Pneumonia causes over 4.5 million outpatient visits and 0.5 million hospitalizations annually, with higher incidence in older adults and men. It is characterized by symptoms like cough, fever, and respiratory distress, often requiring antibiotic treatment based on severity and patient factors. Key prevention strategies include vaccinations and smoking cessation.

1. PNEUMONIA
by
Abdullah Zaki

2. EPIDEMIOLOGY
Over 4.5 million outpatient and emergency room visits
annually.
0.5 million unique CAP hospitalizations each year.
The rate rises with age. Winter > summer months.
Men > women and African American > White.
In 2005, pneumonia and influenza combined were the eighth
most common cause of death in the United States.
Over 60,000 deaths/ year due to pneumonia in the United
States.

3. RISK FACTORS
Older age (marked increase >65 years old)
Chronic comorbidities: chronic lung disease (e.g.,
bronchiectasis, asthma), CHF, stroke, diabetes
mellitus, malnutrition, and immunocompromising
conditions.
Increased risk of macroaspiration:
 Altered consciousness (e.g., stroke, seizure, anesthesia, drug or
alcohol).
 Dysphagia /motility problems.
 Wearing dentures while sleeping.
 Immunocompromising conditions (Diabetes, HIV, Immunosuppressive
medications, Post-transplant), Smoking, alcohol, Illicit Drugs.
 Instrumentation of the respiratory tract (e.g., intubation or
bronchoscopy).
 Viral respiratory tract infection, especially influenza.

4. PATHOGENESIS
 From person to person via droplets or, less commonly,
via aerosol inhalation.
 Colonize the nasopharynx  reach the lung alveoli via
microaspiration.
 Sufficient Inoculum size and/or impaired host immune
defenses  infection.
 Inflammation and lung parenchymal damage, resulting
in pneumonia.

5. DIFFERENTIAL DIAGNOSIS
Noninfectious illnesses that mimic CAP:
 Aspiration or chemical pneumonitis.
 CHF with pulmonary edema.
 Pulmonary embolism.
 Acute exacerbation of COPD

6. CLINICAL PRESENTATION
Mild Pneumonia:
Fever, cough, and shortness of breath.
Severe Pneumonia:
 Respiratory distress
 Sepsis
 Hypotension
 Altered Mental Status
Organ Dysfunction:
 Renal or Liver dysfunction
 Thrombocytopenia

7. Special Considerations:
Subtle symptoms in:
Older patients
 Mental status changes without fever or
leukocytosis
Immunocompromised patients
 Negative chest radiographs, requiring Chest CT
for diagnosis

8. PHYSICAL EXAMINATION
Tachycardia
Tachypnea
Hypoxia
Dullness to Percussion
Tactile Fremitus
Rales/Crackles
Respiratory dystress

9. COMMON PATHOGENS
Typical bacteria include:
 S. pneumoniae
 Haemophilus influenzae
 Staphylococcus aureus
 Group A streptococci
 Moraxella catarrhalis
 Anaerobes
 Aerobic gram-negative bacteria
Consideration of MRSA and multidrug-resistant gram-negative bacilli
in:
 Those with comorbidities
 Recent antibiotic use
 Hospitalization

12. Atypical Bacteria
 Legionella spp
 M. pneumoniae
 C. pneumoniae
 Chlamydia psittaci
Respiratory Viruses
 Influenza A and B viruses
 SARS-CoV-2 (COVID-19)
 Rhinoviruses
 Parainfluenza viruses
 Adenoviruses
 Respiratory syncytial virus

13. FUNGAL PNEUMONIA:
Fungal/ PJP in Immunocompromised, particularly
neutropenics.
Certain fungi (e.g., Histoplasma capsulatum, Coccidioides
spp, Blastomyces dermatitidis) can cause pneumonia in
immunocompromised individuals.
Travel history to endemic areas.

15. DIAGNOSIS
Clinical based upon the following criteria:
New lung infiltrate on imaging
Plus
New onset of fever and Leukocytosis.
 + Decline in oxygenation.
 + Presence of purulent sputum.

16. MANAGEMENT
Ambulatory Care
Mild pneumonia
Normal vital signs (except fever)
PSI scores I to II
CURB-65 scores 0 (or 1 if age >65 years)
Hospital Admission
Peripheral oxygen saturations <92% on room air (significant
change from baseline)
PSI scores ≥III
CURB-65 scores ≥1 (or ≥2 if age >65 years)
ICU Admission Criteria
One of the following criteria:
 Respiratory failure requiring mechanical ventilation
 Sepsis requiring vasopressor support

17. TREATMENT
Outpatient Antibiotic Regimens
Age <65 years and otherwise healthy, Just Emperic
Antibiotics, No pathogen testing needed.
 Amoxicillin (1 g TID) + Azithromycin or Doxycycline
Major comorbidities, smokers, or recent antibiotic use:
 Amoxicillin-Clavulanate + Azithromycin or Doxycycline
 Or third-generation cephalosporin + Azithromycin or
Doxycycline

18. INPATIENT ANTIBIOTIC THERAPY
Initial regimens for hospitalized patients
 Ceftriaxone + Azithromycin
 Or monotherapy with respiratory fluoroquinolone (e.g.,
Levo or Moxifloxacin)
Patients with Pseudomonas risk:
 Combination therapy with antipseudomonal beta-lactam
(piperacillin-tazobactam, cefepime, ceftazidime) +
antipseudomonal fluoroquinolone (ciprofloxacin or
levofloxacin)
Patients with MRSA suspicion:
 Add anti-MRSA agent (Vancomycin or Linezolid) to
Ceftriaxone + Azithromycin

19. ANTIVIRAL TREATMENT
AND GLUCOCORTICOIDS
Antiviral treatment for known or suspected
influenza (e.g., oseltamivir), COVID-19.
Use of glucocorticoids for
immunocompetent and
immunocompromised patients
 Dosage and duration based on severity
 . For immunocompetent patients with significant
hypoxemia (ie, PaO2:FIO2 ratio <300 with an
FiO2 requirement of ≥50 percent
 Continuous infusion of hydrocortisone 200 mg daily
for 4 to 7 days followed by a taper.
For immunocompromised, Steroid use
varies, assess risk vs benefit.

20. ASSESSING CLINICAL RESPONSE
Followup Imaging: Clinical resolution do not require a
follow-up chest radiograph, as radiographic response
lags behind clinical response.
Duration of Antibiotic Therapy
Length of therapy based on infection severity and
comorbidities
Consideration of extended courses for specific cases
Procalcitonin at the time of diagnosis and every one to
two days helps in guiding antibiotic discontinuation.

21. COMPLICATIONS
 Nonresolving pneumonia
 Progression to sepsis and/or respiratory failure
Parapneumonic Effusion
Parapneumonic effusion forms in the pleural space
adjacent to pneumonia.
 Effusions can be Uncomplicated (sterile) or Complicated
(infected but no pus)
 Empyema (collection of pus)
Management of Parapneumonic Effusion and Empyema
 Prompt antibiotic initiation
 Drainage of infected pleural fluid
Antibiotic choices for complicated effusions

23. Duration of Antibiotics
 Uncomplicated bacterial parapneumonic effusions (1-2
weeks)
 Complicated parapneumonic effusions (2-3 weeks)
 Empyema (4-6 weeks)
Chest Tube Removal
Chest tubes can be removed when:
 Drainage volume falls below 50-100 mL/day for 2-3
days
 Pleural imaging shows reasonable size reduction
 No or resolving signs of clinical infection

24. PREVENTION STRATEGIES
Smoking cessation
Influenza vaccination for all patients
Pneumococcal vaccination for at-risk
patients

25. THANK YOU