Pneumonia can be community-acquired (CAP), hospital-acquired/ventilator-associated (HAP/VAP), or healthcare-associated (HCAP). Typical bacteria causing CAP include Streptococcus pneumoniae and atypical bacteria include Legionella and Mycoplasma. Hospital-acquired pneumonia is often caused by multidrug-resistant pathogens like Pseudomonas, Acinetobacter, and MRSA. Treatment depends on location and severity of infection, and involves antibiotics like macrolides, fluoroquinolones, and beta-lactams. Complications can include respiratory failure, abscesses, and ARDS. Prevention involves pneumococcal and influenza vaccines.

1. PNEUMONIA

2. Acute infection of the pulmonary parenchyma
• From the community
CAP
• That occurs 48 hours or more after admission and did not appear to be
incubating at the time of admission/VAP is a type of pneumonia that
develops more than 48 to 72 hours after endotracheal intubation..HAP/VAP
• From health care facilities.Home care,dialysis unit or within 90 days of
discharge from an acute or chronic care facility.HCAP

3. TYPE OF PNEUMONIA ORGANISMS ASSOCIATED
COMMUNITY ACQUIRED
PNEUMONIA
TYPICAL BACTERIAL-Streptococcus pneumoniae, Haemophilus influenzae,
and Moraxella catarrhalis.
ATYPICAL BACTERIAL-Legionella spp, M. pneumoniae, C. pneumoniae,
and Chlamydia psittaci.
VIRAL- Rhinovirus , influenza,MERS-COV
HOSPITAL ACQUIRED
PNEUMONIA/VENTILATOR
ASSOCIATED PNEUMONIA
Aerobic gram-negative bacilli - Escherichia coli, Klebsiella
pneumoniae, Enterobacter spp, Pseudomonas
aeruginosa, Acinetobacter spp
Gram-positive cocci -Staphylococcus aureus, including methicillin-
resistant S. aureus [MRSA], Streptococcus spp .
Nosocomial pneumonia due to viruses or fungi is significantly less
common, except in the immunocompromised patient.
HEALTH CARE ASSOCIATED
PNEUMONIA
Increased risk for multidrug-resistant (MDR) pathogens

5. • M pneumoniae CAP is associated with the following findings:
• Headache, fever, malaise, sore throat in young adult with insidious onset of cough
• Erythema multiforme major (Stevens-Johnson syndrome)
• Cardiac conduction abnormalities
• Hemolytic anemia and cold-agglutinin syndrome
• Neurologic abnormalities, including aseptic meningitis or meningoencephalitis, Guillain-Barre syndrome,
transverse myelitis
• Associated with epidemic outbreaks, eg, in schools or military barracks
• Legionella pneumophila CAP (Legionnaires disease) is associated with the following findings:
• Gastrointestinal and neurologic symptoms in the setting of pneumonia
• Positive history of waterborne exposure
• Relative bradycardia during febrile episode
• Hyponatremia, hypophosphatemia, elevated creatine phosphokinase (CPK) level, elevated ferritin level,
myoglobinuria
• Leukocytosis with relative lymphopenia
• Unresponsive to beta-lactam antibiotics

6. DIAGNOSIS
CLINICAL DIAGNOSIS ETIOLOGICAL DIAGNOSIS
HISTORY GRAM STAIN/CULTURE SPUTUM
SIGNS AND SYMTPTOMS BLOOD CULTURES
IMAGING ANTIGEN TEST (Leigonella urinary antigen,pneumococcal)
PCR (Chlamydia ,mycoplasma,viruses )
SEROLOGY
BRONCHOALVEOLAR LAVAGE/BRONCHOSCOPY

7. CHEST XRAY

8. SEVERITY INDEX (CURB 65)
• C-Confusion
• U-Urea >19 mg/dl
• R-RR >30 breath/min
• B-Blood pressure SBP<90mmhg OR Diastolic<60mmhg
• Age >65 years
• Score 1 point for each feature
• 0-1 -suitable for outpatient treatment
• 2 Require hospitalisation
• 3-5Possible intensive care support

9. TREATMENT
Outpatient treatment
1. Previously healthy and no use of antimicrobials within the previous three months:
A macrolide (azithromycin, clarithromycin, or erythromycin)
OR
Doxycyline*
2. Presence of comorbidities such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous three months (in which case an alternative from a
different class should be selected):
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])
OR
A beta-lactam (first-line agents: high-dose amoxicillin, amoxicillin-clavulanate; alternative agents: ceftriaxone, cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*
3. In regions with a high rate (>25 percent) of infection with high-level (MIC ≥16 mcg/mL) macrolide-resistant Streptococcus pneumoniae, consider use of alternative agents listed in (2) above.
Inpatients, non-ICU treatment
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])
OR
An antipneumococcal beta-lactam (preferred agents: cefotaxime, ceftriaxone, or ampicillin-sulbactam; or ertapenem for selected patients)
¶
PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*
Δ
Inpatients, ICU treatment
An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS azithromycin
OR
An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])
OR
For penicillin-allergic patients, a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) PLUS aztreonam
Special concerns
If Pseudomonas aeruginosa is a consideration:
An antipneumococcal, antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) PLUS either ciprofloxacin or levofloxacin (750 mg)
OR
The above beta-lactam PLUS an aminoglycoside PLUS azithromycin
OR
The above beta-lactam PLUS an aminoglycoside PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]); for penicillin-allergic patients, substitute aztreonam for above beta-lactam
If CA-MRSA is a consideration:
Add vancomycin or linezolid
IDSA/ATS guidelines: Recommended empiric antibiotics for community-acquired pneumonia in adults

10. COMPLICATIONS
• Acute respiratory distress syndrome (ARDS)
• Pleural effusions
• Lung abscesses
• Respiratory failure
• Multi system failure

11. PREVENTION
• Pneumococcol vaccine (>65 years old or with other chronic illnesses
i.e asthma ,DM,CKD)
Nonleukopenic compromised hosts, such as those with rheumatoid
arthritis, SLE, or alcoholism, may not develop an antibody response to
the pneumococcal vaccine and may therefore remain susceptible to
pneumococcal pneumonia.
• Influenza vaccine .

12. REFERENCES
• UPTO DATE
• EMEDICINE
• HARRISONS TEXTBOOK OF IM