
low virulence or non-pathogenic
Risk Factors/ Etiologic Agents I
• Neutropenia due to cytotoxic drugs,
agranulocytosis or acute leukemia
predisposes to pneumonia due to
- Staph aureus
- Gram negative bacteria
 - Candida albicans
- Aspergillus fumigatus
Risk Factors/ Etiologic Agent II
• T-cell defects due to - Pneumocystis carinii
lymphoma, CLL, - Cytomegalovirus
immunosuppressive - Gram negative
drugs, bone marrow bacteria
transplant or - Staph aureus
splenectomy predisposes - Strep pneumoniae
to pneumonia due to - H.influenza
- C. albicans
 - Mycobacteria tuberculosis
Risk Factors/ Etiologic Agent III
• Abnormalities in antibody production due
CLL and myeloma predispose to
pneumonia due to encapsulated
organisms
- Strep.pneumonia
- H.influenza
 Clinical Features
• Fever
• Cough
• Breathlessness

Investigations
1) Chest radiograph
2) Sputum microscopy, culture and
sensitivity. May require sputum induction
 using hypertonic saline in patients with
dry cough
3) Bronchoscopy with broncho-alveolar
lavage (BAL) for M/C/S
4) Lung biopsy
Treatment
• Based on an established etiological
diagnosis
• Empirically
 – broad spectrum antibiotic e.g. 3rd generation
cephalosporin or a quinolone + an
antipseudomonal
penicillin(piperacillintazobactam,
cefepime,imipenem or meropenem) + an
aminoglycoside
• If cause is PCP treat with high dose
septrin
 Prevention
• Use of GCSF factors eg filgrastim(G-CSF)
and sargramostim(GM-CSF) in patients
with neutropenia
THANK YOU !