Pneumonia

By
Dr Randula Samarasinghe
Consultant Physician
 Definition
Infection of the lung tissue distal to
the small air ways resulting in
accumulation of inflammatory
exudate in the alveolar air spaces
and clinical and radiological features
of consolidation.
 Epidemiology

Mortality rate: 5% in community acquired

pneumonia and 30% in nosocomial pneumonia

Death rates increase with comorbidities and age

Affects race and sex equally

 Aetiology
Viral
Bacterial
TB
Fungal
Modes of transmission of pathogens
1.Inhalation
2.Aspiration
3.Haematogenous
 Risk factors for pneumonia
Smoking
Alcohol abuse
Immunosuppression
Lung disease
Hospitalization
 Classification
Community acquired
Hospital acquired
Ventilator associated
Non ventilator associated
Immunocompromised
Other
Aspiration pneumonia
Pneumonia in IV drug use
 Community Acquired
Pneumonia (CAP)
Infection of the lung parenchyma in a
person who is not hospitalized

Organisms
> Typical pathogens
> Atypical pathogens
> TB
> Viruses
> Other pathogens
 Typical pathogens

Streptococcus pneumoniae
Staphylococcus aureus
Haemophilus influenzae
 Pathogens
CAP usually caused by a single
organism
Even with extensive diagnostic testing,
most investigators cannot identify a
specific etiology for CAP in 50% of
patients.
Streptococcus pneumonia is the
causative pathogen 60-70% of the
time
 Streptococcus pneumonia
Most common cause of CAP
Gram positive diplococci
Typical symptoms (e.g. malaise,
shaking chills, fever, rusty sputum,
pleuritic hest pain, cough)
Lobar infiltrate on CXR
 Atypical pathogens
Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella species.
 Atypical Pneumonia

subacute onset
non-productive cough
no focal infiltrate on CXR
Mycoplasma:
in younger patients
extra-pulmonary signs (anemia, skin
rashes), headache, sore throat)

Chlamydia:
Upper respiratory tract symptoms
Legionella
higher mortality rate
water-borne outbreaks
hyponatraemia
diarrhea
 Viruses
Influenza viruses
Varicella zoster virus
Adenovirus
SARS virus
 Viral Pneumonia
More common in children
RSV, influenza, parainfluenza

Post-influenza pneumonia (secondary

bacterial infection)
Streptococcus pneumoniae
Staphylococcus aureus
 Nosocomial Pneumonia
Hospital-acquired pneumonia (HAP)
Occurs 48 hours or more after
admission, which was not incubating at
the time of admission
Ventilator-associated pneumonia
(VAP)
Arises more than 48-72 hours after
endotracheal intubation
 Healthcare-associated
pneumonia (HCAP)
A category of pneumonia in patients with
recent close contact with the health care
system but who are not hospitalised
Pathogens in HCAP,HAP and
VAP
Staphylococcus aureus
Gram negative bacilli
 Pneumonia in Immunocompromised
Patients
Co morbidities, drugs, malignancy,
Alcoholics, HIV
Organisms range from common pathogens
to rare infections
> Pneumocystis
> CMV
> Atypical Mycobacteria
> Fungi
> Nocardia species
 Aspiration pneumonia
Due to aspiration of oropharyngeal flora
Conditions prone to aspirate
eg- conditions with low GCS, post op,
Oesophageal dysmotility
Pathogens
Enterobacteriaceae
Staphylococcus aureus
Streptococcus pneumoniae
 Other bacteria
Anaerobes
Aspiration-prone Pt, putrid sputum, dental disease
Gram negative
Klebsiella - alcoholics
Branhamella catarrhalis - sinus disease, otitis,
COPD
H. influenza
Staphylococcus aureus
IVDU, skin disease, foreign bodies (catheters,
prosthetic joints) prior viral pneumonia
 Diagnosis
Pneumonia is a clinical and
radiological diadnosis which aims to
demonstrate features of
consolidation.
 Clinical Features
Typical Symptoms
Atypical Symptoms
Classical signs of pneumonia -
consolidation
Minimal signs

Can present in sepsis, septic shock or

multiorgan dysfunction
 Investigations
To demonstrate the inflammotory
response
To demonstrate consolidation
To demonstrate organism
To identify complications
To assess ventilatory function
 CXR
Demonstrate consolidation

Presence of complications (pleural

effusion, multilobar disease)
 Infiltrate Patterns
Pattern Possible Diagnosis

Lobar S. pneumo, Kleb, H. flu,

GN
Patchy Atypicals, viral,
Legionella
Interstitial Viral, PCP, Legionella

Cavitary Anaerobes, Kleb, TB, S.

aureus, fungi
Large effusion Staph, anaerobes, Kleb
 Investigations cont....
FBC
ESR/CRP
Blood culture
Sputum studies
Serogical studies
Other relavant investigations to
detect complications
 Management
Specific broad spectrum antibiotics
empirical and ABST
guided

Supportive oxygen, IV fluids, pain

releif
 Management of Poor
Responders
Consider non-infectious illnesses
Consider less common pathogens
Consider serologic testing
Broaden antibiotic therapy
Consider bronchoscopy
 Complications
Respiratory failure
ARDS
Septicaemia
Lung abscess
Empyema
Fibrosis
 Prevention
Smoking cessation
Vaccination
Influenza, pneumococcal
Thank you