COMMUNITY ACQUIRED PNEUMONIA

  • Acute infection of pulmonary parenchyma

  • Causative Organism :
Streptococcus pneumoniae (pneumococci) - most common
Haemophilus influenzae - 2nd most common
Mycoplasma pneumonia
Chlamydia pneumonia

  • Rare :
Legionella
Staphylococcus aureus
Gram negative organism ( klebsiella , pseudomonas)
virus (adenovirus , meta pneumo virus)

  • In India :
- 20% cases of CAP - Tuberculosis
- 40% cases of CAP - Not established


PATHOLOGY :

Initially there is a inhalational of bacteria into the lungs results in phase of Edema 
↓ 
proteinaceous exudates developed in the alveoli
(so there can be a crepitation, crackles of  bronchial breathing in the patient and subsequently patients enter into the following phases)

  • Red hepatization - RBC + Neutrophils (3-4 days)
  • Grey hepatization - RBC lysis + Neutrophils (it signifies successful)(5 -7 days)
  • Resolution - here Macrophages predominantly present because these cells restore the normal tissue




Typical / lobar pneumonia :

  • Lobar consolidation
  • causative organism ;
- Pneumococci
- H. influenza
- staph aureus
- Klebsiella
- pseudomonas
  • Alveolar exudates in air spaces
  • high grade fever
  • productive cough
  • hemoptysis
  • pleuritic chest pain
  • x-ray - large areas of consolidation


Atypical / Interstitial / broncho pneumonia :

  • Patchy interstitial inflammation
  • Causative organism :
- chlamydia
- mycoplasma
  • Interstitial involvement
  • lymphocytic
  • low grade fever
  • Dry cough
  • Scanty sputum
  • Extrapulmonary manifestation
- cold agglutinin disease
- erythema multiforme
- Arthralgia + adenopathy
- Guillain barre syndrome
- myocarditis / pericarditis
- encephalitis
- Bullous meningitis
  • x-ray - Interstitial pattern



clinical feature :

  1. Fever
  2. Breathlessness
  3. Cough
  4. Hemoptysis 
  5. Chest pain : due to pleuritis
  6. Nausea and vomiting
  7. Abdominal pain
  8. Headache
  9. Myalgia


on examination :

  • Respiratory rate - increased
  • Use of accessory respiratory muscles 
- Scalenus
- Sternocleidomastoid muscle
 - Alae nasi
  • Trachea is central

  • Vocal fremitus increased because lung has become solid as Bronchophony
- sometimes vocal fremitus is lesser due to parapneumonic pleural effusion at bottom of one side of the lung

  • ON PERCUSSION : Dull due to consolidation (usually finds resonant in normal lungs)

  • ON AUSCULTATORY : findings in pneumonia is Breath sounds of bronchial breathing not crepitation or crackles. there is gap between inspiration and expiration component.






WORKUP :

  • Complete blood counts (CBC) : TLC increased (Neutrophils counts are increased)
  • Sputum evolution : important work up for choice of antibiotics
- Culture
- Gram stain
  • Blood culture :
  • Urine antigen :
- Legionella pneumophilia
- pneumococcus
  • Chest X - ray : consolidation
- Lobar
- Round
- Bronchopneumonia
- Parapneumonic effusion
  • Biomarkers = CRP( C reactive proteins) , Procalcitonin (helps to identify infective process in the body)




TREATMENT :

  • CURB - 65 Score : Parameters used for the need for hospitalization



 Empirical treatment of CAP :

OPD treatment

  • previous health or not received antibiotics in last 3 months - MACROLIDES (Clarithromycin / Azithromycin)
or

Doxycycline (if macrolides is not available)

  • Co - morbid condition or antibiotics in last 3 months - MOXIFLOXACIN
 or

 β LACTAM + MACROLIDES



IPD treatment

  • ICU  or non ICU - I.V β LACTAM + I.V MACROLIDES
If pseudomonas - add MEROPENEM

If s. aureus - add LINEZOLID


VENTILATOR ASSOCIATED PNEUMONIA  (VAP)

  • MDR (MULTI DRUG RESISTANT)
- Pseudomonas

- Community Acquired MRSA (methicillin resistant staphylococcus aureus)

- Acinetobacter

↓

Treatment

- PIPERACILLIN - TAZOBACTUM

- AMIKACIN

- LINEZOLID (for MRSA)


  • NON - MDR 
- Pneumococcus

Treatment

- PIPERCILLIN - TAZOBACTUM



LOBAR PNEUMONIA



ROUND PNEUMONIA



 

Ventilator associated pneumonia 



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