Pathophysiology

Pathogenesis of typical pneumonia

S pneumoniae generally resides in the nasopharynx and is carried asymptomatically in
approximately 50% of healthy individuals. Invasive disease may occur upon acquisition of a new
epithelium serotype. A strong association exists with viral illnesses, such as influenza. Viral
infections increase pneumococcal attachment to the receptors on activated respiratory
epithelium. Once aerosolized from the nasopharynx to the alveolus, pneumococci infect type II
alveolar cells. The pneumonic lesion progresses as pneumococci multiply in the alveolus and
invade alveolar epithelium. Pneumococci spread from alveolus to alveolus through the pores of
Kohn, thereby producing inflammation and consolidation along lobar compartments.
A recent multivariate analysis showed an independent association between pneumococcal CAP
and alcoholism. Current alcohol abuse was associated with severe CAP. No significant
differences were found in mortality, antibiotic resistance of S pneumoniae, and other etiologies.
Pathogenesis of atypical infection
After aspiration or inhalation, the atypical organisms attach to the respiratory epithelial cells by a
variety of mechanisms. The presence of pili on the surface of Legionella species facilitates
attachment. Once adhered, the organisms cause injury to the epithelial cells and their associated
cilia. Many of the pathogenetic mechanisms may be immune-mediated rather than due to direct
injury by the bacteria. A host defense is mounted via cell-mediated and humoral immunity.
Infection caused by atypical organisms often spreads beyond the lobar boundaries and frequently
is bilateral.
Pathogenesis of nosocomial pneumonia
Aspiration plays a central role in the pathogenesis of nosocomial pneumonia. Approximately
45% of healthy subjects aspirate during sleep, and an even higher proportion of severely ill
patients aspirate routinely. Depending on the number and virulence of the pathogenic organisms
reaching the lower respiratory tract and on the host defense factors, pneumonia may develop.
The oropharynx of hospitalized patients may become colonized with aerobic gram-negative
bacteria within a few days of admission. Therefore, nosocomial pneumonia is caused
predominantly by the gram-negative bacilli. However, the incidence of Staphylococcus aureus
lower respiratory tract infection is increasingly common in the hospitalized and institutionalized
patient and must now be considered a possible pathogen for nosocomial pneumonia.