Pneumonia

Pneumonia

Pneumonia
is an acute infection of the lung parenchyma (alveoli and interstitium) caused by
microorganisms

Classification of Pneumonia:
1- According to Setting / Mode of Acquisition
A. Community-Acquired Pneumonia (CAP)
●​ Acquired outside hospital or within <48 hours of admission
●​ Most common type
B. Hospital-Acquired Pneumonia (HAP)
●​ Develops ≥48 hours after hospital admission
●​ Not present or incubating at admission
●​ Gram-negative pathogens: Pseudomonas aeruginosa , Enterobacteriaceae ,
Acinetobacter spp
●​ Staphylococci (Staphylococcus aureus)
●​ Streptococcus pneumoniae
C. Ventilator-Associated Pneumonia (VAP)
●​ Occurs ≥48 hours after endotracheal intubation
●​ Subtype of HAP
D. Healthcare-Associated Pneumonia (HCAP) (less emphasized in recent
guidelines)
●​ Hospitalization ≥ 2 days within 3 months of infection.
●​ Nursing home or extended-care facility residence.
●​ Antibiotic therapy in preceding 3 months.
●​ Chronic dialysis patients.
●​ Patients who received I.V therapy, chemotherapy or wound care within the last
30 days of the current infection.
2- According to Anatomical position (location& radiology)
A- Lobar pneumonia. B- Bronchopneumonia ( diffuse) . C- Interstitial pneumonia.
D- Necrotizing pneumonia

3- According to Etiology :
Pneumonia

●​ Primary pneumonia: no apparent preexisting conditions that may predispose

to pneumonia
●​ Secondary pneumonia
-​ Bronchial asthma, COPD, heart failure, cystic fibrosis
-​ Viral upper respiratory tract infections with bacterial superinfection
-​ Anatomical abnormalities such as tubercular caverns, bronchial
tumors, or stenosis (postobstructive pneumonia) [9]
-​ Aspiration pneumonia

Etiology:

Community-Acquired Pneumonia (CAP)

Typical pneumonia Atypical bacterial Atypical Viruses pneumonia

pneumonia

-Streptococcus pneumoniae -Mycoplasma pneumoniae RSV

(most common) (most common in the Influenza viruses,
-Haemophilus influenzae ( ambulatory setting) Parainfluenza viruses
most common in patients -Chlamydia pneumoniae CMV
with underlying COBD.) -Chlamydia psittaci Adenovirus
-Moraxella catarrhalis -Legionella pneumophila Coronaviridae (e.g.,
-Klebsiella pneumoniae -Coxiella burnetii SARS-CoV-2)
-Staphylococcus aureus

Hospital-Acquired / •Gram-Negative:
Ventilator-Associated Pseudomonas
Pneumonia aeruginosa(mcc)
Klebsiella pneumoniae
Acinetobacter
Enterobacter
E. coli
•Gram-Positive:
MRSA

Aspiration Pneumonia Anaerobes:(mcc) Risk ↑ in:

Bacteroides Stroke
Fusobacterium Alcohol intoxication
Pneumonia

Peptostreptococcus Seizures

Pneumonia in Encapsulated bacteria

Immunocompromised Pneumocystis jirovecii
Patients Cytomegalovirus (CMV)
Fungal:
Aspergillus
Cryptococcus
Histoplasma

Risk factors:
1- Patient-Related : Age <5 years or >65 years, Malnutrition, Smoking , Alcohol abuse,
Poor oral hygiene
2- Chronic diseases : COPD, asthma, Diabetes mellitus, Chronic kidney disease , Heart
failure , Liver cirrhosis , Stroke (aspiration risk)
3- Immunosuppression : HIV/AIDS, , Long-term corticosteroids, Chemotherapy ,
Post-transplant
4- Impaired airway protection : Alteration in consciousness (e.g., due to stroke, seizure,
anesthesia, drugs, alcohol) , Dysphagia , Smoking ,
5- Environmental factors : Crowded living conditions , Toxins , Endemic exposures ،
Contaminated water systems
6- Surgical procedures : Upper abdominal surgery , Chest surgery
7- Cryptogenic organizing pneumonia : Specific medications (e.g., amiodarone,
bleomycin) , Chronic inflammatory disorders (e.g., rheumatoid arthritis)

Predisposing / Precipitating Factors :

Pathophysiology
protective pulmonary mechanisms :
●​ Nasal hairs & mucociliary clearance
●​ Cough reflex
Pneumonia

●​ Alveolar macrophages
●​ Secretory IgA
●​ Intact epithelium

Routes of infection :
Pneumonia occurs when pathogens overcome host defenses via:
●​ aspiration of oropharyngeal secretions (Most common)
●​ Inhalation of Aerosolized Droplets ( The second most frequent mechanism)
●​ Aspiration of gastric acid (aspiration pneumonitis) , food, or liquids
●​ Hematogenous spread (rare)
●​ Direct spread from adjacent infection

Pathogenesis
1- Failure of protective pulmonary mechanisms
2- pathogen Infiltrate pulmonary parenchyma( terminal bronchioles & alveoli)
→Colonization and Multiplication → interstitial and alveolar inflammation
3- host Inflammatory Response → Activation of alveolar macrophages
4- Release of pro-inflammatory cytokines
●​ IL-1, TNF-α , IL-6 , IL-8 → result in fever
●​ Chemokines, such as IL-8 and granulocyte colony-stimulating factor → stimulate the
release of neutrophils →producing both peripheral leukocytosis and increased
purulent secretions ( Inflammatory Cell Recruitment)
5- Increased capillary permeability → Leakage of exudate, Plasma proteins, Fibrin , RBCs
●​ alveoli exudate → stimulate receptors → productive cough
●​ RBCs → hemoptysis
●​ Alveoli fill with: Neutrophils,Fibrin, Cellular debris → Air replaced by
inflammatory exudate → Lung consolidation
6- Ventilation–Perfusion (V/Q) Mismatch :
Poor ventilation of consolidated areas → Continued perfusion → Hypoxemia →
Increased work of breathing → dyspnea
7- Systemic Inflammatory Response :
Pneumonia

Cytokines enter circulation → Fever , Tachycardia , Leukocytosis , Acute phase

response (↑ CRP)

Pattern of involvement
1.​ Lobar pneumonia :

Phase Features

Congestion( day 1–2) Vascular engorgement, edema

Red hepatization(day 3–4) RBCs + neutrophils in alveoli

Gray hepatization(day 5–7) Fibrin deposition

Resolution (day 8 to week Macrophage clearance

4)

Clinical features:
According to : 1- The immune state of the patient. 2- The infecting agent.
Typical pneumonia is characterized by a sudden onset of symptoms :
-​ Constitutional (Systemic) Symptoms :
High Fever up to 39.5 ( with chills and rigors) , severe Malaise , Fatigue , Anorexia ,
Sweating
-​ dry cough then Productive cough with purulent sputum (yellow-greenish) within 1- 2
days
-​ Tachypnea and dyspnea
-​ Pleuritic chest pain when breathing, often accompanying pleural effusion
-​ Hemoptysis (occasionally)
-​ Wheeze (especially in COPD/asthma)
Examination :
Inspection :
​ Asymmetrical chest movement
​ nasal flaring, thoracic retractions
Palpation
​ ↓ in chest expansion of affected side
Pneumonia

​ ↑ Tactile vocal fremitus

​ No shafted in medsrinum
Percussion
​ Stony Dullness over the area of consolidation
auscultation
​ ↓ air entry
​ Bronchial breathing
​ ↑ vocal resonant
​ Fine or coarse crackles (crepitations) ± phonchi
​ +Ve Egophony → Ask the patient to say “E” audible sounds like “A”
​ +Ve Whispered pectoriloquy , whisper ٤٤ , Clearly audible
​ Pleural rub (if pleurisy)
Atypical pneumonia typically has an indolent course (slow onset) and commonly manifests
with extrapulmonary symptoms.
-​ dry cough
-​ Low-grade fever
-​ Dyspnea
-​ Auscultation often unremarkable
-​ Common extrapulmonary features include fatigue, headaches, sore throat,
myalgias, and malaise.

C. Severe Pneumonia :
​ Severe dyspnea
​ RR ≥30/min
​ Hypoxia (SpO₂ <90%)
​ Hypotension
​ Confusion
​ Signs of sepsis or shock

D- Extrapulmonary Manifestations (Pathogen-Related):

​ Legionella→​ Diarrhea, hyponatremia, confusion
Pneumonia

​ Mycoplasma→ Rash, hemolytic anemia

​ Staph aureus→ Rapid deterioration, abscess
​ Pneumococcal→ Rusty sputum
​ Viral→ ​ Myalgia, sore throat

Diagnosis
Pneumonia is diagnosed by the presence of acute lower respiratory symptoms
PLUS radiological evidence of lung parenchymal infection.

Investigation:
Laboratory:
●​ CBC: leukocytosis (neutrophilia)
●​ ↑ CRP, ↑ ESR
●​ ↑ Serum procalcitonin
●​ Electrolyte abnormalities (e.g., hyponatremia → Legionella)
Microbiological :

Test Induction

Blood cultures Severe CAP / ICU

Sputum Gram stain & culture Severe cases

Urinary antigen (Strep, Legionella Severe CAP

Viral PCR Suspected viral pneumonia

Radiological :
Chest X-Ray (Gold Standard): posteroanterior and lateral
●​ Lobar pneumonia : Opacity of one or more pulmonary lobes , Presence of air
bronchograms
●​ Bronchopneumonia : Poorly defined patchy infiltrates scattered throughout
the lungs ,
Pneumonia

●​ Atypical or interstitial pneumonia : Diffuse reticular opacity , Absent (or

minimal) consolidation
●​ Parapneumonic effusion
Chest CT (usually without contrast)
Indications
●​ Normal or equivocal CXR with high suspicion
●​ Non-resolving pneumonia
●​ Immunocompromised patients
●​ Suspected complications (abscess, empyema)

Oxygenation Assessment :
Pulse oximetry
ABG if SpO₂ <92% or severe disease
PaO₂/FiO₂ ratio

Severity Stratification (After Diagnosis):

A. CURB-65 Score :

Parameter Criteria Score

C Confusion 1

U Urea > 7 mmol/L 1

R RR ≥ 30/min 1

B BP <90 systolic or ≤60 1

diastolic

65 age ≥65 1
Interpretation
●​ 0–1. ​ Mild. ​ Outpatient
●​ 2. ​ Moderate​ Admit (ward)
●​ 3–5. ​ Severe​ ICU / HDU
Pneumonia

B. Pneumonia Severity Index (PSI / PORT Score)

●​ Predicts 30-day mortality
●​ More accurate but complex

Treatment:
Empiric Therapy

1. Community-Acquired Pneumonia (CAP)

Outpatient Hospitalized – ICU

Ward

First-line Amoxicillin 1 g PO Ceftriaxone 1–2 g Ceftriaxone 2 g IV

every 8 hours/ 5-7 IV once daily daily. +
+ Azithromycin 500 Azithromycin 500
mg IV/PO once mg IV daily
daily

2nd Levofloxacin : 750 Ceftriaxone 2 g IV

mg IV/PO once daily. +
daily Levofloxacin 750
mg IV daily

Allergy Azithromycin : 500

mg PO day 1, then
250 mg daily / 5
OR Doxycycli : 100
mg PO every 12
hours

If MARS risk add to above Vancomycin 15–20 mg/kg IV every 8–12 h

Or. Linezolid 600 mg IV/PO every 12 h

If Pseudomonas Piperacillin–Tazobactam 4.5 g IV every 6 h Or Cefepime 2 g IV

risk every 8 h + Levofloxacin 750 mg daily

2 - Hospital-Acquired Pneumonia (HAP)

●​ Piperacillin–Tazobactam. Or. Cefepime
●​ ➕ MRSA coverage
3. Ventilator-Associated Pneumonia (VAP)
Pneumonia

●​ Piperacillin–Tazobactam Or. Meropenem 1 g IV q8h

●​ Levofloxacin OR Amikacin 15–20 mg/kg IV daily.
●​ Vancomycin OR Linezolid

4. Aspiration Pneumonia :
●​ Ampicillin–Sulbactam : 3 g IV every 6 hours. OR (outpatient)
Amoxicillin–Clavulanate 875/125 mg PO every 12 h

Supportive Treatment :
1.​ Oxygen therapy
2.​ IV fluids
3.​ Antipyretics (Paracetamol)
4.​ DVT prophylaxis
5.​ Chest physiotherapy
6.​ Ventilatory support if needed

Differential Diagnosis :

Condition Key Differentiator

Pulmonary edema Bilateral perihilar shadows, cardiomegaly

Pulmonary embolism Sudden dyspnea, normal CXR

ARDS Diffuse bilateral infiltrates

TB Chronic symptoms, upper lobe

Lung cancer Persistent focal consolidation

Complications:
1.​ Para-pneumonic effusion-common
2.​ Empyema.
3.​ Retention of sputum causing lobar collapse
4.​ DVT and pulmonary embolism
Pneumonia

5.​ Pneumothorax, particularly with Staph. aureus

6.​ Suppurative pneumonia/lung abscess
7.​ ARDS, renal failure, multi-organ failure
8.​ Ectopic abscess formation (Staph. aureus)
9.​ Hepatitis, pericarditis, myocarditis, meningoencephalitis
10.​Pyrexia due to drug hypersensitivity