Pneumonia

Pneumonia
 Definition
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 to
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
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.
 Classification
• 1. Community-acquired pneumonia
typical
atypical
2.Nosocomial pneumonia
3. Aspiration pneumonia.
4.Pneumonia in
immunocompromised patients.
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.
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 systemic
steroids, HIV-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%) include
Streptococcus 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, 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 aureus
Klebsiella pneumoniae
Gram-negative pathogens:
> Enterobacter,
> Pseudomonas aeruginosa, and
> Escherichia coli.
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.
 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.
Essentials of diagnosis of hospital-
acquired (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.
 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.
 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.
 A detailed 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 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.
 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.
 Physical
B. The most important information on
physical examination is connected with
signs of lung tissue consolidation due to
local inflammation:
 Dullness to percussion
 Decreased intensity of breath sounds
 Crackles (crepitation) at the beginning and
resolving of inflammation-Local rales

 Pleural friction rub

 The main 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.
 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.
 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.
Left low lobe pneumonia
Low lobe pneumonia
Right upper lobe lobar pneumonia
secondary to Streptococcus
pneumoniae infection
Bacterial pneumonia. Bilateral airspace
infiltration secondary to community-
acquired pneumonia, subsequently
confirmed to be Legionella pneumonia
 Bacterial pneumonia. Rarely, severe
pneumococcal infection may be associated
with necrotizing pneumonia.
 Chest radiographs showing
right middle lobe pneumonia
Hospital-acquired right lower lobe pneumonia; sputum culture
confirmed this to be secondary to gram-negative organisms
Aspergillus pneumonia
Pneumonia caused by Chlamydia
psittasi
Aspiration pneumonia
CT in case of pneumonia
 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.
 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.
Bacterial pneumonia. Pneumococci
on sputum Gram stain.Reading only
Bacterial pneumonia. Histopathological
micrograph of bacterial pneumonia
showing extensive infiltration with
inflammatory cells
 Bacterial pneumonia. Klebsiella
pneumoniae on sputum Gram stain
 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.
 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.
 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.
 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.
 Differential diagnosis
Any case of pneumonia requires
excluding of 2 other
pulmonological problems.
They are
lung cancer and
tuberculous.
 Complications
Pleural effusion
Empyema
Lung abscess
Respiratory failure
Acute heart failure
Death
 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.
 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).
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!
 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
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?
Community-acquired pneumonia:
treatment
Empiric therapy for pneumonia based on
recommendations by the WHO
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.
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.
 Community-acquired pneumonia:
treatment
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).
Community-acquired pneumonia:
treatment
C.Community-acquired pneumonia requiring
hospitalization
The recommended therapy is
a 3rd-generation cephalosporin (ceftriaxone), or
amoxicillin-clavulanate.
Combination therapy is advised with 2nd- or 3rd-
generation cephalosporin + macrolide
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)
 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