PNEUMONIA

Dr. Hinda Hassan Khideer

MBBS ,MRCP
NORMAL CHEST X-RAY

Courtesy of Up To Date
REVIEW OF LUNG ANATOMY

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 WHAT IS PNEUMONIA?
 Infection of the lung
parenchyma
 An acute lower
respiratory tract
infection associated
with fever,
symptoms and signs
in the chest, and
abnormalities on the
chest x-ray
 Causative agents
include bacteria,
viruses, fungi
www.netmedicine.com/xray/xr.htm
 Pneumonia is an infection of the lung tissue.
When a person has pneumonia the air sacs in
their lungs become filled with microorganisms,
fluid and inflammatory cells and their lungs are
not able to work properly. Diagnosis of
pneumonia is based on symptoms and signs of an
acute lower respiratory tract infection, and can
be confirmed by a chest X-ray showing new
shadowing that is not due to any other cause
(such as pulmonary oedema or infarction).
 It is diagnosed in 5–12% of adults who present to
GPs with symptoms of lower respiratory tract
infection, and 22–42% of these are admitted to
hospital, where the mortality rate is between 5%
and 14%.

 Hospital-acquired pneumonia is estimated to

increase hospital stay by about 8 days and has a
reported mortality rate that ranges from 30–70%.
SYMPTOMS
 Fever, rigors, malaise, anorexia( loss of appetite)
 dyspnoea (shortness of breath)

 Cough (purulent sputum, haemoptysis)

 and pleuritic pain(pain that increase with

breathing)
SIGNS
 Pyrexia,
 cyanosis

 confusion(can be the only sign in the elderly—

may also be hypothermic),
 tachypnoea,

 tachycardia, hypotension,

 signs of consolidation (reduced expansion, dull

percussion,Increased tactile vocal fremitus/vocal
resonance, bronchial breathing), and a pleural
rub
 COMPLICATIONS OF PNEUMONIA
Respiratory failure :Type I respiratory failure (PaO2 <8kPa) is
relatively common
Hypotension May be due to a combination of dehydration and
vasodilation due to sepsis. .
Atrial fibrillation Common in the elderly.
Pleural effusion Inflammation of the pleura by adjacent
pneumonia may cause fluid exudation into the pleural space. .
Empyema Pus in the pleural space. It should be suspected if a
patient with a resolving pneumonia develops a recurrent fever.
Lung abscess A cavitating area of localized, suppurative
infection within the lung .
Septicaemia May occur as a result of bacterial spread from the
lung parenchyma into the bloodstream. This may cause
metastatic infection, eg infective endocarditis,meningitis.
Pericarditis and myocarditis May also complicate pneumonia
 SEVERITY
 Severity-of-illness scores can help guide whether a patient
needs hospital admission and should always be supplemented
with clinical judgement

 CURB-65 criteria
 Confusion
 Urea >19 mg/dL
 Respiratory rate ≥30
 Blood pressure (SBP <90 or DBP ≤60)
 ≥65 year old
 ≥2 criteria then needs hospital admission and ≥3 criteria may
need ICU level of care
HOW DO WE CLASSIFY PNEUMONIA?
 One way of classifying pneumonia is radiologically
based and could be any of the above classes (CAP,
HAP, PIC)
1. Bronchopneumonia:-
 Patchy distribution of infection that involves more
than one lobe ( bronchi→ bronchiole → alveoli)
(more patchy alveolar consolidation often both lower
lobes)
2. Lobar pneumonia:-
 Exudates fluids spread and filled part or all lobe
that can be detected radiographically.
 Lobar pneumonia (homogenious consolidation of one
or more lobe
LOBAR PNEUMONIA
HOMOGENEOUS CONSOLIDATION
BRONCHOPNEUMONIA • TYPICALLY PATCHY
AND SEGMENTAL SHADOWING
HOW DO WE CLASSIFY PNEUMONIA?
based on the context in which pneumonia
developed. This indicate the most likely causative
organism)
 Community Acquired Pneumonia (CAP)

 Nosocomial/Hospital Acquired Pneumonia (HAP)

 Others
❑ This classification depends on specific etiological
agents or by the clinical setting in which infection
occurs.
❑ PNEUMONIA SYNDROME:- Involves 7 settings

1) Community Acquired Acute

Pneumonia(CAAP).
2) Community Acquired Atypical
Pneumonia(CAAtP).
3) Nosocomial infections.
4) Necrotizing Pneumonia and Lung
abscess.
5) Aspiration pneumonia.
6) Pneumonia in immunocompromised Pts.
7) Chronic Pneumonia.
COMMUNITY ACQUIRED PNEUMONIA
CAP
 CAP = pneumonia in person not hospitalized or
residing in a long-term care facility for  14 days

Clinical Infectious Diseases 2000;31:347-82

1) COMMUNITY- ACQUIRED
ACUTE PNEUMONIAS
 THEY ARE COMMONLY BACTERIAL IN ORIGIN BUT
MAY FOLLOWS V.U.R.T.Is.
 Strept pneumoniae
✓ Haemophilus influenzae.
✓ Moraxella catarrhalis.
✓ Staphylococcus aureus.
✓ Legionella pneumophila

❑Clinical presentation:-
 Usually abrupt, with…
✓ High fever.
✓ Shaking chills.
✓ Pleuritic chest pain.
✓ Productive mucopurulent cough.
✓ Hemoptysis..?
COMMUNITY ACQUIRED ATYPICAL
PNEUMONIA(CAATP)
❖ Atypical… means:-
a) Atypical amount of sputum.
b) Absence of consolidation.
c) Lack of alveolar exudates.
✓ Mycoplasma pneumoniae .
✓ Chlamydia spp.
✓ Viruses: respiratory syncytial virus.
parainfluenza virus (children).
influenza A and B (adults).
adenovirus (military recruits)
A NTIBIOTIC THERAPY
Low-severity community-acquired
pneumonia
▪ Offer a 5-day course of a single antibiotic to
patients with low-severity community-
acquired pneumonia.
▪ Consider amoxicillin in preference to a
macrolide or a tetracycline for patient with
low-severity community-acquired pneumonia.
Consider a macrolide or a tetracycline for
patients who are allergic to penicillin.
▪ Consider extending the course of the
antibiotic for longer than 5 days as possible
management strategy for patients with low-
severity community-acquired pneumonia
whose symptoms do not improve as expected
after 3 days.
Moderate- and high-severity community-acquired
pneumonia
▪ Consider a 7- to 10-day course of antibiotic therapy .
▪ Consider dual antibiotic therapy with amoxicillin
and a macrolide
▪ Consider dual antibiotic therapy with a beta-
lactamase stable beta-lactam and a macrolide for
patients with high-severity community-acquired
pneumonia
 Available beta-lactamase stable beta-lactams include:
co-amoxiclav, cefotaxime , ceftriaxone, cefuroxime
Monitoring in hospital
 Consider measuring a baseline C-reactive
protein concentration in patients with
community-acquired pneumonia on admission to
hospital, and repeat the test if clinical progress is
uncertain after 48 to 72 hours.
Patient information
Explain to patients with community-acquired pneumonia
that after starting treatment their symptoms should steadily
improve, although the rate of improvement will vary with the
severity of the pneumonia, and most people can expect that by:
1 week: fever should have resolved
4 weeks: chest pain and sputum production should have
substantially reduced
6 weeks: cough and breathlessness should have substantially
reduced
3 months: most symptoms should have resolved but fatigue may still
be present
6 months: most people will feel back to normal.

Advise patients with community-acquired pneumonia to consult

their
healthcare professional if they feel that their condition is
deteriorating or not improving as expected.
CAP - WHY DO WE CARE ABOUT IT?

 5.6 million cases annually

 1.1 million require hospitalization

 Mortality rate =12% in-hospital; near 40% in ICU

patients

Am J Respir Crit Care Med 163:1730-54, 2001

CAP – TESTING

 CXR
 Sputum Gram Stain and culture

 Pulse oximetry

 Routine lab testing – CBC, BMP, LFTs

 ABG

 Thoracentesis if pleural effusion present

Am J Respir Crit Care Med 163:1730-54, 2001

CAP – MODIFYING FACTORS
MODIFYING FACTORS THAT INCREASE THE RISK OF
INFECTION WITH SPECIFIC PATHOGENS
Penicillin-resistant and drug-resistant pneumococci
Age > 65 yr
B-Lactam therapy within the past 3 mo
Alcoholism
Immune-suppressive illness (including therapy w/ corticosteroids)
Multiple medical comorbidities
Exposure to a child in a day care center
Enteric gram-negatives
Residence in a nursing home
Underlying cardiopulmonary disease
Multiple medical comorbidities
Recent antibiotic therapy
Pseudomonas aeruginosa
Structural lung disease (bronchiectasis)
Corticosteroid therapy (10 mg of prednisone per day)
Broad-spectrum antibiotic therapy for > 7 d in the past month
Malnutrition

Am J Respir Crit Care Med 163:1730-54, 2001

CAP -THE SWITCH TO ORAL
ANTIBIOTICS

 Switch if patient meets the following:

 Inproved cough and dyspnea
 Afebrile on 2 occasions 8 hours apart
 If otherwise improving way waive this criteria
 Decreasing WBC count
 Functional GI tract with adequate PO intake

Am J Respir Crit Care Med 163:1730-54, 2001

CAP - PREVENTION
 Influenza Vaccine
 Pneumococcal Vaccine
HOSPITAL-ACQUIRED PNEUMONIA
HAP(NOSOCOMIAL PNEUMONIA)
 Pneumonia occurring ≥48 h post admission
 not present at admission.

 Excludes infection incubating at time of

admission

Am J Respir Crit Care Med 153:1711-25, 1995

❖ Causative agents : mainly are gm-ve rods
(Enterobacteriaceae and Pseudomonas), and
Staph.aureus.
HAP - EPIDEMIOLOGY
 5 to 10 cases per 1,000 hospital admissions
 Incidence MUCH higher with mechanical
ventilation (6-20 fold higher)
 Second most common nosocomial infection but
number one for M & M
 Mortality near 70% in patients with HAP
 Increased length of stay by 7-9 days

Am J Respir Crit Care Med 153:1711-25, 1995

RISK FACTORS FOR HAP
Modifiable Non-modifiable
Depressed level of consciousness Age > 70 years
Enteral nutrition Immunosuppression
Malnutrition Thoracic or abdominal surgery
Mechanical ventilation Underlying chronic lung disease
Oropharyngeal colonization
Re-intubation
Stress ulcer prophylaxis
Supine position
TREATMENT
Empiric treatment guidelines depend on whether
HAP is early or late onset (>4 days) and risk
factors for MDR pathogens present.

Risk Factors for Multi-Drug Resistant pathogens

• Antimicrobial therapy in preceding 90 days
• Onset of pneumonia after 5 days of
hospitalization
• High frequency of antibiotic resistance in the
community or hospital unit
• Duration of ICU stay and mechanical ventilation
• Immunocompromised state
TREATMENT
For early onset with no MDR risk factors:
• Pathogens include S. pneumo, H. influenzae,
MSSA, E. coli, Enterobacter, Proteus.
• Recommended antibiotics: Ceftriaxone or
Levofloxacin or Unasyn or Ertapenem.

Source: American Thoracic Society, Infectious Diseases Society of America. Guidelines

for the management of adults with hospital-acquired, ventilator-associated, and
healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388.
TREATMENT
For late onset or MDR risk factors present:
• Pathogens include Pseudomonas, Klebsiella ESBL,
Acinetobactor, MRSA, Legionella.
• Recommended antibiotics: Cefepime or imipenem or
Zosyn PLUS levofloxacin or gentamicin PLUS
vancomycin or linezolid

Source: American Thoracic Society, Infectious Diseases Society of America. Guidelines for the
management of adults with hospital-acquired, ventilator-associated, and healthcare-
associated pneumonia. Am J Respir Crit Care Med 2005; 171:388.
SPECIAL CONSIDERATIONS
All patients should be re-evaluated for clinical
improvement and review of microbiologic results
at 48 to 72 hours and considered for de-escalation
(narrow spectrum or oral therapy).

The duration of therapy for HAP and VAP is

generally 7 to 8 days except in cases caused by
Pseudomonas or Acinetobacter spp., for which
treatment should continue for 14 days
HAP – FAILURE OF THERAPY
Patients who do not improve within 72 hours of
appropriate antimicrobial therapy should be
evaluated for
▪infectious complications (e.g. empyema or lung
abscess),
▪an alternate diagnosis (e.g. PE, ARDS, neoplasm),

▪Antibiotic resistance

▪or another site of infection (e.g. C. diff colitis,

pleural effusion) to explain the clinical picture.
HAP - PREVENTION
 Hand washing
 Vaccination
 Influenza
 Pneumococcus
 Isolationof patients with resistant
respiratory tract infections
 Enteral nutrition
 Choice of GI prophylaxis
 Subglottoc secretion removal?

Am J Respir Crit Care Med 153:1711-25, 1995

PNEUMOCOCCAL PNEUMONIA
▪ The commonest bacterial pneumonia.
▪ Affects all ages, but is commoner in the elderly,alcoholics,
post-splenectomy,immunosuppressed,and patients with
chronic heart failure or pre-existing lung disease.
▪ Clinical features:
Rapid onset of a high Fever, pleuritic chest pain, herpes
labialis (reactivation of herpes simplex virus).
▪ CXR shows lobar consolidation.

▪ Treatment: amoxicillin, benzylpenicillin, or

cephalosporin
 STAPHYLOCOCCAL PNEUMONIA
▪ May complicate influenza infection or occur in the young,
elderly, intravenous drug users, or patients with underlying
disease, eg leukaemia,lymphoma, cystic fibrosis (CF).
▪ CXR It causes a bilateral cavitating
bronchopneumonia.Characteristically it causes multiple
abscesses in up to 25% which may metastasize to the brain
and bones
▪ Treatment: flucloxacillin ± rifampicin,
MRSA: contact lab; consider vancomycin.
KLEBSIELLA PNEUMONIA
▪ Rare. Occurs in elderly, diabetics, and alcoholics.
▪ Causes a cavitating pneumonia, particularly of
the upper lobes,with abcess formation
▪ The mortality is 30-50%
▪ Treatment:
cefotaxime or imipenem.
PSEUDOMONAS
▪ A common pathogen in bronchiectasis and CF.
▪ It also causes hospital-acquired infections,
particularly on ITU or after surgery.
▪ Treatment: antipseudomonal penicillin,
ceftazidime, meropenem, or ciprofloxacin +
aminoglycoside.
▪ Consider dual therapy to minimize resistance
M YCOPLASMA PNEUMONIAE
▪ It occurs in young patients living in boarding houses
▪ It presents insidiously with flu-like symptoms (headache,
myalgia, arthralgia) followed by a dry cough.
▪ CXR: worse than signs suggest.
▪ Diagnosis: PCR sputum or serology..
▪Complications:
Cold agglutinins may cause an autoimmune haemolytic
anaemia
Skin rash (erythema multiforme,Stevens–Johnson
syndrome,
Glomerulonephritis ,hepatitis,myocarditis , meningo
encephalitis or myelitis; Guillain–Barre syndrome
▪ Treatment: Clarithromycin or doxycycline
LEGIONELLA PNEUMOPHILA
▪ Colonizes water tanks kept at <60°C (eg hotel air-
conditioning and hot water systems) causing
outbreaks.
▪ Flu-like symptoms (fever,malaise, myalgia) precede a
dry cough and dyspnoea.
▪ Extra-pulmonary features include anorexia, D&V,
hepatitis, renal failure, confusion, and coma.
▪ CXR shows bi-basal consolidation.
▪ Blood tests may show lymphopenia, hyponatraemia,
and deranged LFTS. Urinalysis may show
haematuria. Diagnosis: Urine antigen/culture.
▪ Treatment:fluoroquinolone or clarithromycin
 CHLAMYDOPHILA PSITTACI
▪ Causes psittacosis, an ornithosis acquired from
infected birds (typically parrots). Symptoms
include headache, fever, dry cough, lethargy,
arthralgia, anorexia, and D&V.
▪ Extra-pulmonary features are rare, eg meningo-
encephalitis, infective endocarditis, hepatitis,
nephritis, rash, splenomegaly.
▪ CXR shows patchy consolidation. Diagnosis:
Chlamydophila serology.
▪ Treatment: doxycycline or clarithromycin.
PNEUMOCYSTIS PNEUMONIA
▪ Causes pneumonia in the immunosuppressed (eg
HIV).
▪ The organism responsible was previously called
Pneumocystis carinii, and now called Pneumocystis
jirovecii.
▪ It presents with a dry cough, exertional
dyspnoea,fever,
▪ bilateral crepitations.
▪ Diagnosis: Visualization of the organism in induced
sputum,
bronchoalveolar lavage, or in a lung biopsy specimen.
▪ Drugs: High-dose co-trimoxazole), or pentamidine .
Steroids are benefcial if severe hypoxaemia.
▪ Prophyl axis is indicated if the CD4 count is
<200≈106/L or after the 1st attack.
VIRAL PNEUMONIA
▪ Influenza commonest but ‘swine flu’ (H1N1) is
now
▪ considered seasonal and covered by the annual
‘flu vaccine.
▪ Others: measles, CMV,varicella zoster.
 Avian influenza A viruses rarely infect humans
and most follow direct or close contact with
infected poultry. The issue remains a public
health priority because of the ability of the virus
to mutate. Symptoms range from conjunctivitis to
infl uenza- like illness (low pathogenic forms) to
severe respiratory illness and multiorgan failure
(highly pathogenic forms). H7N9 and H5N1 have
been responsible for most human illnesses
worldwide
 Severe acute respiratory syndrome (SARS)
▪ is caused by a corona virus. Major features are persistent fever
(>38°C), chills, rigors, myalgia, dry cough, headache, diarrhoea,
and dyspnoea.
▪ Mortality is 1–50%, depending on age, but no cases since 2004.
Close contacts, or travel to an area with known cases should raise
suspicion.
▪ The mechanism of transmission is human–human .

Middle East respiratory syndrome (MERS)

▪ is a viral respiratory disease caused by novel coronavirus (MERS
CoV) and was first identifi ed in 2012 in Saudi Arabia.
▪ Symptoms include fever, cough, shortness of breath, and
gastrointestinal upset.
▪ Incubation period 14 days. Human-to-human transmission has
been reported in most cases, but camels play a pivotal host role in
animal-to-human transmission.
▪ Large outbreaks linked to healthcare facilities have been reported
in the Middle East and South Korea. The World Health
Organization has reported mortality as high as 36% in