PNEUMONIA:
An acute lower respiratory tract illness associated with
fever,symptoms and signs in the chest and abnormalities on Chest X ray.
An inflammation of lungs caused by acute infection and
characterized by recently developing signs of consolidation both clinically and
radiologically.
CLASSIFICATION AND CAUSES
COMMUNITY ACQUIRED PNEUMONIA:
May be primary or secondary to underlying disease.
Most common cause is Streptococcus pneomonia.
This is followed by Haemophilus Influenzae and Mycoplasma
pneumoniae
Other organisms include : Staphylococcus aureus,Legionella
species,Morexalla catarrhalis and Chlamydia.
Rarer causes include : Coxiella Burnetti and anaerobes.
Viruses account for 15 % of causes.
Flu may be complicated by community acquired MRSA pneumonia
(CA-MRSA)
HOSPITAL ACQUIRED PNEUMONIA
Occurs more than 48 hours after hospital admission.
Most commonly cased by Gram negative enterobacteria or
Staphylococcus aureus.
Other organisms include the following :
Pseudomonas Aeuroginosa
Klebsiella
Bacteroides
Clostridia
ASPIRATION PNEUMONIA
This occurs due to poor swallowing and unwell patients with
low GCS.
Increased incidence occurs in the following patients:
Stroke
Septicemia.
Bulbar palsies
Myasthenia
Decreased consciousness (post ictal)
Oesophageal diseases (Achalasia and reflux)
PNEUMONIAS IN IMMUNOCOMPROMISED PATIENTS
These are caused by the following organsims:
Streptococcus pneumonia
H.Influenzae
Staphycoccus aureus
Mycoplasma oneumonia
Gram negative bacilli
Pneumocystic Jirovecii/carinii
Fungi
Mycobacteria
Viruses: CMV , HSV
CLINICAL FEATURES
SYMPTOMS:
Fever
Rigors
Malaise
Anorexia
Cough
Dyspnoea/shortness of breath.
Purulent sputum
Haemoptysis
Pleuritic chest pain
SIGNS
Fever
Cyanosis
Confusion
Tachypnoea
Tachycardia
Hypotension
Signs of consolidation :Diminished expansion,dull percussion
note,increased tactile vocal fremitus and increased vocal resonance,bronchial
breathing and pleural rub
INVESTIGATIONS
Objective is to:
Establish diagnosis
Identify the pathogen
Assess severity
CXR:
Lobar or multilobar infiltrates,cavitation or pleural
effusion.
Assess oxygen saturation
Arterial blood gases if SaO2 less than 92 %
BLOOD TESTS: FBC,CRP,U&Es,BLOOD CULTURES
SPUTUM FOR MICROSCOPY AND CULTURE
ATYPICAL RESPIRATORY SEROLGY IN SEVERE CASES:
VIRAL SEROLOGY/COMPLEMENT FIXATION TESTS
PNEUMOCOCCAL ANTIGEN IN URINE
LEGIONELLA : SPUTUM CULTURE AND URINE ANTIGEN
PLEURAL FLUID ASPIRATION FOR CULTURE
BRONCHOSCOPY AND BRONCHOALVEOLAR LAVAGE IF PATIENT IS IN ITU
OR
IMMUNOCOMPROMISED
ASSESSMENT OF SEVERITY
CURB – 65 SCORE IS USED TO GUIDE SEVERITY
1 SCORE FOR EACH OF THE FOLLOWING BELOW :
CONFUSION : ABBREVIATED MENTAL TEST SCORE LESS THAN OR EQUAL
TO 8.
UREA > 7 MMOL/L
RESPIRATORY RATE MORE
THAN OR EQUAL TO 30/MIN
SYSTOLIC BLOOD PRESSURE LESS THAN 90 MM HGOR DIASTOLIC LESS
THAN 60 mmHg
AGE MORE THAN OR EQUAL TO 65
MANAGEMENT OF PNEUMONIAS:
ANTIBIOTICS:
These are given orally if not severe pneumonia,and
intravenous in case of sec=vere pneumonia
COMMUNITY ACQUIRED PNEUMONIAS:
MILD:
STREPTOCOCCUS PNEUMONIAE/HAEMOPHILUS INFLUENZAE:
Oral Amoxicillin 500 – 1 Gm 8 hourly or
Clarithromycin 500 mg 12 hourly or Doxycycline 200 mg
loading and 100 mg 12 hourly
MODERATE:
STREPTOCOCCUS PNEUMONIAE/HAEMOPHILUS INFLUENZAE/MYCOPLASMA
PNEUMONIAE:
Oral amoxicillin 500 mg – 1 Gm 8 hourly or Doxycycline 200
mg loading then 100 mg 12 hourly.
COMMUNITY ACQUIRED PNEUMONIA
SEVERE
STREPTOCOCCUS PNEUMONIAE/HAEMOPHILUS INFLUENZAE/MYCOPLASMA
PNEUMONIAE
Co-amoxiclav 1.2 Gm / 8 hourly IV or
Cephalosporin IV eg Cefuroxime 1.5 Gm IV 8 hourly and
Clarithromycin 500 mg 12 horly IV
Add flucloxacillin if staphylococcus is suspected
ATYPICAL PNEUMONIAS:
LEGIONELLA PNEUMOPHILIA :
Consider adding Rifampicin,Treaat
for 14 – 21 days
Chlamydophilia species : Tetracyclines
Pneumocystis Jiroveci : High dose co-trimoxazole
MANAGEMENT OF PNEUOMONIAS
HOSPITAL ACQUIRED PNEUMONIAS:
GRAM NEGATIVE BACILLI:/PSEUDOMONAS/ANAEROBES
AMINOGLYCOSIDE IV PLUS ANTIPSEUDOMONAL PENICILLIN IV OR 3RD
GENERATION CEPHALOSPORIN IV
ASPIRATION PNEUMONIA:
CAUSED BY ANAEROBES AND STREPTOCOCCUS PNEUMONIAE :
CEFUROXIME 1.5 GM/8HOURLY IV PLUS METRONIDAZOLE 500 MG 8 HOURLY IV
NEUTROPENIC PATIENTS :
GRAM POSITIVE COCCI AND GRAM NEGATIVE BACILLI :
AMINOGLYCOSIDE IV PLUS ANTIPEUDOMONAL PENICILLIN IV OR 3RD
GEN CEPHALOSPORINS IV
CONSIDER ANTIFUNGALS FOR FUNGAL PNEUMONIAS IN NEUTROPENIC
PATIENTS
MANAGEMENT OF PNEUMONIAS
OXYGEN:
To keep PaO2 > 8.0 Kpa and saturation > 94 %
IV FLUIDS:
In case of dehydration,anorexia,shock
ANALGESIA:
In case of pleurisy eg by paracdetamol 1 Gm PO 6 hourly.
ITU TREATMENT:
|In case of shock,hypercapnea or uncorrected Hypoxia.
Look for complications in case of failure to improve or
persistent elevation of CRP.
FOLLOW UP:
In 6 weeks time with CXR.
COMPLICATIONS OF PNEUMONIA
PLEURAL EFFUSION
LUNG ABSCESS
EMPYEMA
RESPIRATORY FAILURE
BRAIN ABSCESS
SEPTICEMIA
MULTIPLE ORGAN FAILURE
PERICARDITIS
MYOCARDITIS
CHOLESTATIC JAUNDICE
