Pneumonia

Question 1

Disease/Illness:

• Community acquired, bacterial, and viral

Answer 1

Pneumonia

Question 2

Essentials of Diagnosis:

• Symptoms and signs of an acute lung infection: Fever or hypothermia, cough with or without sputum, dyspnea, chest discomfort, sweats, or rigors.
• Bronchial breath sounds or rales are frequent auscultatory findings.
• Parenchymal infiltrate on chest radiograph.
• Occurs outside of the hospital or less than 48 hours after admission in a patient who is not hospitalized or residing in a long-term care facility.

Answer 2

Pneumonia

Question 3

General Considerations:

Development of lower respiratory tract infections occurs from:

• Aspiration of secretions containing bacteria.
• Inhalation of infected aerosols.

Pulmonary defense mechanisms usually prevents this development.

• Cough reflex
• Mucociliary clearance system
• Immune responses

Community-acquired occurs:

• When there is a defect in one or more of the normal host defense mechanisms.
• When a very large infectious inoculum or a highly virulent pathogen overwhelms the host.

Answer 3

Pneumonia

Question 4

Pneumonia

Streptococcus pneumonia (accounts for 2/3 of acquired pneumonia) Most COMMON
Haemophilus influenza
Mycoplasma pneumonia
Chlamydia pneumonia
Staphylococcus aureus
Neisseria meningitides
Moraxella catarrhalis
Klebsiella pneumonia
Other gram-negative rods
Legionella species
Pseudomonas aeruginosa

Answer 4

Bacteria are more commonly identified than viruses.

Question 5

Pneumonia

Influenza virus
Respiratory syncytial virus
Adenovirus
Parainfluenza virus

Answer 5

Common viral causes of community acquired disease include:

Question 6

Physical Findings:

• Acute or subacute onset of fever.
• Cough with or without sputum production.
• Dyspnea
• Fever or hypothermia
• Tachypnea
• Tachycardia
• Mild arterial oxygen desaturation.
• Many patients will often appear acutely ill.
• Chest examination is often remarkable for altered breath sounds and rales, crackles
• Dullness to percussion may be present if a par pneumonic pleural effusion is present.

Other common symptoms:
Rigors
Sweats
Chills
Chest discomfort
Pleurisy
Hemoptysis
Fatigue
Myalgias
Anorexia
Abdominal pain

Answer 6

Most patients with community acquired: Pneumonia

Question 7

Patients with ________ infection usually present with:

• Constitutional symptoms such as fever, weight loss, and malaise.
• Cough with expectoration of foul- smelling purulent sputum suggests anaerobic infection.
• Absence of productive cough does not rule out such an infection
• Dentition is often poor.
• Patients are rarely edentulous; if so, an obstructing bronchial lesion is usually present.
• Hypo

Answer 7

Anaerobic pleuropulmonary: Pneumonia

Question 8

Essentials of Diagnosis:

• History of/or predisposition to aspiration.
• Indolent symptoms, including fever, weight loss, malaise.
• Poor dentition.
• Foul-smelling purulent sputum (in many patients).

Answer 8

Aspiration Pneumonia and Lung Abscess

Question 9

General considerations:

Aspiration of small amounts of oropharyngeal secretions occurs during sleep in normal individuals but rarely causes disease.

Sequelae of aspiration of larger amounts of material include:
* Nocturnal asthma
* Chemical pneumonitis
* Mechanical obstruction of airways by particulate matter.
* Bronchiectasis
* Pleuropulmonary infection

Answer 9

Aspiration Pneumonia and Lung Abscess

Question 10

Individuals predisposed to disease induced by aspiration include:

• Those with depressed levels of consciousness.
• Drug or alcohol use
• Seizures
• General anesthesia
• Central nervous system diseases
• Those with impaired deglutition due to esophageal disease or neurologic disorders
• Those with tracheal or nasogastric tubes, which disrupt the mechanical defenses of the airways.
• History periodontal disease and poor dental hygiene
• Increased number of anaerobic bacteria in aspirated material.

Answer 10

Aspiration Pneumonia and Lung Abscess

Question 11

Aspiration Pneumonia and Lung Abscess:

• The onset of symptoms is insidious. By the time the patient seeks medical attention, necrotizing pneumonia, lung abscess, or empyema may be apparent.
• Most aspiration patients with necrotizing pneumonia, lung abscess, and empyema are found to be infected with multiple species of anaerobic bacteria.

Answer 11

Aspiration of infected oropharyngeal contents initially leads to pneumonia in dependent lung zones:

Question 12

Aspiration Pneumonia and Lung Abscess:

• Prevotella melaninogenica
• Peptostreptococcus
• Fusobacterium nucleatum
• Bactericides species

Answer 12

*Most of the remainder are infected with both anaerobic and aerobic bacteria. Commonly isolated anaerobic bacteria:

Question 13

Radiographic findings:

• Range from patchy airspace infiltrates to lobar consolidation with air bronchograms to diffuse alveolar or interstitial infiltrates.
• Additional findings can include pleural effusions and cavitation.
• No pattern of radiographic abnormalities is pathognomonic of a specific cause of pneumonia.
• Progression of pulmonary infiltrates during antibiotic therapy or lack of radiographic improvement over time are poor prognostic signs.
• Clearing of pulmonary infiltrates in patients with community- acquired pneumonia can take 6 weeks or longer.
  Usually fastest in young patients, nonsmokers, and those with only single lung involvement

Answer 13

Pneumonia

Question 14

Treatment:

1. Antipyretics, cough suppressants as needed.
2. Maintain hydration and oral intake.
3. Empiric antibiotic options for patients with community-acquired:

Macrolides
* Clarithromycin
* Azithromycin: 500mg, 250 next 4 days

Teracycline
* Doxycycline

Fluoroquinolones
* Levofloxacin
* Moxifloxacin

Alternatives include:
* Erythromycin
* Amoxicillin-potassium clavulanate
* Cefuroxime
* Cefpodoxime
* Cefprozil

Treat symptomatic

Answer 14

Pneumonia

Question 15

Disposition:

Uncomplicated can usually be treated on an outpatient basis with antibiotics and supportive care.

When to Admit:
* Failure of outpatient therapy, including inability to maintain oral intake and medications.
* Exacerbations of underlying disease that would benefit from hospitalization.
* Complications of pneumonia arise (such as hypoxemia, pleural effusion, sepsis, and encephalopathy).
* Other medical or psychosocial needs:
Cognitive dysfunction
Psychiatric disease
Homelessness
Drug abuse
Lack of outpatient resources
Poor overall functional status

Answer 15

Pneumonia

Question 16

Complications:

Complications vary based on causative agent.

• Empyema
• Endocarditis
• Pericarditis
• Cavitation
• Necrotizing pneumonia
• Skin rashes
• Bacteremia
• Sepsis
• Respiratory failure
• ARDS
• Death

Answer 16

Pneumonia