Pneumonia

• Pleurisy, Dyspnea, Hemoptysis
• High fever or hypoothermia, tachypnea, tachycardia
• Crackles
• Bronchial breath sounds
• Tactile fremitus
• Lung consolidation findings (dullness to percussion, egophony, whispered pectoriloquoy, bronchophony, bronchial breath sounds)

Admit to the hospital (there is an increased liklihood of pneumonia, especially in the elderly)

• Chest Xray (visible infiltrates)
• CBC, BMP, BNP
• Pulse Oximetry

For inpatient: blood gasses & sputum culture

Pneumonia acquired outside of hospital or extended care facility

Acute infection of the pulmonary parenchyma that is asssociated with at least two symptoms of acute infection (ex: fever, cough, dyspena) and accompanied by an acute infiltrate on chest x-ray

• Hospitalized >2 days in past 3 months
• Resident of skilled nursing facility
• Receiving IV antibiotics, chemotherapy or wound care
• Receiving hemodialysis

• Smokers
• Alcoholics
• HIV disease
• Any immune deficiencies

Determine which patients can be treated at home

Provide empiric treatment based on likely pathogens uncovered in patient’s history

Sudden chill followed by a fever, pleuritic pain, and productive cough

Begins with a sore throat and headache followed by a non-productive cough and dyspnea

Aspiration Pneumonia

Classic presentaton - abrupt onset fever, cough wth rusty sputum, pleuritic chest pain

• Bacteremia
• Meningitis
• Endocarditis
• Pericarditis
• Empyema

• Respiratory tract infection (especially influenza)
• Common nosocomial infection

patients are extremely ill, produces lung necrosis and multiple small lung abcesses.

• Common nosocomial infection
• IV drug users

• Can cause bacteremia with metastatic seeding of distant sites such as the endocardium, bone, joints, liver, and meninges
• Empyema
• Cavitation
• Pt often left with residual pulmonary fibrosis

X-ray shows a typical bronchopneumia pattern

Sputum: abundant polymorphonuclear leukocytes and small pleomorphic gram- coccobaccili

Pleural Effusion 30%

• Smoking
• COPD

Klebsiella pneumonia is cased by gram negative bacilli and is commonly seen in debilitated or alcoholic patients.

dense lobar consolidation

tissue necrosis (hemoptysis) - sputum maybe dark red and mucoid (like currant jelly)

high incidence of abcess formation

• Often begins with headache,malaise,sore throat and progresses to non-productive cough
• Common in late summer/early fall
• Spread by respiratory droplets
• Long incubation period
• 50% Household spread
• 5-25 Years old; Increasing age prevalence
• Ear pain 30%
• Myringitis/bullae 15%
• Skin exam may show erythema multiform
• WBC <10,000 80% cases

Patchy / Broncho-pneumonia

• Cold Agglutinins titer >1:64. Present in 50% cases
• New PCR test—not widely available

Treat with macrolide or tetracycline

mycoplasma pneumonia

presents with fever, dry cough, non-specific chest film

treat with tetracycline or macrolide

• Low grade fever, productive cough
• more common in winter months
• self-limiting

patchy bronchopneumonia

• underlying pulmonary disease
• alcoholism
• diabetes
• malignancy

• COPD
• Alcoholism
• smoking
• male sex
• immunosuppression

Initial - Fever, Nonproductive cough, N/V, Myalgias, dyspnea, pleuritic chest pain

Intermediate - CHEST PAIN, CONFUSION, DIARRHEA & RELATIVE BRADYCARDIA

Extrapulmonary findings: Myocarditis, pericarditis, rhabdomyolysis, renal dysfunction

• Sputum - Many PMNs & No Bugs
• Hyponatremia <130; Chest pain (30%)
• Diarrhea; Neurological symptoms
• Rapid progression

X-ray-interstitial infiltrates, or areas of patchy consolidation

Cultures poorly (needs buffered charcoal yeast extract agar)

Urinary antigen 80% sensitive

SEROLOGY IgG 1:256 DIAGNOSTIC

Epidemics traced to contaminated cooling systems, whirlpool baths, and potable water

Some authorities feel that the following constellation of clinical features suggests this diagnosis: high fever, hyponatremia, CNS manifestations, lactate dehydrogenase levels of >700 U/mL, or severe disease

For patients who do not require hospitalization, acceptable antibiotics include:

• Erythromycin
• Doxycycline
• Azithromycin
• Clarithromycin
• fluoroquinolone

DO NOT Treat with Penicillins

Drugs, anesthesia, alcohol, head trauma, diminution of gag reflex, edentulous patients

Usually a mixed infection caused by anerobic and aerobic organisms—normal flora of mouth

right middle lobe infiltrates

mycoplasma

legionnaires

viruses

mycoplasma

pneumococcus, TB

ZITHROMAX 500MG QD OR BIAXIN 500mg BID OR ERYTHOMYCIN 500mg QID (for 7-14 days)

Doxycycline 100mg po BID

• 3rd or 4th generation quinolone (some resistances)
• Ketek (telithromycin)

Consider daily injection (1gm) of rocephin (ceftriaxone) until cultures are back

• Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or Levaquin)
• Beta lactam **PLUS** Macrolide

• Adequate hydration essential
• Increased fluid intake, local airway humidification
• Expectorants may help loosen sputum (Guaifenesin)
• Cough suppression not recommended
• Fever controlled with aspirin or tylenol

• AGE > 65?; Temp >101
• Physical exam findings: Change in level of consciousnessSYSTOLIC B/P 90mmHg; PULSE >120; RESP >30Dehydration, vomitingHypothermia

• Laboratory or radiographic findings: Bilateral infiltrates, pulmonary edema, pleural effusion
• Sodium <130; BUN >50; CREAT >2.0; K+>5.5/<3.2, glucose >250, PO2 <60mm Hg ON R.A., WBC < 5,000 / > 20,000; HCT <30 PLTs <100,000

• Abrupt onset of illness
• Significant comorbid illness
• Neoplastic disease, liver disease, renal disease, CHF Impaired host defense - COPD, HIV, diabetes, alcoholism
• Suppurative pneumonia related infection - Empyema, septic arthritis, meningitis, endocarditis
• Failure to respond to outpatient treatment within 24-48 hours

• Medical or psychosocial needs:
• Cognitive dysfunction Psychiatric disease, Homelessness, Drug abuse, Lack of outpatient resources, Poor overall functional status

• Confusion
• BUN >20
• Respiratory rate > 30 breaths/min
• Blood pressure <90/60
• Age <65

• Patients with 0-1 criterion should be treated as outpatients
• Patients with 2 criteria should be hospitalized on a general medical floor
• Pts with 3 or more criterion should be admitted to ICU

All patients should be re-evaluated within 48-72 hours for improvement

Decreased fever, tachypnea, WBC

If patient admitted, should be followed up 48 hours after discharge

Follow up chest x-ray in 2-3 months weeks for all over age 40, all smokers or ex-smokers

• Pneumovax > age 65 or any chronic illness
• Influenza vaccine yearly
• Smoking cessation
• Avoid proton pump inhibitors

typical pneumonia is usually caused by bacteria such as streptococcus pneumonia. Atypical pneumonia is usually caused by the influenza virus, mycoplasma, chlamydia, legionella, adenovirus or other unidentified microorganism.

Age is the main differentiating factor between typical and atypical pneumonia. Young adults are more prone to atypical causes, very young and older persons are more perdisposed to typical causes