PNEUMONIA

DR O.T. EHONDOR
Definition
Inflammation or infection of the lung
parenchyma.
Pneumonitis: Mild segmental infection

TYPES OF PNEUMONIA
A. Community acquired pneumonia (CAP)
B. Hospital acquired Pneumonia (HAP)
C. Ventilator acquired Pneumonia (VAP)
D. Aspiration Pneumonia (AP)
 COMMUNITY ACQUIRED PNEUMONIA

Definition
A syndrome of infection that is usually bacterial
with symptoms and signs of consolidation of a
part or parts of the lung parenchyma.
Epidemiology
• Commonest infectious cause of death.
• It is the 6th leading cause of death in the UK
and US.
• Mortality is up to 50% in those admitted to
ICU.
• Has a mortality of 1%.
Pathophysiology
The lung and the tracheobronchial tree are usually
sterile below the level of the larynx.
Following a breach in the host defences, infectious
agents reach these sites. This may be by :
I. Micro-aspiration (occurs at night in 45% of
normal individuals)
II. Haematogenous spread
III. Direct spread from adjacent structure
IV. Inhalation
V. Activation of a previously dormant infection
Aetiology
In most cases a single pathogen is identified
(85%).
• Streptococcus pneumoniae (Pneumococcus)—
commonest.
• Staphylococuss aureus
• Mycoplasma pneumoniae
• Chlamydia pneumoniae
• Chlamydia Psittaci
• Coxiella burnetti (Q fever)
• Legionella Pneumonia
• Klebsiella pneumoniae
• Haemophilus influenzae
• Pseudomonas aeruginosa
• Viral agents:
– CMV (immunocompromised)
– Influenza A (H5N1)
– SARS (corona virus)
Risk factors for CAP
• Aspiration
• Alcoholism
• Diabetes
• Oral steroids
• Immunosuppression—Legionella
• Cigarette smoking
• COPD (mucus burden—H. influenzae)
• Nursing home residents
– Aspiration: H. infleuenzae
Clinical features
• Fever
• Cough
• Sputum production
• Breathlessness
• Pleuritic chest pain
• Malaise, body weakness, etc.
Examination
 Tachypnoea (↑ RR)
 Tachycardia (due to fever)
 On the chest, the following are seen:
– Reduced chest expansion on the affected side
– TF : increased
– PN: dull
– VR: increased
– BS: bronchial with reduced air entry
– Presence of coarse crepitations

N.B: Normal chest x-ray makes the diagnosis of

CAP unlikely.
Diagnosis
A diagnosis of CAP is made on the basis of
1. Symptoms & signs of acute LRTI (most
important)
2. New focal chest signs
3. New radiographic shadow for which there is no

other explanation
4. At least one systemic feature (e.g sweating,
fever, aches and pains)
5. No other explanation for the illness
Investigations
A. Air bronchogram, consolidation, interstitial
infiltrates, and cavitations
– Pleural effusion (Pneumococcal Infection)
– Lymphadenopathy (Mycoplasma infection)
– Cavitation or spontaneous pneumothorax
( Staphylococcus aureus)
– Upper lobe preponderance suggests Klebsiella
B. Sputum m/c/s
C. FBC
– WBC >15× 109 suggests bacterial infection
D. Blood culture
– 10% will have positive blood culture
E. CT Chest: If diagnosis in doubt, patient is
severely ill and not responding to treatment, in
order to exclude abscess formation, empyema,
underlying malignancy or other interstitial process
F. E/U/Cr
G. Serum protein
H. Pleural fluid for m/c/s, BCH, pH and cytology
Other Investigations include:
• Urinary antigen (SpUA): Streptococcus
pneumoniae
• UA detection, direct immunofluorescence test
(DIF) & PCR: Legionnaire’s disease
• Compliment fixation test: Mycoplasma
pneumoniae
• DIF & CFT: Chlamydia
• Those with O2 saturation of <92% or those with
features of severe pneumonia should have
arterial blood gases measured.
 Treatment
• Oxygen by nasal prong or face mask (aim for O2
saturation of >92%)
• Fluids (monitor with a CV line); Also monitor urine output
• Analgesia (paracetamol or NSAIDs)
• Nutrition—may need nutritional supplement
• Antibiotics: Cephalosporins, co-amoxiclav,
benzylpenicillin, levofloxacin, moxifloxacin
– Co-amoxiclav 1.2g 12hrly IV, or
– Cefuroxime 1.5g 8hrly IV, or
– Ceftriaxone 2g daily IV
– Levofloxacin 500mg 12hrly IV
To continue with oral intake
NB: Add metronidazole—aspiration, alcoholics
 Length of treatment
• Uncomplicated pneumonia: 5-7days
• Severe pneumonia: 14days
• Legionella, staphylococcal disease, Gram
negative disease: 14-21 days
 Indications for ICU admission
• Respiratory failure (PaO2 <8kPa) despite high
flow oxygen
• Tiring patient with a rising PCO2
• Worsening metabolic acidosis despite
antibiotics and optimal fluid management
• Hypotension despite adequate fluid
resuscitation
Prognosis
CURB-65
• Confusion—abbreviated mental test score ≤8
• Urea ≥7mmol/L
• RR ≥30cpm
• Blood pressure: systolic ≤90mmHg and/or
diastolic ≤60mmHg
• Age ≥65

Presence of any 4 of the above correlates with

mortality.
Other poor prognostic factors are:
• Co-existing disease
– COPD, DM, Stroke, Cardiac disease
• Hypoxaemia: PaO2 <8kPa
• Serum albumin <35g/L
• WBC >20 X 109/L or <4 X 109/L
• CXR showing bilateral or multilobar involvement
• Positive blood culture

Follow-up
Radiologic improvement lags behind clinical
improvement hence CXR is done 6weeks after
treatment of CAP.
• HAP—New radiographic infiltrates in the
presence of evidence of infection with onset at
least 72hours after hospital admission.

• VAP—Pneumonia in a mechanically ventilated

patient which develops 48hours after intubation.

• AP—Pneumonia that follows the aspiration of

exogenous materials or endogenous secretions
into the lower respiratory tract.
 Complications of pneumonia
• Lung abscess
• Respiratory failure
• Empyema
• Pleural effusion
• Septicaemia