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Pneumonia

Community Acquired Pneumonia

• From oxford dictionary – Lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid. Inflammation may affect both lungs ( double pneumonia ), one lung ( single pneumonia ), or only certain lobes ( lobar pneumonia ).
• Causes include
  • Streptococcus pneumoniae causes about 50% of cases
  • H. Flu
  • Staph Aureus
  • Klebsiella
  • Legionella
  • Influenza
  • Respiratory syncytial virus (RSV)

Clinical Presentation

• Cough for about a week that is getting worse
• General malaise
• Shortness of breath
• Tachycardia
• Pleuritic chest pain
• Fever and chills
• Sweats

Labs, Studies and Physical Exam Findings

• Dullness to percussion
• Auscultation
  • Bronchial breath sounds
  • Crackles
  • Egophony (E sounds like A)
• Chest x-ray
  • Lobar consolidation
  • Air bronchograms
  • Pleural effusions
• Sputum culture and gram stain (difficult to identify organisms)

Treatment

• Consider patients overall health and asses risk
• First line medications
  • Macrolides
    • Azithromycin
    • Clarithromycin
  • Doxycycline

Nosocomial Pneumonia (Hospital Acquired Pneumonia)

• Pneumonia diagnosis after 48 hours in hospital
• The most common organisms are gram negative bacillus and Staph aureus
• In an intensive care setting Pseudomonas is the most common organism

Clinical Presentation

• Fever and Chills
• Malaise
• Cough
• Dyspnea
• Chest pain
• Purulent sputum

Labs, Studies and Physical Exam Findings

• Elevated white blood cell count
• X-ray
  • New or progressing infiltrates
• Gram stain and culture of sputum
• An ABG will help assess the severity of the disease

Treatment

• Broad spectrum antibiotics are usually started immediately
  • Antipseudomonal antibiotics
    • Pipercillin
    • Cephalosporin
  • MRSA
    • Vancomycin
• As cultures and sensitivities come back antibiotic use can be adjusted

Pneumocystis Pneumonia (PCP)

• Caused by Pneumocystis jirovecii
• This organism can be found in the lungs of healthy people
• An opportunistic agent typically affecting immunocompromised patients
  • Corticosteroid users
  • HIV with CD4 count less than 200
  • Organ transplant patient
• Pneumothorax is complication of PCP

Clinical Presentation

• Fever
• Shortness of breath
• Nonproductive cough

Labs, Studies and Physical Exam Findings

• Physical exam may be unremarkable
• Chest X-ray
  • Diffuse interstitial infiltrates (ground glass appearance)
• Pulse oximetry shows hypoxia
• ABG will show hypoxia

Treatment

• Immunocompromised patients with shortness of breath and a cough should be started on trimethoprim – sulfamethoxazole (TMP-SMX or bactrim)
• A steroid may be used as inflammation of the alveoli exacerbates the hypoxia
• Pentamidine is another medication which may be used to treat PCP though it has a many and frequent side effects.

Other Lung infections You Should Know

• Psittacosis (Parrot Fever)
  • Caused by Chlamydophila psittaci
  • Symptoms are similar to an atypical pneumonia
  • Treatment is with tetracycline or doxycycline
• Histoplasmosis
  • Found in soil with bird and bat droppings
  • The fungus is inhaled
  • Most infections are mild
  • Infections can be very severe in an immunocompromised patient especially in disseminated disease
  • Symptoms
    • Fever
    • Cough
    • Malaise
  • Chest x-ray may be normal in up to 70% of patients
  • Sputum or serum may be cultured, but Histoplasmosis is a slow growing fungus
  • Treatment includes oral Itraconazole or Amphotericin B for a few months and for prophylaxis

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