COMMUNITY ACQUIRED PNEUMONIA

Overview
Community-acquired pneumonia (CAP) is one of the most common infectious diseases addressed by clinicians. CAP is an important cause of mortality and morbidity worldwide. A number of pathogens can give rise to CAP. Typical bacterial pathogens that cause the condition include Streptococcus pneumoniae (penicillin-sensitive and -resistant strains), Haemophilus influenzae (ampicillin-sensitive and -resistant strains), and Moraxella catarrhalis (all strains penicillinresistant). These 3 pathogens account for approximately 85% of CAP cases.[1] CAP is usually acquired via inhalation or aspiration of pulmonary pathogenic organisms into a lung segment or lobe. Less commonly, CAP results from secondary bacteremia from a distant source, such as Escherichia coli urinary tract infection and/or bacteremia. Aspiration pneumonia is the only form of CAP caused by multiple pathogens (eg, aerobic/anaerobic oral organisms).

Etiology
Many organisms cause community-acquired pneumonia, including bacteria, viruses, and fungi. Pathogens vary by patient age and other factors (see Table 1: Pneumonia: Community-Acquired Pneumonia in Children and Table 2: Pneumonia: Community-Acquired Pneumonia in Adults ), but the relative importance of each as a cause of community-acquired pneumonia is uncertain, because most patients do not undergo thorough testing, and because even with testing, specific agents are identified in< 50% of cases.

Table 1

Community-Acquired Pneumonia in Children

Age
Birth to 3 wk

Organisms
Group B streptococci, Listeria monocytogenes, gram-negative bacilli, cytomegalovirus

Treatment
Ampicillin

(or nafcillin

) and Gentamicin

(or cefotaxime

)* 3 wk to 3 mo Streptococcus pneumoniae, viruses (RSV, parainfluenza viruses, metapneumovirus), Bordetella pertussis, Staphylococcus aureus,Chlamydia trachomatis (transnatal exposure) 10 mg/kg IV q 6 h for 1014 days Inpatient non-ICU: Cefuroxime Outpatient: Erythromycin

50 mg/kg IV q 812 h Inpatient ICU: Cefotaxime

66 mg/kg IV tid and Cloxacillin

50 mg/kg IV q 6 h 4 mo to 4 yr S. pneumoniae, viruses (RSV, parainfluenza viruses, influenza viruses, adenovirus, rhinovirus, metapneumovirus), Mycoplasma pneumoniae (in older children), group A streptococci 10 mg/kg po qid Inpatient: Erythromycin Outpatient: Erythromycin

10 mg/kg po qid and

Cefuroxime

50 mg/kg IV q 8 h 5 to 15 yr S. pneumoniae, M. pneumoniae,Chlamydia pneumoniae Outpatient: Clarithromycin

500 mg po bid Inpatient: Ceftriaxone

50 mg/kg once/day IV (maximum 2 g) and Azithromycin

10 mg/kg once/day (maximum 500 mg)

RSV = Respiratory syncytial virus. *For doses and discussion of neonatal pneumonia, see Infections in Neonates: Neonatal Pneumonia. Data from McIntosh K: Community-acquired pneumonia in children. The New England Journal of Medicine 346:429437, 2002.

Table 2
Community-Acquired Pneumonia in Adults
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S. pneumoniae, H. influenzae, C. pneumoniae, and M. pneumoniae are the most common bacterial causes. Pneumonia caused by chlamydia and mycoplasma are often clinically indistinguishable from pneumonias with other causes. Common viral agents include respiratory syncytial virus (RSV), adenovirus, influenza viruses, metapneumovirus, and parainfluenza viruses. Bacterial superinfection can make distinguishing viral from bacterial infection difficult.

C. pneumoniae accounts for 2 to 5% of community-acquired pneumonia and is the 2nd most common cause of lung infections in healthy people aged 5 to 35 yr. C. pneumoniaeis commonly responsible for outbreaks of respiratory infection within families, in college dormitories, and in military training camps. It causes a relatively benign form of pneumonia that infrequently requires hospitalization. Chlamydia psittaci pneumonia (psittacosis) is rare and occurs in patients who own or are often exposed to birds. A host of other organisms cause lung infection in immunocompetent patients, although the term community-acquired pneumonia is usually reserved for the more common bacterial and viral etiologies. Q fever, tularemia, anthrax, and plague are uncommon bacterial syndromes in which pneumonia may be a prominent feature; the latter three should raise the suspicion of bioterrorism. Adenovirus, Epstein-Barr virus, and coxsackievirus are common viruses that rarely cause pneumonia. Varicella virus and hantavirus cause lung infection as part of adult chickenpox and hantavirus pulmonary syndrome; a coronavirus causes severe acute respiratory syndrome (SARSsee Respiratory Viruses: Corona Viruses and Severe Acute Respiratory Syndrome (SARS)). Common fungal pathogens include Histoplasma capsulatum (histoplasmosis) andCoccidioides immitis (coccidioidomycosis). Less common fungi include Blastomyces dermatitidis (blastomycosis) and Paracoccidioides braziliensis (paracoccidioidomycosis).Pneumocystis jiroveci commonly causes pneumonia in patients who have HIV infection or are immunosuppressed. Parasites causing lung infection in developed countries include Toxocara canis or T. catis(visceral larva migrans), Dirofilaria immitis (dirofilariasis), and Paragonimus westermani(paragonimiasis). (For a discussion of pulmonary TB or of specific microorganisms, seeMycobacteria.)

Symptoms and Signs

Symptoms include malaise, cough, dyspnea, and chest pain. Cough typically is productive in older children and adults and dry in infants, young children, and the elderly. Dyspnea usually is mild and exertional and is rarely present at rest. Chest pain is pleuritic and is adjacent to the infected area. Pneumonia may manifest as upper abdominal pain when lower lobe infection irritates the diaphragm. Symptoms become variable at the extremes of age; infection in infants may manifest as nonspecific irritability and restlessness; in the elderly, as confusion and obtundation. Signs include fever, tachypnea, tachycardia, crackles, bronchial breath sounds, egophony, and dullness to percussion. Signs of pleural effusion may also be present (see Mediastinal and Pleural Disorders: Symptoms and Signs). Nasal flaring, use of accessory muscles, and cyanosis are common in infants. Fever is frequently absent in the elderly.

Symptoms and signs were previously thought to differ by type of pathogen, but presentations overlap considerably. In addition, no single symptom or sign is sensitive or specific enough to predict the organism. Symptoms are even similar for noninfective lung diseases such as pulmonary embolism, pulmonary malignancy, and other inflammatory lung diseases.

Diagnosis
y y y Chest x-ray Consideration of pulmonary embolism Sometimes identification of pathogen Risk stratification Antibiotics Antivirals for influenza or varicella Supportive measures y y

Treatment
y y y y

Prevention
Some forms of community-acquired pneumonia are preventable with pneumococcal conjugate vaccine (for patients < 2 yr), H. influenzae B (HIB) vaccine (for patients < 2 yr), pneumococcal pneumonia vaccine (for patients at high risk, such as those with underlying heart, lung, or immune system disorders), varicella vaccine (for patients < 18 mo and a later booster vaccine), and influenza vaccine (for patients age 65 and those at high risksee Immunization and see Table 10: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 06 yr ). Oseltamivir

75 mg po once/day or zanamivir 10 mg once/day can be given for 2 wk to prevent influenza (although resistance has recently been described for oseltamivir

) for household contacts of patients with influenza and to high-risk patients not vaccinated against influenza during influenza epidemics. Pneumococcal pneumonia vaccination is recommended for all patients 65