Pneumonia

Pneumonia

Pneumonia is a generalized infection of the lung parenchyma

Bottom Line Treatment for Pneumonia

Type of Pneumonia	Treatment	Alternative
Community-acquired (CAP)	3rd Generation Cephalosporin + Macrolide	Fluoroquinolone
Hospital-acquired (HAP)	Vancomycin + Piperacillin/Tazobactam
HIV/AIDS	TMP-SMX + Steroids + Cover for Community-acquired
Outpatient < 65 yo	Macrolide only

CURB-65 score

This score is used to determine whether a patient with pneumonia will be admitted.

Pneumococcal vaccine

• Who to vaccinate?
  • Anyone who requests a vaccination
  • Prison inmates
  • Older adults
  • Asplenia
  • Immunocompromised
  • COPD
  • Congestive Heart Failure
  • Healthcare workers*

Community-acquired pneumonia (CAP)

Pneumonia that develops when the patient is not being hospitalized. The most common cause of pneumonia in all patient groups (excluding children) is Streptococcus pneumoniae. Treatment progression is based on symptom resolution and CXR.

Common pathogens causing Pneumonia

Pathogen	Association
Streptococcus pneumoniae	Most common
Staphylococcus aureus	Recent viral infection (influenza)
Haemophilus influenzae	COPD, smokers
Klebsiella pneumoniae	Alcoholism, diabetes, “currant jelly” sputum (hemoptysis from necrotizing disease)
Anaerobes	Poor dentition, aspiration, foul-smelling sputum
Mycoplasma pneumoniae	Young, healthy patients
Chlamydophila pneumoniae	Hoarseness
Legionella	Contaminated water sources, air conditioning, ventilation systems, gastrointestinal signs and symptoms
Chlamydia psittaci	Birds, placenta, sheep
Coxiella burnetti	Animals at the time of giving
Pneumocystis	AIDS < 200 CD4

• Risk factors
  • Cigarette smoking
  • Fluid in lungs (effusion)
  • Splenectomy
  • Immune status
  • Age (>60 yrs, < 2 yrs)
  • Alcohol consumption
• Symptoms
  • Sputum (may not be present in atypical pneumonia)
  • Fever
  • Cough
• Physical findings
  • Rales and Rhonchi
  • Dullness to percussion
  • Egophony (increased resonance over affected fields if lobar pneumonia)
• Investigations
  • Chest X-ray: lobar consolidation (in streptococcal pneumonia); diffuse infiltrates (other causes)
• When to admit
  • Symptoms of respiratory compromise (hypoxia, hypercapnia, tachypnea)
  • Sepsis (hypotension, tachycardia)
  • Patient > 65 years old
  • Significant concomitant illness (cancer, COPD, CHF)
  • Immunodeficiency (HIV/AIDS, Asplenia, On steroids)
• Emergency Treatment
  • Oxygen (as needed)
  • Fluid resuscitation (if hemodynamically unstable)
  • Intubation
• Outpatient treatment
  • PO Macrolide OR Fluoroquinolone
    • Macrolide: Azithromycin, Clarithromycin
    • Fluoroquinolone: Moxiflocacin, Levofloxacin, Gatifloxacin (only IV)
• Inpatient Treatment
  • Third generation cephalosporin e.g. ceftriaxone AND Macrolide, OR
  • Fluoroquinolone
• ICU Treatment ***Add Beta-lactam to cover pseudomonas (if allergic to penicillin switch beta-lactam to aztreonam – effective against Gram-negatives)
  • Beta-lactam AND Macrolide OR,
  • Beta-lactam AND Fluoroquinolone OR,
  • Aztreonam and Fluoroquinolone
• Inpatient and ICU anti-pseudomonal coverage (Risk – Cystic fibrosis, Immunosuppressed)
  • Pipercilin-tazobactam (Beta lactam)
  • Ticarcilin-clavulanate **(Beta-lactam)
  • Ceftazidime (3rd gen cephalosporin)
  • Cefepime (4th gen cephalosporin)
  • Tobramycin (Aminoglycoside)
  • Amikacin (Aminoglycoside)
• Supportive care
  • Chest Physiotherapy (Incentive spirometry)
  • Oxygen monitoring
  • Oxygen supplementation
  • Antipyretics
  • Analgesia
  • Proper hydration
  • Diet and activity

Hospital-acquired pneumonia (HAP)

Pneumonia that develops if the patient has been hospitalized for > 48 hours. Very important to get sputum cultures. Should always be empirically treated with coverage for Pseudomonas and MRSA (broad enough to cover other causes)

• Empiric Treatment
  • Anti-psuedomonals: Ceftazidime, Cefipime, Pipericilin-tazobactam, ticarcilin-clavulanate, Tobramycin, Amikacin AND,
  • Anti-MRSA: Vancomycin, Linezolid

Mycoplasma pneumonia

“Walking pneumonia”. The most common pneumonia in teenagers and young adults. Has mild symptoms of cough, coryza, and low-grade fever with a complete interstitial pneumonia picture on chest X-ray.

• Investigations
  • Chest X-ray: interstitial infiltrates
  • Cold agglutinin assay: best diagnostic test
• Treatment
  • Azithromycin

Legionellosis

Usually occurs in older adults and smokers. Classic risk factors in air-conditioning. Will have additional gastrointestinal symptoms (nausea, diarrhea) and neurological symptoms (incoordination), with relative bradycardia

• Investigations
  • Legionella urine antigen
• Treatment
  • Doxycycline or Macrolide

Coxiella Pneumonia (Q fever)

Pneumonia after exposure to sheep placenta. The diagnosis is serology. Treatment is doxycycline

Pneumocystis jirovecii Pneumonia (PCP)

Common in AIDs patients. Tends to be very hypoxic (+ HIV/AIDS status and severity is an indication to test)

• Investigations
  • Chest X-ray
  • Bronchoalveolar lavage: Best diagnostic
• Treatment
  • TMP/SMX OR Pentamidine (if sulfur allergy)
  ***Dapsone and Atovaquone are NOT USED FOR THERAPY (only for prophylaxis)

GBS Pneumonia

#1 cause of pneumonia and sepsis in neonates. Mothers will be GBS + (with poor prenatal care, did not get penicillin). Can be fatal. Can also cause meningitis.

• Treatment
  • Gentamicin OR Rifampicin

Klebsiella pneumonia

Associated with alcoholics. “Currant jelly sputum”

• Treatment
  • 3rd gen cephalosporin (Ceftriaxone, Cefotaxime)