Pneumonia is an inflammation of the lung parenchyma caused by pathogenic microorganism. Various bacterial species, fungi and viruses may cause it.
The setting in which infection is acquired
could be a predictor of the infecting pathogen.
Bacterial Pneumonia: is defined as bacterial infection of the lung parenchyma associated with recently developed radiological shadowing which may be segmental, lobar or multi lobar.
- Community Acquired Pneumonia (CAP)
- Hospital Acquired pneumonia (HAP)
- Ventilator Associated pneumonia (VAP)
- Health care Pneumonia (HCAP)
- Pneumonia in the immunocompromised
- Aspiration pneumonia
Streptococcus pneumoniae is the most common pathogen in community-acquired pneumonia
Common bacteria causing CAP:
- Streptococcus pneumoniae
- Mycoplasma pneumonia
- Legionella pneumophilia
- Chlamydia pneumonia
- Haemophilus influenza
- Staphylococcus aureus
- Chlamydia psittaci
- Coxiella burnetti
- Klebsiella pneumonia
- Actinomyces israelli
Other causative organisms:
- Pseudomonas aeruginosa (usually implicated in nosocomial pneumonia)
- Sudden onset fever, chills and rigors
- Cough with purulent sputum production
- Pleuritic chest pain
- Breathlessness with short inspiratory efforts
- Herpes labialis
- Signs of lung consolidation.
- Pleural friction rubs.
- Chest signs are very helpful depending on the phase of the inflammatory response
- Dull percusision
- Increased Tactile and vocal fremitus
- Bronchial breath sounds
- Whispering pectoriloquy
Signs of severity
- Urea> 7mmol/L
- Respiratory rate > 30/min
- Systolic BP<90
- Age 65years
Score 1 point for any of the above features present
- 0 or 1 – home treatment
- 2 – Hospital-supervised treatment
- 3 or more – manage in Hospital as severe pneumonia
- 4 or 5 – ICU Admission
- Gradual onset
- Dry cough
- Prominent extra-pulmonary symptoms
- Sore throat
- Chest crackles or rales
- Acute bronchitis
- COPD Exacerbation.
- Pulmonary embolism/infarction
- Pulmonary eosinophilia
- Empyema Thoracis
- Pleural effusion.
- Lung abscess
- Lobar collapse
- Deep vein thrombosis and pulmonary embolism
- Multi organ failure
- Hepatitis, pericarditis, myocarditis,
- Pyrexia from drug hypersensitivity
- Serum E/U/Cr
- Blood Culture
- Cold agglutinins
- Arterial blood gases/ SPO₂
- Sputum gram stain,M/C/S
- Urine pneumococcal and legionella antigen
- Chest X-ray
- Pleural fluid M/C/S
- Eliminate the infection
- Return to normal lung function
- Oxygen to maintain Pao, at or above 8kPa
- IV fluids especially in severe cases
1. Uncomplicated CAP + No modifying factor, + no antibiotics use in the last 3 months:
Amoxicillin Clavulanic acid
- Adult: 1g 12hourly for 5-7 days
- Neonate and premature infants, 25mg/kg 12 hourly;
- Infants up to 3 months, 25 mg/kg 8 hourly;
- 3 months – 12years, 25mg/kg 8hourly increased to 6hourly in more severe infections.
- Adult: initially 2million units 6 hourly.
- preterm and neonate under 7 days, 25mg/kg by IM injection Or by slow IV injection or infusion every 12 hours; double dose in severe infections.
- Neonate 7-28 days: 25mg/kg 8hourly; double dose in severe infections.
- 1 month – 18years: 25mg/kg 4 – 6hourly. Double dose in severe infections.
- Commence oral therapy as soon as possible.
- Macrolide (azithromycin 500mg stat,then 250mg daily,
- Clarithromycin 500mg twice
daily for up to 14days)
Adult: 500mg orally 8 hourly for 5-7 days
- 3 months 2years: 10mg/kg (maximum 125mg) orally 12 hourly
- 2-12 years: 15mg/kg orally 12 hourly
- 12-18 years: 12 hourly. May double doses in severe infections.
2. Patients with history of recent use of Antibiotics
Respiratory quinolone (levofloxacin).
- Quinolones are generally better
avoided in TB endemic areas because of their potential use as part of 2nd line regimen in the treatment of MDR-TB.
- Advanced macrolide+ amoxicillin
Advanced macrolide + amoxicillin + clavulanic acid
3. Complicated CAP
- IV β lactam + advanced macrolide
- Iv respiratory quinolones + advanced macrolide
- Penicillin G+advanced macrolide
Amoxicillin Clavulanic acid:
- Nausea, diarrhoea, skin rashes,
- contraindicated in penicillin hypersensitive individuals.
- Nausea, vomiting, abdominal
discomfort, headaches, rarely antibiotic associated colitis.
- Similar to those mentioned above
but usually milder.
- Hepatoxicity and antibiotic associated colitis are quite rare.
- Pneumococcal vaccine
- Haemophilus influenzae vaccine