Pneumonia

Medicine > Respiratory

Background knowledge 🧠

Definition

Pneumonia is an inflammatory condition of the lung, primarily affecting the alveoli, usually caused by infection.
It differs from a lower respiratory tract infection (LRTI) in that there is consolidation seen on chest radiograph.

Aetiology and Clues

Bacterial:
- Streptococcus pneumoniae (may be preceded by viral infection) → rusty colour sputum, associated HSV reactivation common.
- Haemophilus influenzae (often comorbidities such as COPD, smoking, immunocompromise).
- Staphylococcus aureus (IVDU, occurs after influenza).
- Klebsiella pneumoniae (alcoholism, COPD, diabetes) → red currant jelly colour sputum.
Atypical → headache, malaise, myalgia, rash, diarrhoea
- Mycoplasma pneumoniae (young patients).
- Legionella pneumophila (exposure to travel/air conditioning) → prominent GI symptoms, SIADH.
- Chlamydia pneumoniae (bird exposure).
- Coxiella burnetii (farmyard animal exposure).
Mycobacterial:
- Tuberculosis → upper lobe consolidation/cavitation.
Viral → pneumonitis, coryza
- Influenza.
- Respiratory syncytial virus (RSV).
- Parainfluenza.
Fungal:
- Pneumocystis jirovecii (immunocompromised) → exertional dyspnoea/hypoxaemia.
- Histoplasma.
- Aspergillus.

Types

Clinically divided into 3 broad categories:
- Community acquired pneumonia (CAP).
- Hospital acquired pneumonia (HAP).
- Ventilator-Associated pneumonia (VAP).
Pathogens are likely to be different depending on where you’ve acquired the infection.

Clinical Features 🌡️

Symptoms

Fevers.
Cough (with or without sputum production).
Breathlessness.
Chest pain (pleuritic in nature).

Signs

Tachypnoea and tachycardia.
Fever.
Dullness to percussion.
Coarse crepitations on auscultation.
Bronchial breathing.

Investigations 🧪

Tests

Chest X-ray: consolidation, air bronchograms, alveolar opacities.
Blood tests:
- Full blood count: leucocytosis or leucopenia.
- Inflammatory markers: raised CRP.
- Consider serology for: HIV, Mycoplasma, Coxiella.
Blood cultures: identify causative organism in bacteraemic cases.
Sputum Gram stain and culture: detect causative bacteria.
Urine antigen tests (legionella, pneumococcal).

Management 🥼

Management

Supportive therapy:
- Oxygen (aim saturations 92-96%).
- Invasive ventilation may be required in severe hypoxaemia.
- Hydration.
- Antipyretics.
Antibiotics:
- Usual bacterial cover: e.g. amoxicillin, co-amoxiclav, benzylpenicillin, ceftriaxone, doxycycline, levofloxacin.
- Atypical bacterial cover: e.g. clarithromycin, azithromycin, doxycycline, levofloxacin.
Antivirals: in cases of viral pneumonia (e.g. oseltamivir for influenza).

Complications

Pleural effusion: accumulation of fluid in the pleural space.
Empyema: pus in the pleural space.
Abscess formation: localised collection of pus within the lung.
Respiratory failure: insufficient gas exchange due to alveolar involvement.
Septicaemia: spread of infection to the bloodstream.

Key Points

Pneumonia is an inflammatory condition of the lung, different from LRTI as consolidation is identified on chest radiograph.
It is often caused by infection (bacterial, atypical, mycobacterial, virus, fungal), which have specific clinical clues associated to them.
Early recognition and intervention are crucial to prevent life-threatening complications.
A combination of supportive therapy and antibiotics/antivirals are required for management.

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💡 We've found 3 questions

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30152

Which of the following organisms is a typical cause of community-acquired pneumonia?

29356

A 71-year-old woman is admitted with 5 days of cough productive of purulent sputum and fevers after returning from holiday to Dubai, which has not improved with oral antibiotics prescribed by the GP. She is now confused and dehydrated with some renal impairment evident from the bloods (urea 9 mmol/L, creatinine 140 µmol/L). Chest X-ray now shows bilateral consolidation.

Urinary antigen testing should be undertaken looking for which causative pathogen?

28281

A 44-year-old man presents to the emergency department with a 3-day history of shortness of breath and a productive cough. His observations include temperature 38.2°C, pulse rate 90 bpm, blood pressure 130/86 mmHg, respiratory rate 24/min and saturations 94% on room air. Blood results include white cell count of 13.5 × 10⁶/L, CRP 45 mmol/L, Na⁺136 mmol/L, K⁺4.3 mmol/L, urea 9.2 mmol/L and creatinine 110 µmol/L. On examination, he appears to be alert, and there are dull sounds on percussion over the right lower lobe. A chest radiograph confirms a right lower lung lobe consolidation.

Based on the patient’s CURB-65 score, what is the most appropriate management?

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· Confusion	AMTS <8
· Urea	>7 mmol/L
· Respiratory rate	>30/min
· Blood pressure	systolic <90 mmHg or diastolic 60 mmHg
· Age	>65 years

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