Pneumonia

Clinically presents as an acute illness with cough, purulent sputum, breathlessness and fever together with physical
signs or radiological changes compatible with consolidation of the lung.
Classified by the setting in which the person has contracted their infection:
1) In community setting with no underlying immunosuppression or malignancy community acquired pneumonia
2) In hospital or nursing home hospital acquired pneumonia
3) Immune system is compromised through either genetic defect, immunosuppressive medication, or HIV infection

CAP
Classified either according to the organism responsible for infection or by the site of disease
o Pneumococcus is commonest, 30-50% no identifiable organism, 20% more than 1 organism is present.
o Infection can be localized with whole of 1 or more lobes affected (lobar pneumonia) or diffuse when the lobules of
the lung are mainly affected, often due to infection centred on bronchi and bronchioles (bronchopneumonia).
Other causes of pneumonitis:
1) Chemical insult, aspiration of vomit
2) Radiotherapy
3) Allergic mechanisms
Risk factors
Extremes of age
Co-morbidities: HIV, DM, CKD, Malnutrition, Recent viral resp. infection
Other resp. conditions: cystic fibrosis, bronchiectasis, COPD, obstructing lesion (endoluminal cancer, inhaled foreign
body)
Lifestyle: cigarette smoking, excess alcohol, IV drug use
Iatrogenic: immunosuppressant therapy (corticosteroids)
Clinical features
Cough: dry, productive, hemoptysis
Breathlessness: alveoli become filled with pus and debris, impairing gas exchange (signs of consolidation: coarse
crackles, bronchial breath sounds)
Fever: 39.5-40C; swinging fever indicates empyema
Chest pain: pleuritic due to inflammation of pleura (pleural rub early in the illness)
Extrapulmonary features: not universal, give clinical clue to aetiology
Hemolysis due to cold agglutinins mycoplasma pneumoniae
Atypical presentations in elderly: confusion, recurrent falls
Failed to respond to standard antibiotics: tuberculosis
CURB-65 score
Confusion present
Urea level >7mmol/L
Resp. rate >30/min
BP Systolic <90mmHg; diastolic <60mmHg
65 age
Score 0-1 outpatient, 2 admission 3+ ICU
Complications of pneumonia
1. Parapneumonic effusion and empyema
Early indications of empyema are ongoing fever, and rising or persistently elevated inflammatory markers, despite
antibiotic therapy.

2. Lung abscess
severe localized suppuration within the lung associated with cavity formation visible on chest x ray, often with a
fluid level (indicates an air-liquid interface)
Causes:
I. Aspiration pneumonia
II. Tuberculosis: ?
III. Pneumonia caused by Staph. aureus or Klebsiella pneumoniae
IV. Septic emboli containing staphylococci
V. Spread from an amoebic liver abscess
VI. Bronchial obstruction by an endoluminal cancer
VII. Foreign body inhalation

Clinical features
Persisting or worsening pneumonia associated with production of large quantities of foul smelling sputum
Swinging fever
Malaise and weight loss
Clubbing in chr suppuration
Normocytic anemia
Raised ESR/CRP


HAP
A new onset of cough with purulent sputum along with a compatible Xray demonstrating consolidation, in patients who
are beyond 2 days of their initial admission to hospital or who have been in a healthcare setting within the last 3
months (including nursing/residential homes and hospitals).
The causative organisms differ from those causing CAP, including aerobic gram-negative bacilli, fungi, and viruses.
S.aureus is more common in DM, head trauma, and ICU.

ICP
Opportunistic pathogens: commonly occurring microorganisms/bacteria, viruses and fungi that are found less often.
Symptom pattern may resemble CAP or be more nonspecific.
Pneumocystis pneumonia (PCP) arises from reinfection rather than reactivation of persisting organisms acquired in
childhood.
Clinical features:
High fever
Breathlessness
Dry cough
Rapid desaturation on exercise or exertion
Diffuse bilateral alveolar and interstitial shadowing beginning in the perihilar regions and spreading out in a
butterfly pattern.