Pneumonia is inflammation of the terminal airways and alveoli caused by acute infection by various agents.

Pneumonia can be divided into three groups: community acquired, hospital or nursing home acquired
(nosocomial), and pneumonia in an immunocompromised person.Causes include bacteria (Streptococcus,
Staphylococcus, Haemophilus influenzae, Klebsiella, Legionella). Community Acquired Pneumonia (CAD) is
a disease in which individuals who have not recently been hospitalized develop an infection of the lungs. It is an
acute inflammatory condition that’s result from aspiration of oropharyngeal secretions or stomach contents in the
lungs.

What is pneumonia?
Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi. Prior to the
discovery of antibiotics, one-third of all people who developed pneumonia subsequently died from the infection.
Currently, over 3 million people develop pneumonia each year in the United States. Over a half a million of these
people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die
from pneumonia. Pneumonia is the sixth leading cause of death in the United States.

How do people "catch pneumonia"?

Some cases of pneumonia are contracted by breathing in small droplets that contain the organisms that can cause
pneumonia. These droplets get into the air when a person infected with these germs coughs or sneezes. In other
cases, pneumonia is caused when bacteria or viruses that are normally present in the mouth, throat, or nose
inadvertently enter the lung. During sleep, it is quite common for people to aspirate secretions from the mouth, throat,
or nose. Normally, the body's reflex response (coughing back up the secretions) and their immune system will
prevent the aspirated organisms from causing pneumonia. However, if a person is in a weakened condition from
another illness, a severe pneumonia can develop. People with recent viral infections, lung disease, heart disease,
and swallowing problems, as well asalcoholics, drug users, and those who have suffered a stroke or seizure are at
higher risk for developing pneumonia than the general population. As we age, our swallowing mechanism can
become impaired as does our immune system. These factors, along with some of the negative side effects of
medications, increase the risk for pneumonia in the elderly.

Once organisms enter the lungs, they usually settle in the air sacs and passages of the lung where they rapidly grow
in number. This area of the lung then becomes filled with fluid and pus (the body's inflammatory cells) as the body
attempts to fight off the infection.

What are pneumonia symptoms and signs?

Most people who develop pneumonia initially have symptoms of a cold (upper respiratory infection, for example,
sneezing, sore throat, cough), which are then followed by a high fever (sometimes as high as 104 F), shaking chills,
and a cough with sputum production. The sputum is usually discolored and sometimes bloody. Depending on the
location of the infection, certain symptoms are more likely to develop. When the infection settles in the air passages,
cough and sputum tend to predominate the symptoms. In some, the spongy tissue of the lungs that contain the air
sacs is more involved. In this case, oxygenation can be impaired, along with stiffening of the lung, which results
inshortness of breath. At times, the individual's skin color may change and become dusky or purplish (a condition
known as "cyanosis") due to their blood being poorly oxygenated.

The only pain fibers in the lung are on the surface of the lung, in the area known as the pleura. Chest pain may
develop if the outer aspects of the lung close to the pleura are involved. This pain is usually sharp and worsens when
taking a deep breath and is known as pleuritic pain or pleurisy. In other cases of pneumonia, depending on the
causative organism, there can be a slow onset of symptoms. A worsening cough, headaches, and muscle aches may
be the only symptoms.

Children and babies who develop pneumonia often do not have any specific signs of a chest infection but develop a
fever, appear quite ill, and can become lethargic. Elderly people may also have few symptoms with pneumonia.
How is pneumonia diagnosed?
Pneumonia may be suspected when the doctor examines the patient and hears coarse breathing or crackling sounds
when listening to a portion of the chest with a stethoscope. There may be wheezing, or the sounds of breathing may
be faint in a particular area of the chest. A chest X-ray is usually ordered to confirm the diagnosis of pneumonia. The
lungs have several segments referred to as lobes, usually two on the left and three on the right. When the pneumonia
affects one of these lobes, it is often referred to as lobar pneumonia. Some pneumonias have a more patchy
distribution that does not involve specific lobes. In the past, when both lungs were involved in the infection, the term
"double pneumonia" was used. This term is rarely used today.

Sputum samples can be collected and examined under the microscope. If the pneumonia is caused by bacteria or
fungi, the organisms can often be detected by this examination. A sample of the sputum can be grown in special
incubators, and the offending organism can be subsequently identified. It is important to understand that the sputum
specimen must contain little saliva from the mouth and be delivered to the laboratory fairly quickly. Otherwise,
overgrowth of noninfecting bacteria may predominate. As we have used antibiotics in a broader uncontrolled fashion,
more organisms are becoming resistant to the commonly used antibiotics. These types of cultures can help in
directed more appropriate therapy.

A blood test that measures white blood cell count (WBC) may be performed. An individual's white blood cell count
can often give a hint as to the severity of the pneumonia and whether it is caused by bacteria or a virus. An increased
number of neutrophils, one type of WBC, is seen in bacterial infections, whereas an increase in lymphocytes, another
type of WBC, is seen in viral infections, fungal infections, and some bacterial infections (like tuberculosis).

Bronchoscopy is a procedure in which a thin, flexible, lighted viewing tube is inserted into the nose or mouth after a
local anesthetic is administered. The breathing passages can then be directly examined by the doctor, and
specimens from the infected part of the lung can be obtained.

Sometimes, fluid collects in the pleural space around the lung as a result of the inflammation from pneumonia. This
fluid is called a pleural effusion. If a significant amount of fluid develops, it can be removed. Usually this is done by
inserting a needle into the chest cavity and withdrawing the fluid with a syringe in a procedure called athoracentesis.
Often ultrasound is used to prevent complications from this procedure. In some cases, this fluid can become severely
inflamed (parapneumonic effusion) or infected (empyema) and may need to be removed by more aggressive surgical
procedures. Today, most often, this involves surgery through a tube or thoracoscope. This is referred to as video-
assisted thoracoscopic surgery or VATS

What are some of the organisms that cause pneumonia, and how are they treated?
The most common cause of a bacterial pneumonia is Streptococcus pneumoniae. In this form of pneumonia, there
is usually an abrupt onset of the illness with shaking chills, fever, and production of a rust-colored sputum. The
infection spreads into the blood in 20%-30% of cases (known as sepsis), and if this occurs, 20%-30% of these
patients die.

Two vaccines are available to prevent pneumococcal disease: the pneumococcal conjugate vaccine (PCV7; Prevnar)
and the pneumococcal polysaccharide vaccine (PPV23; Pneumovax). The pneumococcal conjugate vaccine is part of
the routine infant immunization schedule in the U.S. and is recommended for all children < 2 years of age and
children 2-4 years of age who have certain medical conditions. The pneumococcal polysaccharide vaccine is
recommended for adults at increased risk for developing pneumococcal pneumonia including the elderly, people who
have diabetes, chronic heart, lung, or kidney disease, those with alcoholism, cigarette smokers, and in those people
who have had their spleen removed. This vaccination should be repeated every five to seven years, whereas the flu
vaccine is given annually.
Antibiotics often used in the treatment of this type of pneumonia include penicillin,amoxicillin and clavulanic
acid (Augmentin, Augmentin XR), and macrolide antibiotics including erythromycin, azithromycin (Zithromax, Zmax),
and clarithromycin (Biaxin). Penicillin was formerly the antibiotic of choice in treating this infection. With the advent
and widespread use of broader-spectrum antibiotics, significant drug resistance has developed. Penicillin may still be
effective in treatment of pneumococcal pneumonia, but it should only be used after cultures of the bacteria confirm
their sensitivity to this antibiotic.

Klebsiella pneumoniae and Hemophilus influenzae are bacteria that often cause pneumonia in people suffering
from chronic obstructive pulmonary disease (COPD) or alcoholism. Useful antibiotics in this case are the second- and
third-generation cephalosporins, amoxicillin and clavulanic acid, fluoroquinolones
(levofloxacin[Levaquin], moxifloxacin-oral [Avelox], and sulfamethoxazole/trimethoprim [Bactrim, Septra]).

Mycoplasma pneumoniae is a type of bacteria that often causes a slowly developing infection. Symptoms include
fever, chills, muscle aches, diarrhea, and rash. This bacterium is the principal cause of many pneumonias in the
summer and fall months, and the condition often referred to as "atypical pneumonia." Macrolides (erythromycin,
clarithromycin, azithromycin, and fluoroquinolones) are antibiotics commonly prescribed to treat Mycoplasma
pneumonia.

Legionnaire's disease is caused by the bacterium Legionella pneumoniae that is most often found in contaminated
water supplies and air conditioners. It is a potentially fatal infection if not accurately diagnosed. Pneumonia is part of
the overall infection, and symptoms include high fever, a relatively slow heart rate, diarrhea, nausea, vomiting, and
chest pain. Older men, smokers, and people whose immune systems are suppressed are at higher risk of developing
Legionnaire's disease. Fluoroquinolones are the treatment of choice in this infection. This infection is often diagnosed
by a special urine test looking for specific antibodies to the specific organism.

Mycoplasma, Legionnaire's, and another infection, Chlamydia pneumoniae, all cause a syndrome known as
"atypical pneumonia." In this syndrome, the chest X-ray shows diffuse abnormalities, yet the patient does not appear
severely ill. These infections are very difficult to distinguish clinically and often require laboratory evidence for
confirmation.

Pneumocystis carinii pneumonia is another form of pneumonia that usually involves both lungs. It is seen in
patients with a compromised immune system, either fromchemotherapy for cancer, HIV/AIDS, and those treated with
TNF (tumor necrosis factor), such as for rheumatoid arthritis. Once diagnosed, it usually responds well to sulfa-
containing antibiotics. Steroids are often additionally used in more severe cases.

Viral pneumonias do not typically respond to antibiotic treatment. These infections can be caused by adenoviruses,
rhinovirus, influenza virus (flu), respiratory syncytial virus(RSV), and parainfluenza virus (that also causes croup).
These pneumonias usually resolve over time with the body's immune system fighting off the infection. It is important
to make sure that a bacterial pneumonia does not secondarily develop. If it does, then the bacterial pneumonia is
treated with appropriate antibiotics. In some situations, antiviral therapy is helpful in treating these conditions.

Fungal infections that can lead to pneumonia include histoplasmosis, coccidiomycosis, blastomycosis, aspergillosis,
and cryptococcosis. These are responsible for a relatively small percentage of pneumonias in the United States.
Each fungus has specific antibiotic treatments, among which are amphotericin B, fluconazole (Diflucan), penicillin,
and sulfonamides.

Major concerns have developed in the medical community regarding the overuse of antibiotics. Most sore throats and
upper respiratory infections are caused by viruses rather than bacteria. Though antibiotics are ineffective against
viruses, they are often prescribed. This excessive use has resulted in a variety of bacteria that have become resistant
to many antibiotics. These resistant organisms are commonly seen in hospitals and nursing homes. In fact,
 physicians must consider the location when prescribing antibiotics (community-acquired pneumonia, or CAP, versus
hospital-acquired pneumonia, or HAP).

The more virulent organisms often come from the health-care environment, either the hospital or nursing homes.
These organisms have been exposed to a variety of the strongest antibiotics that we have available. They tend to
develop resistance to some of these antibiotics. These organisms are referred to as nosocomial bacteria and can
cause what is known as nosocomial pneumonia when the lungs become infected.

Recently, one of these resistant organisms from the hospital has become quite common in the community. In some
communities, up to 50% of Staph aureus infections are due to organisms resistant to the antibiotic methicillin. This
organism is referred to as MRSA (methicillin-resistant Staph aureus) and requires special antibiotics when it causes
infection. It can cause pneumonia but also frequently causes skin infections. In many hospitals, patients with this
infection are placed in contact isolation. Their visitors are often asked to wear gloves, masks, and gowns. This is
done to help prevent the spread of this bacteria to other surfaces where they can inadvertently contaminate whatever
touches that surface. It is therefore very important to wash your hands thoroughly and frequently to limit further
spread of this resistant organism. The situation with MRSA continues to evolve. The community-acquired strain of
MRSA tends to be responsive to some of the more commonly used antibiotics whereas the hospital-acquired strains
require stronger, more aggressive antibiotic therapies. As this evolution occurs, patients are arriving in the hospital
with the community-acquired strains as well as a previous hospital-acquired strain. This further necessitates
performing bacterial cultures to determine the best course of action.

Conclusions
Pneumonia can be a serious and life-threatening infection. This is true especially in the elderly, children, and
those who have other serious medical problems, such as COPD, heart disease, diabetes, and certain
cancers. Fortunately, with the discovery of many potent antibiotics, most cases of pneumonia can be
successfully treated. In fact, pneumonia can usually be treated with oral antibiotics without the need for
hospitalization.

Pneumonia At A Glance
• Pneumonia is a lung infection that can be caused by different types of microorganisms, including bacteria, viruses,
and fungi.

• Symptoms of pneumonia include cough with sputum production, fever, and sharp chest pain on inspiration
(breathing in).

• Pneumonia is suspected when a doctor hears abnormal sounds in the chest, and the diagnosis is confirmed by a
chest X-ray.

• Bacteria causing pneumonia can be identified by sputum culture.

• A pleural effusion is a fluid collection around the inflamed lung.

• Bacterial and fungal (but not viral) pneumonia can be treated with antibiotics.