Pneumonia

- Inflammation of the lung parenchyma

- Incidence of pneumonia is 0.4-5% in patients presenting with LRTI
- Important differential – acute bronchitis
o How to differentiate between acute bronchitis and pneumonia
 Similarity – cough, purulent or colored sputum
 Increase chance of pneumonia - temp >37.8, crackles on auscultation, SaO2<95 on RA,
HR >100, rigors, pleuritic chest pain, tachypnoea on rest.
 Exam – dullness to percussion, poor air entry, bronchial breath sounds. Crackles that
do not clear with coughing
 Acute bronchitis – unlikely rigors, tachycardia or tachypnea. Gever usually subsides in first
few days of illness.
 OE wheeze. May have crackles that clear with cough
- Physical
- Exam
- Investigation
o Imaging
 CXR - New consolidation
 Confirm diagnosis
 Comparison for follow up imaging
 CXR also for
 Unexplained hypoxaemia or signif breathlessness
 Comorbid lung disease, immunocomprimised – pneumonia may be subtle
 If early illness consolidation may not appear. Repeat in a few days time
- Finding the right pneumonia

Community acquired pneumonia

- Patient comes in from community or in hospital less than 48hours

- Most common bacterial cause of CAP is strep pneumoniae
- Aetiology of CAP
o Strep pneumo – most common cause of CAP
o Legionella – environmental sources
  Present with nonresp symptoms – confusion, diarrhea and hyponatremia (most legionella
pneumophilia or longbechae)
o Mycoplasma pneumoniae and chlamydia pneumoniae
 Non productive cough, ilateral lower zone infiltrate
o Coxiella Burnetti – Q fever – animal exposure
o H flu
 COPD patients
o Klebsiella pneumoniae
o Pseudomonas – rare
 Necrotising or destructive in nature
o Burkholderia
 Tropical regions in Australia
o S aureus
 High severity CAP or cavitary pneumonia.
 Secondary to influenza
 Multifocal S aureus lung infection may indicate underlying endocarditis
o RSV
 High severity bilateral CAP requiring intensive care support
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- Red flags for admission
o Tachypnea >22
o HR >100
o Hypotension
o Acute onset confusion
o O2 sats lower than 92% on RA
 o Multilobar involvement on CXR
o Lactate more than 2mmol/L
- Also assess functional status, social, ability to tolerate oral therapy and ened for supportive oxygen therapy
- Red flags for ICU
o RR >30
o O2 sats <90% on RA
o Multilobar or rapid progression on CXR
o Hypotension <90mmHg systolic
o Acute onset confusion
o Poor peripheral perfusion
o Acute oliguria, elevated serum creatinine or uremia
o Lactate >2mmol/L
o Systolic <90 and lactate >2 indicate systemic hypoperfusion -> inotropic support
- Moderate severity – one red flag for admission but not for ICU
- Diagnosis and investigation
o Cough, dyspnoea, sputum, pleuritic
o Fever
o Nil infiltrate
o Investigations
 CXR
 O2 sats
 Investigation for pneumonia severity
o Further investigations
 Sputum gram stain and culture
 Good sample – few squamous cells. Must be done before antibiotics are started.
 Enteric gram negative bacteria such as e coli and K pneumoniae growth not usful in
low and moderate severity CAP
 NAAT
 Can help rule out/determine viral infections
 VBG
 Can only measure lactate levels
 ABG can be used to measure gas exchange
o PaO2 and PaCO2
 Blood culture
 Collect 2 samples (same place different time or 2 different places
 Pneumococcal
 Consider use in patients with high severity CAP ot already on benpen or amoxy
 Legionella
 High severity CAP with risk factors
- Guidelines on prescribing
o Low or moderate severity -> safe to be placed on penicillin based regime
o High severity -> high risk of severe outcomes-> place on broad spectrum empirical Abx therapy until
investigations back even if most likely is strep pneumoniae
o No adjunct corticosteroids
o Atypical bacteria – mycoplasma pneumoniae, chlamydia pneumoniae and legionella -> doxycycline
or macrolide in low severity who can be reviewed. Doxy + macrolide otherwise. Moderate to severe
add beta lactam.
o Doxycycline cannot be used in pregnant women
o Immediate nonsevere or delayed non severe hypersensitivity – cefuroxime best choice