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Acute Pneumonia
About
Classification
Pathological changes
Microbiological causes
Organism Details Investigations Treatment
SARS-CoV-2. COVID-19 Highly infectious coronavirus. Continuous Cough, loss of taste/smell, fever and fatigue. High risk co-morbidity, the elderly, the immunosuppressed and the obese. In the UK, black, Asian and ethnic minority (BAME)
COVID test, CXR shows bilateral changes, CT shows bilateral ground glass opacities.
High flow oxygen, VTE prophylaxis. Dexamethasone and Anti-virals, e.g. remdesivir. Some need ITU and ventilation and proning.
Streptococcus
pneumoniae Commonest. 70%. Middle aged. Cough with green/rusty sputum, fever, pleurisy. Associated HSV cold sores. Main cause of lobar pneumonia. Cavities with serotype 3 Sputum, blood and urine - pneumococcal antigen
Penicillin (if allergic, Erythromycin) e.g., Treat with Benzyl Penicillin 1-2 g 6 hrly
Mycoplasma pneumoniae Children and young adults. Autumnal and 3–4-year epidemic cycle atypical pneumonia - cough
and sputum absent in 1/3 cases. Preceding flu-like symptoms usually, e.g.
headache, myalgia, GI upset before onset of respiratory symptoms Myocarditis, pericarditis, erythema multiforme, haemolytic anaemia, myalgia, arthralgia, meningo-encephalitis, cold agglutinins
Serology for IgM and IgG antibodies (acute and convalescent titres), cold agglutinins (in 50%). Erythromycin, Azithromycin,
Clarithromycin or
doxycycline
Haemophilus influenzae Especially seen in the
elderly, heavy smokers and COPD patients
No specific features; may be broncho- or lobar
pneumonia Cefuroxime or Co-Amoxiclav
Moraxella catarrhalis
Common cause of bronchopneumonia especially in the
elderly and COPD patients
No specific features; may be broncho- or lobar
pneumonia Cefuroxime or Co-Amoxiclav
Staphylococcus aureus
More common following influenza pneumonia, IV drug, central line Severe pneumonia, post-influenza maybe rapidly fatal. Abscess formation, pneumothorax, empyema
relatively common. Septicaemia: infective emboli causing abscesses in other organs. Nodular consolidation and
cavitation on CXR.
Flucloxacillin
Chlamydia psittaci 'Psittacosis'
Acquired from avian excreta seen in those exposed to birds. Malaise, high fever, dry cough,
hepatosplenomegaly and rose spots on the abdomen.
Hepatitis, encephalitis, renal
failure. Hepatosplenomegaly.
Serology for Chlamydia antibodies -
complement-fixing
antibodies (immunofluorescent
tests to
distinguish types).
Erythromycin,
Azithromycin,
Clarithromycin or
Doxycycline
Chlamydophila
pneumoniae
Causes 5-10% of
community-acquired
Often mild flu-like illness or
acute bronchitis recovering
spontaneously. Pneumonia
also usually mild
CXR:Segmental Infiltrates, Acute and convalescent sera
Erythromycin,
Azithromycin,
Clarithromycin or
doxycycline
Coxiella burnetii
(Q fever)
Only 1% of cases overall Influenza-like illness which
causes pneumonia if it
persists, often with
multiple CXR lesions
Endocarditis. If untreated
chronic infection is fatal
Serology - complement
fixing antibody. CXR: Multiple segmental shadows
Erythromycin,
Azithromycin,
Clarithromycin or
doxycycline
Hypoalbuminaemia and
abnormal LFTs (raised
transaminases) are
common.
Acute renal failure.
Legionella
pneumophilia
Infection from water
system. Sporadic cases source unknown. Middle-aged and older, Recent travel, Autumn time. Outbreaks in immunocompromised
individuals. x 2 in Males. Usually, 2-10 day prodromal of dry cough, confusion, headache, myalgia
or diarrhoea, low WCC, Low Na, abnormal LFTs. CR shadows.
Urine for specific antigen. Immunofluorescent
tests on sputum or
bronchial lavage.
Erythromycin,
Azithromycin,
Clarithromycin or
Ciprofloxacin +/?
rifampicin Despite
these mortality
?20%
Klebsiella Elderly with a history of
heart or lung disease,
diabetes, alcohol
excess or malignancy
Sudden onset, severe
systemic upset, purulent,
mucoid sputum
(Classically redcurrant
jelly). Lobar pneumonia
CXR: cavitating lesions
- lung abscesses
Extensive lobar
consolidation with
cavitation. Widespread consolidation (upper lobes)
Cefuroxime and
Gentamicin
Pseudomonas
aeruginosa
Nosocomial, cystic fibrosis and
neutropenic patients.
Sputum and blood culture
but it does colonise the
upper airway as a
commensal
Ciprofloxacin or
ceftazidime
Anaerobes -
Bacteroides
Aspiration, e.g. due to
stroke. Diabetics
Metronidazole
Pneumocystis
jiroveci (PCP)
(Previously
Pneumocystis
carinii)
The most common
opportunistic
infection in AIDS
(CD4 count
<200/mm3) and
immunosuppressed
patients
High fever, dry cough,
shortness of breath,
tachycardia. Marked
hypoxia, particularly
following exertion. Fine
crackles or nothing to
find on auscultation.
Mortality now 10%
Typical CXR - perihilar
'butterfly' ground glass
shadowing. but may be
normal in early disease.
CT shows ground-glass
shadowing, bronchial
lavage or induced
sputum for diagnosis by
silver staining or by
immunofluorescence
Long-term prophylaxis is
required, e.g. with
co-trimoxazole
Hi-dose i.v.
cotrimoxazole or
i.v. pentamidine
Viral Pneumonia Influenza, Parainfluenza, Measles, RSV in infants, Varicella can cause severe pneumonia with multiple miliary nodular shadows which may calcify Relevant serology Consider Neuraminidase inhibitors if Influenza Clinical
Types
CURB 65 severity 1 point for each:
Other severity markers
Investigations
Management
Antibiotics
Refer for ITU and Mechanical Ventilation if
References
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Pneumonia
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