Pneumonia

 Pneumonia is an infection of the lung tissue caused by various bacteria, viruses or fungi. Identification of the causative organism and drug sensitivity testing is the key to correct treatment. However, because of the serious nature of the infection, antibiotic treatment should be started immediately based on knowledge of the most probable causative organism and the antibiotics used for it treatment. Local knowledge of drug resistance  patterns are also taken into account. Treatment may be maintained or changed based on culture results and assessment of the patient's response to initial treatment. In the event that the cultures of blood or sputum prove negative, empiric treatment is continued with clinical response as a guide.
    

 Severity score for community acquired pneumonia (CURB-65)
  severity score may be based on the following, assigning one point to each of the following      factors (maximum 5 points);

•   Confusion, restlessness, or excessive drowsiness
•   Blood Urea Nitrogen ( > 7 mmol/L)
•   Respiratory rate ( ≥ 30 per minute in adults, and ≥ 50 in children)
•   Low Bp (Systolic Bp < 90 and/or diastolic Bp < 60 mmHg
•   Patients at the extremes of age, (< 5yr or ≥ 65yr)

  0-1; consider home treatment
  2-3; consider short inpatient
  > 3; admit and consider intensive care

 In the presence any of the following additional factors, all cases of pneumonia would warrant hospitalisation.

   CAUSES

•  Community acquired pneumonia
•  Streptococcus pneumonia
•  Streptococcus pyogenes
•  Haemophilus influenza
•  Klebsiella pneumoniae
•  Mycoplasma pneumonia and Legionella pneumophila (tend to occur in epidemics)
•  Staphylococcus aureus (in children after viral illness like measles, in diabetics or in the elderly during 'flu' epidemics)

 

 
Aspiration pneumonia

• Anaerobic and/or gram negative organisms (associated with aspiration e.g. stroke, seizures, unconsciousness)

 

 Hospital acquired pneumonia

•  Gram-negative bacteria e.g. pseudomonas aeruginosa
•  MRSA (Methicillin resistant)
•  VRSA (Vancomycin resistant)
•  Staphylococcus aureus

Others

• pneumocystic jiroveci pneumonia and other fungi (in immunocompromised states e.g. haematological malignancies. HIV/AIDS)
• Viruses

SYMPTOMS

• Fever-short history
• Productive cough
• Sputum-rusty or blood stained, yellowish, greenish
• Pleuritic chest pain - worse on deep breathing or coughing
• Breathlessness
• Sweating
• Muscle achesElderly and immunocompromised patients may have minimum or no symptoms

 

SIGNS

• Rapid breathing
• Grunting (in children)
• Use of accessory muscles of respiration and flaring of the nasal margins
• Lower chest wall indrawing (in children)
• Restricted movement of the affected side of the chest (due to pain)
• Fever
• Rapid pulse rate
• Blood pressure may be normal or low
• Signs of consolidation or pleural effusion on chest examination
• Restlessness or confusion, drowsiness
• Low blood oxygen saturation by pulse oximetry < 92%

 

COMPLICATIONS

• Pleural effusion
• Lung abscess
• Empyema
• Pericardial effusion/pericarditis
• Pneumothorax particularly Staph. aureus infection, pneumocystis jiroveci pneumonia
• Meningitis
• Septicaemia with multi organ failureAdult respiratory distress syndrome (ARDS)

INVESTIGATIONS

• FBC
• C-reactive protein (CRP)
• Chest X-ray
• Sputum gram stain and cultures and sensitivity
• Ziehl-Neelsen stain for acid-fast bacilli (to exclude TB)
• Blood culture and sensitivity
• Blood urea and electrolytes

 

 TREATMENT
Treatment objectives

• To identify patients at greater risk who require in-hospital management
• To alleviate symptoms
• To treat and eradicate the infection
• To prevent and/or manage complications

Non-pharmacological treatment

• Nurse in comfortable position, usually with head raised
• Sponging to control fever, especially in children < 5 years (who are at risk of febrile convulsions)
• Adequate oral hydration (if it can be tolerated)
• Chest physiotherapy

 

 Pharmacological treatment
Ambulatory patient:low severity score < 2

• Antibiotics such as Amoxicillin (Amoxycillin), oral, and Azithromycin, oral  

      Or

• Erythromycin, oral, (if patient is allergic to penicillin)

       Or

• Cefuroxime, oral Or Doxycycline, oral

 

B. Hospitalised patient:Severity score, ≥ 2 or with additional factors as mentioned above

• Oxygen, by face mask or nasal prongs. Maintain oxygen saturation > 92%

       and

• Replace estimated insensible loss With iv fluids normal saline and dextrose saline

        and

• Paracetamol, oral

        and

• - Amoxicillin + Clavulanic Acid, IV

         Or

• Azithromycin, oral

         Or

• Azithromycin, IV (not recommended in children for pneumonia treatment

         Or

• Cefuroxime,IV and Azithromycin, IV

 

Treatment for aspiration pneumonia

• Ceftriaxone, IV

         Or

• Amoxicillin + Clavulanic Acid, IV

         Or

• Ciprofloxacin, IV

         and

• Metronidazole, IV

         Or

• Clindamycin, IV