Pneumonia is infection of the lung tissue. It is characterised by signs and symptoms of a lower respiratory tract infection and diagnosis is confirmed by a chest radiograph.
Presentation
Cough- productive or unproductive
Fever
Rigors
Dysponea
Pleuritic chest pain
Tachycardia
General malaise
Less common symptoms include:
Haemoptysis
Confusion (especially in elderly patients)
Fatigue
Nausea and vomiting
History
How long have the symptoms been going on for? Have they been getting worse/better/stayed the same?
Have they been taking any medications for their symptoms? If so what and have they helped?
Has the patient been in contact with anyone known to have a chest infection recently?
Have they travelled abroad recently?- Identify TB risk
Does the patient have any risk factors for pneumonia?- Age >65 years, smoking, alcoholism, immunosuppressive conditions, and conditions such as COPD, cardiovascular disease, cerebrovascular disease, chronic liver or renal disease, diabetes mellitus and dementia
What is the patient's occupation?- Farm work
Does the patient work with birds or have a bird as a pet?- Exposure to atypical bacteria causing pneumonia
Examination/observations
Febrile
Tachycardia
Tachypnoea
Dyspnoea- laboured breathing/use of accessory muscles
Low oxygen sats/signs of hypoxia
Signs of consolidation- dull percussion, coarse crepitations, increased vocal resonance
Be aware of sepsis:
Febrile
Chills/shivering
Tachypnoea
Reduced consciousness
Reduced urine output
Hypotension- septic shock
Investigations
Oxygen saturations- ABG if considered necessary
Blood tests:
- FBC
- CRP
- U+E's
- LFT's
- Blood Cultures
Chest Radiograph
Sputum culture
If Legionella suspected- urine antigen test for Legionella
CAP vs HAP
Community acquired Pneumonia (CAP) is contracted out of hospital or less than 48 hours of being in hospital
Pneumonia is deemed hospital acquired (HAP) if the patient has been in hospital for over 48 hours.
The causative organisms differ between the two and therefore the management of patients will also be slightly different
CURB 65
Used to assess severity of Community-Acquired Pneumonia (CAP) patients:
C onfusion =1
U rea >7mmol/L =1
R espiratory rate ≥30/min =1
B lood pressure- systolic BP <90mmHg or diastolic BP ≤60mmHg =1
65 - patient aged ≥65 =1
CRB 65 is used to assess patients in the primary care setting
| Score | Risk of Mortality | Management |
|---|---|---|
| 1 | Low (<3%) | May be suitable for outpatient management |
| 2 | Increased (3-15%) | Short stay in-patient treatment or hospital supervised outpatient treatment depending on clinical judgment |
| ≥3 | High (>15%) | Admit patient and consider intensive care assessment |
Causes of CAP
Bacterial
Most common causes:
Streptococcus pneumonia
Haemophillus influenzae
Moraxella catarrhalis- common in patients with COPD
Atypical:
Klebsiella pneumoniae- Alcoholics and those at risk of aspiration e.g. stroke patients
Chlamydia psticacci- 'bird fanciers lung'
Coxiella burnetti- Patients who work with farm animals
Legionella
Viral
Approximately 1/3 of pneumonia in adults is caused by a virus
The most common viruses that cause pneumonia are: influenza, parainfluenza, human respiratory syncytial virus (RSV) and adenovirus
Causes of HAP
Usually bacterial not viral
It is the second most common nosocomial infection (after UTI's) and the leading cause of death from a nosocomial infection
Gram negative bacilli- e.g. pseudomonas aeruginosa
Staph. aureus- including MRSA
Klebsiella pneumoniae
E.coli
Management
Appropriate oxygen therapy
Assess for volume depletion and treat with IV fluids if present
Monitor and record at least twice daily: Temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation and inspired oxygen concentration
Monitor more frequently in those with severe pneumonia or requiring regular oxygen therapy
Low Severity CAP
Outpatient Antibiotic Therapy
Amoxicillin 500mg three times a day for 5 days
Tetracycline (e.g. Doxycyline) or Macrolide (e.g. Clarithromycin) suitable alternatives if patient is hypersensitive to Penicillin
Consider extending course if no improvement within 3 days
Advise patients to consult healthcare professional if they feel that they are getting worse or not improving as expected
Moderate and High Severity CAP
7-10 day course of antibiotics
Consider dual antibiotic therapy with amoxicillin and a macrolide for patients with moderate‑severity community‑acquired pneumonia
Consider dual antibiotic therapy with a beta‑lactamase stable beta‑lactam and a macrolide for patients with high‑severity community‑acquired pneumonia.
HAP
Offer antibiotic therapy within 4 hours
Consider a 5‑ to 10‑day course of antibiotic therapy in accordance with local hospital policy and clinical circumstances
Repeat CRP and chest radiograph in patients who are not progressing satisfactorily within 3 days of treatment
Prior to discharge
Review patients 24 hours before discharge. If they have 2 or more of the following findings then delay discharge:
- temperature higher than 37.5°C
- respiratory rate 24 breaths per minute or more
- heart rate over 100 beats per minute
- systolic blood pressure 90 mmHg or less
- oxygen saturation under 90% on room air
- abnormal mental status
- inability to eat without assistance.
Consider delaying discharge for patients with community‑acquired pneumonia if their temperature is higher than 37.5°C.
