Diagnosis of pneumonia requires two or more symptoms of acute respiratory infection plus infiltrates/ consolidation on chest x-ray or CT chest.
It usually starts as sudden onset fever with productive cough (purulent yellow- green sputum or hemoptysis), breathing difficulty, night sweats, pleuritic chest pain.
The most reliable auscultation finding is Bronchial breathing with I:E ratio of 1:1 instead of conventional 1:2 ratio of vesicular breathing heard in normal lung fields.
CRB -65 is used to decide the need for hospitalization in pneumonia. CURB-65 has a disadvantage that BUN report is not available immediately on presentation. Both are discussed in detail below.
Organism
specific approach to pneumonia
|
CATEGORY |
ETIOLOGY |
|
Atypical |
Mycoplasma, Legionella, Chlamydophila (Chlamydia)
pneumoniae
|
|
Nosocomial or heath care associated |
Staphylococcus,
anaerobes Pseudomonas (Ventilator
associated pneumonia and intubated patients)
|
|
Immunocompromised |
Streptococcus pneumoniae (most common),
Staphylococcus, Pneumocystis Jirovecii (HIV+ patient), mycobacteria
|
|
Aspiration |
Anaerobes |
|
Alcoholics/IV drug users |
S pneumoniae,
Klebsiella, Staphylococcus
|
|
CF |
Staphylococcus,
Pseudomonas, Burkholderia, mycobacteria
|
|
COPD |
Hemophilus influenzae, Moraxella
catarrhalis, S pneumoniae
|
|
Post -viral |
Staphylococcus
|
|
Neonates |
Group B
streptococci Escherichia
coli for India Listeria monocytogenes
|
|
Recurrent |
Obstruction, bronchogenic carcinoma,
lymphoma, Wegener granulomatosis,
immunodeficiency |
Age wise causes of Pneumonia
|
NEONATES |
CHILDREN
|
YOUNG ADULTS
|
ELDERLY
|
|
GBS E coli Listeria |
Viruses S pneumoniae Mycoplasma C pneumoniae Staphylococcus
aureus |
Mycoplasma S
pneumoniae Viruses C
pneumoniae |
S pneumoniae H influenzae S aureus Gram (-) rods Anaerobes in debilitated patients like in
case of PD, AD or neurodegenerative disorders |
Symptoms
·
Cough, shortness of breath, fast
breathing and altered mentation due to hypoxia
·
Atypical symptoms: Dry cough,
headache, myalgia, sore throat, GI symptoms and seizures
Seizures
are seen in legionella pneumophila that can cause SIADH.
· Lung exam shows bronchial breath sounds, rales, wheezing, dullness to percussion, egophony, and tactile fremitus.
Diagnosis
·
Requires two or more symptoms of acute
respiratory infection plus infiltrates/ consolidation on chest x-ray or CT
chest
·
Work up
1. Sputum
Gram stain and nasopharyngeal aspirate
– An
adequate sputum Gram stain sample has many PMNs (>25 cells/High power field)
and few epithelial cells (< 10 cells/HPF)
2. Blood
culture
3. ABG
only in hospitalized patients or outpatients with persistent symptoms
4. If
Legionella is suspected: Urine Legionella antigen test, sputum staining with
direct fluorescent antibody (DFA)
5. Chlamydia
pneumoniae: Serologic
testing, polymerase chain
reaction (PCR).
6. Mycoplasma: Serum
cold agglutinins and serum Mycoplasma antigen may also be used.
7. S pneumoniae:
Urine pneumococcal antigen test, culture.
8. Viral: Nasopharyngeal aspirate, PCR for COVID-19, influenza, respiratory syncytial virus
Treatment
CURB -65
or CRB 65 is used to decide for need for hospitalization
Confusion
Uremia (BUN > 19)
Respiratory rate (> 30 breaths/min)
Blood pressure (SBP < 90 mm Hg
or DBP < 60 mm Hg)
Age > 65 years
|
Score
|
Suggested
care |
|
0-1 (Age alone if present) |
Outpatient treatment
|
|
2 |
Inpatient care |
|
3 |
ICU care |
·
Outpatient treatment with oral
antibiotics is recommended in uncomplicated cases.
· For patients with obstructive diseases (eg, cystic fibrosis [CF] or bronchiectasis), consider adding pseudomonas, staphylococcal, or anaerobic coverage.
|
Patient Features |
Empirical coverage
|
|
CURB score 0-1 Outpatient community-acquired pneumonia, ≤ 65 years
of age, otherwise healthy, no antimicrobials within 3 months
|
Amoxicillin with azithromycin |
|
CURB score 0-1 > 65 years of age or comorbidity (COPD, heart
failure, renal failure, diabetes, liver disease, alcoholic or
antimicrobial use within 3 months
|
Amoxicillin with clavulanic acid + Azithromycin
|
|
CURB score of 2
Community-acquired pneumonia
requiring hospitalization
Non
severe |
Ampicillin-sulbactam
+ Azithromycin
Or Respiratory Fluoroquinolone
–
Levofloxacin
–
Moxifloxacin
–
Gemifloxacin
If recent hospitalization or antibiotic
treatment –
Add Linezolid –
Add Meropenem
|
|
Hospital-acquired pneumonia- hospitalized
> 48 hours or in a long-term care
facility > 14 days; ventilator-associated pneumonia |
Extended-spectrum cephalosporin or
carbapenem with
antipseudomonal activity Add an aminoglycoside or a fluoroquinolone
for coverage of resistant organisms like
pseudomonas until lab sensitivities identify the best
single agent |
Extra mile
|
Evaluate
for complications
of pneumonia 1.
Pleural
effusion 2.
Empyema 3.
Lung
abscess 4.
Necrotizing
pneumonia and Empyema treatment requires surgical drainage and chest tube
placement. |
|
Pneumococcal vaccine should be given to 1.
All children 2.
Patients > 65 years of age 3.
Patients
with splenic dysfunction (eg, sickle cell) or asplenia 4.
Immunocompromised
patients 5.
Diabetes Mellitus
|