Pneumonia

Pneumonia
Pneumonia is a lung infection that can make you very sick. You may cough, run a fever, and have a hard time breathing. For most people, pneumonia can be treated at home. It often clears up in 2 to 3 weeks. But older adults, babies, and people with other diseases can become very ill. They may need to be in the hospital.

You can get pneumonia in your daily life, such as at school or work. This is called communityassociated pneumonia. You can also get it when you are in a hospital or nursing home. This is called healthcare-associated pneumonia. It may be more severe because you already are ill. This topic focuses on pneumonia you get in your daily life.

Alternative Names

Bronchopneumonia

Community-acquired pneumonia

Facts

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.

Common Causative Agents/ Etiologic Agents

Although pneumonia may be caused by myriad pathogens, a limited number of agents are responsible for most cases, Most authors categorize bacterial pneumonias by their infectious agents, which include pneumococcal agents; Haemophilus influenzae; Klebsiella, Staphylococcus, and Legionella species; gram-negative organisms; and aspirated materials. Inhalation of infectious aerosols is probably the most common mode of infection. Some agents, notably Staphylococcus species, may be spread hematogenously.

Risk factors

Coinfection with H1N1 influenza increases the risk of secondary bacterial pneumonia, with S pneumoniae the most likely coinfection. However, pregnant patients with H1N1 influenza in the 2009 pandemic were at increased risk of developing secondary Klebsiella pneumonia with poor clinical outcome.

Other risk factors include local lung pathologies (eg, tumors, chronic obstructive pulmonary disease [COPD], bronchiectasis), chronic gingivitis and periodontitis, and smoking, which impair resistance to infection. Furthermore, any individual with an altered sensorium (eg, seizures, alcohol or drug intoxication) or central nevous system (CNS) impairment (eg, stroke) may have a reduced gag reflex, which allows aspiration of stomach or oropharyngeal contents and which enables aspiration pneumonias.

Typical organisms

Although several of the organisms discussed in this section may be implicated in pneumonia, only a few of them are responsible for the vast majority of cases.

Gram-positive bacteria that can cause pneumonia include the following:

Streptococcus pneumoniae: This organism is a facultative anaerobe identified by its chainlike staining pattern. Pneumococcosis is by far the most common cause of typicalbacterial pneumonia.

Staphylococcus aureus: S aureus is a facultative anaerobe identified by its clusterlike staining pattern. S aureus pneumonia is observed in intravenous drug abusers (IVDAs) and other individuals with debilitations. In patients who abuse intravenous drugs, the infection probably is spread hematogenously to the lungs from contaminated injection sites. Methicillin-resistant S aureus (MRSA) has had a large impact on empiric antibiotic choices at many institutions.

Enterococcus (E faecalis, E faecium): These organisms are group D streptococci that are well-known normal gut florae that can be identified by their pair-and-chain staining pattern. The emergence of vancomycin-resistant Enterococcus (VRE) is indicative of the importance of appropriate antibiotic use.

Actinomyces israelii: This is a beaded, filamentous anaerobic organism that grows as normal flora in the gastrointestinal (GI) tract. A israelii is known to form abscesses and sulfur granules.

Nocardia asteroides: N asteroides is a weakly gram-positive, partially acid-fast bacillus (AFB) that forms beaded, branching, thin filaments. It is known to cause lung abscesses and cavitations. Erosion into the pleura can also occur, resulting in hematologic spread of the organism.

Gram-negative pneumonias occur most often in individuals who are debilitated, immunocompromised, or recently hospitalized. Individuals living in long-term care facilities where other residents are intubated are also at risk for these infections. Gram-negative bacteria include the following:

Pseudomonas aeruginosa: P aeruginosa is an aerobic, motile bacillus often characterized by its distinct (grapelike) odor.

Klebsiella pneumoniae: K pneumoniae is a facultatively anaerobic, encapsulated bacillus that can lead to an aggressive, necrotizing, lobar pneumonia. Patients with chronic alcoholism, diabetes, or COPD are at increased risk.

Haemophilus influenzae: H influenzae is an aerobic bacillus that comes in both encapsulated and nonencapsulated forms. Several major subtypes have been identified, which have varying levels of pathogenicity; encapsulated type B (HiB) is known to be particularly virulent, although routine vaccination against this subtype has decreased the prevalence of severe disease caused by H influenzae.

Escherichia coli: E coli is a facultatively anaerobic, motile bacillus; it is well known to colonize the lower GI tract and produce the essential vitamin K.

Moraxella catarrhalis: M catarrhalis is an aerobic diplococcus known as a common colonizer of the respiratory tract.

Acinetobacter baumannii: A baumannii is a pathogen that has been well described in the context of ventilator-associated pneumonia (VAP).

Francisella tularensis: F tularensis is the causative agent of tularemia, or rabbit fever. F tularensis is a facultative intracellular bacterium that multiplies within macrophages and that is typically transmitted to humans via a tick bite; its reservoir animals include rodents, rabbits, and hares. F tularensis can also be transmitted in an airborne manner or contracted from handling dead, infected animals. It is commonly spoken of in terms of its potential use as a biologic weapon.

y y

Bacillus anthracis: B anthracis is the agent responsible for inhalational anthrax. Yersinia pestis: Y pestis infection is better known as the black plague, but other members of the Yersinia family are responsible for a wide variety of infectious presentations.

Atypical organisms

Atypical organisms are generally associated with a milder form of pneumonia, the so-called "walking pneumonia." A feature that makes these organisms atypical is the inability to detect them on Gram stain or to cultivate them in standard bacteriologic media.Atypical organisms include the following:

Mycoplasma species: The mycoplasmas are the smallest known free-living organisms in existence; they lack cell walls (and therefore are not apparent after Gram stain) but have protective 3-layered cell membranes.

Chlamydophila species (C psittaci, C pneumoniae): Psittacosis, also known as parrot

disease or parrot fever, is caused by C psittaci and is associated with the handling of various types of birds. y Legionella species: Legionella species are gram-negative bacteria found in freshwater and are known to grow in complex water distribution systems. Institutional water contamination is frequently noted in endemic outbreaks. Legionella species are the causative agents of Legionnaires disease. y Coxiella burnetii:C burnetii is the causative agent of Q fever. It is spread from animals to humans; person-to-person transmission is unusual. Animal reservoirs typically include cats, sheep, and cattle. y Bordetella pertussis:B pertussis is the agent responsible for pertussis or whooping cough.

Anaerobic organisms

Pneumonia due to anaerobes typically results from aspiration of oropharyngeal contents, as previously mentioned. These infections tend to be polymicrobial and may consist of the following anaerobic species, some of which have already been discussed above: Klebsiella, Peptostreptococcus, Bacteroides, Fusobacterium, and Prevotella.

Signs and Symptoms

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 of the blood can be impaired, along with stiffening of the lung, which results in shortness 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 in the infection. 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.

Diagnostic Tests
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. Pneumonia caused by bacteria or fungi can 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 from the mouth 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 directing 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 most 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. Using this device, the doctor can directly examine the breathing passages (trachea and bronchi). Simultaneously, samples of sputum or tissue 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. After numbing the skin with local anesthetic a needle is inserted into the chest cavity and fluid can be withdrawn and examined under the microscope. This procedure is called a thoracentesis. 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.

Prognosis

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.

Treatment

Approach Considerations

Almost all major decisions regarding management of pneumonia address the initial assessment of severity. See Risk Stratification under Clinical Presentation.

Perhaps the most important initial determination is that of the need for hospitalization. In

determining site or level of care, options include outpatient, medical ward care, or medical intensive care unit (ICU) management.

Consider using the pneumonia severity index (PSI) score as a guide for inpatient care and mortality risk. The Agency for Healthcare Research and Quality (AHRQ) has an interactive tool to calculate the PSI score.

Note that the PSI score may underestimate the patient's need for admission (ie, a young otherwise healthy patient who is vomiting or has social factors that precludes him or her taking medicine). Conversely, the PSI score tends to overestimate the mortality in the higher risk patients.

Direct admission to an intensive care unit (ICU) is mandated for any patient in septic shock with a requirement for vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation.

Transfer, if needed, is safe for a patient in otherwise stable condition who is being admitted for antibiotic therapy and pulmonary toilet. Patients who are severely ill and those with signs of respiratory failure, sepsis, and/or neutropenia must be stabilized before transfer.

Respiratory support

Antibiotic therapy is the mainstay of treatment of bacterial pneumonia. However, patients who have bronchospasm with infection benefit from inhaled bronchodilators, administered by means of a nebulizer metered-dose inhaler.

For patients with mild shortness of breath, only supplemental oxygen with a nasal cannula may be required for ventilatory support. Administer ventilatory support when simple supplemental oxygen is not sufficient or when the patient cannot cope with the work of breathing.

Moderate dyspnea requires high oxygen concentrations, such as those provided by a Venti-mask or partial rebreathing face mask. Use these masks with caution in patients with chronic obstructive pulmonary disease (COPD). Patients in respiratory failure or those with COPD who need high oxygen concentrations may require endotracheal intubation and ventilation.

An alternative to intubation may be use of a continuous positive airway pressure (CPAP) mask. Patients who are awake and can tolerate mask application may avoid intubation. However, in patients with productive cough, noninvasive ventilation is often avoided because it may impair clearance of respiratory secretions, which can lead to worsening infection and recurrent aspiration. Nasal CPAP is not usually as well tolerated as a full mask (which covers both the nose and mouth) in the emergent situation.

Fluid resuscitation

Patients with hypotension and/or tachycardia may benefit from an intravenous crystalloid bolus in the field. Many individuals with pneumonia also have volume depletion. In elderly patients with underlying cardiac disease, take care to avoid aggressive fluid administration, which may cause volume overload.

Empiric antibiotic therapy

Empiric therapy for the hospitalized patient should be initially broad and cover the likely causative organisms. Use caution in patients who are elderly or debilitated. If bacteremia is present in persons with pneumococcus who are older than 80 years, the mortality rate remains approximately 40%, even with treatment.

Many regions have guidelines for evaluation and treatment of community-acquired pneumonia (CAP). This usually includes a minimum time from door to antibiotic of 4 hours or less. Failure to abide by these time parameters may be associated with poor outcome. When in doubt, administer the first antibiotic dose.

Other initial treatments may include correction of electrolyte levels and chest physiotherapy (to assist in drainage of secretions).

Corticosteroids

The role of supplementing corticosteroids in patients with hypotension from septic shock remains controversial. Previously, it was recommended that septic patients who were hypotensive despite fluid resuscitation and vasopressor support be screened for occult adrenal insufficiency. However, current guidelines recommend empiric therapy with stress-dose steroids in these patients who remain hypotensive despite fluids and pressors, to avoid delay in treatment of presumed adrenal insufficiency.

Drotrecogin alfa

A recombinant version of human activated protein C, drotrecogin alfa is the first immunomodulatory drug approved for the treatment of severe sepsis. It is recommended in patients with CAP who have persistent septic shock despite adequate fluid resuscitation. Its use is recommended in patients at high risk of death.

Medication Summary

The mainstay of drug therapy for bacterial pneumonia is antibiotic treatment. The choice of agent is based on the severity of the patient's illness, host factors (eg, comorbidity, age), and the presumed causative agent. Although intravenous (IV) penicillin G is currently not favored, doses in the range of 20-24 million U/d result in serum levels that exceed minimum inhibitory concentration (MIC) levels of most resistant pneumococci.

Glucocorticoids

The role of glucocorticoids in acute bacterial pneumonia is not yet clear. Classic teaching warns that the use of glucocorticoids in infection may impair the immune response. However, findings show that local pulmonary inflammation may be reduced with systemic glucocorticoids. In the future, these drugs may be a useful adjunct in the immunocompetent patient. In one study, routine use of oral prednisone in bacterial pneumonia showed no benefit.[66]

Outpatient/inpatient antibiotic administration

Outpatients are given oral agents, and, for the most part, parenteral medications are given to admitted patients. This rationale does not preclude the clinician from giving an initial IV dose of antibiotics in the emergency department and then sending the patient home on oral agents, if the

patient's condition warrants such action. The patient's condition, infection severity, and microorganism susceptibility should determine the proper dose and route of administration.

A rational approach may be to administer an oral extended-spectrum macrolide or amoxicillin and clavulanate (Augmentin) to those with mild, outpatient disease. Oral fluoroquinolone may be substituted if a comorbidity or allergy to the first-line agents is present or for good dosing compliance. Admitted patients should receive IV therapy, a third-generation cephalosporin alone or with a macrolide. An alternative regimen would be IV fluoroquinolones.

Pediatric antimicrobial therapy

All agents discussed in the next sections are for use in persons older than 5 years. In children younger than 5 years, initial treatment of pneumonia includes IV ampicillin or nafcillin plus gentamicin or cefotaxime (for neonates), and ceftriaxone or cefotaxime can be administered as a single agent (for >28 d to 5 y). An alternative regimen includes a penicillinase-resistant penicillin plus an antipseudomonal aminoglycoside.

Outpatient treatment of mild-to-moderate pneumonias in children usually involves agents similar to those used for acute otitis media. Most of the pneumonias in these patients probably have a viral cause. In children who have features suggesting a bacterial etiology (eg, an infiltrate on chest radiograph and/or positive findings at sputum Gram staining), the administration of antibiotics may be good clinical practice. In these cases, many clinicians begin empiric therapy with amoxicillin, but its spectrum of activity is lacking, because children in this group who do not have nonviral pneumonia usually have an infection caused by S pneumoniae and Mycoplasma species.

H influenzae type B has been less common since the introduction of the HIB vaccine. Children younger than 2 years may still be at risk for H influenzae type B infection, because their immune response is not sufficient, as it is in older children. A typical regimen for outpatient therapy may include a new macrolide agent or a second-generation or third-generation cephalosporin. Cost is a potential drawback for all agents.

Macrolides

The best initial antibiotic choice is thought to be a macrolide. Macrolides provide the best coverage for the most likely organisms in community-acquired bacterial pneumonia (CAP). Macrolides have effective coverage for gram-positive, Legionella, and Mycoplasma organisms. Azithromycin administered intravenously may be an alternative to intravenous erythromycin.

Macrolides, as a class, have the potential disadvantage of causing gastrointestinal (GI) upset. Compared with erythromycin, newer agents have fewer GI adverse effects and drug interactions, although all macrolides have the potential for drug interactions similar to those of erythromycin. Newer macrolides offer improved compliance because of reduced dosing frequency, improved action against H influenzae, and coverage of Mycoplasma species (unlike cephalosporins). The main disadvantage is cost.

Macrolides are primarily recommended for the treatment of CAP in patients younger than 60 years who are nonsmokers without comorbidity. Give special consideration to recommendations for antibiotic use in patients with comorbidity or those with CAP who are older than 60 years. Although patients in this group are still susceptible to S pneumoniae, they should receive treatment for broader coverage that includes Haemophilus, Moraxella, and other gram-negative organisms. Therefore, a prudent course of action for empiric outpatient therapy is to include: (1)

one of the macrolide agents described previously plus a second- or third-generation cephalosporin or amoxicillin and clavulanate or (2) trimethoprim and sulfamethoxazole (TMPSMZ) as a single agent.

Patients who have moderate clinical impairment or comorbidity are best treated with parenteral agents and, unless a particular agent is strongly suspected, broad coverage should be afforded. Regimens for this use include a macrolide plus a second-generation or third-generation cephalosporin, (as single agents) Ampicillin and sulbactam (Unasyn), piperacillin and tazobactam (Zosyn), or ticarcillin and clavulanate (Timentin).

Cephalosporins

Second-generation cephalosporins maintain the gram-positive activity of first-generation cephalosporins, provide good coverage against Proteus mirabilis, H influenzae, E coli, K pneumoniae, and Moraxella species, and provide adequate activity against gram-positive organisms.

Of these agents, cefprozil, cefpodoxime, and cefuroxime seem to have better in vitro activity against S pneumoniae. Second-generation cephalosporins are not effective against Legionella or Mycoplasma species. These drugs are generally well tolerated, but cost may be a factor. Oral second-generation and third-generation cephalosporins offer increased activity against gramnegative agents and may be effective against ampicillin-resistant S pneumoniae.

Third-generation cephalosporins have wider activity against most gram-negative bacteria (eg, Enterobacter, Citrobacter, Serratia, Neisseria, Providencia, Haemophilus species), including beta-lactamaseproducing strains.

Intravenous cephalosporins may be combined with a macrolide agent. They broaden the gramnegative coverage, and in the case of third-generation agents, they may be effective against resistant S pneumoniae. In addition, some third-generation agents are effective against Pseudomonas, whereas second-generation agents are not.

Combination drugs

The combination of trimethoprim and sulfamethoxazole (TMP-SMZ) may be used in the patient with pneumonia and a history of chronic obstructive pulmonary disease (COPD) or smoking. It may be also used as a single agent in younger patients in whom a Haemophilus species is the suspected agent.

TMP-SMZ is well tolerated and inexpensive. However, allergic reactions are more often associated with drugs in this class than with other antibiotics. Reactions span the spectrum from simple rash (most likely) to Steven-Johnson syndrome and toxic epidermal necrolysis (rare). Many potential drug interactions are noted.

When a severely ill patient has features of sepsis and/or respiratory failure, and/or when neutropenia is known or suspected, treatment with an intravenous macrolide is combined with an intravenous third-generation cephalosporin and vancomycin. An alternative regimen may include imipenem, meropenem, or piperacillin and tazobactam plus a macrolide and vancomycin. A fulminant course also must raise the suspicion of infection with Legionella or Mycoplasma species, Hantavirus, psittacosis, or Q fever.

Fluoroquinolones, including levofloxacin, moxifloxacin, and gatifloxacin, may also be used.

These agents are available in oral and parenteral forms and have convenient dosing regimens, which allow easier conversion to oral therapy that results in good patient compliance. Note that in July 2008, a warning was issued from the US Food and Drug Administration (FDA) regarding the risk of tendonitis and tendon rupture with fluoroquinolone use.

Mycobacterium Pneumoniae, common causative agent of Pneumonia.

Cross somparison between a normal alveoli and an Pneumonia-infected alveoli.

Main signs and symptoms of Pneumonia.

People are advised to practice infection preventive procedures as seen here during an ourtbreak.

Pneumonia
Submitted by: Jan Nikko E. Capin

Submitted to: Dr. Armin Fullante Professor