clinical Muhannad Hawari

Community Acquired Pneumonia

 What do you know about Pneumonia?
Ø hospital and community acquired
Ø there are typical and atypical
Ø pathogen different form children and adult
Ø septic shock is complication
 Example
Ø Mr. Smith is a 68 years gentleman. PMH: DM on insulin and hypertension
Ø He is not a smoker
o always ask about smoking history
Ø He presents with 3 days history of fever
Ø He also has a productive cough with brown sputum and feels short of breath
Ø VS: T: 38.9, RR: 32, BP 89/50, 02 89% RA, HR 100
o RR: 32, tachypnea
o BP 89/50 hypoxic
Ø Chest exam show bronchial breathing in the right lower zone posteriorly with
increase TVF.
o bronchial breathing: Loud and high pitched, through part of inspiration and
all of expiration
o TVF: tactile fremitus indicates denser or inflamed lung tissue
 CXR
Ø normal: mediastinum not widened, left and right heart border clear,
diaphragm and costophrenic angle clear, lung parenchyma normal
Ø abnormal: white abnormality
 Community-acquired pneumonia (CAP)
An acute infection of the pulmonary parenchyma outside of the hospital.
Ø most common and morbid conditions encountered in clinical practice.
Ø CAP is the 2nd most common cause of hospitalization and the most
common infectious cause of death.
 Risk factors
Ø Older age or extremes of age
Ø Chronic comorbidities (heart diseases, COPD, immunosuppression, or dialysis)
Ø Viral respiratory tract infection (may lead to a secondary bacterial infection)
Ø Impaired airway protection (chronic aspiration e.g in people with seizures, ELS)
Ø Smoking and alcohol overuse
Ø Other lifestyle factors

Done by Alanoud Adam

clinical Muhannad Hawari

 Microbiology
Ø Typical bacteria
o Common causes — S.pneumoniae (pneumococcus)
o Haemophilus influenzae
o Moraxella catarrhalis
o Staphylococcus aureus
o Group A streptococci
o Aerobic gram -ve (eg, Enterobacteriaceae such as Klebsiella or E.coli)
o Microaerophilic bacteria and anaerobes (associated with aspiration)
Ø Atypical bacteria
refers to the intrinsic resistance of these organisms to beta-lactams and their
inability to be visualized on Gram stain or cultured using traditional techniques
o Legionella spp  water contamination
o Mycoplasma pneumoniae
o Chlamydia pneumoniae
o Chlamydia psittaci
o Coxiella burnetiid
Ø Respiratory viruses
o Influenza A and B viruses  most common viral pneumonia
o Rhinoviruses: usually come with sneezing &rhinorrhea
o Parainfluenza viruses
o Adenoviruses
o Respiratory syncytial virus  common in pediatrics
o Human metapneumovirus: it is rare
o Coronaviruses (eg, Middle East respiratory syndrome coronavirus)
o Human bocaviruses
 Pathogenesis
Ø respiratory viral infection progress going to the LRT, present
with cough→ reach to the alveoli encounter with bacteria→ pus
 Clinical Presentation:
Ø Variable severity / Cough (with or without sputum production)
Ø Dyspnea / Fever
Ø Pleuritic chest pain  sharp pain when taking a deep breath
Ø Sepsis / Septic shock  in severe cases may lead to hypotension

Done by Alanoud Adam

clinical Muhannad Hawari

Ø Physical exam: tachypnea, hypoxia, febrile, confusion, including rales/crackles

and rhonchi, bronchial breathing, increase Tactile fremitus, Ego phony, and
dullness to percussion.
o Egophony: increased resonance of voice
 Consolidation:
Ø Opacity (too white)
Ø Ill defined (hazy) -no vol. loss-
Ø Air bronchograms (air-filled bronchi)
Ø Silhouette signs (the loss of normal borders)
 Labs
Ø Elevated WBC with neutrophilia
Ø Elevated CRP, ESR, Procalcitonin -infection-
Ø Sputum C/S (Could be negative)
Ø Blood cultures / Respiratory viruses screen
Ø Urinary antigen testing for S. pneumonia
Ø Testing for Legionella PCR when available, urinary antigen test as an alternate)
 Diagnosis
Ø The demonstration of an infiltrate on chest imaging in a patient with a clinically
compatible syndrome.
 Assessment of severity
Ø CURB-65
o if pat. had low score but he is very noxious don’t
sent him home
o if pat. hypoxic don’t send him home
o if pat. cant go back to hospital don’t send him home
Ø Pneumonia severity index
o complex no need to know it
 Three of these criteria warrants ICU admission:
Ø Altered mental status
Ø Hypotension requiring fluid support
Ø Temperature <36°C (96.8°F)
Ø Respiratory rate ≥30 breaths/minute
Ø Arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2) ratio ≤250
Ø Blood urea nitrogen (BUN) ≥20 mg/dL (7 mmol/L)
Ø Leukocyte count <4000 cells/microL
Ø Platelet count <100,000/mL

Done by Alanoud Adam

clinical Muhannad Hawari

Ø Multilobar infiltrates
 Complications of CAP
Ø Septic shock / inotropic support
Ø Respiratory failure / intubation
Ø Lung abscess common in aspiration pneumonia
Ø Complicated pleural effusion and empyema must be drained
Ø Antibiotic alone doesn’t work  Aspiration and chest tube insertion
Ø Pleura might fibroses  trapping of lung in the future
 Management
Ø Target S. pneumoniae the commonest and atypical pathogens.
Ø Outpatients
o Oral amoxicillin (or Amoxacillin, 3rd generation cephalosporins) +
macrolide (eg, azithromycin or clarithromycin) or doxycycline.
o a respiratory fluoroquinolone (Levofloxacin)
Ø Inpatient:
Ø B-Lactam (penicillin's or 3rd gen. cephalosporins (ceftriaxone) +
Macrolid/doxycycline
Ø MRSA/Pseudomonas  use appropriate AB
Ø ICU  use broad spectrum AB

 For how long will you treat the patient?

Ø afebrile and clinically stable for at least 48h to 5 days.

Ø Patients with mild infection generally require 5 to 7 days of therapy.
Ø Patients with severe infection or chronic comorbidities require 7 to 10d
Ø Extended courses for immunocompromised patients, patients with infections
caused by certain pathogens (eg, P. aeruginosa), or those with complications.
 Prevention
Ø Smoking cessation
Ø Influenza vaccination for all patients
Ø Pneumococcal vaccination for at-risk patients
 Take home messages
Ø CAP is an infection of the lung parenchyma
Ø Clinical presentation and signs
Ø CXR findings
Ø Assessment of severity
Ø Management

Done by Alanoud Adam