Pneumonia

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Pneumonia is an infection in one or both lungs. It can be caused by bacteria, viruses, or fungi. Bacterial pneumonia is the most common type in adults. Pneumonia causes inflammation in the air sacs in your lungs, which are called alveoli. The alveoli fill with fluid or pus, making it difficult to breathe.

Types of Pneumonia
Community acquired Pneumonia
Bacterial Streptococcus pneumoniae, Staphy lococcus aureus, Haemophilus, Moraxella
Atypical Mycoplasma, Chlamydia, Legionella, TB, community acquired MRSA
Viral influenza, para-influenza, metapneumo virus, RSV, adenovirus
Fungal blastomycosis, cryptococcus, histoplasmosis
Aspiration Pneumonia
Polybacterial Including Anaerobes Bacteroides, Peptostreptococcus, Fuso bacterium spe cies and other Gram positive bacilli
Chemical Pneumonitis
Nosocomial Pneumonia
Polybacterial Staphylococcus aureus, MRSA, Pseudomonas aeruginosa, Enterobacteriaceae (Klebsiella, Escherichia coli, Serratia), Haemophilus, Acinetobacter
Viral influenza
Ventilator associated Pneumonia
Nursing home acquired Pneumonia
Pathophysiology
Complication of Pneumonia
Pulmonary ARDS, lung abscess cavitay formation, parapneumonic effusion/empyema, pleuritis hemorrhage
Extrapulmonary purulent pericarditis, hyponatremia, sepsis
Surface Lung Markings
Inferior margin of the lungs level of 6th rib at the mid clavicular line, level of 8th rib at the mid axillary line, and level of 10th rib at the mid scapular line
Oblique (Major) Fissures draw a line diagonally from T3 vertebral body posteriorly to the 6th rib anteriorly
Horizontal (Minor) Fissure draw a horizontal line at the level of right anterior 4th rib


Investigations
Basics
Labs: CBCD, electrolytes, urea, Cr, troponin/CK, AST, ALT, ALP, bilirubin, urinalysis
Microbiology blood C&S, sputum Gram stain/ AFB/C&S/fungal, urine C&S
Imaging CXR CT chest
ABG if respiratory distress, and for PSI if deciding on possible hospitalization
Special
Bronchoscopy
Nasopharyngeal swab if suspect viral infection, check for influenza A/B, parainfluenza, human metapneumovirus, RSV, adenovirus
Mycoplasma IGM
Urine for Legionella Antigen
Diagnostic and Prognostic Issues
Pneumonia Severity of Illness (PSI) Score
Scoring age, female ( 10), nursing home (+10), cancer (+30), liver disease (+20), heart failure (+10), CVA (+10), renal failure (+10), altered men tal status (+20), RR >30 (+20), SBP P 408C [>1048F] (+15), HR >125 (+10), pH 10.7 mmol/L [>30 mg/dL] +20, Na 13.9 mmol/L [>250 mg/dL] +10, hematocrit
Utility originally developed as a prognostic tool. Consider admission if PSI score >90. Clinical judgment more important than PSI in determining admission
Management
Acute ABC, O2, IV, consider salbutamol 2.5 mg NEB q6h + q1h PRN
Antibiotics
* Tetracycline doxycycline 100 mg PO BID 10 days
* Macrolides azithromycin 500 mg PO first day, then 250 mg PO daily 4 days; clarithromycin 250 500 mg PO BID 10 days
* Fluoroquinolones levofloxacin 500 mg PO daily 10 days (or 750 mg 5 days), moxifloxacin 400 mg PO daily 10 days; avoid if   exposed to fluoroquinolone within last 3 6 months
* β-Lactams amoxicillin 1g PO TID, amoxicillin clavulanate 2 g PO BID, cefuroxime 750 mg IV q8h or 500 mg PO BID, cefotaxime 1 g IV q8h
* Anaerobic coverage if suspect aspiration, add clindamycin 150 450 mg PO q6h or 600 900 mg IV q8h or metronidazole 500 mg PO/IV BID/TID
* Anti-Pseudomonal ceftazidime, cefepime, meropenem, ciprofloxacin, aminoglycosides, pipera cillin tazobactam (do not use same class of agent when double covering for pseudomonas)
* Further Gram-Negative Coverage ciprofloxacin 500 mg PO BID, gentamicin 6 mg/kg IV q24h, tobramycin 6 mg/kg IV q24h (follow levels to adjust dosing)
* Anaerobic Coverage if suspect aspiration, replace gentamicin with clindamycin 150 450 mg PO q6h or 600 900 mg IV q8h or add metronidazole 500 mg PO BID
* Antibiotic Course 10 14 days for most, 21 days for Pseudomonas, Staphylococcus aureus, and Acinetobacter
Aspiration Pneumonia clindamycin 600 mg IV BID, switch to 300 mg PO QID when stable. May add cefotaxime for Gram positive and Gram negative coverage
Non Pharmacologic Treatments
Vaccinations influenza vaccine annually and pneumococcal vaccine booster at 5 years
Chest Physiotherapy
Treatment Issues
Important Note avoid using the same antibiotic class if given within 3 months
Outpatient Antibiotics Choice
Previously Healthy macrolide (azithromycin, clarithromycin, or doxycycline). Other antibiotic choices include fluoroquinolone, macrolide plus amoxicillin + clavulanate
Comorbidities (COPD, diabetes, renal failure, HF, malignancy) macrolide or fluoroquinolone
Suspected Aspiration with infection amoxicillin clavulanate or clindamycin
Influenza with bacterial, Superinfection β lactam or fluoroquinolone
Inpatient Antibiotic Choice second third generation b lactam plus macrolide or respiratory fluoroquinolone
ICU Antibiotics Choice
Pseudomonas Unlikely macrolide plus β lactam or fluoroquinolone plus β lactam
Pseudomonas unlikely but β-Lactam Allergy fluoroquinolone with or without clindamycin
Pseudomonas likely double coverage with agents that are effective against Pseudomonas (different classes)
Pseudomonas likely but β-Lactam Allergy aztreonam plus levofloxacin or aztreonam plus moxifloxacin, with or without aminoglycoside
Nursing Home Antibiotics Choice
Treatment in Nursing Home fluoroquinolone or macrolide plus amoxicillin clavulanate
In Hospital fluoroquinolone or macrolide plus amoxicillin clavulanate
Discharge Decision clinical stabilization usually takes 2 3 days. When symptoms have significantly improved, vital signs are normalized, and patient has defervesced, patients at low risk may be safely discharged on the day of switching to oral therapy without adverse consequences. Time to radiographic resolution is variable, with up to 5 months for pneu mococcal pneumonia associated with bacteremia
Note: consider vancomycin or linezolid if MRSA sus pected; emergence of community acquired MRSA associated with serious necrotizing infections

Specific Entities
Causes of non resolving Pneumonia: Non infectious (malignancy especially bronchoalveolar carcinoma or lymphoma, cryptogenic organizing pneumonia, hemorrhage), non bacterial (viral, fungal), immunocompromised host, antibiotic resistance, pneumonia complications (abscess, empyema, ARDS)
Causes of Recurrent Pneumonia
Immunocompromised: Suppressants (steroids, chemotherapy, transplant medications, alcohol), AIDS, Diabetics, Decreased nutrition, Immunoglobulin (hypogammaglobulinemia), Solid organ failure (renal, liver, splenectomy), Tumors
Pulmonary bronchiectasis, COPD, cystic fibrosis, abnormal anatomy
GI aspiration
Lung Abscess
Causes Anaerobes (Peptostreptococcus, Prevotella, Bacteroides, Fusobacterium), Gram positive (S. milleri, microaerophilic streptococcus, S. aureus), Gram negative (Klebsiella, Haemophilus,Legionella). Nocar dia and actinomycosis can rarely cause lung abscess

Treatments: Clindamycin until radiographic improvement and stabilization (usually several weeks to months, can be completed with oral antibiotics once patient is stable). No need for percutaneous drainage. If complicated abscess, consider lobectomy or pneumonectomy

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