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Updated: Jul 30 2022

Community-Acquired Pneumonia

  • Snapshot
    • An 88-year-old man presents to the emergency department from home after developing increasing shortness of breath, fatigue, poor appetite, and malaise. His symptoms began approximately 4 days ago, when he noticed he had a productive cough with green-yellow sputum. His temperature is 101°F (38.3°C), blood pressure is 136/93 mmHg, pulse is 101/min, and respirations are 22/min. Physical exam is notable for crackles in the right lower lobe and dullness to percussion. Chest radiography demonstrates a lobar consolidation.
  • Introduction
    • Definition
      • pulmonary parenchymal infection of the lower respiratory tract acquired outside the healthcare setting
  • Epidemiology
    • Incidence
      • a leading cause of morbidity and mortality worldwide
    • Risk factors
      • chronic lung disease (e.g., chronic obstructive pulmonary disease [COPD])
      • diabetes mellitus
      • proton pump inhibitors
      • smoking
      • high alcohol consumption
      • aspiration
  • Etiology
    • Bacterial
      • Streptococcus pneumoniae (most common)
      • Staphylococcus aureus (seen postinfluenza)
      • Mycoplasma pneumoniae (in young patients)
      • Chlamydophila pneumoniae (in young patients)
      • Legionella species(in elderly patients, immunocomprosed, and smokers)
      • Hemophilus influenzae (in COPD)
      • Moraxella catarrhalis (in COPD)
      • Mixed flora, especially anaerobes like Klebsiella pneumoniae (in alcohol use disorder and aspiration)
    • Viral
      • influenza
      • respiratory syncytial virus
      • rhinovirus
      • parainfluenza virus
      • coronavirus
    • Fungal
      • pneumocystis jiroveci (in patients with HIV)
  • Presentation
    • Symptoms
      • productive or non-productive cough
      • dyspnea
      • pleuritic chest pain
      • fatigue and malaise
    • Physical exam
      • fever
      • tachypnea
      • increased work of breathing
      • pulmonary auscultation
        • rales/crackles
        • rhonchi
      • tactile fremitus
      • egophony
      • dullness to percussion
  • Imaging
    • Radiography of the chest
      • findings
        • lobar consolidation
        • pleural effusion
        • cavitary lesions
  • Studies
    • Sputum Gram stain and culture
    • Blood cultures
      • acquire before administering antibiotics
    • Other studies depend on clinical suspicion, such as
      • urine legionella antigen testing
      • induced sputum acid-fast bacillus stain and myocbacterial culture for tuberculosis
      • direct fluorescent-antibody or PCR testing of a nasopharyngeal swab or sputum for viral causes
      • procalcitonin
        • elevated in bacterial pneumonia
          • useful in differentiating bacterial vs. viral pneumonia
    • Bronchoscopy is considered in
      • critically ill patients
      • patients who fail to respond to therapy
      • chronic pneumonia
      • immunosuppressed
  • Differential
    • COPD exacerbation
      • differentiating factor
        • patient has a history of COPD
  • Treatment
    • Prevention
      • PPSV23 in
        • > 65 years of age
        • 19-64 with chronic medical conditions such as
          • asplenia
          • immunocompromised
          • smokers
      • PCV13 in
        • all children and young patients
      • yearly influenza vaccination
      • incentive spirometry
      • proper oral hygiene
        • tooth brushing, denture care, and fixing dental caries
          • oral flora contains gram-positive, gram-negative, and anaerobic bacteria
      • reducing number of medications that decrease salivation since this has a protective effect on oral bacteria
      • proper positioning
        • upright sitting during eating or at least have bed be set at > 30°of incline
          • especially during comatose states
    • Medical
      • empiric antibiotics in the outpatient setting
        • medications
          • amoxicillin clavulinic acid
            • can add one of the following
              • azythromycin
              • doxycycline
      • empiric antibiotics in the inpatient setting
        • medications
          • levofloxacin or moxifloxacin
          • ceftriaxone and azithromycin
          • if aspiration
            • cover for anaerobes
              • clindamycin or ampicillin-sulbactam
  • Complications
    • Respiratory failure
    • Sepsis
    • Septic shock
    • Empyema
      • requires both drainage and antibiotics for successful treatment
  • Prognosis
    • Improved mortality with administration of antibiotics
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