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Pneumonia

From Mediwikis

This has a varied pathology, and so varied presentations

Causative Organisms

Bacteria

  • Streptococcus pneumoniae- Most common, acute onset with flu-like symptoms.
  • Haemophilus influenzae
  • Staphylococcus aureus- Post viral infection in inpatients
  • Mycoplasma pneumoniae- Usually very mild, incidence peaks every 4–5 years.
  • Legionella spp.-More severe pneumonia, contracted from inhaled water droplets. Young smokers are especially at risk.
  • Klebsiella pneumonia- More common in alcoholics and with other comorbidities. High mortality
  • Chlamydophila pneumoniae

Viruses

  • Influenza A+B
  • Respiratory Syncytial Virus
  • Varicella Zoster Virus
  • Adenoviruses
  • Severe Acute Respiratory Syndrome

Fungi

Mainly in individuals with weakened immune systems (AIDS)

  • Aspergillosis
  • Pneumocystis Pneumonia

Parasites

  • Toxoplasmosis gondii
  • Schistosoma

Signs & Symptoms

  • Cough- dry or productive
  • Dyspnoea
    Symptoms of pneumonia.svg
  • Fever (+ Rigors)
  • Decreased chest expansion
  • Dull Percussion
  • Bronchial breath sounds
  • Increased Vocal Resonance
  • Hypotension
  • Chest Pain (pleuritic)
  • Systemic signs
    • Fever
    • Confusion
    • Hypotension
    • Abdominal pain

Risk Factors

  • Age- Very young & very old.
  • Lung Disease- Cystic Fibrosis, COPD
  • Aspiration- In stroke/ ventilator
  • Alcoholism
  • Nursing Home residents
  • Recent viral illness
  • Occupation
  • Faulty air conditioning(legionella)

Classification

  • Lobar vs Bronchia
  • Upper vs Lower
  • Severity
  • Viral, Bacterial, Protozoal, Fungal
  • Source- Community vs Hospital Acquired, Ventilator-associated

CURB-65

  • Confusion
  • Urea > 7 mmol/L
  • Respiratory Rate >=30/min
  • Blood Pressure <90 sys +/- <60 dia.
  • 65 years of age or greater.

CURB-65 score:

  • 0-1- Low Risk- community management
  • 2-3- Mid Risk- Short inpatient admission
  • 4-5 High Risk- Prolonged admission, critical care may be needed

Investigations

Bloods

Antero-posterior chest x-ray of a patient showing increased shadowing in the right upper lobe. (Source: CDC Public Health Image Library).
  • WCC
  • CRP
  • ABG’s

Others

  • Sputum/ Blood Culture
  • Serology
  • Urinary antigens, in severe cases

Imaging

  • CXR- repeat after 72 hours if no improvement


Management

General

  • Supplemental Oxygen
  • IV fluids
  • Physiotherapy- In patients with inadequate sputum clearance
  • Nutritional support
  • Analgesia

Antibiotic Choice

Using CURB-65 score above, and clinical judgement:

  • Low risk- Amoxycillin/ Clarithromycin/ Doxycycline PO
  • Mid risk- Amoxycillin + Clarithromycin
    • OR Doxycycline/Levofloxacine/Moxifoxacin PO or IV
  • High risk- Co-amoxiclav + Clarithromycin
    • OR cephalosporin + clarithromycin
    • OR benzylpenicillin + fluoroquinolone