(RQUEIGGAAs the most common URTI and is usually caused by (GIGNTSTAEIGH The usual symptoms are general malaise, nasal dis- charge, sneezing and cough. Involvement of the pharynx causes a sore throat, and that of the larynx a hoarse or ‘lost’ voice. If complicated by tracheitis or bronchitis, chest tightness and wheeze typical of asthma occur. Specific investigation is rarely warranted and treatment is symp- tomatic. Symptoms usually resolve quickly, but (SBSaISaNUIAIS ‘go to the chest’, a more (QEiT&IGIAGHOSISONeStiIma ought to be considered. A variety of viruses causing URTI may also trigger exacerbations of asthma or COPD and aggravate other lung diseases.Figures from the UK suggest that an estimated 5-11/1000 adults suffer from community-acquired pneumonia (CAP) each year, accounting for around 5%-12% of all lower respiratory tract infections. CAP may affect all age groups but is commonest at the extremities of age. Most cases are spread by droplet infection, and while CAP may occur in previously healthy individuals, several factors may impair the effectiveness of local defences and predispose to CAP (Box 17.36). (Fig. 17.31) remains the most common infecting agent, and thereafter the likelihood that other organisms may be involved depends on the age of the patient and the clinical context. @i) (GSBIBID ave recognised as important causes of CAP in children and their contribution to adult CAP is increasingly recognized. The common causative organisms are shown in Box 17.37. Clinical features Pneumonia, particularly lobar pneumonia, usually presents as an acute illness. GYStSRIGHESIURES) such as fever, rigors, shivering and malaise, predominate and delirium may be present. The appetite is invariably lost and headache frequently reported. include cough, which at first is characteris- tically short, painful and dry, but later is accompanied by the expec- toration of mucopurulent sputum. Rust-coloured sputum may be produced by patients with Strep. pneumoniae infection and the occa- sional patient may report haemoptysis. Pleuritic chest pain may be a presenting feature and on occasion may be referred to the shoulder or anterior abdominal wall. Upper abdominal tenderness is sometimes apparent in patients with lower lobe pneumonia or those with asso- ciated hepatitis. Less typical presentations may be seen in childhood and old age.GEARED should first focus on the respiratory and pulse rates, blood pressure and an assessment of the mental state, as these are important in assessing the severity of the illness. In the UK, severity is assessed using @URERSSISEORED which takes into account both examination and investigation findings (Fig. 17.32). CREStISighs\Wary)) ‘thrOUgholit) An assessment of the state of nutrition is important, par- ticularly in old age and frailty. The presence of herpes labialis may point to streptococcal infection, as may the finding of ‘rusty’ sputum. The differential diagnosis of pneumonia is shown in Box 17.38. Infections of the respiratory system * 583 = T ? Likely to be sutable for | Consider hospital-supervsed | Manage in hospital as home treatment treatment ‘Severe pneumonia Options may incude ‘Assess fo ICU admission, Inpatient especially if CURB-6S Shar {Hospiarauperised oupaten| _Seore=dc8 Fig, 17.32 Hospital CURE-65.“Detns asa mea ts sce of 8 rss, or new Bsonenaton person, pace ome CU = tee cae unt @ wea 7 mmol = 20 mg| Do eT Cigarette smoking Nd age | © Upper respiratory act Recent influenza infection | infections « Pre-existing lung disease ‘+ Aicoho! oHV | © Glucocorticoid therapy ‘Indoor air pollution En Bacteria * Streptococcus pneumoniae * ‘Staptylococcus aureus. | BALL ee) | | © Mycoplasma pneumonize ptaci | ‘© Legionella pneumophila Coxiella umeti(Q fever) | | ‘© Chiamycia preumoniae ‘Neasiela pneumoniae || = Haemopniusinuencae (Freidanders baci) | y | | Viruses >| | Intuenza, paranfivenza + Adenovius| 1 | | + Measies + Cytomegaiovrus | ; | | © Herpes simplex + Coronavruses (SARS-O0V and t Varela ERS-Co¥) | | a a | ens = made Est espraty store, SARS = ever acu reepratry 11 | syncrame) 17.38 Differential diagnosis of pneumonia | © Pulmonary infarction ;° Pulmonary/pleural tuberculosis | © Pulmonary oedema (can be unilateral) | ¢ Pulmonary eosinophilia | © Malignancy: bronchoalveolar cell carcinoma © Cryptogenic organising pneumonia/bronchiolitis obliterans organising pneumonia (COP/BOOP)17.42 Complications of pneumonia Para-pneumonic effusion - common Empyema Retention of sputum causing lobar collapse Deep vein thrombosis and pulmonary embolism Pneumothorax, particularly with Staphylococcus aureus Suppurative pneumonia/lung abscess | ARDS, renal failure, multi-organ failure Ectopic abscess formation (Staphylococcus aureus) Hepatitis, pericarditis, myocarditis, meningoencephalitis Arrhythmias (e.g. atrial fibrillation) Pyrexia due to drug hypersensitivity ecececeee (ARDS = acute respiratory distress syndrome) ec ue EE Blood | Full blood count | © Very high (>20x 10%) or low (<4%10°/L) white cell count: marker | of severity | © Neutrophil leucocytosis >15x10°/L: suggests bacterial aetiology ‘* Haemolytic anaemia: occasional complication of Mycoplasma Urea and electrolytes © Urea >7 mmol. (~20 mg/dl): marker of severity ‘© Hyponatraemia: marker of severity Liver function tests © Abnormal if basal pneumonia inflames liver © Hypoalbuminaemia: marker of severity Erythrocyte sedimentation rate/C-reactive protein | © Non-specificlly elevated | Blood culture | * Bacteraemia: marker of severity fe Cold agglutinins © Positive in 50% of patients with Mycoplasma Arterial blood gases | © Measure when Se, <93% or when clinical features are severe, to | assess ventilatory failure or acidosis| Sputum | Sputum samples * Gram stan See Fig, 1731), culture and antimicrobial sensituty | testing | Oropharym swab ‘+ Palymerase chan reaction for Mycoplasma pneumoniae and other atypical pathogens Urine ‘+ Pheumacoocal andor Legonela antigen Chest X-ray Lobar pneumonia ‘Patchy opactcaton evoves into homogeneous consolidation of fected lve ‘Air bronchogram air-fled bronchi appear lucent against consolidated lung tissue) may be present (Fig, 17 33) Bronchopneumonia ‘Typically patchy and segmental shadowing Complications ‘+ Para-pneumonic effusion, intrapulmonary abscess or empyema | Staphylococcus aureus ‘Suggested by muitiovarstadowing,cawtaton, pneumatocees and abscesses Pleural fluid * Atays asptat and cuitue when present in more than trial amount, preferably with ultrasound guidance Fg. 1738 Poumon one ng mate ne.) Pe ranma ocr ao ng (Bars ve exenate coseTypical CAP 1, Common agents a b. Haemophilus influenzae (15%) ©. Aerobic gram-negative rods (6% to 10%)—Klebsiella (and other Enterobacteriaceae) d. S. aureus (2% to 10%) 2. Clinical features a. Symptoms * Acute onset of fever and shaking chills « Pleuritic chest pain (suggests pleural effusion) * Dyspnea b. Signs * Tachycardia, tachypnea 3. Chest radiograph (CXR) a b. Multilobar consolidation indicates very serious illness | C. Atypical CAP 1. Common agents Mycoplasma pneumoniae (most common) Chlamydia pneumoniae Chlamydia psittaci Coxiella burnetii (Q fever) Legionella spp. Viruses: influenza virus (A and B), adenoviruses, parainfluenza virus, RSV 2. Clinical features a. Symptoms ‘+ Insidious onset—headache, sore throat, fatigue, myalgias ‘+ Dry cough (no sputum production) ‘© Fevers (chills are uncommon) b. Signs ‘+ Pulse-temperature dissociation—normal pulse in the setting of high fever is suggestive of atypical CAP © Wheezing, rhonchi, crackles © CXR | * Diffuse reticulonodular infiltrates ‘© Absent or minimal consolidationOxygen should be administered to all patients with (265) SHOSaNEypOR Jo maintain the target oxygen saturations specified on p. 195. Continuous positive airway pressure @PAB) should be considered in those who remain hypoxic despite high-concentration oxygen therapy, and these patients should be managed in a high- dependency or intensive care environment where (ii@@HaniGalVermlaton is available. Indications for referral to an intensive care unit are summa- rised in Box 17.40, Intravenous fluids should be considered in those with severe illness, in older patients and those with vomiting. It may be appropriate to discon- tinue hypertensive agents temporarily, particularly if there is evidence of acute kidney injury secondary to sepsis. Otherwise, an adequate oral intake of fluid should be encouraged. Vasopressor support may be required in patients with shock. Prompt administration of appropriate antibiotics improves the outcome. The initial choice of antibiotic is guided by clinical context, severity assess- ment, local knowledge of antibiotic resistance patterns and antibiotic Quidelines. Current regimens are detailed in Box 17.41. in most patients with uncomplicated pneumonia @(SS@aICOUBENSTSGSEUATS although treatment is usually required for longer in patients with pneumonia due to Legionella pneumophila, Staph. aureus or Klebsiella pneumoniae. It is important to relieve pleural pain in order to allow the patient to breathe normally and cough efficiently. For the majority, simple analgesia with SERSSEOREOESSEMONSMNSAIDS is sutficient. In some patients, opiates may be required but must be used with extreme caution in indi- viduals with poor respiratory function. (PRYSIGHREPEBY is not usually indicated in patients with CAP, although it may be helpful to assist expectoration in patients who suppress cough because of pleural pain.FP 17.41. Antibiotic treatment for community-acquired I [iscabds cde eal ‘Low severity CAP (CURB-65 score 0-1) '* Amasécillin 500mg 3 times dally orally or IV if necessary") If patient is allergic to penicilin | | + Doneyeine 200m9 aang dose ten 100mpay ray or cathromycn | 500mg twice daily orally ‘Moderate severity CAP (CURB-65 score 2) ‘Amoxicilin 500 mg~1 g 3 times daily orally (or IV if oral medication not (possible?) or benzyipenicilin 1.2g 4 times daily IV '* plus clarithromycin 500 mg twice daily orally/V Mt patient is allergic to penicillin '* Doxycycline 200 mg loading dose then 100 mg/day orally or levofloxacin ‘500 mpg/day orally | Seesra.C Clee so score 2.) + Co-amoniclay 1.29 3 times daily IV or cefuroxime 1.59 3 times daily WV or ceftriaxone 1-2 daily IV © plus clarithromycin 500mg twice daily IV + orberaipenilin 1.294 times daly Vu levolaxacin 500mg twice dy If Legionella is strongly suspected + Consider zotng levtoxan 500mg toe daly ‘Wret e w ua perts rde oacmi gucce a0 ats Se) pater reasons woud ncuaeerpared corscousess, pared svaloweg rex rd onal | arto reasons fr maabeopten (QB ~ se i 17 32: N = ravers) | ‘Aexpted hon Ben Thrace Sacer denehealthcare- associated infection (HAI) after surgical-site infections and the leading cause of HAl-associated death. OIGeripatiéntS are particularly at risk, as are patients in intensive care units. The term ventilator-associ- ated pneumonia @¥AB)is used to describe pneumonia that develops in a person who is mechanically ventilated. The factors predisposing to the development of HAP are listed in Box 17.43, Clinical features and investigation The diagnosis should be considered in a - patient who ocytosis or leuc openia SPA CMe eee es LB) TT cae Reduced host defences against bacteria | © Reduced immune defences (e.g. glucocorticoid treatment, diabetes, malignancy) * Reduced cough reflex (e.g. post-operative) © Disordered mucociliary clearance (e.g. anaesthetic agents) * Bulbar or vocal cord palsy Aspiration of nasopharyngeal or gastric secretions * Immobilty or reduced conscious level * Vomiting, dysphagia (N.B. stroke disease), achalasia or severe reflux © Nasogastric intubation |_| Bacteria introduced into lower respiratory tract © Endotracheal intubation/tracheostomy © Infected ventilators/nebulisers/bronchoscopes ‘ | © Dental or sinus infection Bacteraemia © Abdominal sepsis ie Intravenous cannula infection | © Infected emboli(aap an ear ang 00/125 1g ary te 5 Or a sme ‘2001 on ety an 10019 yr 4p ay cure Pen row 3 es br 503s rere 459 4 ys son 2930nes0m 20a oxy 7 43 recy resid 59493 ns oy sera 0591 103tnes aay 201593 bes ny _ 01 yn ye a emgn Here a Sofia 209g eso wc ly aca cag ose vercomjon crcarrain (ead coe 25 mgng © 20mg CaN udm ‘ereaay pape) marun 29 pe ae ity Brg Wen dy 3 ms, en mpg oy 000mg no cy or Pneumonia Pearls « Inalcoholics, think of Klebsiella pneumoniae; in immigrants, think of TB. + In-nursing home residents, consider a nosocomial pathogen and predilection for the upper lobes (eg, Pseudomonas), + HIV-positive patients are at risk for P. carinii and M, tuberculosis, but are still more likely to have a typical infectious agent. + Legionella pneumonia is common in organ transplant recipients, patients with renal failure, patients with chronic lung disease, and smokers and presents with GI symptoms and hyponatremia. Legionella pneumonia ‘srare in healthy children and young adults,| ee These conditions are considered together, as their aetiology and clinical features overlap. GUSBUREINEISNSUMIORINs characterised by GESTS of he ung enh malbyieinTORBROGES nce abscess formation is a characteristic histological feature, (UNO) (@GSCESS is usually taken to refer to lesions in which there is a large local ised collection of pus, or a cavity lined by chronic inflammatory tissue from which pus has escaped by rupture into a bronchus Symptoms © Cough with large amounts of sputum, sometimes fetid and blood-stained Pleural pain common © Sudden expectoration of copious amounts of foul sputum if abscess tuptures into a bronchus Clinical signs High remittent pyrexia Profound systemic upset Digital clubbing may develop quickly (10-14 days) Consolidation on chest examination; signs of cavitation rarely found Pleural rub common Rapid deterioration in general health, with marked weight loss if not adequately treated[Chest X-ray with lung abscess. . Treatment 1. Hospitalization is often required if lung abscess is found. Postural drainage should be performed. 2. Antimicrobial therapy. a. Antibiotic regimens include coverage for the following: * Gram-positive cocci—ampicillin/sulbactam or amoxicillin/clavulanic acid, ampicillin/sulbactam, or vancomycin for S. aureus. Anaerobes—clindamycin or metronidazole. © If gram-negative organisms are suspected, add a fluoroquinolone or ceftazidime. b. Continue antibiotics until the cavity is gone or until CXR findings have improved considerably—this may take months!