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Pneumonia
Danielle M Hansen, DO, MS
PNEUMONIA
 Definition: Infection of Lung Parenchyma
 1/6 of All Deaths in USA

Most Common Infectious Cause of Death
Pneumonia Defense Mechanisms
Defense Mechanism
Cough Reflex
Things that Impair the
Defense Mechanism
Anesthesia
Neuromuscular Disorder
Coma
Mucociliary Apparatus
Cigarette Smoke
Corrosive Gases
Phagocytic Action of Alveolar
Macrophages
Alcohol
Secretion Clearance
Cystic Fibrosis
Innate, Humoral, Cell-Mediated
Immunity
Tobacco
Classification of Pneumonia
Community-Acquired, Acute
S. pneumoniae
H. influnzae
M. catarrhalis
Staph aureus
Enterobacteriacea
Community-Acquired, Atypical
Mycoplasma
Chlamydia
Legionella
Coxiella burnetti
Viruses
Nosocomial
Enterobacteriacea
Pseudomonas
S. Aureus (MRSA)
Aspiration
Anaerobic oral flora
Aerobic bacteria
Immunocompromised Host
CMV
PCP
MAC
Aspergillosis
Candidiasis
Classification of Pneumonia
Community-Acquired, Acute
S. pneumoniae
H. influnzae
M. catarrhalis
Staph aureus
Enterobacteriacea
Community-Acquired, Atypical
Mycoplasma
Chlamydia
Legionella
Coxiella burnetti
Viruses
Nosocomial
Enterobacteriacea
Pseudomonas
S. Aureus (MRSA)
Aspiration
Anaerobic oral flora
Aerobic bacteria
Chronic
Nocardia
Actinomyces
Granulomatous
Necrotizing and Abscess
Anaerobic
Staph aureus
Klebsiella
Strep pyogenes
Immunocompromised Host
CMV
PCP
MAC
Aspergillosis
Candidiasis
CAP - ACUTE
 Clinical Presentation:
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High Fever, Shaking Chills
Cough Productive of Mucopurulent Sputum
Pleuritic Chest Pain, Pleural Friction Rub
 Clinical Course:
Marked Improvement
in Symptoms after 48-72
Hours of Antibiotics
 <10% Mortality

Pathogenesis of Acute CAP
Invasion of Lung
Parenchyma
Normal
Alveoli
Inflammatory Exudate
Fills Alveoli
Consolidation
Pneumonia
Morphology of Acute CAP
 Bronchopneumonia
 Patchy Consolidation
 Lobar Pneumonia
 Fibrinosuppurative
Consolidation of Entire
Lobe or Large Portion
of Lobe
Pathogens of Acute CAP
 S. pneumoniae
 H. influnzae
 M. catarrhalis
 Staph aureus
 Enterobacteriacea
<10 epi’s/lpf
Streptococcus Pneumoniae
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= Pneumococcus
Most Common Cause of CAP Up to 50%
Colored Sputum
False Positive Sputum Cultures
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Normal Flora of Nasopharynx
Blood Cultures More Specific

30% Mortality if Bacteremic
 Treatment:
 Fluoroquinolones, Amoxil, PCN, Macrolides
 Some Resistant Strains
 Immunization
Staphylococcus Aureus
 Follows Influenza or ABX
 Colored Sputum
 Treatment:
 1st Generation Cephalosporin or PCN
 Vanco (if MRSA suspected)
 High Incidence of Complications
 Lung Abscess
 Empyema
 Glomerulonephritis
 Pericarditis
Enteric Gram-Negatives
Klebsiella, E. Coli, Proteus
 Most Frequent Cause of GN Pneumonia
 Debilitated and Malnourished
Chronic Alcoholics
 Sputum
 Treatment:
 Fluoroquinolones
 Pip+Tazo
ECF
Haemophilus Influenzae
 Gram-Negative Coccobacilli
 Encapsulated Form > Unencapsulated Form

Infections from Unencapsulated Forms
 Elderly, COPD
 Bronchopneumonia
 Treatment:

Ampicillin, Augmentin, Doxycycline,
3rd Generation Cephalosporins,
Fluoroquinolones, TMP/SMX
 Immunization for b Serotype
Moraxella Catarrhalis
 Gram Negative Cocci
 COPD, DM, CA
 Treatment:
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Doxycycline
Macrolide
Cephalosporin
Augmentin
CAP - ATYPICAL
 Clinical Presentation:

Symptoms out of Proportion to PE Findings
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Less Sputum
No Consolidation
Moderate WBCs
 Clinical Course:
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Sporadic Form < 1% Mortality
Interstitial Form has been Epidemic
Secondary Bacterial Infections
Pathogenesis of Atypical CAP
Organism Attaches to Upper
Respiratory Tract Epithelium
Cell Necrosis and Inflammatory
Response
Interstitial Inflammation
Morphology of Atypical CAP
 Patchy or Lobar
 No Pleural Involvement
Pathogens of Atypical CAP
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Mycoplasma
Chlamydia Pneumoniae
Legionella
Coxiella Burnetti (Q Fever)
Viruses:
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Influenza
Respiratory Syncytial Virus
Adenovirus
Rhinovirus
Rubeola
Varicella
Mycoplasma Pneumoniae
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Most Common Cause of Atypical CAP
Children and Young Adults
Sporadic or Epidemic
2-3 Week Incubation Period
Extrapulmonary Manifestations:
 Hemolytic Anemia
 Splenomegaly
 Erythema Multiforme
 Arthritis
 Myringitis Bullosa
 Pharyngitis
 Tonsillitis
 Mental Status Change
 Diagnosis: Complement Fixation to Measure IgM Antibody
 Treatment: Macrolide, Doxycycline
 Up to 6 Months Recovery
Legionella Pneumophila
 Artificial Aquatic Environments
 Transmitted by Inhalation or Aspiration
 Associated Diarrhea, Neuro Sx

Na and Phos
 Fatality Rate 50% in Immunosuppressed
 Diagnosis:
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Antigen in Urine
+Fluorescent Antibody Test on Sputum
Culture is Gold Standard
 Treatment: Macrolides or Quinolones
Chlamydophilia Pneumoniae
 Young Adults
 Laryngitis precedes Pneumonia by 2-3 Wks
 Diagnosis:
 IgM titer > 1:16
 Positive Culture
 PCR
 4x Increase in IgG
 Treatment: x 3 Wks
 Doxycycline
 Macrolides
Influenza Virus
 8 Helices of Single-Stranded RNA Encodes Nucleoprotein
Determines Type (A, B, C)
Lipid Bilayer = Envelope Containing Hemagglutinin and
Neuraminidase
 Determines Subtype (H1-3, N1-2)
Type A is Major Cause of Human Infections
 Epidemics
 Antigenic Drift (Mutations of Hemagglutinin and
Neuraminidase)
 Pandemics
 Antigenic Shift (Hemagglutinin and Neuraminidase
Replaced with Animal Virus RNA Segments)
Type B, C Infect Children
Treatment: Oseltamir (Tamiflu) and Zanamivir (Relenza)
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Severe Acute Respiratory Syndrome
 Pandemic of 2002 started in China
 > 8,000 Cases
 774 Deaths
 Coronavirus from Animals
 Diffuse Alveolar Damage, Multinucleated Giant Cells
 Clinical Presentation:
 Incubation Period 2-10 Days
 Dry Cough, Malaise, Myalgias, Fever, Chills
 Clinical Course:
 1/3 Resolve
 2/3 Progress to SOB, Tachypnea, Pleurisy
 10% Mortality
NOSOCOMIAL PNEUMONIA
 Types:
 Hospital Acquired (HAP)
>48 hours after Admission
 Ventilator Associated (VAP)
 >48 hours after Intubation
 Healthcare Associated (HCAP)
 Hospitalized >2 Days within 90 Days
 Resident of ECF
 IV ABX, Chemo, Wound Care within 30 Days
 Hemodialysis
 Pathogens:
 GNR (Enterobacteriaceae and Pseudomonas)
 Staph Aureus (MRSA)
 Life-Threatening
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Pseudomonas Aeruginosa
 Risk Factors:
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ICU
Steroids
ABX > 7 Days in Past Month
CHF
Malnutrition
Cystic Fibrosis
 Extrapulmonary Spread Hematogenously
 Treat with 2 Antipseudomonals
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Aminoglycoside + Antipseudomonal Beta-Lactam
ASPIRATION PNEUMONIA
 Abnormal Gag and/or
Swallowing Reflex
 Pneumonia from Oral
Flora

Aerobes > Anaerobes
 Chemical Pneumonitits
from Gastric Acid
 Necrotizing, Fulminant
Course
 Lung Abscess or
Empyema are Common
Complications
 Treatment: Augmentin
or Clindamycin
CHRONIC PNEUMONIA
 Localized Lesion with/without Nodes
 Immunocompetent
 Granulomatous Inflammation
 Fungal
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Histoplasma Capsulatum
Blastomyces Dermatitidis
Coccidioides Immitis
Histoplasmosis
 Ohio and Mississippi Rivers and
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Caribbean
Inhalation of Bird and Bat
Droppings Contaminated with
Spores
Primary Stage:
 Self-Limited or Latent
 Coin Lesion on Chest X-Ray
Secondary Stage:
 Chronic, Progressive
 Cough, Fever, Night Sweats
 Lung Apices
Extrapulmonary Manifestations:
 Adrenals
 Liver
 Meninges
No Treatment Indicated unless
Disseminated
Blastomycosis
 Central and SE U.S., Canada, Mexico, Africa, India,
and the Middle East
 Male : Female 10:1
 Clinical Presentation:
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Abrupt Onset
Productive Cough
Headache
Chest Pain, Abdominal Pain
Weight Loss, Anorexia
Fever, Chills, Night Sweats
 May Resolve, Persist, or Progress to Chronic
 Treatment: Itraconazole
Coccidioidomycosis
 SW and Far West U.S. and
Mexico Deserts
 >80% of Population in Endemic
Areas are Infected
 Only 10% are Symptomatic
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Lung Lesions
Fever
Cough
Pleuritic Pain
Erythema Nodosum or
Multiforme
 Treat if Hemoptysis or
Abnormal CXR with
Fluconazole or Amphotericin B
IDSA/ATS CAP Guidelines 2007
Pneumonia Severity Index – Step 1
Lab & x-ray
PE
PMHx
Demographics
Pneumonia Severity Index – Step 2
Risk Factors
Points
Age (M)
Years
Age (F)
Years-10
ECF
10
Active Neoplasm
30
Chronic Liver Dz
20
CHF
10
Cerebrovascular Dz
10
CKD
10
Altered Mental Status
20
Resp > 30
20
SBP < 90
20
Temp < 35 or > 40
15
Pulse > 125
10
pH < 7.35
30
BUN > 30
20
Na < 130
20
Glucose > 250
10
Hematocrit < 30
10
PaO2 < 60
10
Pleural Effusion
10
Pneumonia Severity Index – Step 3
Class
Points
I
Mortality
Treatment
0.1
Outpatient
II
< 70
0.6
Outpatient
III
71-90
2.8
Observation
IV
91-130
8.2
Inpatient
V
> 130
29.2
Inpatient
CURB-65
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Confusion (disorientation to person, place, or time)
Urea (blood urea nitrogen) >7 mmol/L (20 mg/dL)
Respiratory rate >30 breaths/minute
Blood pressure (systolic <90 or diastolic <60)
Age >65 years
Score
0-1
2
>3
Mortality
0.7-2.1
Treatment
Outpatient
9.2
>14.5
Inpatient
ICU
Indications for Etiology Testing
Empiric Outpatient Treatment
 Healthy and No ABX within 3 months:
 Macrolide
Or
 Doxycycline
 Comorbidities (chronic heart, lung, liver or renal
disease; diabetes mellitus; alcoholism; malignancies;
asplenia; immunosuppressing conditions or use of
immunosuppressing drugs) or ABX within 3 months
Fluoroquinolone
Or
 B-Lactam Plus Macrolide
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 For Macrolide-Resistant Streptococcus pneumoniae
 Fluoroquinolone
Or
 B-Lactam Plus Macrolide
Empiric Inpatient Treatment
 Non-ICU:
 Fluoroquinolone
Or
 B-Lactam
Plus
Macrolide
 ICU:
 B-Lactam (cefotaxime,
ceftriaxone, or
ampicillin-sulbactam)
Plus
Azithromycin
Or
Fluoroquinolone
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For Penicillin-Allergy:
 Fluoroquinolone and
Aztreonam
Special Circumstances
 For Pseudomonas:
Piperacillin-tazobactam, cefepime, imipenem, or
meropenem
Plus
 Ciprofloxacin or Levofloxacin
Or
 Aminoglycoside and Azithromycin
Or
 Aminoglycoside and Fluoroquinolone
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For Penicillin-Allergy, Substitute Aztreonam for B-Lactam
 For CA-MRSA:
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Vancomycin or Linezolid
Extras
 First Dose of ABX in ER
 IV to PO when:
 Hemodynamically Stable
 Clinically Improving
 Able to Ingest RX
 Functioning GI Tract
 Length of Treatment:
 Minimum of 5 days
 Afebrile for 48–72 hours
 Clinically Stable
 Immunizations:
 Influenza
 Pneumococcal
 Smoking Cessation