Pneumonia

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Pneumonia is an infection of the lung tissue caused by various bacteria, viruses or fungi. Identification of the causative organism and drug sensitivity testing is the key to correct treatment. However, because of the serious nature of the infection, antibiotic treatment should be started immediately based on knowledge of the most probable causative organism and the antibiotics used for its treatment.  Local knowledge of drug resistance patterns are also taken into account. Treatment may be maintained or changed based on culture results and assessment of the patient’s response to initial treatment. In the event that the cultures of blood or sputum prove negative, empiric treatment is continued with clinical response as a guide. 

The severity of the illness is a key factor in the decision for admission, and the choice of first or second-line treatment.  

Severity score for community acquired pneumonia (CURB-65)

Severity score may be based on the following, assigning one point to each of the following factors (maximum 5 points);

• Confusion, restlessness, or excessive drowsiness
• Blood Urea Nitrogen (>7 mmol/L)
• Respiratory rate (≥ 30 per minute in adults, and ≥ 50 in children)
• Low BP (Systolic BP < 90 and/or diastolic BP < 60 mmHg)
• Patients at the extremes of age, (< 5yr or  ≥ 65yr)

 

Score 0-1; consider home treatment

Score 2-3; consider short inpatient hospitalisation

Score > 3; admit and consider intensive care

 

In the presence any of the following additional factors, all cases of pneumonia would warrant hospitalisation:

• Coexisting diseases such as chronic lung disease, heart failure or renal disease
• Extensive disease, multiple lobes involved
• Low oxygen saturation SpO₂, < 92% on room air
• Severe tachycardia

Causes

Community acquired pneumonia

• Streptococcus pneumonia
• Streptococcus pyogenes
• Haemophilus influenza
• Klebsiella pneumoniae
• Mycoplasma pneumonia and Legionella pneumophila (tend to occur in epidemics)
• Staphylococcus aureus (in children after viral illness like measles, in diabetics or in the elderly during ‘flu’ epidemics)

Aspiration pneumonia

• Anaerobic and/or gram negative organisms (associated with aspiration e.g. stroke, seizures, unconsciousness)

Hospital acquired pneumonia

• Gram-negative bacteria e.g. Pseudomonas aeruginosa 
• MRSA (Methicillin resistant) 
• VRSA (Vancomycin resistant) 
• Staphylococcus aureus 

Others

• Pneumocystis jiroveci pneumonia and other fungi (in immunocompromised states e.g. haematological malignancies, HIV/AIDS)
• Viruses

Symptoms

• Fever - short history 
• Productive cough 
• Sputum - rusty or blood stained, yellowish, greenish
• Pleuritic chest pain - worse on deep breathing or coughing
• Breathlessness
• Sweating
• Muscle aches
• Elderly and immunocompromised patients may have minimum or no symptoms

Signs

• Rapid breathing 
• Grunting (in children)
• Use of accessory muscles of respiration and flaring of the nasal margins
• Lower chest wall indrawing (in children)
• Restricted movement of the affected side of the chest (due to pain)
• Fever
• Rapid pulse rate
• Blood pressure may be normal or low
• Signs of consolidation or pleural effusion on chest examination
• Restlessness or confusion, drowsiness
• Low blood oxygen saturation by pulse oximetry < 92%

Complications

• Pleural effusion 
• Lung abscess
• Empyema
• Pericardial effusion/pericarditis
• Pneumothorax particularly Staph. aureus infection, Pneumocystis jiroveci pneumonia
• Meningitis
• Septicaemia with multi organ failure
• Adult respiratory distress syndrome (ARDS)

Investigations

• FBC
• C-reactive protein (CRP)
• Chest X-ray
• Sputum gram stain and culture and sensitivity
• Ziehl-Neelsen stain for acid-fast bacilli (to exclude TB)
• Blood culture and sensitivity
• Blood urea and electrolytes

Treatment

Treatment Objectives

• To identify patients at greater risk who require in-hospital management 
• To alleviate symptoms
• To treat and eradicate the infection 
• To prevent and/or manage complications 

Non-pharmacological treatment

• Nurse in comfortable position, usually with head raised
• Sponging to control fever, especially in children < 5 years (who are at risk of febrile convulsions)
• Adequate oral hydration (if it can be tolerated)
• Chest physiotherapy

Pharmacological Treatment 

Ambulatory patient: low severity score < 2 (see above)

 

Hospitalised patient: Severity score, ≥ 2 or with additional factors as mentioned above 

 

 

Referral Criteria

• Refer to the paediatrician or physician specialist if no improvement occurs (i.e. fever remains high, patient is still breathless, or repeat X-rays  show complications or no resolution).