1. A 25-year-old female was admitted with complaints of shortness of breath, loose stools, facial swelling and fever for a week and body pains. Chest X-ray showed consolidation in the right lung. She was diagnosed with pneumonia and pleural effusion, with a relapse of tuberculosis. 2. She was treated with oxygen, antibiotics including piperacillin-tazobactam and metronidazole, thoracentesis, and other supportive care. Her condition improved with treatment. 3. Pneumonia is classified based on location and cause. Risk factors, clinical presentation, diagnosis and management depend on whether it is community-acquired, hospital-acquired, or

1. Case presentation on pneumonia
Presented by :
METI.BHARATH KUMAR
16DK1T0014
Pharm-D(Intern)

2. Demographics
• Name :xyz
• Age :25
• Sex:female
• Admission No: 1133
• Department : general medicine
unit :fm -7
• Date of admission :6-1-2022
• Consultant physician:Dr Maheswara Reddy

3. Subjective evidence
• A 25 yrs old female patient admitted in female
medical ward with complaints of-
c/o shortnesss of breath since 1 week
c/o loose stools
c/o swelling of face since 3 days
c/o fever since 1 week
c/o generalized body pains
Past medical history : MDR TB ( completed the
course of ATT)

4. Objective evidence
• Chest x ray : consolidation of right lung
• CBP: Hb:7.7 g/dl
WBC:56000cells/micro lit
plt :155000cells/micro lit
Sr electrolytes: sodium: 141mmol/lit
potassium:3.7mmol/lit
chlorine:93
ESR: 75mm/hr
CRP: 112mg/dl
• Development of Complication of pneumonia i.e.,
pleural effusion

5. Assessment
• Based on subjective and objective evidence
present condition is diagnosed as pneumonia
with pleural effusion and relapse of TB.

6. planning
vitals
• Pt is c/c
• PR:120bpm
• BP:100/70mmhg
• RS: right lung
consolidation,crepts+
• P/A: soft
• CNS:NFND
• Saturation of oxygen:93% at
RA
• UOP: 500ml
Treatment
• Oxygen inhalational
• Inj nor adrenaline 2 amp in
1NS
• IVF
• Inj piptaz 4.5g in 100ml NS iv
tid
• Inj metrogyl 100ml iv tid
• Thoracenter therapeutic
• Protein rich diet
• Strict I/O charting
• Syp ascoryl 10ml tid
• T mucinac po tid

7. planning
vitals
• Pt is c/c
• PR:100bpm
• BP:110/70mmhg
• RS:crepts +
• P/A:soft
• CNS:NFND
• Saturation of oxygen:95%
Treatment
• Oxygen inhalational
• Inj nor adrenaline 2 amp in
1NS
• IVF
• Inj piptaz 4.5g in 100ml NS iv
tid
• Inj metrogyl 100ml iv tid
• Thoracenter therapeutic
• Protein rich diet
• Strict I/O charting
• Syp ascoryl 10ml tid
• T mucinac po tid

8. planning
vitals
• Pt is c/c
• PR:110
• BP:100/60mmhg
• RS:crepts +
• P/A:soft
• CNS:NFND
• Saturation of oxygen: 98%
Treatment
• CST
• Antibiotic changed to
amoxyclav 1.25g iv bd
• Inj clindamycin 600mg i
100ml NS iv BD added

9. Pharmaceutical care issues
• No pharmaceutical care issues

10. Drug chart
S.N
O
GENERIC
NAME
BRAND
NAME
INDICATION DOSE RO
A
FREQUE
NCY
1 NORADRENALI
NE
Inotropic effect 2amp iv 8
drps/min
2 Piperacillin+ta
zobactum
piptaz To reduce infection 4.5g iv Bd
3 metronidazole metrogyl To reduce infection 100ml iv Tid
4 Ambroxol+lev
osalbutamol+g
aifensein
ascoril To reduce cough with
mucus
10ml Po Tid
5 acetylcystiene mucinac To reduce respiratory
disease with mucus
600mg Po Tid
6 Amoxicillin+cla
ulanate
Amoxyclav To reduce infection 1.25g Iv Bd
7 clindamycin To reduce fungal
infection
600mg iv Bd

11. discussion
• An acute or chronic inflammatory condition of the
lower respiratory tract and lung parenchyma that is
most commonly due to an infection and results in a
clinical syndrome of respiratory symptoms such as
cough, shortness of breath, and pleuritic chest pain
associated with fever and malaise and accompanied by
radiographic abnormalities.
• The lungs are made up of small sacs called alveoli ,
which fill with air when a healthy person breathes .
When an individual has pneumonia , the alveoli are
filled with pus and fliud, which makes breathing
difficulty and limits oxygen intake and causes hypoxia.

12. Classification of pneumonia :
based on anatomical site :1.Lobar pneumonia
2.bronchopneumonia
3.interstitial pneumonia
Based on aetiology –causative agent
Based on mode of aquiring pneumonia: CAP and
HAP

13. 13

14. Place of acquisition of the infection.
This determines which pathogens are likely to cause the
disease.
a. Community-acquired pneumonia (CAP) occurs without
prior contact to the healthcare system in the outpatient
setting or within 48 hours of hospital admission.
b. Hospital-acquired pneumonia (HAP) is defined as a
pneumonia that occurs 48 hours after admission and was
not incubating at the time of admission (e.g., no signs of
pulmonary infection on hospital admission).
c. Ventilator-associated pneumonia (VAP) occurs greater
than or equal to 48 to 72 hours after endotracheal
intubation.

15. Risk Factors
1. Community-acquired pneumonia.
Risk factors:
a. Alcoholism and smoking; these are associated with a
decreased cough and mucociliary clearance.
b. Age greater than 65 years.
c. Recent viral upper respiratory tract infection; influenza is
classically followed by a bacterial pneumonia caused by S.
pneumoniae or S. aureus.
d. Underlying pulmonary diseases (e.g., chronic obstructive
pulmonary disease [COPD], bronchiectasis, lung cancer).
e. Immunosuppression (e.g., HIV infection, solid organ or stem
cell transplantation, and chronic corticosteroid use).

16. f. Medical comorbid conditions (e.g., heart failure, chronic
kidney disease, chronic liver disease, and diabetes
mellitus); these are associated with altered immune
defense and risk for increased colonization.
g. Proton-pump inhibitor therapy; initiation of treatment
with these in the last 30 days might be associated with
an increased risk of gastric bacterial colonization that
can eventually be aspirated into the lungs.
h. Stroke or sedating medications; these are associated
with altered levels of consciousness, decreased cough,
and dysphagia (increases risk of aspiration).

17. • 2. Hospital-acquired pneumonia/ventilator-associated
pneumonia risk factors. These risk factors often combine
an increased aspiration risk, immunosuppression,
colonization with more pathogenic microorganisms, and
alteration of the respiratory tract:
• a. Severity of underlying illness (e.g., malnutrition, uremia,
neutropenia)
• b. Prior surgery
• c. Prior and recent antibiotic administration
• d. Presence of invasive respiratory devices
• e. Supine positioning
• f. Enteral feeding with nasogastric or orogastric tubes
• g. Stress ulcer prophylaxis
• h. Blood transfusions
• i. Poor oral hygiene

18. Etiology
• A. CAP-Related Microorganisms
1.Streptococcus pneumoniae
Risk factors associated with drug-resistant Streptococcus pneumoniae
(DRSP):
a. Age greater than 65 years
b. History of alcoholism
c. Antimicrobial therapy within 3 months
d. Immunosuppression and/or significant comorbid medical
conditions
e. Exposure to children in daycare
2. Staphylococcus aureus
3. Klebsiella pneumoniae
4. Haemophilus influenzae and Moraxella catarrhalis

19. 5. Pseudomonas aeruginosa is a rare pathogen in CAP except in
patients with structural lung disease such as cystic fi brosis and
bronchiectasis.
6. Atypical pneumonia microorganisms account for up to 60% and may
be present as copathogens in 40% of cases. The most common
microorganisms include:
a. Mycoplasma pneumoniae
b. Chlamydophila pneumoniae.
c. Legionella spp
7.virus :RSV,influenza virus, adenovirus
8. Fungal pathogens most commonly seen are Cryptococcus
neoformans and the endemic mycoses Histoplasma capsulatum,
Blastomyces dermatitidis, and Coccidioides immitis.

20. • Hospital-Acquired Pneumonia and Ventilatory-
Associated Pneumonia Related Microorganisms.
.Viral or fungal pathogens are uncommon
immunocompetent hosts. The microbiology of both
conditions is similar:
1. Pseudomonas aeruginosa (very common after more
than 4 days of mechanical ventilation)
2. Klebsiella pneumoniae, Escherichia coli, Enterobacter
spp, Serratia spp
3. Acinetobacter baumannii (commonly associated with
prolonged mechanical ventilation and signifi cant
antimicrobial resistance)
4. Stenotrophomonas maltophilia
5. Staphylococcus aureus, especially methicillin-resistant
Staphylococcus aureus (MRSA).

21. Pathophysiology
1.Micro organism gains access to lower respiratory
tract by failure of defence mechanism by lungs
like cough reflux,muco ciliary clearance.
2. This results in proliferation of microbial pathogen
at alveolar level and the host response to those
pathogens.
3. Alveolar edema and exudate formation
4.Alveoli and bronchioles fill with fliud
5.Promotion abcess formation
6.Tissue necrosis
21

22. Mechanisms
• Bacterial
Most bacteria enter the lungs via small aspirations of organisms residing in
the throat or nose.[Half of normal people have these small aspirations
during sleep. While the throat always contains bacteria, potentially
infectious ones reside there only at certain times and under certain
conditions.
A minority of types of bacteria such as Mycobacterium
tuberculosis and Legionella pneumophila reach the lungs via contaminated
airborne droplets.
Bacteria can also spread via the blood.
The neutrophils also release cytokines, causing a general activation of the
immune system. This leads to the fever, chills, and fatigue common in
bacterial pneumonia.The neutrophils, bacteria, and fluid from
surrounding blood vessels fill the alveoli, resulting in the consolidation
seen on chest X-ray.
22

23. Viruses may reach the lung by a number of different routes.
• Respiratory syncytial virus is typically contracted when people touch
contaminated objects and then touch their eyes or nose.
• Other viral infections occur when contaminated airborne droplets are
inhaled through the nose or mouth.
• Once in the upper airway, the viruses may make their way into the lungs,
where they invade the cells lining the airways, alveoli, or lung
parenchyma.
• Some viruses such as measles and herpes simplex may reach the lungs via
the blood.
• Primarily white blood cells, mainly mononuclear cells, generate the
inflammation. As well as damaging the lungs, many viruses simultaneously
affect other organs and thus disrupt other body functions. Viruses also
make the body more susceptible to bacterial infections; in this way,
bacterial pneumonia can occur at the same time as viral pneumonia.
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24. Clinical presentations
• fever
• breathing difficulty, such as shortness of breath
• Chest retractions
• chest pain that may get worse with coughing or breathing deeply
• coughing up mucus
• sweating
• chills or shivering
• muscle aches
• low energy and fatigue
• loss of appetite
• headaches
• confusion or disorientation, especially in older adults
• dizziness
• nausea and vomiting
• coughing up blood
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25. Diagnosis
• Thorough history taking ( immunization status)
Identifying the onset of symptoms and clinical
presentation
• physical examination
In physical examination vital sign assessment is important
1.Tachypnea and hypoxia(SpO2) is important sign of
pneumonia
2.Auscultation : rales are heard in bacterial .p,
low pitch wheezing throught chest in viral.P
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26. • Chest x ray and blood cultures
• Indication for chest x ray:hypoxemia,RD,
failure of intial antibiotic therapy,hospitalization
• Indication for blood or sputum culture is severe
pneumonia
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27. Diagnosis
• The World Health Organization has defined pneumonia in
children clinically based on either a cough or difficulty
breathing and a rapid respiratory rate, chest indrawing, or a
decreased level of consciousness.
• A rapid respiratory rate is defined as greater than 60
breaths per minute in children under 2 months old, greater
than 50 breaths per minute in children 2 months to 1 year
old, or greater than 40 breaths per minute in children 1 to 5
years old.
• In children, low oxygen levels and lower chest indrawing
are more sensitive than hearing chest crackles with
a stethoscope or increased respiratory rate.Grunting and
nasal flaring may be other useful signs in children less than
five years old.
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28. Bacterial pneumonia
• Illness is sudden onset with
greater severity
• Typically associated with high
fever , chills , cough, dyspnea ,
and ascultatory findings of
lung consolidations
• The chest radiograph often
shows lobar consolidation
• The WBC count is elevated
with predominance of
neutrophils
Viral pneumonia
• It has gradual onset with
cough,wheezing; fever is
less prominent
• WBC count will be normal
or slightly elevated
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29. Management
A. Outpatient Management.
The recommendation for using empiric antimicrobial therapy
is based on likely pathogens to cause infection as outlined
the following:
1. Previously healthy patient without DRSP risks (see Section
II.A.1).
a. Azithromycin 500 mg PO daily or
b. Doxycycline 100 mg PO BID
2. Presence of comorbidities and/or DRSP risks.
a. Moxifl oxacin 400 mg PO daily or
b. Levofl oxacin 750 mg PO daily or
c. Amoxicillin 1 g PO TID plus azithromycin 500 mg PO
daily or doxycycline 100 mg PO BID

30. B. Inpatient Management.
The first dose of the antibiotic drug should be administered without
delay:
1. Inpatient, non-ICU setting
a. Moxifl oxacin 400 mg PO/IV daily or
b. b. Levofloxacin 750 mg PO/IV daily or
c. c. Ceftriaxone 1 g IV daily plus azithromycin 500 mg PO/IV daily
2. Inpatient, ICU setting
a. Risk factors for Pseudomonas; consider the following (gentamicin
5 mg/kg IV q24 can be added to these regimens):
i. Piperacillin–tazobactam 4.5 g IV q6 or
ii. Meropenem 500 mg IV q8 or
iii. Cefepime 2 g IV q8 or
iv. Aztreonam 2 g IV q8 (patients allergic to penicillin)
Plus
i. Moxifl oxacin 400 mg PO/IV daily or
ii. Levofl oxacin 750 mg PO/IV daily or
iii. Ciprofl oxacin 400 mg IV q12 or
iv. Azithromycin 500 mg PO/IV daily

31. b. Risk factors for MRSA; add the following to the
aforementioned regimens:
i. Vancomycin 15 mg/kg IV q12–24 or
ii. Linezolid 600 mg PO/IV q12
C. HCAP/HAP/VAP.
Broad-spectrum antimicrobial therapy is recommended
initially as empirical therapy for the most likely causative
pathogen. Empirical therapy should be based on the local
antibiotic susceptibility patterns. Suggested empirical
regimens include:
1. Healthcare-associated or hospital-acquired pneumonia
a. Early onset (less than 5 days of hospitalization) and no
multidrug resistance microorganism risks.
i. Ceftriaxone 1 to 2 g IV daily or
ii. Moxifl oxacin 400 mg IV daily or
iii. Levofl oxacin 750 mg IV daily

32. b. Late onset and multidrug resistance microorganism
risks.
i. Piperacillin–tazobactam 3.375–4.5 g IV q6 or
ii. Cefepime 1–2 g IV q8–12 or
iii. Ciprofloxacin 400 mg IV q12. Add vancomycin 15
mg/kg IV q12–24 or
iv. Linezolid 600 mg IV q12 if concern for MRSA infection
D. Influenza Pneumonia.
Oseltamivir 75 mg PO BID for 5 days. It should be started
within 48 hours of symptoms onset.

33. Management of Antibiotic Therapy
1. Pathogen-directed therapy. Once culture results or other
reliable microbiological methods reveal a specific etiology
of pneumonia, antimicrobial therapy can be directed
against this pathogen.
2. 2. Intravenous to oral switch. This can be done with the
equivalent oral therapy once the patient is
hemodynamically stable, clinically improving, and able to
ingest and absorb medications.
3. 3. Discharge from the hospital. Patients can be discharged
into a safe environment once they are clinically stable and
have no other active medical problems.
4. 4. Length of antimicrobial therapy a. CAP. The treatment
recommendation is for a minimum of 5 days. At therapy
discontinuation patients should be afebrile for 48 to 72
hours and have stable vital signs and a normal mental
status. b. HCAP/HAP/VAP. Most patients are successfully
treated within 8 days; P. aeruginosa, Acinetobacter spp, or
MRSA may require longer therapy (e.g., 14–21 days).

34. Patient education
• Advice patient attainder to complete entire
course of antibiotics.
• Explain that a chest x ray is usually taken 4 to 6
wks after recovery.
• Avoid the patient stay in smoking area.
• Provide healthy diet
• Clearing the nose which interferes with feeding
• Prevention by proper immunization .
34