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Pneumonia Dr. Meg-angela Christi Amores Definition • infection of the pulmonary parenchyma • often misdiagnosed, mistreated, and underestimated • community-acquired pneumonia (CAP) or health care–associated pneumonia (HCAP) – hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) Pathophysiology • proliferation of microbial pathogens at the alveolar level and the host's response • aspiration from the oropharynx • inhaled as contaminated droplets • hematogenous spread Pathophysiology • Host defense: – hairs and turbinates of the nares – branching architecture of the tracheobronchial tree traps particles on the airway lining – gag reflex and the cough mechanism – normal flora adhering to mucosal cells of the oropharynx – resident alveolar macrophages • host inflammatory response, rather than the proliferation of microorganisms, triggers the clinical syndrome of pneumonia • inflammatory mediators, such as interleukin (IL) 1 and tumor necrosis factor (TNF), results in fever Pathology • Edema – presence of a proteinaceous exudate • Red hepatization – erythrocytes in the cellular intraalveolar exudate • Gray hepatization – neutrophil is the predominant cell, fibrin deposition is abundant, and bacteria have disappeared • Resolution Etiology • Typical: – S. pneumoniae, Haemophilus influenzae, S. aureus and gram-negative bacilli such as Klebsiella pneumoniae and Pseudomonas aeruginosa • Atypical: – Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella spp. as well as respiratory viruses such as influenza viruses, adenoviruses, and respiratory syncytial viruses (RSVs Risk factors • CAP:alcoholism, asthma, immunosuppression, institutionalization, and an age of 70 years versus 60–69 years Clinical Manifestations • frequently febrile, with a tachycardic response, and may have chills and/or sweats and cough • pleura is involved, the patient may experience pleuritic chest pain • fatigue, headache, myalgias, and arthralgias • Crackles, bronchial breath sounds Management • Diagnosis – CLINICAL – XRAY – suggests etiology • pneumatoceles suggest infection with S. Aureus • upper-lobe cavitating lesion suggests tuberculosis – Sputum Gram stain and culture – Blood culture Management • Treatment : CAP – Site of Care • Home • Hospital – Antibiotics • Empiric • Previously healthy and no antibiotics in past 3 months • A macrolide [clarithromycin (500 mg PO bid) or azithromycin (500 mg PO once, then 250 mg od)] or Doxycycline (100 mg PO bid)