COMMUNITY ACQUIRED PNEUMONIA

RIYA RAJU VARGHESE

 DEFINITION

Community-acquired pneumonia is defined as pneumonia that is acquired

outside the hospital.
 ETIOLOGY
Many organisms cause community-acquired pneumonia, including bacteria, viruses, and fungi.

Bacterial causes
The most common bacterial causes are
● S. pneumoniae
● H. influenzae
● C. pneumoniae
● M. pneumoniae

❏ S. pneumoniae and MRSA can cause necrotizing pneumonia.

❏ P. aeruginosa is an especially common cause of pneumonia in patients with cystic fibrosis,

neutropenia, advanced acquired immunodeficiency syndrome (AIDS), and/or
bronchiectasis.

❏ Q fever, tularemia, anthrax, and plague are uncommon bacterial syndromes in which
pneumonia may be a prominent feature.
Viral causes
Common viral causes include
● Coronaviruses (since 2020, primarily SARS-CoV-2)
● Respiratory syncytial virus (RSV)
● Adenoviruses
● Influenza viruses
● Metapneumovirus
● Parainfluenza viruses

❏ 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.

❏ Coronaviruses cause severe acute respiratory syndrome (SARS), the Middle

East respiratory syndrome (MERS), and COVID-19.
Other causes

Common fungal pathogens include

● Histoplasma capsulatum (histoplasmosis)
● Coccidioides immitis (coccidioidomycosis).
Less common include
● Blastomyces dermatitidis (blastomycosis)
● Paracoccidioides braziliensis (paracoccidioidomycosis).

❏ Pneumocystis jirovecii commonly causes pneumonia in patients who have

human immunodeficiency virus (HIV) infection or are immunosuppressed .
Parasites causing lung infection in developed countries include
● Toxocara canis or T. catis (toxocariasis)
● Dirofilaria immitis (dirofilariasis)
● Paragonimus westermani (paragonimiasis).

Pneumonia in children
In children, the most common causes of pneumonia depend on age:

● < 5 years: Most often viruses; among bacteria, S. pneumoniae, S. aureus, and
S. pyogenes, are common
● ≥ 5 years: Most often the bacteria S. pneumoniae, M. pneumoniae, or
Chlamydia pneumoniae
 SYMPTOMS AND SIGNS
Symptoms include
● malaise, chills, rigor, fever, cough(productive in older children and adults and dry in infants,
young children, and older adults) , dyspnea(mild and exertional and is rarely present at rest), and
chest pain(pleuritic and is adjacent to the infected area).
● Pneumonia may manifest as upper abdominal pain when lower lobe infection irritates
the diaphragm. Gastrointestinal symptoms (nausea, vomiting, diarrhea) are also
common.
● Infection in infants may manifest as nonspecific irritability and restlessness.
● In older adults, the infection may manifest 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. Nasal flaring, use of accessory muscles, and cyanosis
are common among infants. Fever is frequently absent in older patients.
 DIAGNOSIS

Diagnosis of pneumonia is suspected on the basis of clinical presentation and infiltrate seen on chest
xray. When there is high clinical suspicion of pneumonia and the chest x-ray does not reveal an
infiltrate, doing computed tomography (CT) or repeating the chest x-ray in 24 to 48 hours is
recommended.
Typically, testing includes oxygen saturation, complete blood count, and a basic or complete
metabolic profile.

Differential diagnosis
● acute bronchitis
● chronic obstructive pulmonary disease (COPD)
● heart failure
● organizing pneumonia
● hypersensitivity pneumonitis
● pulmonary embolism
In outpatients with mild pneumonia, no further diagnostic testing is
needed.
In patients with moderate or severe pneumonia, a WBC count and
measurement of electrolytes, blood urea nitrogen (BUN), and
creatinine are useful to classify risk and hydration status. Pulse
oximetry or arterial blood gas (ABG) testing should also be done to
assess oxygenation. Those who require hospitalization, 2 sets of blood
cultures are obtained to assess for bacteremia and sepsis.

Pathogen identification
Diagnosis of etiology can be difficult. A thorough history of
exposures, travel, pets, hobbies, and other exposures is essential to
raise suspicion of less common organisms.
Chest x-ray findings are
suggestive:
● Multilobar infiltrates suggest S. pneumoniae
or Legionella pneumophila infection.
● Interstitial pneumonia (on chest x-ray, appearing
as increased interstitial markings and subpleural
reticular opacities that increase from the apex to
the bases of the lungs) suggests viral or
mycoplasmal etiology.
● Cavitating pneumonia suggests S. aureus or a
fungal or mycobacterial etiology.
Pneumonia of the Right Lower Lobe
This chest x-ray shows an infiltrate that does not obscure the
right heart border (ie, there is no silhouette sign). the part of the
lung affected by this infiltrate is the part not contiguous with the
right heart border; that part is the right lower lobe.
● Blood cultures, About 12% of all patients hospitalized with
pneumonia have bacteremia; S. pneumoniae accounts for two
thirds of these cases.

● Sputum testing can include Gram stain and culture for

identification of the pathogen. It also allows for testing for viral
pathogens via direct fluorescence antibody testing or
polymerase chain reaction (PCR). In patients whose condition is
deteriorating and in those unresponsive to broad-spectrum
antibiotics, sputum should be tested with mycobacterial and
fungal stains and cultures.
● Urine testing for Legionella antigen and pneumococcal antigen are simple and rapid and have
higher sensitivity and specificity than sputum Gram stain and culture for these pathogens.

● The pneumococcal antigen test is recommended for patients who are severely ill; have had
unsuccessful outpatient antibiotic treatment; or who have pleural effusion, active alcohol
abuse, severe liver disease, or asplenia.

● COVID-19 test using reverse transcriptase-polymerase chain reaction (RT-PCR) testing of

respiratory secretions (nasopharyngeal specimen is preferred) is recommended in patients
presenting with pneumonia during the current pandemic.

● Serum procalcitonin can help distinguish bacterial infection

from other causes of infection or inflammation.
 Treatment
Intensive care unit (ICU) admission is required for patients who-
● Need mechanical ventilation
● Have hypotension (systolic blood pressure ≤ 90 mm Hg) that is unresponsive to volume
resuscitation

Other criteria, especially if ≥ 3 are present, that should lead to consideration of ICU admission include
● Hypotension requiring fluid support
● Respiratory rate >30/minute
● PaO2/fraction of inspired oxygen (FIO2) < 250
● Multilobar pneumonia
● Confusion
● Blood urea nitrogen (BUN) > 19.6 mg/dL (> 7 mmol/L)
● Leukocyte count < 4000 cells/microL (< 4 × 109/L)
● Platelet count < 100,000/microL (< 100 × 109/L)
● Temperature < 36° C
Their are prediction rules which has led to a reduction in unnecessary hospitalizations for patients who
have milder illness.one such is CURB-65 , in that 1 point is allotted for each of the following risk factors:

● Confusion
● Uremia (BUN ≥19 mg/dL [6.8 mmol/L])
● Respiratory rate > 30 breaths/minute
● Systolic Blood pressure < 90 mm Hg or diastolic blood pressure ≤ 60 mm Hg
● Age ≥ 65 years

Scores can be used as follows:

● 0 or 1 points: Risk of death is < 3%. Outpatient therapy is usually appropriate.

● 2 points: Risk of death is 9%. Hospitalization should be considered.
● ≥ 3 points: Risk of death is 15 to 40%. Hospitalization is indicated, and, particularly with 4 or 5 points, ICU
admission should be considered.
Treatment for adults

EMPIRICAL OF CAP -EMPIRICAL TREATMENT OF CAP -Outpatient

Outpatient

For syndromes suggesting typical bacterial pneumonia: amoxicillin-clavulanate with the

addition of azithromycin if legionella species are a consideration; levofloxacin or moxifloxacin
may be used instead.

• For syndromes suggesting influenza pneumonia: oseltamivir with observation for secondary
bacterial infection

For syndromes suggesting viral pneumonia other than influenza: symptomatic therapy

• For syndromes suggesting mycoplasma or chlamydophila pneumonia: azithromycin or

doxycycline
 EMPIRICAL TREATMENT OF CAP - Inpatient

• For initial empirical therapy: a beta-lactam (ceftriaxone, cefotaxime, or ceftaroline) plus

azithromycin; levofloxacin or moxifloxacin may be used instead

• If influenza is likely: oseltamivir

• If influenza is complicated by secondary bacterial pneumonia: ceftriaxone or cefotaxime

plus either vancomycin or linezolid in addition to oseltamivir

If Staphylococcus aureus is likely: vancomycin or linezolid in addition to the antibacterial

regimen

• If pseudomonas pneumonia is likely: antipseudomonal beta-lactam (piperacillin-tazobactam,

cefepime, meropenem, or imipenem- cilastatin). plus azithromycin
TREATMENT FOR CHILDREN

For children treated as outpatients, treatments are dictated by age:

● < 5 years: Amoxicillin or amoxicillin/clavulanate is usually the drug of choice. If atypical

pathogen as the cause a macrolide (eg, azithromycin, clarithromycin) can be used
instead.
● ≥ 5 years: Amoxicillin or amoxicillin plus a macrolide. Amoxicillin/clavulanate is an alternative.

For children treated as inpatients, antibiotic therapy tends to be more broad-spectrum and depends
on the child's previous vaccinations:

● Fully immunized (against S. pneumoniae and H. influenzae type b): Ampicillin or penicillin
G (alternatives are ceftriaxone or cefotaxime).
● Not fully immunized: Ceftriaxone or cefotaxime (alternative is levofloxacin).

If MRSA is suspected, vancomycin or clindamycin is added and

If an atypical pathogen suspected , a macrolide is added.(both case)
ANTIVIRAL THERAPY FOR VIRAL PNEUMONIA

Ribavirin is not used routinely for respiratory syncytial virus

pneumonia in children or adults but may be used occasionally in
high-risk children age < 24 months.
For influenza, oseltamivir or zanamivir.Alternatively,

baloxavir. Acyclovir is recommended for varicella lung

infections.

Though pure viral pneumonia does occur, superimposed

bacterial infections are common and require antibiotics directed
against S. pneumoniae, H. influenzae, and S. aureus.
 Case presentation

A 66-year-old man accompanied by his wife, arrived at the Emergency Department

complaining of shortness of breath, fever, and cough. His symptoms started 8
days ago with mild fever, cough, myalgia, headache & sore throat were he received
antipyretic, antihistamine and cough syrup after consulting his family doctor
through a telephone call.
After initial improvement, he had a worsening of symptoms starting 3 days ago
with productive cough, pleuritic chest pain, fever, chills and malaise.
Last night he developed dyspnea and high fever, so he decided to come to the
Emergency Department today.
Medical History

•X-smoker 2 years (30 pack years).

• COPD.
• Type 2 diabetes.
• Medications include
• Inhaled salbutamol (100 ug)+ beclomethasone diproprionate (50 ug) 2 puffs x 3.
• Sustained release theophylline (200mg cap 1x2).
• Gliclazide (80mg tab. 1x1).

Examination

• Confused.
• Temperature: 39.0°C.
• Blood pressure: 120/70.
• Pulse rate: 120 bpm.
• Respiratory rate: 30 per minute.
• Clinical signs of right upper zone consolidation and bilateral scattered rhonchi.
• No cyanosis, pedal edema or jugular venous distension is noted.
Lab — • Hgb 13.4 gm/dI, Hct 40%.
• WBC 15,800/ul with 88% polymorphonuclear cells, 8% bands.
• Na+ 137 mEq/L, K+ 3.7 mEq/L.
• BUN 32 mg/dl, creatinine 1.8 mg/dl.
• RBG 260 mg/dl.
• Arterial blood gas (room air):
pH 7.38, PCO 53 mmHg, PO 58 mmHg, 02 Sat- 89%

Sputum (gram stain)→Gram-positive diplococcus

Sputum culture & Sensitivity: Positive for Streptococcus pneumoniae

Differential diagnosis

● Community acquired pneumonia

● acute bronchitis
● chronic obstructive pulmonary disease (COPD)
TREATMENT

• Fluid & Antipyretics (Paracetamol IV)

• Sugar blood chart & Insulin accordingly
• Cough syrup
• SR theophylline
• Inhalation ttt → salbutamol + ipratropium bromide
• 0, therapy → NP 2 L/min
• Empiric Antibiotic- Levofloxacin 750 mg/24h + Ceftriaxone 1gm /12h IV
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