Pneumonia

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Exclusions

  • patients less than 16 years old
  • immunocompromised patients
  • hospital-acquired pneumonia (onset after 4 days of hospitalization)
  • aspiration pneumonia
  • patients with cystic fibrosis or tuberculosis
  • pregnant women
  • residents of long-term care facilities


Definition

Acute infection of the pulmonary parenchyma that is associated with:

  • at least two of the following symptoms:
    • fever, rigors, new cough with or without sputum production or chronic cough with change in colour of sputum, pleuritic chest pain, shortness of breath

AND

  • auscultatory findings consistent with pneumonia (localized crackles, bronchial breath sounds)

AND

  • the presence of a new opacity on chest X-ray.


CAP is Pneumonia that has been acquired in the community in a patient:

  • who has not been hospitalized within 14 days prior to onset of symptoms

OR

  • who has been hospitalized less than 4 days prior to onset of symptoms.

History

  • Occupation
  • Recent travel
  • fever ± chills
  • new onset of cough (may or may not be productive)
  • pleuritic chest pain
  • constitutional symptoms (fatigue, headache, nausea/vomiting, abdominal pain, myalgias)

PE

  • temperature >37.8°C (may be lower in frail elderly)
  • tachypnea: respiratory rate ≥25/minute (must be counted for full minute)
  • signs of consolidation: diminished chest expansion, increased tactile and vocal fremitus, dullness on percussion, diminished air entry, bronchial breath sounds, whispering pectoriloquy, localized crackles, pleural rub


Management

  • Follow-up for outpatients should occur at 48–72 hours.
  • Follow-up chest X-ray recommended at 6 weeks to ensure resolution and exclude underlying diseases such as empyema, lung abscess, and malignancy if:
  • extensive/necrotizing pneumonia
  • smoker
  • alcoholism
  • COPD
  • >5% weight loss in past month
  • >50 years old.


Organisms

No comorbid factors

  • Streptococcus pneumoniae
  • Mycoplasma pneumoniae
  • Chlamydia pneumoniae
  • S. pneumoniae

Comorbid factors

  • Moraxella catarrhalis
  • Haemophilus influenzae
  • C. pneumoniae
  • Staphylococcus aureus
  • Enterobacteriaceae


Hospitalized Moderate/severe patients

  • S. pneumoniae
  • Enterobacteriaceae
  • H. influenzae
  • C. pneumoniae
  • S. aureus
  • Legionella spp. (rare)
  • Group A streptococci


Basic info

  • Pneumonia (together with influenza) is the sixth leading cause of death in the US
  • Rates highest in 0-4 yrs (12-18 cases per 1000)
  • ≥60yrs = 20 cases per 1000
  • 71% are CAP
  • Attack rate of Pneumococcal pneumonia in unvaccinated elderly = 12-15%


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