Cebu Normal University

GRADUATE SCHOOL
Osmeňa Blvd., Cebu City

PNEUMONIA

John Louis S. Ricamora, AHSE, BSN, RN

MSN 4006 – Advanced Psychopathology
Pneumonia

- is an infection of the pulmonary tissue

- can be community acquired or hospital
acquired
- caused by a virus, mycoplasmal agents,
bacteria, or the aspiration of foreign
substances.
Types of Pneumonia
Viral pneumonia

Assessment:
a. Mild fever, slight cough and malaise, to
high fever, severe cough, and prostration
b. Nonproductive or productive cough of
small amounts of whitish sputum
c. Wheezes or fine crackles
Interventions:
a. Administer oxygen with cool mist as
prescribed.
b. Increase fluid intake.
c. Administer antipyretics for fever as
prescribed.
d. Administer CPT as prescribed.
e. Antimicrobial therapy is reserved for
children in whom the presence of
infection is demonstrated by cultures.
Primary atypical pneumonia
(Mycoplasma pneumoniae)

- most common cause of pneumonia in

children between the ages of 5 and 12 years
- more prevalent in crowded living
conditions
Assessment:
a. Fever, chills, anorexia, headache,
malaise and muscle pain
b. Rhinitis, sore throat, and dry, hacking
cough
c. Nonproductive cough initially; then
production of seromucoid sputum that
becomes mucopurulent or blood streaked

Interventions: symptomatic
Bacterial pneumonia

- hospitalization is indicated when pleural

effusion or empyema accompanies the
disease and is mandatory for children with
staphylococcal pneumonia
Assessment:

a. Acute onset, fever, toxic appearance

b. Infant: irritability, lethargy, poor
feeding, abrupt fever (may be
accompanied by seizures); respiratory
distress (air hunger, tachypnea, and
circumoral cyanosis)
c. Older child: headache, chills,
abdominal pain, chest pain, meningeal
symptoms (meningism)
d. Hacking, nonproductive cough
e. Diminished breath sounds or scattered
crackles
f. As the infection resolves, coarse crackles
and wheezing are heard and the cough
becomes productive with purulent sputum.
Interventions:
a. Antimicrobial therapy is initiated as
soon as the diagnosis is suspected.
b. Administer oxygen (via hood, mist tent,
or nasal cannula) for respiratory distress
as prescribed.
c. Place the child in a mist tent as
prescribed; cool humidification moistens
the airways and assists in temperature
reduction.
d. Suction mucus from the infant to maintain
a patent airway if the infant is unable to
handle secretions.
e. Administer CPT q 4 hours as prescribed.
f. Encourage the child to lie on the affected
side (if pneumonia is unilateral) to splint the
chest and reduce the discomfort caused by
pleural rubbing.
g. Provide liberal fluid intake (administer
cautiously to prevent aspiration); IV
administered fluids may be necessary.
h. Administer antipyretics for fever as
prescribed; monitor temperature frequently
because of the risk for febrile seizures.
i. Institute isolation precautions with
pneumococcal or staphylococcal pneumonia
(according to agency policy).
j. Administer antitussives as prescribed.
k. Continuous closed chest drainage may be
instituted if purulent fluid is present.
l. Promote bed rest to conserve energy.
m. Fluid accumulation in the pleural cavity
may be removed by thoracentesis;
thoracentesis also provides a means of
obtaining fluid for culture and for instilling
antibiotics directly into the pleural cavity.
Organisms that cause pneumonia
and their treatments
 Streptococcus Pneumoniae

- most common cause of a bacterial

pneumonia there is usually an abrupt onset of
the illness with shaking chills, fever, and
production of a rust-colored sputum.
 Pneumococcal Conjugate Vaccine
(PCV7; Prevnar)

- is part of the routine infant immunization

schedule in the U.S. and is recommended for
all children < 2 years of age and children 2-4
years of age who have certain medical
conditions.
 Pneumococcal Polysaccharide Vaccine
(PPV23; Pneumovax)

- is recommended for adults at increased risk

for developing pneumococcal pneumonia
including the elderly, people who have
diabetes, chronic heart, lung, or kidney
disease, those with alcoholism, cigarette
smokers, and in those people who have had
their spleen removed.
 - Antibiotics often used in the treatment of
this type of pneumonia include penicillin,
amoxicillin and clavulanic acid (Augmentin,
Augmentin XR), and macrolide antibiotics
including erythromycin, azithromycin
(Zithromax, Zmax), and clarithromycin
(Biaxin).
Klebsiella pneumoniae and Hemophilus
influenzae
- are bacteria that often cause pneumonia in
people suffering from chronic obstructive
pulmonary disease (COPD) or alcoholism.
- Useful antibiotics in this case are the
second- and third-generation cephalosporins,
amoxicillin and clavulanic acid,
fluoroquinolones (levofloxacin [Levaquin],
moxifloxacin-oral [Avelox], gatifloxacin-oral
[Tequin], and sulfamethoxazole and
trimethoprim [Bactrim, Septra]).
 Mycoplasma pneumoniae
- is a type of bacteria that often causes a
slowly developing infection. Symptoms
include fever, chills, muscle aches, diarrhea,
and rash. This bacterium is the principal
cause of many pneumonias in the summer
and fall months, and the condition often
referred to as "atypical pneumonia."
- Macrolides (erythromycin, clarithromycin,
azithromycin, and fluoroquinolones) are
antibiotics commonly prescribed to treat
Mycoplasma pneumonia.
 Legionella pneumoniae
- most often found in contaminated water supplies
and air conditioners. It is a potentially fatal infection
if not accurately diagnosed. Pneumonia is part of
the overall infection, and symptoms include high
fever, a relatively slow heart rate, diarrhea, nausea,
vomiting, and chest pain. Older men, smokers, and
people whose immune systems are suppressed are at
higher risk of developing Legionnaire's disease.
- Fluoroquinolones are the treatment of choice in
this infection. This infection is often diagnosed by a
special urine test looking for specific antibodies to
the specific organism.
Chlamydia pneumoniae

- all cause a syndrome known as "atypical

pneumonia." In this syndrome, the chest x-ray
shows diffuse abnormalities, yet the patient does not
appear severely ill. These infections are very
difficult to distinguish clinically and often require
laboratory evidence for confirmation.
 Pneumocystis carinii

- pneumonia is another form of pneumonia

that usually involves both lungs. It is seen in
patients with a compromised immune system,
either from chemotherapy for cancer,
HIV/AIDS, and those treated with TNF
(tumor necrosis factor), such as for
rheumatoid arthritis.
- Once diagnosed, it usually responds well to
sulfa-containing antibiotics. Steroids are
often additionally used in more severe cases.
 Viral pneumonias
- do not typically respond to antibiotic treatment.
These infections can be caused by adenoviruses,
rhinovirus, influenza virus (flu), respiratory
syncytial virus (RSV), and parainfluenza virus
(that also causes croup). These pneumonias
usually resolve over time with the body's immune
system fighting off the infection. It is important to
make sure that a bacterial pneumonia does not
secondarily develop. If it does, then the bacterial
pneumonia is treated with appropriate antibiotics.
In some situations, antiviral therapy is helpful in
treating these conditions.
 Fungal infections

- that can lead to pneumonia include

histoplasmosis, coccidiomycosis, blastomycosis,
aspergillosis, and cryptococcosis. These are
responsible for a relatively small percentage of
pneumonias in the United States.
- Each fungus has specific antibiotic treatments,
among which are amphotericin B, fluconazole
(Diflucan), penicillin, and sulfonamides.
Algorithm: Philippine Community-
Acquired Pneumonia (CAP)
Guidelines 2004
Guidelines on Pneumonia Empiric
Therapy: (Usual Recommended
Dosages of Antibiotics in Adults,
50-60 Kg Body Weight, with
Normal Liver and Renal Function)
1. Low Risk CAP (Out-Patient)
Common Organisms: 1. Strep. Pneumoniae, 2. H.
influenzae, 3. M. pneumoniae, 4. C. pneumoniae, 5. M.
catarrhalis; Mortality rate at 1-5%

a. For previously healthy, choice of:

Amoxicillin 500 mg cap TID PO (standard regimen) or
Co-trimoxazole forte (Globaxol forte) tab BID PO or
Macrolides like:
- Roxithromycin (Macrol, Rulid) 150 mg tab BID PO x 7
days
- Clarithromycin (Klaricid) 500 mg tab BID PO x 7 days
- Azithromycin 500 mg tab OD x 3 days or 2 grams
single dose
b. For those with stable co-morbid illness,
choice of:

Co-Amoxiclav (Amoclav, Augmentin)

375-625 mg tab TID PO or
Cefuroxime (Zegen) 250-500 mg tab BID PO
or Macrolides as above.
2. Moderate Risk CAP (In-Patient)
Common Organisms: Above organisms plus: 1. Enteric
gram-negative bacilli, 2. Anaerobic bacteria, 3. Legionella
pneumophilia; Mortality rate 5-25%

a. Choice of:
Cefuroxime (Zegen, Zinacef) 750 mg q 8 hr IV
Ampicillin-Sulbactam (Unasyn) 750 mg-1.5 gm q 8 hr IV
Co-Amoxiclav (Amoclav, Augmentin) 600 mg-1.2 gm q 8 hr
IV
plus b. Azithromycin IV
or c. New Fluoroquinolones Alone PO: (Cheaper option)
Ex. Levofloxacin (Levox) 500 mg tab OD PO x 5-7 days
3. High Risk CAP (Intensive Care)
Common Organisms: Above organisms plus:
1. Staphylococcus aureus, 2. Pseudomonas aeruginosa;
Mortality rate at 50%

a. Choice of: Ceftazidime 1-2 gm q 8 hr IV

or Piperacillin-Tazobactam (Tazocin) 2.25 gm q 6-8 hr IV
or Meropenem 500 mg q 8 hr IV
or Cefepime 1-2 gm q 12 hr IV
plus b. Azithromycin IV
or Levofloxacin (Levox) 500 mg IV OD x 3 days then 500
mg tab PO x 4 days
+/- c. For those with risk for Pseudomonas: Ciprofloxacin
200 mg q 12 hr IV x 3 days then 500 mg tab PO x 4 days
or Amikacin 500 mg IV q 12 hr or Gentamicin IV
4. For Aspiration Pneumonia:

a. Aspiration Pneumonia (community-

acquired)
Clindamycin 300-600 mg q 6-8 hr IV
or Penicillin G 1-2 millions units q 4 hr IV
b. Aspiration Pneumonia (nosocomial)
Piperacillin-Tazobactam (Tazocin) 2.25 gm q
6-8 hr IV
or Clindamycin 300-600 mg q 6-8 hr IV
plus Tobramycin 80 mg q 8 hr IV
5. Treatment Based on Typical and Atypical
Clinical Presentation:
a. Typical Presentation: Fever, acute onset,
pleuritic chest pain, lobar consolidation by x-
ray, yellow copious phlegm, pleural effusion.
Treatment: Beta-lactams (e.g. Co-amoxiclav)
or Cephalosporins (e.g. Cefuroxime)
b. Atypical Presentation: No fever, chronic,
intersitial infiltrates by x-ray, scanty white
phlegm
Treatment: Macrolides (e.g. Clarithromycin)
6. Cheeper Antibiotic Options:

a. For CAP Category I and Category II:

Amoxicillin PO for Typical Pneumonia
Roxithromycin PO for Atypical Pneumonia
b. For CAP Category III:
New Fluoroquinolones Alone PO
Ex. Levofloxacin (Levox) 500 mg tab OD PO
Diagnostics:

CBC
Creatinine
Chest X-ray PA-L
Sputum G/S and C/S
Sputum AFB 3x (for TB suspect)
Therapeutics:

1. Antibiotic regimen as listed above given

for a maximumof 7-8 days only to minimize
the emergence of resistance.
2. Berodual nebulization (10 gtts in 3 ml
NSS) q 6 hours and prn
3. Switch Therapy: Intravenous antibiotic
treatment may be shifted to oral antibiotics
after 48-72 hours if the following parameters
are fulfilled: (a) there is less cough and
resolution of respiratory distress
(normalization of respiratory rate), (b) the
temperature is normalizing, (c) the etiology is
not a high risk (virulent/resistant) pathogen,
(d) there is no unstable co-morbid conditions
or life-threatening complications, and (e) oral
antibiotics are tolerated.
4. For abundant secretions, may give
Acetylcysteine (Fluimucil) 100 mg or 200 mg
sachet disolved in ½ glass H2O TID.
Discontinue if patient has wheezing.
Integrated Management on Childhood
Illness (IMCI)
 How is pneumonia prevented?
- Vaccines are available for the prevention of
specific types of pneumonia. This is usually given
to persons not less than 65 years old and children.
Ask your doctor about it.
- Maintain a healthy, clean lifestyle, eat a balanced
diet, get enough rest, and exercise regularly to
enhance your immune system.
- Stop smoking! Smoking destroys the natural
defense of the lungs and may lead to other lung
diseases.
- Avoid crowded places especially when your
immune system is low (after an illness).
Thank you for listening
and God bless us all!