Pneumonias

Dr Uwanuruochi Kelechukwu
 Pneumonia
• Definition:
Inflammation of lung parenchyma*
characterized by consolidation, with alveolar
air spaces filled with exudates, inflammatory
cells and fibrin.
Infection of pulmonary parenchyma
• Most caused by bacteria or viruses, chemical
inhalation, trauma, and a few from rickettsia,
fungi and yeasts.
 Classification
• Differentiated: Community
acquired/Nosocomial/ Ventilator
associated/Healthcare associated
• Bacterial/Viral/Fungal/Parasitic/Eosinophilic
• Lobar/Bronchopneumonia/ Interstitial/Diffuse
• Organism Incubation period
• Respiratory syncytial virus 1 to 4 days
• Influenza virus 18 to 72
hours
• Streptococcus pneumonia 1-3 days
• Klebsiella Pneumonia 1-3 days
• Mycoplasma Pneumonia 2-10 days
• COVID-19 2 -14 days
 Classifications:
Community acquired pneumonia
• An acute infection of the pulmonary
parenchyma that is associated with at least
some symptoms of acute infection,
accompanied by the presence of an
acute infiltrate on a chest radiograph, or
auscultatory findings consistent with
pneumonia, in a patient not hospitalized or
residing in a long term care facility for > 14
days before onset of symptoms.
 Classifications:
Community acquired pneumonia
• CAP-Onset in community or during 1st 2 days
of hospitalization (Strep. pneumoniae most
common)
 Hospital-acquired pneumonia
• Pneumonia occurring 48 hours or more after
admission, which was not incubating at the
time of admission (acquired in a hospital). It is
likely to involve hospital-acquired infections,
with higher risk of multidrug-resistant
pathogens.
Health care–associated pneumonia
• Healthcare-associated pneumonia can be
defined as pneumonia in a patient with at
least one of the following risk factors:
• hospitalization in an acute care hospital for
two or more days in the last 90 days;
• residence in a nursing home or long-term care
facility in the last 30 days
• receiving outpatient intravenous therapy (like
antibiotics or chemotherapy) within the past
30 days
Health care–associated pneumonia
• HCAP was used to identify patients at risk for
infection with multidrug-resistant pathogens.
HCAP is no longer recognized as a clinically
independent entity -This is due to increasing
evidence from a growing number of studies
that many patients defined as having HCAP
are not at high risk for MDR pathogens. As a
result, 2016 IDSA guidelines removed
consideration of HCAP as a separate clinical
entity
 Ventilator-associated pneumonia
• occurs in people breathing with the help of
mechanical ventilation, arises more than 48 to
72 hours after endotracheal intubation
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 nths
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
 Other clinical classes
• Suppurative & Aspiration pneumonia
(Anaerobic organisms are implicated in
aspiration pneumonia and lung abscess)

• Pneumonia in immunocompromised patient:

caused by opportunistic organisms
 Anatomical Classification
Lobar pneumonia if one or more lobe is involved
Broncho-pneumonia (Lobular)
1.more patchy alveolar consolidation
associated with bronchial and bronchiolar
inflammation often affecting both lower lobes
2.the pneumonic process has originated in
one or more bronchi and extends to the
surrounding lung tissue
 Anatomical Classification
• Bronchopneumonia: mostly descending
infection that affects the bronchioles and
adjacent alveoli; usually involves the lower
lobes or right middle lobe; manifests as typical
pneumonia
• Interstitial pneumonia: interstitial
inflammation, particularly caused by
mycoplasma and viral infections; manifests as
atypical pneumonia
• Miliary pneumonia: multiple small infiltrations
 Classifications-Aetiological
• Bacterial (the most common cause of
pneumonia)
• Viral pneumonia
• Fungal pneumonia
• Aspiration pneumonia
• Chemical pneumonia (ingestion of kerosene
or inhalation of irritating substance)
 Routes of infection
• Inhalation: organisms bypass normal
respiratory defence mechanisms or when the
inhales aerobic organisms that colonize the
upper respiratory tract or respiratory support
equipment
• Aspiration: aspiration of colonized upper
respiratory tract secretions
• Hematogenous: from a distant source reaches
the lungs via the blood stream.
 Clinical Features: Typical
pneumonia
Symptoms
• – Sudden/subacute onset
• – Fever, chills, rigors
• – Productive cough, Mucopurulent sputum
breathlessness and Pleuritic chest pain
Findings: Dullness on percussion, Bronchial
breathing and crackles, tachycardia,
tachypnea
• – CXR: air‐bronchogram, consolidation
 Atypical pneumonia:
• – Gradual onset
• – Afebrile, sore throat, myalgia, fatigue,
diarrhea
• – Dry cough
• – Breath sound: Rales
CXRay: Uni/bilateral patchy infiltrates or
interstitial
• –WBC: usual normal or slight high
Common etiology are Mycoplasma pneumoniae,
 Differential diagnosis

• Pulmonary infarction
• Pulmonary edema
• Acute respiratory distress syndrome
• Lung cancer or metastatic cancer
• Atelectasis
• Pulmonary thromboembolism
• Radiation pneumonitis
• Drug reactions involving the lung
 Risk Factors

• Advanced age • Upper respiratory

• chronic illnesses tract infections
• Cigarette • Alcohol
smoking • Corticosteroid
• Dementia therapy
• HIV
• Malnutrition
• Recent influenza
• Previous episode
infection
of pneumonia
• Pre-existing lung
• Splenectomy disease
 Laboratory Tests:

Microbiological tests
• Sputum Gram stain/ culture and sensitivity
• Sputum for Ziehl Neelsen stain
• Sputum cytology

Routine blood investigations

• CBC with differential
• Very high (> 20 × 109/L)) wbc indicate
severity
 Laboratory Tests:

Imaging studies
• X‐Ray chest P/A & lateral view

Serological test
• Pneumococcal antigen test
• Legionella antigen

• Pulse oximetry
• Arterial oxygen saturation- Measure when SaO2 <
93% or when severe clinical features to assess
ventilatory failure or acidosis
 Laboratory Tests:

Imaging studies
• X‐Ray chest P/A & lateral view
• Lobar pneumonia Patchy opacification evolves
into homogeneous consolidation of affected lobe
Air bronchogram (air-filled bronchi appear lucent
against consolidated lung tissue) may be present.
• Bronchopneumonia: Typically patchy and
segmental shadowing
• Complications: Para-pneumonic effusion,
intrapulmonary abscess or empyema
 Chest radiography
• Postero‐anterior and lateral view‐ important
• Establish the diagnosis
• Delineate the extent of consolidation
• Indicate the presence of underlying disorders
• Identify complications (pleural effusion,
multilobar disease, lung abscess)
• To prognosticate the disease
Chest X Ray (mostly five patterns)
• 1. Lobar‐ S. Pneumoniae
• 2. Patchy pattern‐ Viruses, Atypicals,
Mycoplasma, Chlamydia, Legionella
• 3. Interstitial‐ Influenza, CMV, PCP, Milliary TB
• 4. Lung abscess‐ S. Aureus, anerobes
• 5. Nodular‐ Fungal infection (Histoplasmosis,
Coccidiomycosis, cryptococosis)
Lobar pneumonia: extensive opacity restricted to one pulmonary lobe; positive air
bronchogram ; unilateral pleural effusion may be visible
Bronchopneumonia: poorly defined patchy infiltrates scattered throughout the lungs,
air bronchogram is unusual
Air Bronchogram
 Interstitial
pneumonia-Peribronchovascular
infiltrates

•Atypical or interstitial pneumonia: diffuse reticular opacity,

•absent (or minimal) consolidation
Pleural effusion
 Severity-CURB-65
• 1 point for each of : Confusion, Urea
>7mmol/l, Resp rate>30/min, SBP <90,
DBP<60mmHg, Age >65 years.
• If 3 or more manage as severe pneumonia
(consider ICU)
• 2 admit to hospital
• 1 or 0-treat as Out patient
 Severity-PSI
• Demographic factors Temperature <35 degrees C or >=
Sex Male (0 points) Female (-10 40 degrees C (15 points)
points) Pulse >= 125/minute (10 points)
Age (1 point for each year) • Laboratory and radiographic findings
Nursing home resident (10 points) Arterial pH < 7.35 (30 points)
• Comorbid illnesses Blood urea nitrogen >= 30 mg/dL
Neoplastic disease (30 points) (11 mmol/L) (20 points)
Liver disease (20 points) Sodium < 130 mEq/L (20 points)
Congestive heart failure (10 Glucose >= 250 mg/dL (14 mmol/L)
points) Cerebrovascular disease (10 (10 points)
points) Renal disease (10 points) Hematocrit < 30 percent (10
• Physical examination findings points)
Altered mental status (20 points) PO2< 60 mmHg or oxygen
Respiratory rate >= 30/minute (20 saturation < 90% (10 points)
points) Pleural effusion (10 points)
Systolic blood pressure < 90 mmHg (20
points)
 Pneumonia Score Interpretation
• 0-50 Points Class I 0.1% Mortality
• 51-70 Points Class II 0.6% Mortality
• 71-90 Points Class III 0.9% Mortality
Treat as outpatient

• 91-130 Points Class IV 9.3% Mortality

• 131-395 Points Class V 27.0% Mortality
Admit to hospital
 Treatment
• Oxygenation
• Fluid balance
• Antibiotics
• Nutrition
• Analgesic
 Oxygen
• Administered to all patients with tachypnoea,
hypoxaemia, hypotension or acidosis
• Maintain PaO2 at or above 8 kPa (60 mmHg)
or the SaO2 at or above 92%.
• High concentrations (35% or more) if no
hypercapnia (in COPD.)
• If prolonged, transfer to ICU for mech
ventilation
 Antibiotics
• The initial choice of antibiotic is guided by
severity, antibiotic resistance patterns
• Empirical therapy with amoxicillin is
recommended as the first line for CAP, with
doxycycline or clarithromycin as alternatives
• For severe CAP use of
a β-lactam (e.g. cephazolin) plus macrolide
(e.g. azithromycin) or
a fluoroquinolones is recommended
 Antibiotics
• For HAP third- and fourth-generation
cephalosporins, carbapenems,
fluoroquinolones, aminoglycosides, and
vancomycin are recommended
• Aspiration Pneumonia options include
clindamycin,
a beta-lactam antibiotic plus metronidazole,
or an aminoglycoside
 Antibiotics
• Pseudomonas
• An antipneumococcal, antipseudomonal
β-lactam [piperacillin/tazobactam, cefepime ,
imipenem, meropenem) plus flouroquinolons
• Above β-lactams plus an aminoglycoside and
azithromycin
• Above β-lactams plus an aminoglycoside plus
an antipneumococcal fluoroquinolone
Antimicrobial options for common
bacteria in HAP
• Organism Antimicrobial
options
• Staph. aureus Flucloxacillin, Clindamycin
• Enterobacter spp. Ciprofloxacin,
Meropenem, Ami
noglycosides
• MRSA Clindamycin,
Vancomycin,, Linezolid,
 Aspiration pneumonia
• Organism Antimicrobial options
• Strep. Pneumonia & IV Cefuroxime +
Anaerobes Metronidazole