Pnumonia

‫ا‬ ‫ا ا‬
University of Gezira
Faculty of Medicine
Pneumonia
By Dr. Mahmoud H. Salih

MBBS- MRCP - clinical MD
Assistant Professor of Internal Medicine
2022
Case scenario..
 A 68 years old male presented to the ER with acute history of

Fever and chills, productive cough with purulent sputum And
SOB.
 Clinically: he is confused, his RR = 28 c/m, PR = 120 b/m.
BP = 70/50mm/hg. auscultation to the chest reveals
crepitations.
• What is the Diagnosis? • What is the suitable treatment?
• Which Type? • Are you going to admit him to the hospital?
• What investigations are required? • What is the prognosis?
Definition
 Pneumonia:
Inflammation of the substance of the lungs. It is usually caused

by bacteria. Rarely viruses and fungi.
Incidence:
 Pneumonia continues to be an important cause of mortality

across all age groups.
 The UK mortality rate for all patients admitted to hospital
with community-acquired pneumonia ranges from 5.7% to
14%, and for those patients admitted to intensive care is >
30%.
C/P:
 acute illness with cough, purulent sputum and fever , SOB,

pluritic chest pain. Together with physical signs or
radiological changes compatible with consolidation of the lung.
Classification:
 can be classified both anatomically and on the basis of the
aetiology.
Classification by site
1. Lobar pneumonia:
 localized, with the whole of one or more lobes affected.

 Inflammation involves alveoli rather than airways
Air-bronchogram
CT Air-bronchogram
2. Bronchopneumonia:
 Diffuse, when they primarily affect the small airways instead

of alveoli.
 Small, multifocal, bilateral areas of air-space disease.
Bilateral Patchy
consolidation
BRONCHOPNEUMONIA
Classification by etiology
1. Community-acquired pneumonia:
 Streptococcus pneumoniae (60–70%)

 Haemophilus influenzae
 Staphylococcus aureus
 Atypical organisms, including:Mycoplasma pneumoniae (5–15%),
Legionella pneumophila ,Chlamydia psittaci, Chlamydia pneumoniae
and Coxiella burnetii (Q fever).
 Viral Pneumonia: influenza, SARS, H1N1, Varicella,COVID.
2. Nosocomial (hospital-acquired)
pneumonia:
 This is defined as pneumonia that develops 2 days or more after
admission to hospital (0.5–5% of hospitalized patients).
 It has a higher mortality rate than community-acquired pneumonia at >
30%.
 The organisms usually involved include:
 S. aureus (MRSA).
 Gram-negative bacteria:Klebsiella, Pseudomonas, Escherichia coli, Proteus.
 Treatment:
 Prevention: good hand hygiene, prompt anti septic measures.
 If MRSA is suspected give Vancomycin.
 If Pseudomonas is suspected Give anti Pseudomonal Regimen.
3. Aspiration pneumonia:
 May complicate impaired consciousness and dysphagia. Particulate

matter may obstruct the airway, but also chemical pneumonitis may
develop from aspiration of acid gastric contents, leading to pulmonary
oedema.
 Anaerobes are the principal pathogens, arising from the oropharynx,
 There are typically 2–3 separate isolates in each case ,Multiple
pulmonary abscesses or empyema may result.
 Treatment:
 IV cephalosporin + Metronidazol
 Chest physiotherapy is important.
Specific Pneumonias:
Streptococcus pneumoniae
 Cause 35- 80% of pneumonias. There is an abrupt onset of illness, with

high fever and rigors.
 Examination reveals crackles or bronchial breathing, and herpetic cold
sores may be present in more than a third of cases.
 Elderly patients may present with general deterioration or confusion
 Capsular polysaccharide antigen may be detected in serum, sputum,
pleural fluid or urine.
 Vaccine available. Treat with penicillin.
Staphylococcus aureus
 May follow a viral illness; it has a high mortality rate (30–70%).

 The disease is more common in intravenous drug users.
 Specific features include the following:
 There is toxin production with extensive tissue necrosis
 Staphylococcal skin lesions may develop
 Chest radiograph shows patchy infiltrates with abscess formation in
25%.
Mycoplasma pneumoniae
 Tends to affect young adults; it occurs in epidemics every 3–4 years.

 There is typically a longer prodrome, usually of ≥2 weeks, and the
white cell count (WCC) may be normal.
 Cold agglutinins occur in 50%; the mortality is low.
 Extrapulmonary complications include:
 peri-/myocarditis
 erythema multiforme, Erythema nodosum.
 haemolytic anaemia, DIC, thrombocytopenia.
 meningoencephalitis
 bullous myringitis
 hepatitis and pancreatitis
 Treatment is with macrolides, e.g. erythromycin 500mg four

times daily (or clarithromycin or azithromycin) for 7–10 days.
 A tetracycline, e.g. doxycycline 100mg twice daily, is also
effective.
Erythema multiforme
Legionella pneumophila
 Outbreaks are usually related to contaminated water-cooling systems, showers or air-

conditioning systems, but sporadic cases do occur.
 Legionnaires’ disease usually affects middle-aged and elderly patients, often with
underlying lung disease.
 Males are affected more than females.
 Diagnosis is by direct fluorescent antibody staining or serological tests; antigen may
be detected in the urine.
 Treatment : macrolides, azithromycin being the drug of choice.
 Quinolones are also effective
Clinical and laboratory features:
 Gastrointestinal upset common; diarrhoea, jaundice, pancreatitis may

occur
 WCC often not elevated with lymphopenia; thrombocytopenia/
pancytopenia may occur
 Hyponatraemia due to syndrome of inappropriate antidiuretic hormone
secretion (SIADH)
 Headache, confusion.
 Abnormal liver and renal function in 50%
Investigations:
 Sputum and blood should always be sent for culture but antibiotic treatment should
not be delayed.
 CBC and inflammatory markers.
 RFT and electrolytes.
 Severe cases need to be admitted to hospital and a chest X-ray performed.
 Other investigations ,e.g. blood gases ,are useful to detect respiratory failure and
provide a baseline for comparison if the patient deteriorates.
Prognosis:
 The overall mortality for patients admitted to hospital with community-

acquired pneumonia is currently 5%, except for Staph .aureus
pneumonia where it exceeds 25%.
Signs of severe pneumonia (CURB-65 criteria):
 •Confusion (<8/10 score on abbreviated mental test [AMT])

 •Urea >7 mmol/L
 •Respiratory rate >30 breaths/min
 •BP systolic <90 mmHg and/or diastolic <60 mmHg
 •Age >65.
 Patients with three or more CURB criteria are at high risk of death and are regarded
as having severe community-acquired pneumonia.
 Score 0–1. Treat as outpatient.
 Score 2. Admit to hospital.
Other markers of increased pneumonia severity (and
there fore prognosis) include:
 •Hypoxaemia (PO <8 kPa despite oxygen therapy)

 • Multilobar involvement
 White cell count <4 × 10/L or >20 × 10/L
 • Hypoalbuminaemia
 • Positive blood cultures.
 The presence of coexisting disease is also a bad prognostic factor.
Treatment:
 General Measures:
 IV fluids.
 Antipyretics.
 Oxygen if needed.
 Specific Measures:
 antibiotic according to the type and clinical picture.
Community acquired
 A single antibiotic (oral amoxicillin) can be used for stable community patients.
 Treatment is with oral amoxicillin and a macrolide (eg. clarithromycin) for non-
severe cases requiring hospitalisation.
 A broad-spectrum, β-lactamase, stable antibiotic, such as co-amoxiclav, or
cephalosporins given intravenously, coupled with a macrolide, is indicated in severe
cases.
 Intravenous treatment should be stepped down to oral treatment after
48 hours provided that the patient is improving
 If a specific organism is isolated, the appropriate antibiotic is given.
 Treatment should continue for 7–10 days depending on response. Up to
21 days of treatment is recommended for legionella pneumonia.
Complications:
 Lung abscess:
 Lung abscesses are normally due to mixed anaerobic infection and are commonly
caused by bacteria found in the oral cavity.
 A lung abscess may be suspected when the patient is slow to improve from
pneumonia.
 The mortality rate is high at 20–30%.
 A chest radiograph will show single or multiple fluid-filled cavities.
 Risk factors include the following:
 • Immunocompromise
 • Unconciousness.
 • Bronchial carcinoma
 • Dental disease
 • Pneumonia
 • Septic emboli (eg from right heart infective endocarditis).
 Prolonged courses of antibiotics are needed, sometimes with percutaneous drainage.
 Empyema
 A collection of pus in the pleural space may complicate up to 15% of community-
acquired pneumonias and is more common when there is a history of excess alcohol
consumption, poor dentition, aspiration or general anaesthesia.
 A diagnosis of empyema is suspected if a patient is slow to improve, has a persistent
fever or elevation of the WCC or CRP, and has radiological evidence of a pleural
fluid collection.
 The pH of pleural fluid is <7.2
 Untreated, extensive fibrosis occurs in the pleural cavity, weight loss and clubbing
develop, and the mortality rate is high at 10–20%
 The mainstay of treatment is drainage of the pleural space combined with high-dose
intravenous antibiotic treatment.
 For those who fail to resolve with medical therapy, thoracotomy and decortication of
the lung may be necessary
Case scenario..
 A 68 years old male presented to the ER with acute history of

Fever and chills, productive cough with purulent sputum And
SOB.
 Clinically: he is confused, his RR = 28 c/m, PR = 120 b/m.
BP = 70/50mm/hg. auscultation to the chest reveals
crepitations.
• What is the Diagnosis? • What is the suitable treatment?
• Which Type? • Are you going to admit him to the hospital?
• What investigations are required? • What is the prognosis?
Thanks..

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‫ا‬ ‫ا ا‬

By Dr. Mahmoud H. Salih

 A 68 years old male presented to the ER with acute history of

Inflammation of the substance of the lungs. It is usually caused

 Pneumonia continues to be an important cause of mortality

 acute illness with cough, purulent sputum and fever , SOB,

 localized, with the whole of one or more lobes affected.

 Diffuse, when they primarily affect the small airways instead

 Streptococcus pneumoniae (60–70%)

 May complicate impaired consciousness and dysphagia. Particulate

 Cause 35- 80% of pneumonias. There is an abrupt onset of illness, with

 May follow a viral illness; it has a high mortality rate (30–70%).

 Tends to affect young adults; it occurs in epidemics every 3–4 years.

 Treatment is with macrolides, e.g. erythromycin 500mg four

 Outbreaks are usually related to contaminated water-cooling systems, showers or air-

 Gastrointestinal upset common; diarrhoea, jaundice, pancreatitis may

 The overall mortality for patients admitted to hospital with community-

 •Confusion (<8/10 score on abbreviated mental test [AMT])

 •Hypoxaemia (PO <8 kPa despite oxygen therapy)

 A 68 years old male presented to the ER with acute history of

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