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Pneumonia
Tammy Wichman MD
Assistant Professor of Medicine
Pulmonary-Critical Care
Creighton University Medical Center
 The
#1 cause of death in the United States
from infectious disease is:
 A. Meningitis
 B. Pneumonia
 C. Gastroenteritis
 D. Urinary Tract Infections
 E. Toe fungus
Pneumonia
 Most
deadly infectious disease in the U.S.
 6th leading cause of death
 Average mortality 14%
 $20 billion/year in U.S.1
 Community acquired pneumonia affects
~4 million patients and results in 10 million
physician visits, 1 million hospitalizations,
and >50,000 deaths annually
1 File Chest 2004; 125:1888-1901
Defense Mechanisms

80% of cells lining central airways are ciliated,
pseudostratified,
columnar epithelial cells
 Each ciliated cell contains
about 200 cilia that beat in
coordinated waves about
1000x/minute
 So the lower respiratory tract
is normally sterile
Pneumonia Pathophysiology

Microbial pathogens enter the lung by:

Aspiration of organisms from oropharynx



More common in patients with impaired level of consciousness:
alcoholics, IVDA, seizures, stroke, anesthesia, swallowing disorders,
NG tubes, ETT
Gram positive and anaerobes: Strep pneumo, H flu, Mycoplasma,
Moraxella, Actinomyces
Gram negatives:
• more likely with hospitalization, debility, alcoholism, DM, and advanced age
• Source may be stomach which can become colonized with these organisms
with use of H2blockers

Inhalation of Infectious Aerosols


Hematogenous Dissemination



Influenza, Legionella, Psittacosis, Histoplasmosis, TB
Staph aureus
Fusobacterium infections of the retropharyngeal tissues: Lemierre’s
syndrome
Direct inoculation and Contiguous Spread

Tracheal intubation, stab wounds
At the left the alveoli are filled with a neutrophilic exudate that
corresponds to the areas of consolidation seen grossly with the
bronchopneumonia. This contrasts with the aerated lung on the right
of this photomicrograph.
What is pneumonia?

Infection of the lower respiratory tract

Which of the following is NOT a symptom of pneumonia?
A. Cough
B. Shortness of breath
C. Fever
D. Abdominal pain
E. Chest tightness
F. Confusion
G. Hot, erythematous 1st toe





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
Clinical presentation

Pneumonia should be considered in any patient
who has newly acquired respiratory symptoms:
cough, sputum production, dyspnea, especially if
accompanied by fever and abnormal breath
sounds and crackles
 In elderly or immunocompromised, pneumonia
may present with confusion, failure to thrive,
worsening of underlying chronic illness, falling
Pneumonia Symptoms
 “Typical”
pneumonia: sudden onset of
fever, cough productive of purulent
sputum, pleuritic chest pain
 “Atypical”: gradual onset, dry cough,
prominence of extrapulmonary symptoms:
headache, myalgias, fatigue, sore throat,
nausea, vomiting
 Includes diverse entities and has limited
clinical value
Pneumonia
 Which
of the following is NOT a sign of
pneumonia?
 A. Dullness to percussion
 B. Tracheal deviation
 C. Bronchial breath sounds
 D. Egophany, increased tactile fremitus
 E. Late inspiratory crackles
Pneumonia Diagnosis

Radiography: CXR




confirm the presence and location of the pulmonary
infiltrate
assess the extent of the infection
detect pleural involvement, pulmonary cavitation, or
lymphadenopathy
May be normal when the patient is unable to
mount an inflammatory response
(immunocompromised) or is in the early stage of
an infiltrative process (hematogenous S. aureus
pneumonia)





A 64 year old female with DM and HTN is
admitted to 4600 with RLL pneumonia. T 39.3
HR 118 R 28 BP 110/60 Sats 92% on 4 L NC.
She has crackles in her RLL. You should:
A. Order a sputum gram stain and culture. Wait
for the results before ordering antibiotics.
B. Order a sputum gram stain and culture.
Empirically start Ceftriaxone and Azithromycin.
C. Order a sputum gram stain and culture.
Empirically start Vancomycin and Zosyn.
D. Start Ceftriaxone and Azithromycin.
Pneumonia Diagnosis


Sputum gram stain and culture:
Controversial: no rapid, easily done, accurate,
cost-effective method to allow immediate results
 Expectorated sputum is frequently contaminated
by oropharyngeal flora




Low power magnification to assess squamous
epithelial cells
Culture and sensitivity are only accurate if there are
<10 epi’s per low power field
Best results if the specimen contains >25 WBCs per
LPF
If patient has a productive cough, send sputum
for gram stain and culture: could be of use in
directing treatment if patient fails to respond to
empiric therapy








Same patient. What other tests do you want?
Blood cultures.
Urine cultures.
Urine for Legionella antigen.
Urine for pneumococcal antigen.
Urine for chlamydia antigen.
HIV test.
Bronchoscopy with culture of respiratory
secretions.
Pneumonia Diagnosis

Blood cultures are positive in 11% of patients
with CAP, more commonly in patients with
severe illness
 Urine antigen assays for L pneumophila
serogroup 1 can be done easily and rapidly.
Sensitivity 70% Specificity >90%
 Assay for pneumococcal urinary antigen :
sensitivity 50-80% and specificity 90%
 Responsible pathogen is not defined in as many
as 50% of patients




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


In February, a 55yo F with rheumatoid arthritis
and chronic bronchitis presents to the office with
a cough productive of green sputum, a fever and
generalized myalgias x 2 days. T 101.6 HR 110
R 24 BP 125/80. On exam, she has crackles in
her LLL and dullness to percussion. You should
A. Give her a presciption for Azithromycin
B. Check her O2 sats and order a CXR
C. Check her for Influenzae A
D. Order a CBC, BMP, LFTs
E. A, B, and C
F. B, C, and D
G. B and C
Pneumonia Diagnosis

Routine laboratory tests: CBC, electrolytes,
hepatic enzymes) are of little value in
determining the etiology of pneumonia, but may
have prognostic significance and influence the
decision to hospitalization. Should be
considered in patients who may need
hospitalization, >65 yr, or with coexisting illness.
 All admitted patients should have oxygen
saturation assessed by oximetry
Pneumonia Diagnosis
 Invasive
testing: percutaneous
transthoracic needle aspiration or
bronchoscopy are not routinely
recommended.

May be helpful in:
• immunocompromised hosts
• suspected tuberculosis in the absence of
productive cough
• non-resolving pneumonia
• pneumonia associated with suspected neoplasm
or foreign body
• suspected Pneumocystis carinii






Which of the following findings would indicate an
increased risk of death in patients with
community-acquired pneumonia?
A. BUN <8 mmol/L
B. Diastolic blood pressure >70 mm Hg
C. Respiratory rate >30 breaths per minute
D. Unilobar lung infiltrate
E. PO2 = 65 mm Hg while breathing room air
 Pneumonia
 Severity
 Index
Pneumonia
Severity
Index
Site of Treatment
 Class
I or II: Outpatient treatment
 Class III: Potential outpatient or brief
inpatient observation
 Class IV and V: Inpatient
 Physician decision making: medical and
psychosocial comorbidities, ability to take
po, substance abuse, ability to do ADLs
CURB 65
 Confusion
 Urea
level (>19)
 Respiratory rate (>30)
 Blood Pressure SBP< 90 or DBP <60
 Age
 Excellent
indicator for mortality
 All
of the following are reasons to admit a
patient with pneumonia to the ICU
EXCEPT:
 A. Need for mechanical ventilation
 B. Shock requiring pressors
 C. High WBC count with bandemia
 D. Decreased urine output
ICU Admission

Minor Criteria


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

RR>30/min
PaO2/FiO2 <250
Multilobar pneumonia
Systolic BP <90
Diastolic BP <60
Major Criteria




Need for mechanical ventilation
Increase in the size of infiltrates by >50% within 48hrs
Septic shock
Acute renal failure (uop <80ml in 4 h or serum
Cr>2.0)

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
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
In April, a 45yo F with HTN presents to the office
with fever x 3 days and a cough. T 102.5 HR 95
R 22 BP 130/80 Sats 94% on RA. CXR shows
RUL infiltrate.
A. You should check a CBC, BMP, and LFTs
and consider admitting her based on the results
B. You should admit her for 24 hour observation
C. You should check for Influenzae A
D. The most likely organisms are Strep
pneumonia, Mycoplasma, Chlamydia, and H. flu
and she should be treated with Azithromycin or
Doxycycline
Group I: Outpatients
No cardiopulmonary disease
No modifying factors
Organism:
Streptococcus pneumonia
Mycoplasma pneumonia
Chlamydia pneumonia
Hemophilus influenzae
Miscellaneous
Legionella
Mycobacterium
Fungi
Treatment:
Advanced generation
macrolide(azithromycin or
clarithromycin)
OR doxycycline
 All
of the following have been identified as
risk factors for community-acquired
Legionella pneumonia EXCEPT:
 A. Cigarette smoking
 B. Chronic pulmonary disease
 C. Acquired immunodeficiency syndrome
 D. Advanced age
 E. Chronic illness, including diabetes, liver
disease, and renal disease





A 68 yo M with DM, HTN, CAD, is admitted to
the hospital with community acquired
pneumonia. He is recently retired from the
insurance industry and has been caring for his
grandson several mornings a week. He doesn’t
smoke but he does drink 2-3 cocktails every
night. T 101.6 HR 85 R 22 BP 95/60 Sats 92%
on 3L NC. CXR shows an infiltrate in the lingula.
He is at risk for
A. Penicillin resistant pneumococus
B. Pseudomonas
C. MRSA
D. Enteric gram negatives
Modifying Factors that Increase the
Risk of infection with Specific
Pathogens
Penicillin-resistant pneumococci




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
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
Enteric gram negatives





Age >65
B-lactam therapy within the past 3 months
Alcoholism
Immune suppressive illness (including tx with corticosteroids)
Multiple medical comorbidities: DM, CRI, CHF, CAD, malignancy,
chronic liver disease
Exposure to a child in a day care center
Residence in a nursing home
Underlying cardiopulmonary disease
Multiple medical comorbidities
Recent antibiotic therapy
Pseudomonas aeruginosa




Structural lung disease (bronchiectasis)
Corticosteroid therapy (>10mg prednisone/day)
Broad spectrum antibiotic therapy for > 7 days in past month
Malnutrition
 The
mortality rate for patients with nursing
home-acquired pneumonia is:
 A. 10%
 B. 20%
 C. 40%
 D. 60%
 E. 80%
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Group II: Outpatient, with
cardiopulmonary disease, and/or
other modifying factors
Organism:
Strep pneumonia
Mycoplasma
Chlamydia
Mixed infection
Hemophilus influenzae
Enteric gram-negatives
Viruses
Miscellaneous
Moraxella, Legionella,
anaerobes, TB, fungi

Therapy:
 B -lactam (oral
cefpodoxime, cefuroxime,
high-dose amoxicillin,
amoxicillin/clavulanate or
parenteral ceftriaxone
PLUS
 Macrolide or doxycycline
OR
 Antipneumococcal
fluoroquinolone
Group III: Inpatients

Organism
 Strep pneumonia
 Hemophilus influenzae
 Mycoplasma
 Chlamydia
 Mixed infection
 Enteric gram-negatives
 Aspiration
 Virus
 Miscellaneous





Therapy:
1. Intravenous B -lactam:
cefotaxime, ceftriaxone,
ampicillin/sulbactam,
high-dose amipicillin
PLUS
Intravenous or oral
macrolide or doxycycline
OR
2. Antipneumococcal
fluoroquinolone





A 45 year old female with lupus is admitted to
the ICU with community acquired pneumonia
and septic shock. She was intubated in the ER
due to hypoxemic respiratory failure. Currently,
T 102 HR 125 R 28 BP 90/60 on Dopamine.
She should be started on:
A. Vancomycin and Zosyn
B. Levofloxacin
C. Ceftriaxone and Levofloxacin
D. Doxycycline and Gentamicin
ICU Patients

Organisms:
 Strep pneumonia
 Legionella
 Hemophilus influenzae
 Enteric gram-negative
bacilli
 Staphylococcus aureus
 Mycoplasma
 Respiratory Viruses
 Miscellaneous






Therapy:
1. Intravenous B -lactam:
cefotaxime, ceftriaxone,
ampicillin/sulbactam,
high-dose amipicillin
PLUS either
Intravenous or oral
macrolide or doxycycline
or
Antipneumococcal
fluoroquinolone
ICU Patients with Risks for
Pseudomonas aeruginosa




1. Selected iv
antipseudomonal B -lactam
(cefepime, imipenem,
meropenem,
piperacillin/tazobactam)
PLUS iv antipseudomonal
quinolone
OR
2. Selected iv
antipseudomonal B -lactam
PLUS iv aminoglycoside PLUS
either iv macrolide or iv
nonpseudomonal
fluoroquinolone
 The
organism(s) most commonly found in
patients with nosocomial pneumonia is
(are):
 A. Aerobic Gram-negative rods
 B. Staphylococcus aureus
 C. Legionella species
 D. Streptococcus pneumoniae
 E. Haemophilus influenzae
Hospital-Acquired Pneumonia

Enteric aerobic gram
negative bacilli
 Pseudomonas
aeruginosa
 Staphylococcus aureus
 Oral anaerobes




Antipseudomonal
cephalosporin (cefepime,
ceftazidime) OR
Antipseudomonal
carbepenem OR B lactam/B -lactamase
inhibitor
PLUS
Antipseudomonal
fluoroquinolone OR
aminoglycoside
PLUS
Vancomycin or Linezolid

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


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The mechanism thought to account for most
cases of nosocomial pneumonia includes:
A. Inhalation of infected aerosols from
respiratory equipment
B. Hematogenous spread from another infected
site outside the lung
C. Spread from a contiguous infected site
D. Aspiration of pathogen-laden oropharyngeal
secretions
E. Inhalation of infected droplet nuclei from
other patients in the area
 Which
of the following has been
demonstrated to reduce the incidence of
nosocomial pneumonia?
 A. Nasogastric tubes
 B. Enteral feedings
 C. Hand washing
 D. Isolation of patients with pneumonia
 E. Antacids






Metastasis to skin and
CNS
Hyponatremia, AMS,
renal and hepatic
dysfunction
Night sweats, weight
loss
Erythema multiforme,
hemolytic anemia,
encephalitis, transverse
myelitis
Erythema nodosum
Increased risk after
Influenzae pneumonia

Staph aureus

Histoplasma

Legionella

Mycoplasma

Nocardia

TB
 The
organism most commonly associated
with life-threatening community acquired
pneumonia is:
 A. Streptococcus pneumoniae
 B. Legionella pneumophila
 C. Klebsiella pneumoniae
 D. Pseudomonas aeruginosa
 E. Staphylococcus aureus
Strep pneumonia







Encapsulated lancet shaped diplococcus
Causes up to 50% of community acquired
pneumonia
Patients present with acute onset of hard,
shaking chills and pleuritic chest pain
Usually have high WBC, however may have very
low WBC if overwhelming infection
Sputum may be rusty colored
CXR often shows lobar consolidation
If bacteremic, mortality is 30%
Drug Resistant Strep pneumonia

Prevalence continues to increase worldwide:



PCN resistant 18-22%
macrolide resistant 24-32%
Patients with high level resistance (penicillin MCI
>4mg/mL) showed an increased risk of
suppurative complications
 Most common mechanisms of resistance to
macrolides are methylation of a ribosomal target
encoded by erm gene and efflux of the
macrolides by cell membrane protein
transporter, encoded by mef gene
Predicting Antimicrobial Resistance
in Invasive Pneumococcal
Infections
Clinical Infectious Diseases 2005;40:1288-97
 3339
patients
 Risk factors for penicillin-resistance or
macrolide resistance: antibiotic use (PCN,
TMP-SMX, and azithro) in last 3 months
 Risk factors for fluoroquinolone resistance:
previous use of fluoroquinolones,
residence in a NH; nosocomial acquisition
Percentage of Pneumococcal Isolates That Were Nonsusceptible to Various Antibiotics from
Children under Two Years of Age (Panel A) and Adults 65 Years of Age or Older (Panel B) with
Invasive Disease, 1999 to 2004
Kyaw, M. H. et al. N Engl J Med 2006;354:1455-1463
Clinical Course






Target time for appropriate initiation of
antimicrobials within 4 hours of admission
Fever x 2-4 days
Leukocytosis usually resolves by Day 4
Abnormal physical findings (crackles) persist
beyond 7 d in 20-40%
CXR clears by 4 weeks in 60% patients
Delayed resolution with increasing age, multiple
coexisting illness, alcoholism, bacteremia
When to switch to oral therapy
 Oral
= iv: doxycycline, linezolid,
quinolones
 Improvement in cough and dyspnea
 Afebrile
 WBC decreasing
 Functioning GI tract
 Patient can be discharged home the same
day that clinical stability occurs and oral
therapy is initiated.
Prevention




Recommendations by CDC:
Pneumococcal vaccine: age >65 or if
chronically ill: CHF, COPD, DM, ETOH,
cirrhosis, asplenia, long-term care facilities.
Revaccinate after 5 years.
Influenzae vaccine: age >65, residents of
long-term care facilities, chronic pulmonary
or cardiovascular disease, hospitalization in
the preceding year, immunosuppression,
pregnant women in 2nd or 3rd trimester
during flu season
Patients should be counseled during
hospitalization regarding smoking cessation
Annual Incidence of Invasive Disease Caused by Penicillin-Susceptible and PenicillinNonsusceptible Pneumococci among Children under Two Years of Age, 1996 to 2004
Kyaw, M. H. et al. N Engl J Med 2006;354:1455-1463
Annual Incidence of Invasive Disease Caused by Penicillin-Nonsusceptible Pneumococci in
Persons Two Years of Age or Older, 1996 to 2004
Kyaw, M. H. et al. N Engl J Med 2006;354:1455-1463
 In
immunocompetent adults for whom the
pneumococcal vaccine is indicated, the
protection efficacy is:
 A. 0%
 B. 10%
 C. 30%
 D. 60%
 E. 80%





A 34yo F with JRA presents to the office with a
3 day history of a cough productive of yellow
sputum, fever, and myalgias. On physical exam,
she is mildly tachypneic but not in distress T 104
HR 115 R 28 BP 105/60 Saturations 94% RA.
Physical exam reveals rales in her LLL. She has
dullness to percussion at her left base and
increased tactile fremitus. The next step in her
management is:
A. Sputum gram stain
B. Chest radiograph
C. Give her a prescription for Augmentin
D. Admit her to the hospital
 What
 A.
 B.
 C.
 D.
 E.
should she be treated with?
Vancomycin and Imepenem
Keflex
Azithromycin
Ceftriaxone
Levofloxacin
 A 55yo
with CHF presents to the ER with a
1 day history of cough, fever, shaking
chills, and weakness. She is obviously
uncomfortable, with mildly increased work
of breathing. T 100.8 HR 125 R 32 BP
100/55 Saturations 86% on RA. Lungs
have crackles in her right upper lobe. She
has 1+ edema bilaterally. She is alert and
oriented.
 You
should now obtain all of the following
labs EXCEPT:
 A. CBC
 B. Electrolytes
 C. PT, PTT
 D. ABG
 E. Sputum culture
 F. Blood cultures








ABG: pH 7.36 pCO2 42 pO2 50
Na 134 K 4.3 Cl 95 HCO3 20 BUN 42 Cr 1.4
glucose 145
WBC 18.3 Hgb 10.3 Hct 32 Plt 130
She should be:
A. Given a prescription for Azithromycin and
sent home
B. Admitted to the hospital. Start Ceftriaxone
and Azithromycin after she coughs up a sputum
sample.
C. Admitted to the hospital. Start Levofloxacin
immediately
D. Admitted to the ICU and started on
mechanical ventilation
PORT Score
 Age
55-10=45
 CHF
+10
 RR
+20
 HR 124
+10
 BUN
+20
 pO2
+10
115
Class IV Mortality 8-9%

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
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
A 70yo F resident of a nursing home is evaluated in the
ER due to decreased mental status and hypothermia.
She has a history of stroke and is currently taking only
aspirin. She has been able to eat on her own and there
have been no witnessed aspirations. She has not been
treated recently with antibiotics. WBC 12 Hgb 12
Electrolytes are normal and she has mild chronic renal
insufficiency. CXR shows small interstitial infiltrate in
RLL. She receives empiric treatment for communityacquired pneumonia. Therapy for which of the following
should also be considered?
A. Pseudomonas aeruginosa
B. Anaerobic bacteria
C. Enteric gram-negative organisms
D. Aspergillus fumigatus
E. Mycobacterium tuberculosis
 A 28yo
M presents to the ER with
increasing shortness of breath and
subjective fever and chills. In the ER,
patient is in moderate respiratory distress.
T 102 HR 140 R 38 BP 85/55 Sats 80%
on RA. Lungs have rales throughout. He
has no peripheral edema. He knows his
name and knows he is in the ER but he is
unsure of the date (thinks it is 2003).
 You
should do all of the following
EXCEPT:
 A. Start IVF wide open
 B. Get an ABG
 C. Wait on ABG before starting oxygen
 D. Order a CXR
 E. Admit to the ICU






In carefully performed prospective studies on the
etiology of community-acquired pneumonia, the
organism most often identified in patients ill
enough to require hospitalization is:
A. Streptococcus pneumoniae
B. Unknown
C. Chlamydia pneumoniae
D. Mycoplasma pneumoniae
E. Haemophilus influenzae
 In
patients with bacteremic pneumonia the
organism most likely to be found is:
 A. Staphylococcus aureus
 B. Klebsiella pneumoniae
 C. Haemophilus influenzae
 D. Streptococcus pneumoniae
 E. Pseudomonas aeruginosa






A 65 yo M develops bilateral lower lobe
pneumonia and is treated as an outpatient with
amoxicillin/clavulanic acid for 72hours. Despite
this treatment, he deteriorates and is admitted to
the hospital. Within 12 hours of admission, he
develops respiratory failure requiring admission
to the ICU, intubation, and mechanical
ventilation. The organism most likely to account
for the severity of disease despite treatment with
Augmentin is:
A. Moraxella catarrhalis
B. Chlamydia pneumoniae
C. Klebsiella pneumoniae
D. Legionella pneumophila
E. Streptococcus pneumoniae
Pneumonia
 Common
infection
 Pathophysiology
 Clinical presentation
 Risk factors for mortality
 Treatment