Dr Md Main Uddin, Assistant Professor (Medicine), Cox’s Bazar Medical College, Bangladesh

1. Pneumonia
Dr Md Main Uddin
Assistant Professor (Medicine)
Cox’s Bazar Medical College

2. Contents
 Definition
 Classification
 CAP
a. Epidemiology
b. Etiology, Risk factors
c. C/F, D/D
d. Investigation
e. Treatment, F/up

3. Definition
 Pneumonia is as an acute respiratory illness
associated with recently developed
radiological pulmonary shadowing, which
may be segmental, lobar or multilobar.

4. Types of Pneumonia
 The context in which pneumonia develops is
highly indicative of the likely organism(s)
involved; therefore, pneumonias are usually
classified as community- or hospital-
acquired, or as occurring in
immunocompromised hosts.
 The term ‘atypical pneumonia’ has been
dropped.

5.  In the past, pneumonia was typically
classified as community-acquired (CAP),
hospital-acquired (HAP), or ventilator-
associated (VAP).

6.  The potential involvement of MDR pathogens
has led to a new category of pneumonia—
termed health care–associated pneumonia
(HCAP)—distinct from CAP and the likely
pathogens are MRSA, Pseudomonas
aeruginosa, Acinetobacter spp. and
Enterobacteriaceae

7. Clinical Conditions Associated with
Health Care–Associated Pneumonia
 Hospitalization for 2 days in prior 3 months
 Nursing home residence
 Antibiotic therapy in preceding 3 months
 Chronic dialysis
 Home infusion therapy, home wound care
 Family member with MDR infection

8. Epidemiology
 In the United States, ~80% of the 4 million
CAP cases that occur annually are treated on
an outpatient basis, and ~20% are treated in
the hospital. CAP results in more than
45,000 deaths annually. The incidence rates
are highest at the extremes of age.

9.  Worldwide, CAP continues to kill more
children than any other illness, and its
propensity to ease the passing of the frail
and elderly led to pneumonia being known as
the ‘old man’s friend’.

10. Pathophysiology
 Pneumonia results from the proliferation of
microbial pathogens at the alveolar level and
the host's response to those pathogens.
 The host inflammatory response, rather than
the proliferation of microorganisms, triggers
the clinical syndrome of pneumonia.

11. Common Bugs for Pneumonia
Community-Acquired
 Streptococcus
pneumoniae
 Mycoplasma pneumoniae
 Chlamydophila psittaci or
pneumoniae
 Legionella pneumophila
 Haemophilus influenzae
 Staphylococcus aureus
 Influenza, RSV, CMV
HCAP or HAP
 Escherichia
 Pseudomonas
 Klebsiella
 Acinetobacter
 Staph. aureus
(including MRSA)
 anaerobes.

12. Epidemiologic Factors Suggesting Possible
Causes of Community-Acquired Pneumonia
 Alcoholism -- Streptococcus pneumoniae,
oral anaerobes, Klebsiella pneumoniae,
Acinetobacter spp., Mycobacterium
tuberculosis
 COPD and/or smoking -- Haemophilus
influenzae, Pseudomonas aeruginosa,
Legionella spp., S. pneumoniae, Moraxella
catarrhalis, Chlamydia pneumoniae

13.  Structural lung disease (e.g., bronchiectasis)
-- P. aeruginosa, Burkholderia cepacia,
Staphylococcus aureus
 Dementia, stroke, decreased level of
consciousness -- Oral anaerobes, gram-
negative enteric bacteria
 Local influenza activity -- Influenza virus, S.
pneumoniae, S. aureus

14. Risk factors for CAP include alcoholism,
asthma, immunosuppression,
institutionalization, and old age.

15. Pneumonia - Symptoms
 Cough (productive or
non-productive)
 Dyspnea
 Pleuritic chest pain
 Fever or hypothermia
 Myalgias
 Chills/Sweats
 Fatigue
 Headache
 Diarrhea (Legionella)
 URI, sinusitis
(Mycoplasma)

16. Physical signs
Vitals: Fever or hypothermia
Lung Exam: Dullness on percussion,
bronchial breath sounds, crackles and a
pleural friction rub may be heard on
auscultation.
Unfortunately, the sensitivity and
specificity of the findings on physical
examination are less than ideal,
averaging 58% and 67%, respectively.

18.  Therefore, chest radiography is often necessary to
differentiate CAP from other conditions.
 Radiographic findings may include risk factors for
increased severity (e.g., cavitation or multilobar
involvement).
 Occasionally, radiographic results suggest an
etiologic diagnosis. For example, pneumatoceles
suggest infection with S. aureus, and an upper-lobe
cavitating lesion suggests tuberculosis

19. Chest X-ray
RUL
RML
RLL
LUL
Lingula
LLL
RUL
RML
RLL
LUL
Lingula
LLL

20. Chest X-ray – Pneumonia

21. Chest X-ray - Pneumonia

22. Chest X-ray -- Pneumonia

23. Special Clues on Chest X-ray
 Lobar pneumonia – Strep. Pneumonia
 Diffuse interstitial infiltrates – Pneumocystis
 UL infiltrate – Tuberculosis
 Diffuse interstitial infiltrates – Tuberculosis
in HIV

24. Etiologic Diagnosis
 Gram's Stain and Culture of Sputum -- The
sensitivity and specificity of the sputum
Gram's stain and culture are highly variable.
 Even in cases of proven bacteremic
pneumococcal pneumonia, the yield of
positive cultures from sputum samples is
50%.

25. Etiologic Diagnosis
 Blood Cultures --The yield from blood
cultures, even when samples are collected
before antibiotic therapy, is disappointingly
low.
 Only ~5–14% of cultures of blood from
patients hospitalized with CAP are positive,
and the most frequently isolated pathogen is
S. pneumoniae.

26. Etiologic Diagnosis
 Antigen Tests -- Two commercially available
tests detect pneumococcal and certain
Legionella antigens in urine.
 Polymerase Chain Reaction
 Serology

27. Treatment
Community-Acquired Pneumonia
 Site of Care -- the choice is sometimes
difficult. There are currently two sets of
criteria: the Pneumonia Severity Index (PSI),
a prognostic model used to identify patients
at low risk of dying; and the CURB-65
criteria, a severity-of-illness score

28. The CURB-65 criteria include five
variables:
 confusion (C); urea >7 mmol/L (U); respiratory rate
30/min (R); blood pressure, systolic 90 mmHg or
diastolic 60 mmHg (B); and age 65 years (65).
 Patients with a score of 0, among whom the 30-day
mortality rate is 1.5%, can be treated outside the
hospital.
 With a score of 2, the 30-day mortality rate is 9.2%,
and patients should be admitted to the hospital.
 Among patients with scores of 3, mortality rates are
22% overall; these patients may require admission to
an ICU.

30. Treatment of
Community-Acquired Pneumonia
 The CAP treatment guidelines in the United
States represent joint statements from the
IDSA and the ATS
 Outpatients -- Previously healthy and no
antibiotics in past 3 months
 A macrolide [clarithromycin (500 mg PO bid)
or azithromycin (500 mg PO once, then 250
mg qd)] or Doxycycline (100 mg PO bid)

31. Comorbidities or antibiotics in
past 3 months
 A respiratory fluoroquinolone [moxifloxacin
(400 mg PO qd), gemifloxacin (320 mg PO
qd), levofloxacin (750 mg PO qd)] or
 A B-lactam [preferred: high-dose amoxicillin
(1 g tid) or amoxicillin/clavulanate (2 g bid);
alternatives: ceftriaxone (1–2 g IV qd),
cefpodoxime (200 mg PO bid), cefuroxime
(500 mg PO bid)] plus a macrolide

32. Inpatients
 A respiratory fluoroquinolone [moxifloxacin (400 mg
PO or IV qd), gemifloxacin (320 mg PO qd),
levofloxacin (750 mg PO or IV qd)]
 A – B-lactam[cefotaxime (1–2 g IV q8h), ceftriaxone
(1–2 g IV qd), ampicillin (1–2 g IV q4–6h),
ertapenem (1 g IV qd in selected patients)] plus a
macrolide[oral clarithromycin or azithromycin (as
listed above for previously healthy patients) or IV
azithromycin (1 g once, then 500 mg qd)]

33. The duration of treatment for CAP has
generated considerable interest
 Patients were previously treated for 10–14 days, but
studies with fluoroquinolones suggest that a 5-day
course is sufficient for otherwise uncomplicated
CAP.
 Even a single dose of ceftriaxone has been
associated with a significant cure rate.
 A longer course is required for patients with
bacteremia, metastatic infection, or infection with a
virulent pathogen such as P. aeruginosa or CA-
MRSA.

34.  In most patients with uncomplicated
pneumonia, a 7-day course is adequate,
although treatment is usually required for
longer in those with Legionella,
staphylococcal or Klebsiella pneumonia.
 Oral antibiotics are usually adequate unless
the patient has a severe illness, impaired
consciousness, loss of swallowing reflex, or
functional or anatomical reasons for
malabsorption.

35. General Considerations
Adequate hydration
Oxygen therapy for hypoxemia
Assisted ventilation
Patients with severe CAP who
remain hypotensive despite fluid
resuscitation may have adrenal
insufficiency and may respond to

36. Most patients respond promptly to
antibiotic therapy
 However, fever may persist for several days
and the chest X-ray often takes several
weeks or even months to resolve, especially
in old age.
 Delayed recovery suggests either that a
complication has occurred , that the
diagnosis is incorrect or, alternatively, that
the pneumonia may be secondary to a
proximal bronchial obstruction or recurrent
aspiration.

38. Discharge and follow-up
 The decision to discharge patients depends on their
home circumstances and the likelihood of
complications.
 A chest X-ray need not be repeated before discharge
in those making a satisfactory clinical recovery.
 Clinical review should be arranged around 6 weeks
later and a chest X-ray obtained if there are
persistent symptoms, physical signs or reasons to
suspect underlying malignancy.

39. Prevention
 Current smokers should be advised to stop.
 Influenza and pneumococcal vaccination
should be considered in selected patients.
 In developing countries, tackling
malnourishment and indoor air pollution, and
encouraging immunisation against measles,
pertussis and Haemophilus influenzae type b
are particularly important in children

40. Ventilator-Associated Pneumonia
 Most research on VAP has focused on illness
in the hospital setting. However, the
information and principles based on this
research can be applied to non-ICU HAP and
HCAP as well.

41. Clinical Conditions Associated with
Health Care–Associated Pneumonia
 Hospitalization for 2 days in prior 3 months
 Nursing home residence
 Antibiotic therapy in preceding 3 months
 Chronic dialysis
 Home infusion therapy, home wound care
 Family member with MDR infection

42. Microbiologic Causes of
Ventilator-Associated Pneumonia
Non-MDR Pathogens MDR Pathogens
Streptococcus pneumoniae Pseudomonas aeruginosa
Other Streptococcus spp. MRSA
Haemophilus influenzae Acinetobacter spp.
MSSA Antibiotic-resistant Enterobacteriaceae
Antibiotic-sensitive
Enterobacteriaceae
Enterobacter spp.
Escherichia coli ESBL-positive strains
Klebsiella pneumoniae Klebsiella spp.
Proteus spp. Legionella pneumophila
Enterobacter spp. Burkholderia cepacia
Serratia marcescens Aspergillus spp.

43. Empirical Antibiotic Treatment of VAP
 If it were not for the risk of infection with MDR
pathogens (MRSA, Pseudomonas
aeruginosa, Acinetobacter spp. and
Enterobacteriaceae), VAP could be treated
with the same antibiotics used for severe
CAP.

44. Patients without Risk Factors for MDR
Pathogens
 Ceftriaxone (2 g IV q24h) or
 Moxifloxacin (400 mg IV q24h), ciprofloxacin
(400 mg IV q8h), or levofloxacin (750 mg IV
q24h) or
 Ampicillin/sulbactam (3 g IV q6h) or
 Ertapenem (1 g IV q24h)

45. Patients with Risk Factors for MDR
Pathogens
 A B-lactam
Ceftazidime (2 g IV q8h) or cefepime (2 g IV
q8–12h) or Piperacillin/tazobactam (4.5 g IV
q6h), imipenem (500 mg IV q6h or 1 g IV
q8h), or meropenem (1 g IV q8h) plus

46. A second agent active against gram-negative
bacterial pathogens:
 Gentamicin or tobramycin (7 mg/kg IV q24h) or
amikacin (20 mg/kg IV q24h) or Ciprofloxacin
(400 mg IV q8h) or levofloxacin (750 mg IV q24h)
plus
 An agent active against gram-positive bacterial
pathogens:
Linezolid (600 mg IV q12h) or Vancomycin (15
mg/kg, up to 1 g IV, q12h)

47.  The standard recommendation for patients
with risk factors for MDR infection is for three
antibiotics: two directed at P. aeruginosa and
one at MRSA. The choice of a B-lactam
agent provides the greatest variability in
coverage, yet the use of the broadest-
spectrum agent—a carbapenem, even in an
antibiotic combination—still represents
inappropriate initial therapy in 10–15% of
cases.

48. Hospital-Acquired Pneumonia
 Hospital-acquired or nosocomial pneumonia
is a new episode of pneumonia occurring at
least 2 days after admission to hospital.
 While significantly less well studied than
VAP, HAP in nonintubated patients—both
inside and outside the ICU—is similar to
VAP.

49. Health Care–Associated Pneumonia
 Healthcare-associated pneumonia (HCAP) is the
development of pneumonia in a person who has
spent at least 2 days in hospital within the last 90
days, or has attended a haemodialysis unit, received
intravenous antibiotics, or been resident in a nursing
home or other long-term care facility.
 HCAP represents a transition between classic CAP
and typical HAP.
 The definition of HCAP is still in some degree of flux
because of a lack of large-scale studies.