Gretchelle Malazarte BSN 4 C

Etiology

Many organisms cause community-acquired pneumonia, including bacteria, viruses, and fungi. Pathogens vary by patient age and
other factors, but the relative importance of each as a cause of community-acquired pneumonia is uncertain, because most
patients do not undergo thorough testing, and because even with testing, specific agents are identified in< 50% of cases. S.
pneumoniae, H. influenzae, C. pneumoniae, and M. pneumoniae are the most common bacterial causes. Pneumonia caused by
chlamydia and mycoplasma are often clinically indistinguishable from pneumonias with other causes. Common viral agents include
respiratory syncytial virus (RSV), adenovirus, influenza viruses, metapneumovirus, and parainfluenza viruses.

Symptoms and Signs

Symptoms include malaise, cough, dyspnea, and chest pain. Cough typically is productive in older children and adults and dry in
infants, young children, and the elderly. Dyspnea usually is mild and exertional and is rarely present at rest. Chest pain is pleuritic
and is adjacent to the infected area. Pneumonia may manifest as upper abdominal pain when lower lobe infection irritates the
diaphragm. Symptoms become variable at the extremes of age; infection in infants may manifest as nonspecific irritability and
restlessness; in the elderly, as confusion and obtundation.

Signs include fever, tachypnea, tachycardia, crackles, bronchial breath sounds, egophony, and dullness to percussion. Signs of
pleural effusion may also be present. Nasal flaring, use of accessory muscles, and cyanosis are common in infants. Fever is
frequently absent in the elderly.

Symptoms and signs were previously thought to differ by type of pathogen, but presentations overlap considerably. In addition, no
single symptom or sign is sensitive or specific enough to predict the organism. Symptoms are even similar for noninfective lung
diseases such as pulmonary embolism, pulmonary malignancy, and other inflammatory lung diseases.

Diagnosis
• Chest x-ray
• Consideration of pulmonary embolism
• Sometimes identification of pathogen

Diagnosis is suspected on the basis of clinical presentation and is confirmed by chest x-ray. The most serious condition
misdiagnosed as pneumonia is pulmonary embolism, which may be more likely in patients with minimal sputum production, no
accompanying URI or systemic symptoms, and risk factors for thromboembolism

Chest x-ray almost always demonstrates some degree of infiltrate; rarely, an infiltrate is absent in the first 24 to 48 h of illness. In
general, no specific findings distinguish one type of infection from another, although multilobar infiltrates suggest S.
pneumoniaeor Legionella pneumophila infection and interstitial pneumonia suggests viral or mycoplasmal etiology.

Hospitalized patients should undergo WBC count and electrolytes, BUN, and creatinine testing to classify risk and hydration status.
Two sets of blood cultures are often obtained to detect pneumococcal bacteremia and sepsis, because about 12% of all patients
hospitalized with pneumonia have bacteremia; S. pneumoniae accounts for 2⁄3 of these cases. Whether the results of blood
cultures alter therapy commonly enough to warrant the expense is under study. Pulse oximetry or ABG should also be done.

Pathogens

Attempts to identify a pathogen are not routinely indicated; exceptions may be made for critically ill patients, patients in whom a
drug-resistant or unusual organism is suspected (eg, TB, P. jiroveci), and patients who are deteriorating or not responding to
treatment within 72 h.

The use of Gram stain and culture of sputum for diagnosis is of uncertain benefit, because specimens often are contaminated and
because overall diagnostic yield is low. Samples can be obtained noninvasively by simple expectoration or after hypertonic saline
nebulization for those unable to produce sputum. Alternatively, patients can undergo bronchoscopy or endotracheal suctioning,
either of which can be easily done through an endotracheal tube in mechanically ventilated patients. Testing should include
mycobacterial and fungal stains and cultures in patients whose condition is deteriorating and in those unresponsive to broad-
spectrum antibiotics.

Additional tests are indicated in some circumstances. Patients at risk of Legionella pneumonia (eg, patients who smoke, have
chronic pulmonary disease, are > 40, receive chemotherapy, or take immunosuppressants for organ transplantation) should
undergo testing for urinaryLegionella antigen, which remains present long after treatment is initiated, but the test detects only L.
pneumophila serogroup 1 (70% of cases). A 4-fold rise in antibody titers to ≥ 1:128 (or a single titer of ≥ 1:256 in a convalescent
patient) is also considered diagnostic. These tests are specific (95 to 100%) but are not very sensitive (40 to 60%); thus, a positive
test indicates infection, but a negative test does not exclude it.

Infants and young children with possible RSV infection should undergo rapid antigen testing of specimens obtained with nasal or
throat swabs. No other tests for viral pneumonias are done; viral culture and serologic tests are rarely clinically warranted.

PCR testing for mycoplasma and chlamydia species, although not widely available, holds promise as a highly sensitive and
specific rapid diagnostic test and is likely to play a greater role as PCR technologies are refined.

Prognosis
Candidates for outpatient treatment usually improve over 24 to 72 h. Hospitalized patients may improve or deteriorate depending
on comorbidities. Aspiration is a major risk factor for death, as are older age and number and type of comorbidities. Pneumonia
caused by certain organisms may also increase the risk of death. Death may be caused by pneumonia itself, progression to sepsis
syndrome affecting other organs, or exacerbation of comorbidities.
Pneumococcal infection accounts for about 66% of fatal cases of community-acquired pneumonia in which an etiologic agent is
known. The overall mortality rate in hospitalized patients is about 12%. Poor prognostic factors include age < 1 or > 60 yr;
involvement of more than one lobe; peripheral WBC count < 5000/μL; comorbidities (eg, heart failure, alcoholism, hepatic or renal
insufficiency), immunosuppression (eg, agammaglobulinemia, anatomic or functional asplenia), infection with serotypes 3 and 8;
and hematogenous spread with either positive blood cultures or extrapulmonary complications (usually arthritis, meningitis,
endocarditis). Infants and children are at special risk of pneumococcal otitis media, bacteremia, and meningitis.

Mortality in Legionella infection is 10 to 20% among community-acquired cases and is higher among immunosuppressed or
hospitalized patients. Patients who respond do so slowly, and x-ray abnormalities usually persist for ≥ 1 mo. Most patients require
hospitalization, many require ventilator support, and 10 to 20% die despite appropriate antibiotic therapy.

Prognosis in mycoplasma pneumonia is excellent; nearly all patients recover.

Chlamydophila pneumoniae responds more slowly to treatment than mycoplasma pneumonia and tends to recur if therapy is
stopped prematurely. Young adults with C. pneumoniae usually do well, but the elderly have a mortality rate of 5 to 10%.

Treatment

• Risk stratification
• Antibiotics
• Antivirals for influenza or varicella
• Supportive measures

A prediction rule may be used to estimate mortality risk. The rule has been used to identify those patients who can be safely
treated as outpatients and those who require hospitalization because of high risk of complications. However, the rule was not
developed to determine site of care. Thus, the rule should supplement, not replace, clinical judgment, because many
unrepresented factors, such as likelihood of adherence, ability to care for self, and wishes to avoid hospitalization, should also
influence triage decisions.Also, certain criteria that extend across a continuum of severity have dichotomous cutoffs; eg, a heart
rate of 124 beats/min may indicate distress, but points are not assigned unless heart rate is ≥ 125 beats/min. ICU admission is
required for patients who need mechanical ventilation and for those with hypotension (systolic BP < 90 mm Hg) that is
unresponsive to volume resuscitation. Other criteria that mandate consideration for ICU admission include respiratory
rate > 30/min, PaO2/inspired O2 (FIO2)< 250, multilobar pneumonia, diastolic BP < 60 mm Hg, confusion, and BUN > 19.6 mg/dL.

Appropriate treatment involves starting antibiotics as soon as possible, preferably ≤ 8 h after presentation. Supportive care
includes fluids, antipyretics, analgesics, and for patients with hypoxemia O2.

Because organisms are difficult to identify, antibiotics are selected based on likely pathogens and severity of illness. Consensus
guidelines have been developed by many professional or. Guidelines should be adapted to local susceptibility patterns, drug
formularies, and individual patient circumstances. Importantly, none provide recommendations for treatment of viral pneumonia.

Ribavirin and RSV Ig have been used alone and in combination for RSV bronchiolitis in children, but their effectiveness is
controversial, and neither is standard practice. Ribavirin is not used in adults with RSV infection. Oseltamivir 75 mg po bid or
zanamivir 10 mg inhaled bid started within 48 h of symptom onset and given for 5 days reduces the duration and severity of
symptoms in patients who develop influenza infection.

Acyclovir 5 to 10 mg/kg IV q 8 h for adults or 250 to 500 mg/m2 body surface area IV q 8 h for children is recommended for
varicella lung infections. Some patients with viral pneumonia, especially those with influenza, develop superimposed bacterial
infections and require antibiotics directed against S. pneumoniae, H. influenzae, andStaphylococcus aureus.

With empiric treatment, 90% of patients with bacterial pneumonia improve. Improvement is manifested by decreased cough and
dyspnea, defervescence, relief of chest pain, and decline in WBC count. Failure to improve should trigger suspicion of an unusual
organism, resistance to the antimicrobial used for treatment, empyema, coinfection or superinfection with a 2nd infectious agent,
an obstructive endobronchial lesion, immunosuppression, metastatic focus of infection with reseeding (in the case of
pneumococcal infection), or nonadherence to treatment (in the case of outpatients). If none of these can be proven, treatment
failure is likely due to inadequate host defenses.

Most viral pneumonias resolve without specific treatment.

Chest physical therapy can be used to treat pneumonia; however, there is no clear evidence for its efficacy. Follow-up x-rays
should be obtained 6 wk after treatment in patients > 35; persistence of an infiltrate at≥ 6 wk raises suspicions of an underlying,
possibly malignant endobronchial lesion or of TB.

Prevention
Some forms of community-acquired pneumonia are preventable with pneumococcal conjugate vaccine (for patients < 2 yr), H.
influenzae B (HIB) vaccine (for patients < 2 yr), pneumococcal pneumonia vaccine (for patients at high risk, such as those with
underlying heart, lung, or immune system disorders), varicella vaccine (for patients < 18 mo and a later booster vaccine), and
influenza vaccine (for patients age ≥ 65 and those at high risk.

75 mg po once/day or zanamivir 10 mg once/day can be given for 2 wk to prevent influenza (although resistance has recently been
described for oseltamivir ) for household contacts of patients with influenza and to high-risk patients not vaccinated against
influenza during influenza epidemics. Pneumococcal pneumonia vaccination is recommended for all patients ≥ 65