>educational:

>other:

>administrative:

>contact us:

>resp notes:

>downloads:

>go back to:

Pneumonia

Classification

Pattern of infection
- lobar pneumonia (in healthy patients)
- bronchopneumonia (in ill patients)

Aetiology
- CAP (community acquired pneumonia)
- HAP (hospital acquired pneumonia): nosocomial, occurring ³ 2 days after admission
- aspiration
- in the immunocompromised

[Return to top]

---

Clinical features

Chest symptoms
- fever
- cough
- pleurisy
- dyspnoea

Systemic syptoms
- headache
- confusion
- malaise
- myalgia

Typical pneumonia
- chest symptoms > systemic symptoms

Atypical pneumonia
- systemic symptoms > chest symptoms (also prolonged prodrome)

[Return to top]

---

Organisms in CAP

Typical
- Streptococcus pneumoniae (> 60%)
- Haemophilus influenzae

Atypical
- Mycoplasma pneumoniae (5–18% )
- Legionella spp.
- Chlamydia psittaci
- Staphylococcus aureus

Viral
- RSV (10%)
- influenza

Timing
< 5 days = CAP

> 5 days = S. aureus (esp. post-influenza), Gram -ves (P. aeruginosa, Klebsiella, E. coli, enterobacter), anaerobes (esp. aspiration pneumonia)

[Return to top]

---

Severity

CURB
- Confusion (new-onset, AMT - Urea > 7 mM
- RR > 30
- BP < 90 / 60 mmHg

Severe CAP
- = CURB >/=2 (mortality > 20-80%)

Other factors
- WCC > 12 or < 4
- Temp > 38 or < 32
- age > 65
- PaO2 < 8
- multiple lobes

[Return to top]

---

Investigation of suspected bacterial pneumonia

Urine
- Legionella Ag
- Pneumococcal Ag
- Hb haemolysis with mycoplasma cold agglutinins

- (Sputum: culture )

Bloods
- culture (FBC, U+Es, LFTs, CRP)
- atypical serology (days 0, 10) if CURB >/= 2
- ± ABGs (if SaO2 =/< 92%)

Pleural aspirate
- MC+S

CXR
- consolidation (air bronchogram)
- effusion
- abscess

- post-resolution CXR (exclude cancer, esp. in smokers)

± Special
- CT: detect complications
- bronchoscopy: exclude cancer in smokers > 50 years

[Return to top]

---

Management of CAP

A
B: O2
C: fluids

Antibiotics
- CURB = 0* amoxycillin PO 500 mg TDS or erythromycin PO 500 mg QDS (if penicillin sensitivity)

- CURB = 1* admit & amoxycillin PO/IV 500 mg TDS or erythromycin PO/IV 500 mg QDS

- CURB > 1* admit & cefuroxime IV 1.5g TDS & erythromycin IV 500 mg QDS

* also use clinical judgement to decide if need to manage as out or in-patient and whether to use (IV) cefuroxime

[Return to top]

---

Failure to improve

Measure
- expect 50% decrease in CRP at day 4

Causes
- W: wrong diagnosis (PE, oedema, cancer, bronchiectasis)
- A: atypical / resistant pathogen
- C: complication
- S: overwhelming sepsis

[Return to top]

---

Complications of pneumonia

Local
- parapneumonic effusion
- empyema
- abscess
- pneumothorax
- ARDS

Distant
- septicaemia
- renal failure
- haemolytic syndrome

[Return to top]

---

Prevention

Vaccination
- pneumococcal (Pneumovax II)
- influenza

If...
- elderly
- chronic disease (heart, lung, liver, kidney)
- DM
- asplenic (including sickle-cell)
- immunosuppression (HIV)

Supportive
- O2
- fluids
- physiotherapy

Antibiotics
- cefotaxime + gentamicin

or meropenem
or piperacillin / tazobactam (Pseudomonas)
or metronidazole (anaerobes - if ? aspiration)
or vancomycin (MRSA)

or amphotericin (if ? fungal in immunosuppressed patients)

[Return to top]

---