Chapter 12.

Pneumonia
Mokhtar Soussi MSc, FRCP

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neumonia refers to inflammation of the lungs caused

by microbial infection such as bacteria and other
organisms. Non infectious pneumonias, including toxic
exposure-induced, are usually called pneumonitis. It
usually affects the alveoli, distal airways and interstitium of the lung, and is typically associated with new
radiological changes - either segmental or lobar - on the
chest radiograph. Pneumonia is a disease of high morbidity and mortality. It is the most common cause of
hospital admission, and the most fatal infection acquired
in hospitals with higher mortality at the extremes of age.
In developing countries pneumonia is the leading cause
of death, exceeded only by dehydration from severe
diarrhea. The lungs are protected by several complex
defense systems to prevent organisms and other substances from reaching the lower respiratory tract. There
are different routes of infection which include airborne,
aspiration, micro aspiration and haematogenous spread.

Pathology
There are four patterns of pneumonia:
Lobar pneumonia
Bronchopneumonia
Interstitial pneumonia
Miliary pneumonia
Four stages of pathology:
Congestion
Red hepatisation
Grey hepatisation
Resolution, which may not be absolute
During early stages the affected part of the lung is
perfused but not ventilated, resulting in right to left
shunt and hypoxia. If the patient has a normal respiratory reserve hyperventilation with a low pCO2 will
result, in an attempt to compensate for the low PO2.

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Pneumonia

Later in the course of the disease, especially in patients

with COPD, the respiratory system may fatigue leading
to hypoventilation and increased PCO2.
Lobar pneumonia is characterized by homogeneous
consolidation of one or more lung lobes, while bronchopneumonia is associated with patchy consolidation of
alveolar and bronchial inflammation often involving
both lower lobes.

Classification
Anatomical

Lobar
Lobular
Bronchopneumonia
Interstitial
Millary

Aetiology

Bacterial
Viral
Fungal

Clinical

Community acquired pneumonia

Hospital acquired pneumonia
Aspiration Pneumonia
Pneumonia in the immune-compromised

Community Acquired Pneumonia (CAP)

CAP affects more than 5 million adults per year in the
USA and it is the number one cause of death from infectious diseases. The mortality from CAP in patients who
are not admitted to hospitals is less than 1%. However,
this figure increases to 12-14% in hospitalized patients,
and up to 40% in patients admitted to the ICU.

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In the UK one million people are affected annually, with

incidence rate from 8 to 15 per 1000 per year, with
similar figures in the Arab world. There is increased
incidence at the extremes of age.
The majority of patients are healthy, but there are
risk factors associated with increased incidence of
community acquired pneumonia, such as alcohol abuse,
cigarette smoking, immunocompromised patients, old
age, and chronic illness. Most cases can be managed at
home and about 20% require hospitalization.
Aetiology
There are many microbial causes of CAP which can be
identified by examining different sources including
sputum, blood culture, pleural fliud, tracheobronchial
secretions and bronchial lavage. These are important in
clarifying causative microorganisms and management of
patients with CAP. Sufficient sputum specimen can be
obtained in only 50% of patients; there is no microbiological diagnosis in aproximately 40% of patients with
CAP. In general, reliable microbiological diagnosis can
be made in only 20% of patients with pneumonia. There
are limited data about the pathogenesis of community
acquired pneumonia in Libya. It is estimated that streptococcus pneumonia is the most common type followed
by Hemophylus influenza, mycoplasma pneumonia,
staphylococcus pneumonia, and klebsiella species.
Typical Bacterial Pathogens (80%)

Streptococcus pneumoniae
Hemophylus influenza
Moraxella catarrhalis

Atypical Pathogens (10%)

Legionella species
Mycoplasma pneumonia

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P
Pneumoni
ia

Chla
amydia.

Less C ommon Bacteria

B
l Pathog
gens

Kleb
bsiella pneu
umonia
Stap
phylococcuss aureus
Pseu
udomonas aeruginosa
a

Viral Aetiology
A
y

Ade novirus
V
RSV
Influ
uenza viruss
Han
ntavirus
Rhin
novirus

Unusua
al Patho gens

Pne umocystis carinii

c
Q feever
Tula
aremia
Psit tacosis
Plag
gue
Lepttospirosis

Commu
unity
Acquiired
Pneum
monia
Strepto
ococcu
spneumonia
Mycop
plasma
pneum
monia

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84

Hospita l Acquir
red (Nos
socomia
al)
Pneumo
onia (HA
AP)
HAP is a neew episode of pneumo
onia which occurs at leeast
4 days aftter admisssion to ho spital. It is
i the seco
ond
common cause
c
of no
osocomial infection,
i
and a lead
ding
cause of mortality,
m
wh
hich is incrreased with
h the length
h of
stay in hosspital. The incidence of HAP is 5-10
5
cases per
1000 hosp ital discharrges. In IC U it accoun
nts for 25%
% of
all infectio
ons and ab out 90% o ccurs durin
ng mechan
nical
ventilation
n (VAP).
The mo
ost importa nt differen tiation betw
ween CAP and
HAP is thee spectrum of causativve organism
ms; the patthogens involvved are usu
ually gram negative ba
acteria, ana
aerobes, and staphyloco
occal aureu s, especiallly MRSA. The
T
incidence of HAP i s higher in
i debilita ted, immu
unesuppressed
d, elderly, ventilated,
v
a
and
criticallly ill patie nts,
especially with como
orbidities such
s
as CO
OPD, and post
p
surgery. Th
he symptom
ms are simiilar to gram
m positive CAP
C
but patien ts tend to be sicker and worsen
n quickly. Paatment, oxyygen
tients may require inttensive antiibiotic trea
supplemen
nt, proper fluid
f
balancce, and posssibly assissted
ventilation
n, but despi te this activve intensivee managem
ment
about 25- 50%
5
with grram negativve pneumo nia will diee.

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Pneumonia

Aspiration Pneumonia
This type of pneumonia results from the introduction of
microorganisms through aspiration of foreign objects or
gastric contents into the lower respiratory tract. Predisposing factors include loss or depression of cough reflex.
Causative organisms include: enterobacteraeces, staphylococcal aureus, streptococcal pneumonia, gram negative
organisms, bacteroids and anaerobic cocci. The mortality
rate is around 23%. Risk factors include; Alcoholic
stupor, hypnotic drug overdose, elderly and debilitated
patients, general anesthesia, stroke, epilepsy, oesophageal dysfunction. Usually apical segments of the lower
lobe are affected.

Pneumonia in the Immunocompromised

Patient
The clinical presentation is atypical, usually starting
insidiously with irritating dry cough, dyspnea, on a
background of fatigue, weight loss and fever. Radiological findings include single or multiple sites of focal
consolidation with atypical pattern on CXR. The causative organism varies depending on the degree of immunosuppression. Pneumocystic carinii pneumonia (PCP) is
one of the common organisms infecting immunsuppressed hosts especially HIV where it is considered as
AIDS defining infection. Dry cough and tachypnea with
cyanosis and little physical signs of the chest are characteristics. Chest x-ray shows bilateral perihilar, interstitial pattern, granular or reticular or ground glass
appearance.

Clinical Feature of Pneumonia

History is seldom helpful in identifying the cause of
pneumonia, but sore throat and upper respiratory symptoms may be associated with viral and atypical infec-

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tions. Recent contact with birds may suggest psittacosis.

Contact with farm animal suggests Q fever pneumonia,
and social history including geographic locations may
suggest endemic causes like fungal pneumonia in the
southwest USA, and TB pneumonia in endemic areas.

Symptoms
Pneumonia presents with variable symptoms which
include malaise, myalgia, fever, chills, rigors, dry or
productive cough, heamoptesis, dyspnea, and chest pain
(dull ache or peripheral sharp pleuritic pain often referred to the shoulder or upper abdominal wall). Seriously ill immunocompromised or elderly patients may
have little or no fever and may manifest with an acute
confessional state. Certain features may suggest particular infection; pneumoccocal pneumonia may produce
rusty sputum, pseudomonas and heamophilus species
may produce green sputum, and klebsiella and type 3
pneumococcal infection may produce sputum resembling
currant jelly. In atypical pneumonia headaches, malaise,
nausea, vomiting, and diarrhea can be the predominant
features.

Physical Signs
Typical signs of pneumonia are tachypnea, tachycardia,
cyanosis, and herpes labialis. On chest examination,
dullness on percussion, increased tactile fremetus, egophony, crackles and pleural rub may be present. Physical
signs of fluid in the pleural space may be present if the
patient develops parapneumonic pleural effusion. In
legionella and mycoplasma infection (atypical pneumonia), the chest signs correlate poorly with chest x-ray.

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Pneumonia

Features Associated with Increased

Mortality
Clinical

Respiratory rate > 30/min

Age 60 years or more
Diastolic BP < 60 mm Hg
Confusion
Involvement of more than one lobe on CXR
Comorbidity

Laboratory

Leukocytosis > 20,000 per ml,

Leucopenia < 4000 per ml,
Positive blood culture,
Hypoalbuminemia,
Blood urea > 7 mmol / l.
Certain causative organisms are associated with
high mortality rates, such as Pseudomonas aeruginosa, Klebsiella, E. coli and Staphylococcus aureus.

Differential Diagnosis

Pulmonary infarction
Pulmonary oedema
Inflammatory conditions below diaphragm (cholecystitis, peptic ulcer, acute pancreatitis, liver abscess)
Lung cancer, especially with post obstructive pneumonia.
Other pulmonary parenchymal conditions such as
pulmonary eosinophilia, Wegners granulomatosis,
acute allergic alveolitis, radiation pneumonitis,
chemical pneumonitis, and atelectsis.

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Complications of Pneumonia

Pleural effusion
Empyema
lung abscess
Pneumococcal septicemia
meningitis
arthritis
endocarditis

Investigations
The aim of investigating patients with clinical features
suggestive of pneumonia is to confirm the diagnosis
radiologically, establish the microbiological aetiology-if
possible- and to assess the severity of the pneumonia.
The Infectious Diseases Society of America (IDSA) and
American Thoracic Society (ATS) differ in their recommendation on the usefulness of routine sputum gram
stain and cultures in COP. The IDSA recommends routine checks of sputum gram stain and cultures, whereas
the ATS does not recommend such action because- as
mentioned above- a reliable bacteriological diagnosis
can be made only on a fraction of patients with CAP.
Sputum acid fast smear should be performed in high risk
patients to rule out tuberculosis. Serologic tests are
seldom routinely useful, but in atypical organisms may
be the only way of diagnosis. Bronchoscopy and BAL,
transbronchial biopsy, percutaneous transthoracic
needle aspiration and open lung biopsy are indicated in
certain patients to clarify the cause of pneumonia. Blood
cultures are important and can be positive in 6-25% of
patients with pneumonia. Radiological studies, arterial
blood gases, CBC, liver function tests, blood urea, sodium and potassium are important investigations in
assessing patients with pneumonia.

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Pneumonia

Radiological Examinations
Typically, in patients with lobar pneumonia there will be
a homogeneous opacity involving the affected lobe or
segment (figures 1&2). Patchy consolidation is the
radiological change in patients with bronchopneumonia
and atypical pneumonia. Cavitating lesions would suggest staphylococcal pneumonia, anaerobic infections,
necrotizing pneumonia, or superinfection of an existing
cavity. The radiological changes usually appear 12-18
hours after the onset of the disease, while resolution
takes up to four weeks in 60% of patients. It may take
longer in patients above age 50, or with comorbidity.
CT scan of the chest is useful in patients with clinically suspected pneumonia andwho have no changes on
chest x-ray.

Figure 1. Chest X-Ray showing right upper lobe pneumonia

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Figure 2. Chest X-ray showing right lower lobe pneumonia

Treatment of Pneumonia
Selection of antibiotics is easy when the causative organism is identified, but in the majority of cases the therapy
is empiric depending on the clinical and radiological
features. A delay in initiating antibiotic therapy may
result in increased morbidity and mortality. Patients
who are admitted to hospital are usually treated with
parenteral antibiotics. It is important to be familiar with
local patterns of causative organisms and antimicrobial
resistance when selecting the empirical therapy. Penicillin was the mainstay of therapy for pneumococcal infection; alternative antibiotics include Cephalosporin,
Macrolids, fluoroquinolones, Vancomycin and Tetracycline. In 1967, Penicillin resistant pneumococci (PRP)
emerged. Risk factors for PRP include age >60; use of
-lactamase therapy within the previous 3 months,
alcoholism, immunosuppressive therapy, and multiple
medical comorbidities.

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Pneumonia

Anti-microbial Treatment of Pneumonia

European Respiratory Society Guidelines

Outpatient treatment: Amoxicillin or Tetracycline

and alternatively, Amox/clav, Macrolides, or Fluoroquinolones.
Inpatient Non-severe: Penicillin G +/- macrolide,
co-amoxiclav+/-macrolide, or 3rd cephalosporin
+/- macrolide.
Inpatient Severe:
No risk of Pseudomonas aeruginosa: 3rd cephalosporin +/- macrolide
Risk
of
Pseudomonas
aeruginosa:
Antipseudomonal cephalosporin

American Thoracic Society Guidelines

Outpatient treatment: Macrolides, Doxycycline, or

Fluoroquinolone.
Inpatient Non-severe : -Lactam plus a Macrolides,
or Fluoroquinolone.
Inpatient Severe:
No risk of Pseudomonas aeurginosa: IV -lactam
plus either IV azithromycin or IV fluoroquinolones
Risk of Pseudomonas aeurginosa: IV antipseudomonal -lactam plus IV antipseudomonal fluoroquinolone antibiotic

Further Reading
1.

Davidsons principle and practice of medicine. 20th

Edition Churchill Livingston 2006.

2.

Harrisons principles of internal medicine. 16th Edition McGraw Hill company 2004.

3.

Pulmonary / Respiratory therapy secrete 3rd Edition

Mosby 2006.

4.

ATS Guidlines Guidelines for the Management of

Adults with Community-acquired Pneumonia. Am. J.

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Respir. Crit. Care Med., Volume 163, Number 7, June

2001, 1730-1754.
5.

Guidelines for the management of adult with lower

respiratory tract infections. ERS task force. Eur Respir J 2005; 26: 11381180.

Web Sites
1.

www.Timely topics in medicine respiratory.com

2.

www.uptodate.com