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PTG Pneumonia, Aspiration
i
BASIC INFORMATION
DEFINITION
Aspiration pneumonia is a vague term that
refers to pulmonary abnormalities following ab-
normal entry of endogenous or exogenous sub-
stances in the lower airways. It is generally
classied as:
Aspiration (chemical pneumonitis)
Primary bacterial aspiration pneumonia
Secondary bacterial infection of chemical
pneumonitis
ICD-9CM CODES
507.0 Aspiration pneumonia
EPIDEMIOLOGY &
DEMOGRAPHICS
INCIDENCE (IN U.S.):
Few reliable data
20% to 35% of all pneumonias
5% to 15% of all community-acquired pneu-
monias
PEAK INCIDENCE: Elderly patients in hospitals
or nursing homes
PREVALENCE (IN U.S.): Unknown (unreliable
data)
PREDOMINANT SEX: Males and females af-
fected equally
PREDOMINANT AGE: Elderly
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
Shortness of breath, tachypnea, cough, sputum,
fever after vomiting, or difculty swallowing
Rales, rhonchi, often diffusely throughout lung
ETIOLOGY
Complex interaction of etiologies, ranging from
chemical (often acid) pneumonitis after aspiration
of sterile gastric contents (generally not requiring
antibiotic treatment) to bacterial aspiration
COMMUNITY-ACQUIRED ASPIRATION
PNEUMONIA:
Generally results from predominantly anaero-
bic mouth bacteria (anaerobic and micro-
aerophilic streptococci, fusobacteria, gram-
positive anaerobic nonspore-forming rods),
Bacteroides species (melaninogenicus, inter-
medius, oralis, ureolyticus), Haemophilus in-
uenzae, and Streptococcus pneumoniae
Rarely caused by Bacteroides fragilis (of un-
certain validity in published studies) or
Eikenella corrodens
High-risk groups: the elderly; alcoholics; IV
drug users; patients who are obtunded;
stroke victims; and those with esophageal
disorders, seizures, poor dentition, or recent
dental manipulations.
HOSPITAL-ACQUIRED ASPIRATION
PNEUMONIA:
Often occurs among elderly patients and oth-
ers with diminished gag reex; those with
nasogastric tubes, intestinal obstruction, or
ventilator support; and especially those ex-
posed to contaminated nebulizers or unster-
ile suctioning.
High-risk groups: seriously ill hospitalized
patients (especially patients with coma, aci-
dosis, alcoholism, uremia, diabetes mellitus,
nasogastric intubation, or recent antimicro-
bial therapy, who are frequently colonized
with aerobic gram-negative rods); patients
undergoing anesthesia; those with strokes,
dementia, or swallowing disorders; the el-
derly; and those receiving antacids or H
2

blockers (but not sucralfate).
Hypoxic patients receiving concentrated O
2

have diminished ciliary activity, encouraging
aspiration.
Causative organisms:
1. Anaerobes listed above, although in many
studies gram-negative aerobes (60%) and
gram-positive aerobes (20%) predominate.
2. E. coli, P. aeruginosa, S. aureus including
MRSA, Klebsiella, Enterobacter, Serratia,
Proteus spp., H. inuenzae, S. pneu-
moniae, Legionella, and Acinetobacter
spp. (sporadic pneumonias) in two thirds
of cases.
3. Fungi, including Candida albicans, in
fewer than 1%.
Dx
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Other necrotizing or cavitary pneumonias (espe-
cially tuberculosis, gram-negative pneumonias)
See Pulmonary Tuberculosis.
WORKUP
Chest x-ray examination
Complete blood count (CBC), blood cultures
Sputum Gram stain and culture
Consideration of tracheal aspirate
LABORATORY TESTS
CBC: leukocytosis often present
Sputum Gram stain
1. Often useful when carefully prepared im-
mediately after obtaining suctioned or
expectorated specimen, examined by ex-
perienced observer.
2. Only specimens with multiple white blood
cells and rare or absent epithelial cells
should be examined.
3. Unlike nonaspiration pneumonias (e.g.,
pneumococcal), multiple organisms may
be present.
4. Long, slender rods suggest anaerobes.
5. Sputum from pneumonia caused by acid
aspiration may be devoid of organisms.
6. Cultures should be interpreted in light of
morphology of visualized organisms.
IMAGING STUDIES
Chest x-ray often reveals bilateral, diffuse,
patchy inltrates and posterior segment upper
lobes. Chemical pneumonitis typically affects
the most dependent regions of the lungs.
Aspiration pneumonia of several days or lon-
ger duration may reveal necrosis (especially
community-acquired anaerobic pneumonias)
and even cavitation with air-uid levels, indi-
cating lung abscess.
Rx
TREATMENT
NONPHARMACOLOGIC THERAPY
Airway management to prevent repeated
aspiration
Ventilatory support if necessary
ACUTE GENERAL Rx
Acute aspiration of acidic gastric contents with-
out bacteria may not require antibiotic therapy;
consult infectious disease or pulmonary expert.
Community-acquired anaerobic aspiration
pneumonia: clindamycin (600 mg IV twice
daily followed by 300 mg q6h orally). Intrave-
nous penicillin G (1 to 2 million U q4 to 6h)
can also still be used. Alternative oral agents
include: amoxicillin-clavulanate (875 mg
orally twice daily), amoxicillin plus metroni-
dazole or oral moxioxacin (400 mg orally
once daily). Do not use metronidazole alone,
as this is associated with high failure rates.
Nursing home aspirations: levooxacin
500-750 mg qd or piperacillin-tazobactam
3.375 g q6h or ceftazidime 2 g q8h /
vancomycin if MRSA suspected or known
Hospital-acquired aspiration pneumonia:
C Piperacillin-tazobactam 3.375 g IV q6h, or
cefoxitin 2 g IV q8h / vancomycin IV to
cover MRSA. Alternative agents are ceftri-
axone 1 g IV q24h plus metronidazole 500
mg IV q6h or 1 g IV q12h.
C Knowledge of resident ora in the micro-
environment of the aspiration within the
hospital is crucial to intelligent antibiotic
selection; consult infection control nurses
or hospital epidemiologist.
C Conrmed Pseudomonas pneumonia should
be treated with antipseudomonal beta-
lactam agent plus an aminoglycoside until
antimicrobial sensitivities conrm that less
toxic agents may replace the aminoglycoside.
C Do not use metronidazole alone for anaer-
obes.
DISPOSITION
Repeat chest x-ray examination in 6 to 8 wk.
REFERRAL
For consultation with infectious disease and/or
pulmonary experts for patients with respiratory
distress, hypoxia, ventilatory support, pneumonia
in more than one lobe, or necrosis or cavitation
on x-ray examination or for those not responding
to antibiotic therapy within 2 to 3 days.
SUGGESTED READINGS
available at www.expertconsult.com
RELATED CONTENT
Aspiration Pneumonia (Patient Information)
AUTHOR: GLENN G. FORT, M.D., M.P.H.
e.881.e1 Pneumonia, Aspiration
SUGGESTED READINGS
Daoud E, Guzman J: Are antibiotics indicated for the treatment of aspiration
pneumonia? Cleve Clin J Med 77(9):573, 2010.
Ott SR et al: Moxioxacin vs. ampicillin/sulbactam in aspiration pneumonia and
primary lung abscess, Infection 36:23, 2008.
Shigemitsu H, Afshar K: Aspiration pneumonias: under-diagnosed and under-
treated, Curr Opin Pulm Med 13(3):192-198, 2007.
882 Pneumonia, Bacterial PTG EBM
i
BASIC INFORMATION
DEFINITION
Bacterial pneumonia is an infection involving
the lung parenchyma.
ICD-9CM CODES
486.0 Pneumonia, acute
507.0 Pneumonia, aspiration
482.9 Pneumonia, bacterial
481 Pneumonia, pneumococcal
482.1 Pneumonia, Pseudomonas
482.4 Pneumonia, staphylococcal
482.0 Pneumonia, Klebsiella
482.2 Pneumonia, Haemophilus inuenzae
EPIDEMIOLOGY &
DEMOGRAPHICS
The incidence of community-acquired pneu-
monia (CAP) is 1 in 100 persons. CAP is the
most common infectious cause of death in
the U.S.
The incidence of health care facilityacquired
pneumonia (HCAP) is 8 cases per 1000 per-
sons annually.
Primary care physicians see an average of
10 cases of pneumonia annually.
Hospitalization rate for pneumonia is 15%
to 20%.
Most cases of pneumonia occur in the winter
and in elderly patients.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
Fever, tachypnea, chills, tachycardia, cough
Presentation varies with the cause of pneu-
monia, the patients age, and the clinical
situation:
C Patients with streptococcal pneumonia
usually present with high fever, shaking
chills, pleuritic chest pain, cough, and copi-
ous production of rusty-appearing purulent
sputum. Pleurisy and parapneumonic effu-
sions are also common. Potential complica-
tions include bacteremia, empyema, and
distant infections (e.g., meningitis).
C Mycoplasma pneumoniae: insidious onset;
headache; dry, paroxysmal cough that is
worse at night; myalgias; malaise; sore
throat; extrapulmonary manifestations
(e.g., erythema multiforme, aseptic menin-
gitis, urticaria, erythema nodosum) may be
present.
C Chlamydia pneumoniae: persistent, non-
productive cough, low-grade fever, head-
ache, sore throat.
C Legionella pneumophila: high fever, mild
cough, mental status change, myalgias,
diarrhea, respiratory failure.
C MRSA pneumonia: often preceded by in-
uenza, may present with shock and
respiratory failure.
C Elderly or immunocompromised hosts
with pneumonia may initially present
with only minimal symptoms (e.g., low-
grade fever, confusion); respiratory and
nonrespiratory symptoms are less com-
monly reported by older patients with
pneu monia.
C In general, auscultation of patients with
pneumonia reveals crackles and dimin-
ished breath sounds.
C Percussion dullness is present if the pa-
tient has pleural effusion.
C The clinical impression of pneumonia has
an overall sensitivity of 70% to 90%;
specicity ranges from 40% to 70%.
ETIOLOGY
Streptococcus pneumoniae (20% to 60% of
CAP cases)
Haemophilus inuenzae (3% to 10% of CAP
cases)
L. pneumophila (1% to 5% of adult pneumo-
nias) (2% to 8% of CAP cases)
Klebsiella, Pseudomonas, Escherichia coli
Staphylococcus aureus (3% to 5% of CAP
cases)
Atypical organisms such as M. pneumoniae,
C. pneumoniae, and L. pneumophila impli-
cated in up to 40% of cases of CAP
Pneumococcal infection responsible for 50%
to 75% of CAPs. Inuenza infection is one of
the important predisposing factors to S. pneu-
moniae and S. aureus pneumonia; gram-
negative organisms cause 80% of nosoco-
mial pneumonias
Predisposing factors:
1. Chronic obstructive pulmonary disease:
H. inuenzae, S. pneumoniae, Legionella
2. Seizures: aspiration pneumonia
3. Compromised hosts: Legionella, gram-
negative organisms
4. Alcoholism: Klebsiella, S. pneumoniae,
H. inuenzae
5. HIV: S. pneumoniae
6. IV drug addicts with right-sided bacterial
endocarditis: S. aureus
7. Older patient with comorbid diseases:
C. pneumoniae
Dx
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Exacerbation of chronic bronchitis
Pulmonary embolism or infarction
Lung neoplasm
Bronchiolitis
Sarcoidosis
Hypersensitivity pneumonitis
Pulmonary edema
Drug-induced lung injury
Viral pneumonias
Fungal pneumonias
Parasitic pneumonias
Atypical pneumonia
Tuberculosis
WORKUP
Laboratory evaluation and chest x-ray.
Table E1-329 summarizes diagnostic testing for
CAP. Useful tools for assessing severity of illness
are the CURB-65 (see following) and Pneumonia
Severity Index. Poor prognostic indicators are
hypotension (SBP 90 or DBP 60), respiratory
rate 30/min, hyperpyrexia (40 C), or hypo-
thermia (35 C). None of these indices is as
valuable as clinical judgment of the physician.
LABORATORY TESTS
Complete blood count with differential; white
blood cell count is elevated, usually with left
shift
Blood cultures (hospitalized patients only):
positive in approximately 20% of cases of
pneumococcal pneumonia
Pneumococcal urinary antigen test can be
used to detect the C-polysaccharide antigen
of S. pneumoniae. It is a useful tool in the
treatment of hospitalized adult patients with
CAP.
Direct immunouorescent examination of
sputum when suspecting Legionella (e.g.,
direct uorescent antibody stain is a highly
specic and rapid test for detecting legionel-
lae in clinical specimen) or urine Legionella
antigen test
Serologic testing for HIV in selected patients
Serum electrolytes (hyponatremia in suspected
Legionella pneumonia), BUN, creatinine
Pulse oximetry or arterial blood gases: hy-
poxemia with partial pressure of oxygen
60 mm Hg while the patient is breathing
room air, a standard criterion for hospital
admission
IMAGING STUDIES
Chest x-ray: ndings vary with the stage and
type of pneumonia and the hydration of the pa-
tient (Fig. 1-654):
Classically, pneumococcal pneumonia pre-
sents with a segmental lobe inltrate.
Diffuse inltrates on chest x-ray can be seen
with L. pneumophila, M. pneumoniae, viral
pneumonias, P. jirovecii (carinii), miliary tu-
berculosis, aspiration, aspergillosis.
An initial chest x-ray is also useful to rule out
the presence of any complications (pneumo-
thorax, empyema, abscesses).
Rx
TREATMENT
NONPHARMACOLOGIC THERAPY
Avoidance of tobacco use
Oxygen to maintain partial oxygen pressure
in arterial blood 60 mm Hg
IV hydration, correction of dehydration
Assisted ventilation in patients with signi-
cant respiratory failure
ACUTE GENERAL Rx
Initial antibiotic therapy should be based on
clinical, radiographic, and laboratory evaluation.
Macrolides (azithromycin or clarithromycin)
or levooxacin is recommended for empiric
outpatient treatment of CAP. Box E1-47 sum-
marizes empirical therapy regimens for
severe CAP. Cefotaxime or a beta-lactam/
beta-lactamase inhibitor can be added in pa-
tients with more severe presentation who
insist on outpatient therapy. Duration of
treatment ranges from 7 to 14 days. The
treatment of choice in suspected Legionella
pneumonia is either a quinolone (e.g., moxi-
oxaxin) or a macrolide (e.g., azithromycin)
antibiotic.
In the hospital setting, patients admitted to
the general ward can be treated empirically
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A
Right middle lobe infiltrate
obscures right heart border
B
Dense right middle
lobe infiltrate
FIGURE 1-654 Pneumonia, right middle lobe. A, Anteroposterior chest x-ray. B, Lateral chest x-ray. This 73-year-old man
presented with cough and yellow sputum, fever 39.3 C, tachycardia, and oxygen saturation of 93% on room air. His chest
x-ray shows classic right middle lobe pneumonia. The opacity in A obscures the right heart border, which lies immediately
adjacent. On the lateral x-ray (B), this appears as a more circumscribed density overlying the heart. (From Broder JS:
Diagnostic imaging for the emergency physician, Philadelphia, 2011, Saunders.)
with a second- or third-generation cephalo-
sporin (ceftriaxone, ceftizoxime, cefotaxime,
or cefuroxime) plus a macrolide (azithromy-
cin or clarithromycin) or doxycycline. An an-
tipseudomonal quinolone (levooxacin or
moxioxacin) can be substituted in place of
the macrolide or doxycycline.
Empiric therapy in ICU patients: IV beta-
lactam (ceftriaxone, cefotaxime, ampicillin-
sulbactam) plus an IV quinolone (levooxacin,
moxioxacin) or IV azithromycin.
In hospitalized patients at risk for P. aeruginosa
infection, empiric treatment should consist of
an antipseudomonal beta-lactam (merope-
nem, doripenem, imipenem, or piperacillin-
tazobactam) plus an aminoglycoside plus an
antipseudomonal quinolone.
In patients with suspected methicillin-
resistant S. aureus, vancomycin or linezolid
is effective.
CHRONIC Rx
Parapneumonic effusion empyema can be man-
aged with chest tube placement for drainage.
Instillation of brinolytic agents (streptokinase,
urokinase) by chest tube may be necessary in
resistant cases.
DISPOSITION
Most patients respond well to antibiotic ther-
apy. Risk factors for a poor outcome from
CAP. are summarized in Box E1-48.
Indications for hospital admission are:
1. Hypoxemia (oxygen saturation 90%
while patient is breathing room air)
2. Hemodynamic instability
3. Inability to tolerate medications
4. Active coexisting condition requiring hos-
pitalization
A criterion often used to determine hospital
admission is known as the CURB-65: Con-
fusion, BUN 19.6 mg/dl, Respiratory rate
30 breaths/min, systolic BP 90 mg Hg,
and diastolic BP 60 mm Hg, age 65. Pa-
tients are generally admitted to the hospital if
they fulll 2 or more criteria and to the ICU if
they have 3 or more criteria.
!
PEARLS &
CONSIDERATIONS
COMMENTS
Use of gastric acid suppressive therapy
(H
2
receptor antagonists, proton pump inhibi-
tors [PPIs]) has been associated with an
increased risk of CAP. It appears that PPI
therapy started within the previous 30 days is
associated with an increased risk for CAP,
whereas longer-term current use is not.
Causes of slowly resolving or nonresolving
pneumonia:
1. Difcult to treat infections: viral pneumo-
nia, Legionella, pneumococci or staphylo-
cocci with impaired host response, tuber-
culosis, fungi
2. Neoplasm: lung, lymphoma, metastasis
3. Congestive heart failure
4. Pulmonary embolism
PTG EBM Pneumonia, Bacterial
5. Immunologic or idiopathic: Wegener gran-
ulomatosis, pulmonary eosinophilic syn-
dromes, systemic lupus erythematosus
6. Drug toxicity (e.g., amiodarone)
If patients with pneumonia are not doing well,
repeat lms should be taken promptly. In
those with complete clinical recovery, it is
reasonable to wait 6 to 8 wk before repeating
the radiograph to document clearing of the
inltrate. The benet of routine radiography
after pneumonia has been questioned due to
the low 1 yr incidence of lung cancer. Oppo-
nents propose a selective approach limiting
follow-up chest x-ray to middle-aged and
older adults.
EVIDENCE
available at www.expertconsult.com
SUGGESTED READINGS
available at www.expertconsult.com
RELATED CONTENT
Bacterial Pneumonia (Patient Information)
AUTHOR: FRED F. FERRI, M.D.
e.883.e1
EVIDENCE
Abstract
[1]
Background:
Telavancin is a lipoglycopeptide bactericidal against gram-positive
pathogens.
Methods:
Two methodologically identical, double-blind studies (0015 and 0019)
were conducted involving patients with hospital-acquired pneumonia
(HAP) due to gram-positive pathogens, particularly methicillin-resis-
tant Staphylococcus aureus (MRSA). Patients were randomized 1:1 to
telavancin (10 mg/kg every 24 h) or vancomycin (1 g every 12 h) for
721 days. The primary end point was clinical response at follow-up/
test-of-cure visit.
Results:
A total of 1503 patients were randomized and received study medication
(the all-treated population). In the pooled all-treated population, cure
rates with telavancin versus vancomycin were 58.9% versus 59.5%
(95% condence interval [CI] for the difference, 5.6% to 4.3%). In the
pooled clinically evaluable population (n=654), cure rates were 82.4%
with telavancin and 80.7% with vancomycin (95% CI for the difference,
4.3% to 7.7%). Treatment with telavancin achieved higher cure rates
in patients with monomicrobial S. aureus infection and comparable cure
rates in patients with MRSA infection; in patients with mixed gram-
positive/gram-negative infections, cure rates were higher in the vanco-
mycin group. Incidence and types of adverse events were comparable
between the treatment groups. Mortality rates for telavancin-treated
versus vancomycin-treated patients were 21.5% versus 16.6% (95% CI
for the difference, 0.7% to 10.6%) for study 0015 and 18.5% versus
20.6% (95% CI for the difference, 7.8% to 3.5%) for study 0019. In-
creases in serum creatinine level were more common in the telavancin
group (16% vs 10%).
Conclusions:
The primary end point of the studies was met, indicating that telavancin
is noninferior to vancomycin on the basis of clinical response in the
treatment of HAP due to gram-positive pathogens.
A
Evidence-Based Reference
1. Rubinstein E et al for the ATTAIN Study Group: Telavancin versus vancomycin
for hospital-acquired pneumonia due to Gram-positive pathogens, Clin Infect
Dis 52:31-40, 2011.
A
Pneumonia, Bacterial
SUGGESTED READINGS
Aujesky D et al: Prospective comparison of three validated prediction rules for
prognosis in community-acquired pneumonia, Am J Med 118:384-392, 2005.
Bruns AHW et al: Patterns of resolution of chest radiograph abnormalities in adults
hospitalized with severe community-acquired pneumonia, Clin Infect Dis
45:983, 2007.
Carratala J et al: Outpatient care compared with hospitalization for community-
acquired pneumonia, Ann Intern Med 142:165, 2005.
Davidson R et al: Resistance to levooxacin and failure of treatment of pneumo-
coccal pneumonia, N Engl J Med 346:747, 2002.
Halm EA, Teirstein AS: Management of community-acquired pneumonia, N Engl J
Med 347:2039, 2002.
Sarkar M et al: Proton-pump inhibitor use and the risk for community-acquired
pneumonia, Ann Intern Med 149:391-398, 2008.
Sord R et al: Current and potential usefulness of pneumococcal urinary antigen
detection in hospitalized patients with community-acquired pneumonia to
guide antimicrobial therapy, Arch Intern Med 171(2):166-172, 2011.
Tang KL et al: Incidence, correlates, and chest radiographic yield of new lung
cancer diagnosis in 3398 patients with pneumonia, Arch Intern Med 171:1193,
2011.
Thibodeau K, Viera AJ: Atypical pathogens and challenges in community-acquired
pneumonia, Am Fam Physician 69:1699, 2004.
Watkins RR, Lemonovich TL: Diagnosis and management of community-acquired
pneumonia in adults, Am Fam Physician 83(11):1299-1306, 2011.
e.883.e2
Pneumonia, Bacterial
Test Sensitivity Specicity Comment
Chest radiograph 65%-85% 85%-95% CT is more sensitive to inltrates. Recommended for all patients.
Computed tomography Gold standard Not infection specic Should not be done routinely but helpful to identify cavitation and
loculated pleural uid. Recommended in the evaluation of non-
responding patients.
Blood cultures 10%-20% High when positive Usually shows pneumococcus (in 50%-80% of positive samples)
and denes antibiotic susceptibility. Recommended in patients
with severe CAP, particularly if not on antibiotic therapy at the
time of testing.
Sputum Gram stain 40%-100% depend-
ing on criteria
0%-100% depending on
criteria
Can correlate with sputum culture to dene predominant organ-
ism and can be used to identify unsuspected pathogens. Rec-
ommended if sputum culture is obtained. May not be able to
narrow empirical therapy choices.
Sputum culture Use if suspect drug-resistant or unusual pathogen, but positive
result cannot separate colonization from infection. Obtain via
tracheal aspirate in all intubated patients.
Oximetry or arterial blood gas Both dene severity of infection, need for oxygen; if hypercarbia
is suspected, a blood gas sample is needed. Recommended in
severe CAP.
Serologic testing for Legionella, Chla-
mydia pneumoniae, Mycobacterium
pneumoniae, viruses
Accurate, but usually requires acute and convalescent titers col-
lected 4-6 wk apart. Not routinely recommended.
Legionella urinary antigen 50%-80% Specic to serogroup 1, but the best acute diagnostic test for
Legionella.
Pneumococcal urinary antigen 70%-100% 80% False positives if recent pneumococcal infection. Can increase
sensitivity with concentrated urine.
Serum procalcitonin Not a routine test, but if done, should be measured with the
highly sensitive Kryptor assay. May help guide duration of ther-
apy and need for ICU admission.
TABLE E1-329 Diagnostic Testing for Community-Acquired Pneumonia (CAP)
From Vincent JL et al: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders
No Pseudomonal Risk Factors
Selected -lactam (cefotaxime, ceftriaxone)
plus
Intravenously administered macrolide or quinolone (moxioxacin or levooxacin*)
Pseudomonal Risk Factors Present
Selected antipseudomonal -lactam (cefepime, piperacillin/tazobactam, imipenem,
meropenem)
plus
Ciprooxacin or levooxacin*
or
Selected antipseudomonal -lactam
plus
Aminoglycoside
plus
Intravenously administered macrolide or antipneumococcal quinolone (moxioxacin or
levooxacin*)
BOX E1-47 Empirical Therapy Regimens for Severe Community-
Acquired Pneumonia
*For patients with normal renal function, the recommended dose of levooxacin is 750 mg daily. Note: Al-
though routine MRSA coverage is not recommended for all severe community-acquired pneumonia, consider
CA-MRSA, especially after inuenza and with bilateral necrotizing pneumonia, and if suspected, treat by adding
either linezolid or the combination of vancomycin and clindamycin.
From Vincent JL et al: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders.
e.883.e3 Pneumonia, Bacterial
Patient-Related Factors
Male sex
Absence of pleuritic chest pain
Nonclassic clinical presentation
Neoplastic illness
Neurologic illness
Age >65 years
Family history of severe pneumonia or death from sepsis
Abnormal Physical Findings
Respiratory rate >30 breaths/min on admission
Systolic (<90 mm Hg) or diastolic (<60 mm Hg) hypotension
Tachycardia (>125 beats/min)
High fever (>40 C) or afebrile
Confusion
Laboratory Abnormalities
Blood urea nitrogen >19.6 mg/dl
Leukocytosis or leukopenia (<4000/mm
3
)
Multilobar radiographic abnormalities
Rapidly progressive radiographic abnormalities during therapy
Bacteremia
Hyponatremia (<130 mmol/L)
Multiple organ failure
Respiratory failure
Hypoalbuminemia
Thrombocytopenia (<100,000/mm
3
)
Arterial pH <7.35
Pleural effusion
Pathogen-Related Factors
High-risk organisms:
Type III pneumococcus, Staphylococcus aureus, gram-negative bacilli (including
Pseudomonas aeruginosa), aspiration organisms, severe acute respiratory syndrome
Possibly high levels of penicillin resistance (minimal inhibitory concentration of at least
4 mg/L) in pneumococcus
Therapy-Related Factors
Delay in initial antibiotic therapy (more than 4-6 hours)
Initial therapy with inappropriate antibiotic therapy
Failure to have a clinical response to empirical therapy within 72 hours
BOX E1-48 Risk Factors for a Poor Outcome from Community-Acquired
Pneumonia
From Vincent JL et al: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders.
884 Pneumonia, Mycoplasma PTG
i
BASIC INFORMATION
DEFINITION
Mycoplasma pneumonia is an infection of the
lung parenchyma caused by a small bacterium,
Mycoplasma pneumoniae.
SYNONYMS
Primary atypical pneumonia
Eatons pneumonia
Walking pneumonia
ICD-9CM CODES
483 Mycoplasma pneumonia
EPIDEMIOLOGY &
DEMOGRAPHICS
INCIDENCE (IN U.S.):
It is a frequent cause of community-acquired
pneumonia. CDC estimates 2 million cases a
yr with 100,000 pneumonia-related hospitali-
zations.
Many cases probably resolve without coming
to medical attention.
Incidence is estimated at one case per 1000
persons annually.
Incidence is estimated to at least triple every
(approximately) 5 yr during epidemics.
PEAK INCIDENCE:
Some increased incidence in fall to early
winter
Seems more prevalent in temperate climates
PREVALENCE (IN U.S.):
Estimated to be present in one in every ve
patients hospitalized for pneumonia (gener-
ally a self-limited disease, so its true preva-
lence is unknown)
Estimated to cause 7% of all cases of pneu-
monia and approximately half the cases in
those aged 5 to 20 yr
PREDOMINANT SEX: Equal distribution
PREDOMINANT AGE:
Most commonly affected: school-age chil-
dren and young adults (ages 5 to 20 yr)
Occurs in older adults as well, especially with
household exposure to a young child
More severe infections in affected elderly
patients
GENETICS: Familial disposition:
None known
May be more severe in patients with sickle
cell anemia
Neonatal infection: severe respiratory distress,
sometimes requiring intubation, attributed to
this disease in infants.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
Nonexudative pharyngitis (common)
Headache, otalgia common
Fever may be mild or not present
Rhonchi or rales without evidence of consoli-
dation (common) in lower lung zones
Associated with bullous myringitis (nonspe-
cic nding; perhaps no more frequently than
in other pneumonias)
Skin rashes in up to one fourth of patients
1. Morbilliform
2. Urticaria
3. Erythema nodosum (unusual)
4. Erythema multiforme (unusual)
5. Stevens-Johnson syndrome (rare)
Muscle tenderness (50% of the patients)
On examination (and conrmed with testing):
1. Mononeuritis or polyneuritis
2. Transverse myelitis
3. Cranial nerve palsies
4. Meningoencephalitis
Lymphadenopathy and splenomegaly
Conjunctivitis
Table 1-330 summarizes the clinical mani-
festations of Mycoplasma pneumoniae.
ETIOLOGY
Infection is spread person-to-person via respi-
ratory droplets or secretions with an incubation
period of 1 to 4 wk.
Dx
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Chlamydia (now known as Chlamydophila)
pneumoniae
Chlamydophila psittaci
Legionella spp.
Coxiella burnetii
Several viral agents
Q fever
Streptococcus pneumoniae
Pulmonary embolism or infarction
WORKUP
Chest x-ray
Thorough history and physical examination
Laboratory tests
Evaluation guided by symptoms and ndings
LABORATORY TESTS
White blood cells (WBCs):
1. WBC count 10,000/mm
3
in approxi-
mately one fourth of patients
2. Differential count nonspecic
3. Leukopenia rare
Cold agglutinins:
1. Detected in approximately half of the pa-
tients
2. Also may be found in:
a. Lymphoproliferative diseases
b. Inuenza
c. Mononucleosis
d. Adenovirus infections
e. Occasionally, Legionnaires disease
3. Titers typically 1:64
a. May be detectable with bedside testing
b. Appear between days 5 and 10 of the
illness (so may be demonstrable when
patient is rst examined) and disap-
pear within 1 mo
Complement xation testing assay specic
for mycoplasm antigens of paired sera (four-
fold rise) or a single titer 1:32 in patients
with pneumonia and a compatible history:
1. Considered diagnostic in the appropriate
clinical setting
2. Other assays include ELISA, antigen
capture-enzyme immunoassay, and PCR
Culture of the organism from specimens
1. Only truly specic test for infection
2. Technically difcult and done reliably by
few laboratories
3. May require weeks to get results
Sputum
1. Often no sputum produced for laboratory
testing
2. When present, Gram-stained specimens
show polymorphonuclear cells without
organisms
Infection occasionally complicated by pan-
creatitis or glomerulitis
Disseminated intravascular coagulation is a
rare complication
Electrocardiographic evidence of pericarditis
or myocarditis may be present
IMAGING STUDIES
Predilection for lower lobe involvement (up-
per lobes involved in less than a fourth), with
radiographic abnormalities frequently out of
proportion to those on physical examination
(Fig. 1-655)
Small pleural effusions in approximately 30%
of patients
Large effusions: rare
Inltrates: patchy, unilateral, and with a seg-
mental distribution, although multilobar in-
volvement may be seen
Evidence of hilar adenopathy on chest radio-
graphs in 20% to 25%
Rare cases reported:
1. Associated lung abscess
2. Residual pneumatoceles
3. Lobar collapse
4. Hyperlucent lung syndrome
TABLE 1-330 Clinical Manifestations of Mycoplasma Pneumoniae
Infection
From Cohen J, Powderly WG: Infectious diseases, ed 2, St Louis, 2004, Mosby.
Respiratory tract Pharyngitis, laryngitis, acute bronchitis, bronchopneumonia
Skin and mucosa Maculopapular and vesicular exanthema, urticaria, purpura, erythema nodosum,
erythema multiforme, Stevens-Johnson syndrome
Central nervous system Meningitis, meningoencephalitis, acute psychosis, cerebellitis, Guillain-Barr
syndrome?
Parenchymatous organs Pancreatitis, diabetes mellitus, nonspecic reactive hepatitis, subacute thyroiditis?
Miscellaneous Hemorrhagic bullous myringitis, hemolytic anemia, pericarditis, thromboembolism?
Some association remains uncertain.
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PTG Pneumonia, Mycoplasma
Rx
TREATMENT
ACUTE GENERAL Rx
Therapy: azithromycin 500 mg qd 3 or 500
mg initially, then 250 mg daily for 4 days for
adults. For children: 10 mg/kg in one dose on
rst day, then 5 mg/kg in one dose for 4 days
or clarithromycin: 500 mg bid for 10 days in
adults, 15 mg/kg per day in two divided
doses for 10 days in children. Alternatives
include erythromycin (500 mg qid) for adults
or 30 to 40 mg/kg per day in four divided
doses in children or doxycycline: 2 to 4 mg/
kg per day in one or two divided doses for 10
days, maximum daily dose: 100 to 200 mg,
but this agent cannot be used in young chil-
dren or women of childbearing age. Respira-
tory uoroquinolones such as Levaquin or
moxioxacin are alternative agents for treat-
ment in adults but should not be used in
young children.
Therapy shortens the duration and severity of
symptoms and may hasten radiographic
clearing, but the disease is self-limiting.
CHRONIC Rx
Effective antimicrobial therapy does not elim-
inate the organism from the respiratory se-
cretions, which may be positive for weeks.
Serum antibody response does not necessar-
ily provide lifelong immunity.
Chronic symptoms do not occur, although
clinical relapses may occur 7 to 10 days after
the initial response and may be associated
with new areas of inltration.
DISPOSITION
Clinical improvement is almost universal
within 10 days.
Inltrates generally clear within 5 to 8 wk.
Rare deaths are likely attributable to underly-
ing medical diseases.
Person-to-person spread can be minimized
by avoiding open coughing, especially in en-
closed areas.
REFERRAL
Not responding to treatment
Severe infection
Severe extrapulmonary manifestations
Multilobe involvement accompanied by respi-
ratory embarrassment (very rare)
!
PEARLS &
CONSIDERATIONS
COMMENTS
X-ray resolution complete by 8 wk in approxi-
mately 90% of patients.
FIGURE 1-655 Localized airspace opacication resulting from Mycoplasma pneumoniae. (From Specht
N [ed]: Practical guide to diagnostic imaging, St Louis, 1998, Mosby.)
SUGGESTED READINGS
available at www.expertconsult.com
AUTHOR: GLENN G. FORT, M.D., M.P.H.
RELATED CONTENT
Mycoplasmal Pneumonia (Patient Information)
e.885.e1
SUGGESTED READINGS
Daxboeck F: Mycoplasma pneumoniae central nervous system infections, Curr
Opin Neurol 19(4):374-378, 2006.
La Scola B et al: Mycoplasma pneumoniae: a rarely diagnosed agent in ventilator-
acquired pneumonia, J Hosp Infect 59(1):74, 2005.
Michelow IC et al: Diagnostic utility and clinical signicance of naso- and oropha-
ryngeal samples used in a PCR assay to diagnose Mycoplasma pneumoniae
infection in children with community-acquired pneumonia, J Clin Microbiol
42(7):3339-3341, 2004.
Waites KG, Talkington DF: Mycoplasma pneumoniae and its role as a human
pathogen, Clin Microbiol Rev 17(4):697, 2004.
Pneumonia, Mycoplasma
886 Pneumonia, Pneumocystis jirovecii (carinii) PTG
i
BASIC INFORMATION
DEFINITION
Pneumocystis jirovecii pneumonia (PJP) is a
serious respiratory infection caused by the fun-
gal or protozoal organism P. jirovecii (formerly
known as P. carinii ).
SYNONYMS
PCP
PJP
ICD-9CM CODES
136.3 Pneumocystis jirovecii (P. carinii)
pneumonia
EPIDEMIOLOGY &
DEMOGRAPHICS
INCIDENCE (IN U.S.):
Seen primarily in the setting of AIDS
Approximately 11 cases per 100 patient-
years among HIV-infected patients with CD4
lymphocyte counts 100/mm
3
Also seen in other immunocompromised pa-
tients with severe cell-mediated immune de-
ciency (congenital T-cell deciency, acute
leukemia, lymphoma, bone marrow or organ
transplant deciency)
Rituximab use has been associated with
Pneumocystis pneumonia in HIV-negative pa-
tients, most of whom had hematologic can-
cers.
PEAK INCIDENCE: Age 20 to 40 yr (parallel to
AIDS epidemic)
PREDOMINANT SEX: Equal incidence when
corrected for HIV status
PREDOMINANT AGE:
2 yr
20 to 40 yr
GENETICS: Neonatal infection:
Most frequent opportunistic infection among
HIV-infected children, occurring in approxi-
mately 30%
Neonatal occurrence unusual
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
Fever, cough, shortness of breath present in
almost all cases
Lungs frequently clear to auscultation, al-
though rales occasionally present
Cyanosis and pronounced tachypnea in se-
vere cases
Hemoptysis unusual
Spontaneous pneumothorax
ETIOLOGY
P. jirovecii (formerly P. carinii) recently reclas-
sied as a fungal organism
Reactivation of dormant infection
Extrapulmonary involvement rare
Dx
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Other opportunistic respiratory infections:
1. Tuberculosis
2. Histoplasmosis
3. Cryptococcosis
Nonopportunistic infections:
1. Bacterial pneumonia
2. Viral pneumonia
3. Mycoplasmal pneumonia
4. Legionellosis
Occurs virtually exclusively in the setting of
profound depression of cellular immunity
WORKUP
Chest x-ray
Arterial blood gases
Because Pneumocystis cannot be cultured,
diagnosis relies on detection of the organism
by colorimetric or immunouorescent stains
or PCR.
Sputum examination for cysts of PJP and to
exclude other pathogens
Bronchoscopy with bronchoalveolar lavage or
lung biopsy for diagnosis if sputum examina-
tion is negative or equivocal. Stains such as
Gomori methenamine silver stain or toluidine
blue O are used to identify the organism.
LABORATORY TESTS
Arterial blood gas monitoring
Elevated lactate dehydrogenase in majority of
cases
HIV antibody test if cause of underlying im-
mune deciency state is unclear
IMAGING STUDIES
Diffuse uptake on gallium scanning of the lungs
is suggestive but not diagnostic.
Rx
TREATMENT
NONPHARMACOLOGIC THERAPY
Supplemental oxygen
Ventilatory support if needed
Prompt thoracotomy if pneumothorax de-
velops
ACUTE GENERAL Rx
For conrmed or suspected PJP:
Trimethoprim-sulfamethoxazole (15 to 20
mg/kg trimethoprim and 75 to 100 mg/kg
sulfamethoxazole qd) PO or IV per day di-
vided and given q6 to 8h
Pentamidine (4 mg/kg IV qd)
Either regimen with prednisone (40 mg
PO bid):
1. If arterial oxygen pressure 70 mm Hg
2. If arterial-alveolar oxygen pressure differ-
ence 35 mm Hg
3. Dose tapered to 20 mg bid after 5 days
and 20 mg qd after 10 days
Therapy continued for 3 wk
Alternative therapies available for patients
unable to tolerate conventional therapy:
1. Dapsone/trimethoprim
2. Clindamycin/primaquine
3. Atovaquone
CHRONIC Rx
After completion of therapy, lifelong prophy-
laxis should be maintained with trimethoprim-
sulfamethoxazole (one single-strength tablet
PO qd or double-strength three times weekly).
Patients intolerant of this therapy should be
treated with dapsone (50 mg PO qd) plus
pyrimethamine (50 mg PO weekly) plus leu-
covorin (25 mg PO weekly).
Inhaled pentamidine (300 mg monthly by
standardized nebulizer) is less effective and
is reserved for patients intolerant to other
forms of prophylaxis.
Same approach taken to all HIV-infected pa-
tients with CD4 lymphocyte counts 200 to
250/mm
3
or 20% of the total lymphocyte
count because of their high risk of PJP.
DISPOSITION
After completion of therapy, long-term ambula-
tory follow-up is mandatory to provide second-
ary prevention of PJP (see Chronic Rx above)
and management of the underlying immunode-
ciency syndrome.
REFERRAL
To pulmonologist for bronchoscopy if diagno-
sis cannot be conrmed by sputum examina-
tion
To an infectious disease specialist if case is
severe or difcult to manage
!
PEARLS &
CONSIDERATIONS
COMMENTS
All patients, especially those with severe infec-
tion or intolerant of conventional therapy, should
be followed by a physician experienced in the
management of PJP and, if appropriate, in the
long-term management of HIV infection or other
underlying disease.
Severe and life-threatening hypoglycemia
may occur after 1 or 2 wk after start of IV pent-
amidine. Monitor closely and advise the patient
of symptoms of hypoglycemia.
SUGGESTED READINGS
available at www.expertconsult.com
AUTHOR: GLENN G. FORT, M.D., M.P.H.
RELATED CONTENT
Pneumocystis Pneumonia (Patient Information)
e.886.e1
SUGGESTED READINGS
Kovacs JA, Masur H: Evolving health effects of pneumocystis, JAMA 301(24):2578-
2585, 2009.
Torres HA et al: Inuence of type of cancer and hematopoietic stem cell transplan-
tation on clinical presentation of Pneumocystis jirovecii pneumonia in cancer
patients, Eur J Clin Microbiol Infect Dis 25(6):382, 2006.
Pneumonia, Pneumocystis jirovecii (carinii)
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PTG Pneumonia, Viral
i
BASIC INFORMATION
DEFINITION
Viral pneumonia is infection of the pulmonary pa-
renchyma caused by any of a large number of viral
agents. The most important viruses are discussed.
SYNONYMS
Nonbacterial pneumonia
Atypical pneumonia
ICD-9CM CODES
480.8 Viral pneumonia
487.0 Viral pneumonia due to inuenza
EPIDEMIOLOGY &
DEMOGRAPHICS
INCIDENCE (IN U.S.):
Inuenza virus:
1. 10% to 20% of population in temperate
zones infected during 1-2 mo epidemics
occurring yearly during winter months.
2. Up to 50% infected during pandemics.
3. Pneumonia develops in small percentage
of infected persons.
Incidence of other important viral pneumo-
nias is not known precisely.
PEAK INCIDENCE:
Inuenza:
1. Winter months for inuenza A
2. Year round for inuenza B
3. Peak of pneumonia seen weeks into the
outbreak of infection
Respiratory syncytial virus (RSV) and parain-
uenza virus:
1. Winter and spring
Adenovirus:
1. Endemic (military)
Varicella:
1. Spring in temperate zones
Measles:
1. Year round
Cytomegalovirus (CMV):
1. Year round
PREVALENCE (IN U.S.):
Often related to immune status of the popula-
tion or presence of an epidemic
Normal hosts (estimates):
1. 86% of cases of pneumonia resulting in
hospitalization in American adults
2. 16% of pediatric pneumonias managed
as outpatients
3. 49% of hospitalized infants with pneu-
monia
Important problem in hosts with impaired
immunity
PREDOMINANT SEX:
None generally
Male sex may predispose to more severe
respiratory disease in RSV infection
PREDOMINANT AGE:
Inuenza:
1. Overall incidence greatest at age 5 yr
2. Lower with increasing age
3. The most serious sequelae in those with
chronic medical illnesses, especially car-
diopulmonary disease
4. Hospitalizations greatest in infants and
adults aged 64 yr
RSV and parainuenza virus:
1. Young children (as the major cause of
pneumonia)
2. Occurs throughout life
Adenoviruses:
1. Young children
2. Adults, primarily military recruits
Varicella:
1. Approximately 16% of adults (not infected
in childhood) who contract chickenpox
2. Acute varicella during pregnancy more likely
to be complicated by severe pneumonia
3. 90% of reported varicella pneumonia
cases are in adults (highest incidence
ages 20 to 60 yr)
Measles:
1. Young adults and older children who re-
ceived a single vaccination (5% failure
rate)
2. Measles during pregnancy more likely to
be complicated by pneumonia
3. Underlying cardiopulmonary diseases and
immunosuppression predispose to seri-
ous pneumonia complicating measles
4. Before availability of measles vaccine,
90% of pneumonias in those 10 yr
5. Currently more than one third of U.S. pa-
tients 14 yr
6. 3% to 50% of measles cases are compli-
cated by pneumonia
CMV:
1. Neonatal through adult
2. Immunosuppression is key predisposing
factor
GENETICS:
Familial disposition:
Close contact, not genetics, is important in
acquisition
Congenital anomalies and immunosuppres-
sion worsen course of RSV pneumonia
Congenital infection:
CMV is the most common intrauterine infec-
tion in the U.S.
Pneumonia occurs occasionally in infants
with symptomatic congenital infection.
Neonatal infection:
Severe RSV pneumonia
Adenovirus pneumonia
1. 5% to 20% mortality rate
2. Can lead to residual restrictive or obstruc-
tive functional abnormalities
Varicella neonatorum
1. Disseminated visceral disease including
pneumonia
2. May develop in neonates whose mothers
develop peripartum chickenpox
CMV pneumonia
1. Generally fatal
2. Associated with severe cerebral damage
in this population
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
1. Inuenza:
Fever, cough, or sore throat (reffered to as
inuenza-like illness [ILI])
Uncomfortable or lethargic appearance
Prominent dry cough (rarely hemoptysis)
Flushed integument and erythematous
mucous membranes
Rales or rhonchi
2. RSV and parainuenza:
Fever
Tachypnea
Prolonged expiration
Wheezes and rales
3. Adenoviruses:
Hoarseness
Pharyngitis
Tachypnea
Cervical adenitis
4. Measles:
Conjunctivitis
Rhinorrhea
Kopliks spots (white lesions on the buccal
mucosa)
Exanthem (maculopapular rash that starts
on the head, then moves down to rest of
body)
Pneumonitis
a. May occur as a complication in 3% to
4% of adolescents and young adults
b. Coincident with rash
c. May also develop after apparent re-
covery from measles
Fever
Dry cough
5. Varicella:
Fever
Maculopapular or vesicular rash (all lesions
at the same stage)
a. Becomes encrusted
b. Pneumonia typical 1 to 6 days after
rash appears
c. Pneumonia accompanied by cough
and occasionally hemoptysis
Few auscultatory abnormalities noted on
examination of the lungs
6. CMV:
Fever
Paroxysmal cough
Occasional hemoptysis
Diffuse adenopathy when pneumonia oc-
curs after transfusion
ETIOLOGY
Viral infection can lead to pneumonia in both
immunocompetent and immunocompromised
hosts.
Dx
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Bacterial pneumonia, which frequently com-
plicates (i.e., can follow or be simultaneous
with) viral pneumonia
Other causes of atypical pneumonia:
1. Mycoplasma spp.
2. Chlamydia spp.
3. Coxiella spp.
4. Legionnaires disease
Acute respiratory distress syndrome (ARDS)
Physical ndings and associated hypoxemia
confused with pulmonary emboli
WORKUP
Information about the current prevalent strain
of inuenza virus can be obtained from local
888 Pneumonia, Viral PTG
health departments or from the Centers for
Disease Control and Prevention.
Inuenza and other viruses may be cultured
from respiratory secretions during the initial
few days of the illness (special media and
techniques necessary).
Respiratory viral panels that use PCR-based
assays to test for a variety of viruses are ex-
tremely sensitive and are becoming the test
of choice.
Rapid u tests have a 50% sensitivity in diag-
nosing inuenza (a negative test does not
mean the patient does not have inuenza).
Measles and adenovirus pneumonia are usu-
ally diagnosed clinically and can be conrmed
with serology.
CMV may be grown in culture or PCR ampli-
ed from bronchoalveolar lavage samples. An
algorithm for the workup and management of
suspected severe inuenza pneumonia in the
critical care unit is described in Fig. E1-656.
Open lung biopsy is required for a denite
diagnosis of CMV pneumonia.
LABORATORY TESTS
Sputum Gram stain (usually produced in
scanty amounts) typically shows few poly-
morphonuclear leukocytes and few bacteria.
White blood cell count may vary from leuko-
penic to modest elevation, usually without a
leftward shift.
Disseminated intravascular coagulation oc-
casionally complicates adenovirus type 7
pneumonia.
Multinucleated giant cells on Tzanck prepa-
ration of an unroofed vesicular lesion are
useful in diagnosing varicella in a patient with
an inltrate (also found in herpes simplex).
Severe immunosuppression is associated with
symptomatic CMV pneumonia (usually reacti-
vation of latent infection or in previously sero-
negative recipients from the donor).
Hypoxemia may be profound.
Cultures may be helpful in identifying super-
infecting bacterial pathogens.
When they occur, parapneumonic pleural ef-
fusions are exudative.
IMAGING STUDIES
Chest radiographs may demonstrate a spec-
trum of ndings from ill-dened, patchy, or
generalized interstitial inltrates, which can
be associated with ARDS.
A localized dense alveolar inltrate suggests
a superimposed bacterial pneumonia.
Small calcied nodules may develop as a
radiographic residual of varicella pneumonia.
Rx
TREATMENT
NONPHARMACOLOGIC THERAPY
General:
Measures to diminish person-to-person trans-
mission
Modied bed rest
Maintenance of adequate hydration
Possible ventilatory support for severe pneu-
monia or ARDS
Inuenza:
Yearly prophylactic strain-specic inuenza
vaccination (only subvirion vaccine should be
used in children 13 yr) can be given to
prevent infection.
Live, attenuated inuenza vaccines adminis-
tered by nose drops as effective as injected
inactivated viral vaccines.
RSV:
Isolation techniques are important in limiting
spread of RSV infections.
Immunoglobulins with a high RSV-neutralizing
antibody titer are benecial in treatment.
Adenoviruses:
Intestinal inoculation of respiratory adenovi-
ruses has been used to successfully immu-
nize military recruits.
Although they produce no disease in recipi-
ents, the viruses may be shed chronically and
may infect others at a later date.
These vaccines are not available for civilian
populations.
Varicella:
Live, attenuated varicella vaccine has been
successfully used in clinical trials.
Varicella-zoster immune globulin should be
administered within 4 days of exposure to
prevent or modify the disease in susceptible
persons.
Nonimmunized persons exposed to varicella
are potentially infectious between 10 and
21 days after exposure.
Measles:
Effective measles vaccine is available:
C The vaccine should be administered at age
15 mo.
C A second dose should be administered at
the time of school entry.
Live, attenuated vaccine or gamma-globulin
can prevent measles in unvaccinated per-
sons if administered early after exposure.
Vitamin A given PO for 2 days reduces mor-
bidity and mortality rates from measles in
exposed children.
Severe acute respiratory syndrome (SARS)
associated coronaviruses:
No vaccine currently available.
Supportive care: ribavirin ineffective, use of
steroids or interferon-alpha of unclear value.
ACUTE GENERAL Rx
General: Administer appropriate antibiotics
for bacterial superinfections.
Inuenza:
C Amantadine and rimantadine for inuenza
A (not active against inuenza B). Early use
can speed recovery from small airways
dysfunction, but whether it inuences the
development or course of pneumonia is
uncertain.
C The neuraminidase inhibitors oseltamivir
and zanamivir are effective if given in the
rst 48 hours of symptoms of inuenza;
their efcacy in established inuenza
pneumonia is unclear.
C Aerosolized ribavirin or amantadine may
have a role in severe inuenza pneumonia
but have not been approved for this indi-
cation.
RSV and parainuenza:
C Ribavirin aerosol is effective for severe
RSV pneumonia.
C There is no approved antiviral therapy for
parainuenza virus pneumonia.
Adenoviruses: no effective agent; some
case reports of cidofovir use but unproved.
Varicella:
C Varicella pneumonia can be treated with IV
acyclovir.
C Adults who develop chickenpox should
be considered for acyclovir treatment,
which may prevent the development of
pneu monia.
Measles: no effective antimeasles agent.
CMV:
C Acyclovir can prevent CMV infection in re-
nal transplant recipients.
C Ganciclovir and foscarnet, with or without
CMV hyperimmune globulin, show promise
in the treatment of serious CMV infection,
including pneumonia, in compromised
hosts.
DISPOSITION
Supportive therapy is useful.
Death is possible during acute illness.
Residual functional abnormalities may be
persistent or develop into or predispose to
chronic respiratory diseases in later life.
Morbidity and mortality rates after most viral
pneumonias are increased by bacterial su-
perinfection.
REFERRAL
Uncertainty about the diagnosis in a compro-
mised host.
Symptoms or ndings are progressive.
Severe respiratory compromise, diffuse inl-
trates, or the development of ARDS.
!
PEARLS &
CONSIDERATIONS
COMMENTS
Inuenza spreads by close contact and by
small droplets transmitted by cough.
RSV is effectively transmitted by fomites and
by direct contact (little by aerosol).
Varicella is transmitted by direct contact or by
aerosol.
Of the three major forms of parainuenza vi-
ruses (types 1 to 3), type 3 is the most com-
mon cause of viral pneumonia; types 1 and 2
primarily cause laryngotracheitis.
Recent evidence indicates that a newly dis-
covered virus known as metapneumovirus is a
common cause of upper respiratory infections
worldwide; this virus can cause pneumonia.
SUGGESTED READINGS
available at www.expertconsult.com
AUTHORS: PHILIP A. CHAN, M.D., and
GLENN G. FORT, M.D., M.P.H.
RELATED CONTENT
Viral Pneumonia (Patient Information)
e.888.e1
Suspected severe influenza: diffuse
pneumonitis, other critical illness
High probability case Low probability case
PCR
PCR
PCR PCR
PCR
PCR
Nasopharyngeal swab + tracheal aspirate
for influenza PCR/culture
Oseltamivir 75 mg PO/ng bid, Rx CAP
Store sample for serology
Repeat nasopharyngeal +
tracheal aspirate (if intubated)
Continue oseltamivir
for 10 days
D/C CAP antibiotics
if no bacterial
pathogen identified
Weekly influenza PCR (tracheal or
nasopharyngeal aspirate) until negative
PCR or negative culture
Weekly sputum bacterial cultures
D/C oseltamivir
Continue CAP antibiotics
for 7-14 days
Convalescent (28 day)
influenza serology if no
other pathogen identified
D/C oseltamivir
Continue CAP antibiotics
for 7-14 days
Convalescent (28 day)
influenza serology if no
other pathogen identified
FIGURE E1-656 Suggested algorithm in the workup and management of suspected severe inu-
enza pneumonia in the critical care unit. CAP, Community-acquired pneumonia; D/C, discontinue; PCR,
polymerase chain reaction. (From Vincent JL et al: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders.)
SUGGESTED READINGS
Cheng VC et al: Medical treatment of viral pneumonia including SARS in immuno-
competent adults, J Infect 49(4):262, 2004.
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