PNEUMONIA

COMMUNITY ACQUIRED PNEUMONIA

Defined as acute infection pulmonary parenchyma in a patient who acquired the infection in the community Approximately 5-6 cases per 1000 Streptococcus pneumonia is the most common cause Predisposing conditions: Alterations in level of consciousness microaspiration Smoking and alcohol Lung disease Malnutrition Overlying viral infection Recent hospitalization or antibiotics Indigenous population Steroid use Microorganisms Typical organisms: 1. Streptococcus pneumoniae 2. Hameophillus influenzae 3. Staphylococcus aureus those recovering from influenza 4. Group A strep 5. Moraxella catarrhalis 6. Anaerobic and aerobic gram negatives a. Klebisella underlying disease like DM or COPD, alcoholics (redcurrant jelly sputum) b. Pseudomonas bronchiectasis, repeated antibiotics, prolonged steroids, immunocompromise c. Acinetobacter d. Moraxella e. E. coli, Serratia, Proteus Atypical organisms: 1. Legionella 2. Mycoplasma 3. Chlamydophillia pneumonia Clinical Evaluation Clinical features: o History Cough, fever, pleuritic chest pain, dyspnea, sputum production mucopurulent bacterial watery atypical rust-coloured sputum pneumococcal redcurrant jelly - klebsiella Sometimes, gastrointestinal symptoms (nausea, vomiting, diarrhea) o Physical examination General: Tachypnea, tachycardia

Auscultation: Reduced breath sounds, bronchial breathing, crackles, increased fremitus, whisper pectoriloquy Percussion: dullness

Guidelines for Management A. Diagnosis Diagnosis of pneumonia requires 1. Evidence of consolidation on CXR 2. Plus one of: o Temperature >38 o Dyspnea o Chest pain o Cough B. Investigations Initial: Urgent CXR EUC, CBC SpO2 ABG (if sats <94%) Blood cultures If admitted: Sputum gram stain and cultures Sputum/nasal swab/throat swab for viral PCR Urinary Legionella antigen detection Pleurocentesis (if effusion) o pH, gram stain, culture, LDH, cell count Risk Stratification SMART-COP Systolic BP <90 (2 points) Multilobar CXR involvement Albumin <35 Respiratory rate Tachycardia Confusion Oxygen saturation (>50yo: <90%, <50yo, <93%) pH <7.35 C. Treatment If score 0-2: Consider outpatient treatment Amoxicillin + Doxycycline PO for 7 days If score 3-4: Admission Amoxycillin + Azithromycin + Gentamicin (in high risk groups) for 7-10 days If score 5-6: ICU admission If score 7+: Ventilator support Amoxycillin + Azithromycin + Gentamicin IV for 10 days If allergic to penicillin: use Cefuroxime for oral, Ceftriaxone for IV, Roxithromycin replaces doxycycline

Doxycycline/roxithromycin covers atypicals like mycoplasma and chlamydia If pneumococcus resistant, vancomycin and fluoroquinolones (moxifloxacin) are options If legionella positive in urine antigen test/culture, azithromycin is the drug