1. Pneumonia An acute respiratory illness associated with recently developed pulmonary shadowing which is either segmental or affecting more than one lobe

2. Pneumonia - classification Community-aquired Hospital-aquired Immuno-compromised host

3. Lobar pneumonia – a radiological and pathological term referring to homogenous consolidation of one or more lung lobes, often with associated pleural inflammation Bronchopneumonia –more patchy alveolar consolidation associated with bronchial and bronchiolar inflammation often affecting both lower lobes

4. Community-aquired pneumonia Common organisms: –Streptococcus pneumoniae – 30% –Chlamydia pneumoniae – 10% –Mycoplasma pneumoniae – 9% –Legionella pneumoniae – 5%

5. Community-aquired pneumonia Uncommon organisms: Haemophilus influenzae Staphylococcus aureus Chlamydia psitacci Coxiella burnetii Klebsiella pneumoniae Actinomyces israelii

6. Community-aquired pneumonia No microbiological diagnosis is established in approximately 40% of patients with community- acquired pneumonia admitted to hospital!

7. Community-acquired pneumonia symptoms Cough (short, painful, at first dry, later productive) Fever Malaise Pleuritic chest pain Loss of appetite Headache

8. Community-acquired pneumonia physical signs in lobar pneumonia Fever, tachycardia, tachypnoe, evidence of hypoxaemia, pleurisy and pleural rub Signs of consolidation (within 2 days): Reduced movements of chest wall on affected side impairment of percussion note (dull) high-pitched bronchial sounds Increased vocal resonance Fine crepitations Signs of resolution: coarse crepitations

9. Community-acquired pneumonia physical signs in bronchopneumonia Fever, tachycardia, tachypnoe, evidence of hypoxaemia, Symetrically diminished movement of chest wall Sometimes impaired percussion note Normal vocal resonance Breath sounds usually harsh vesicular with prolonged expiration Rhonchi and coarse crepitations

10. Community-acquired pneumonia investigations To obtain a radiological confirmation of the diagnosis To exclude other conditions that may mimic pneumonia To obtain a microbiological diagnosis To help assess the severity of the pneumonia To identify the development of complications

11. To obtain a radiological confirmation of the diagnosis Radiological examination is essential to confirm diagnosis of pneumonia! In lobar pneumonia – homogenous opacity localised to the affected lobe (within 12-18 hours of the onset of the illness) Very helpful if complications occur (pleural effusion, intrapulmonary abscess, empyema)

12. Differential diagnosis of pneumonia Pulmonary infarction (often presents like bacterial pneumonia, but pyrexia usually less, cough not so troublesome, haemophysis much more common and the source of embolism may be apparent) Pulmonary/pleural tuberculosis Pulmonary oedema (no fever!) Inflammatory conditions below the diaphragm Remember! Recurrent pneumonias in an older patient may be „a mask” of lung cancer!

13. To obtain a microbiological diagnosis Sputum Blood culture - rarely positive but 100% specificity Serology – to diagnose Mycoplasma, Chlamydia, Legionella and viral infection; also Pneumococcal antigen in serum Tracheal aspirate, bronchoalveolar lavage, protected brush specimen, percutaneous needle aspiration

14. What should be done if pneumonia suspected/diagnosed Microbiological investigation Radiological examination Arterial blood gas measurement (when pO 2 < 60% - hospital) General blood tests with blood morphology, urea, creatinine, electrolytes and aminotransferases measurements (high neutrophil leucocytosis – bacterial, normal white cell count – atypical agents, leucopenia – viral)

15. Antibiotic treatment at home Amoxycillin 500 mg 8-hourly orally for 7-10 days; 14 days or longer for Legionella, Staphylococcus aureus and Klebsiella If allergic to penicillin: –Clarithromycin 500 mg 12-hourly orally or –Erythromycin 500 mg 6-hourly orally If mycoplasma or legionella is suspected: –Clarithromycin 500 mg 12-hourly orally or –Erythromycin 500 mg 6-hourly orally

16. Resolution of radiologic changes In most of cases: 3 – 12 weeks Total resolution: in 50% of patients after 2 weeks In 73% after 6 weeks If no resolution – wrong diagnosis? (tuberculosis, pulmonary infarction, lung cancer)

17. Complications of pneumonia Parapneumonic effusion – common Empyema Retention of sputum causing lobar collapse Development of thromboembolic disease Pneumothorax – particularly with Staph. Aureus Suppurative pneumonia/lung abscess ARDS Ectopic abscess formation (Staph. Aureus) Hepatitis, pericarditis, myocarditis, meningoencephalitis Pyrexia due to drug hypersensitivity

18. Hospital-acquired pneumonia A new episode of pneumonia occuring at least 2 days after admission to hospital Pathogenic organisms responsible: mainly Gram-negative bacteria: Escherichia, Pseudomonas, Klebsiella species, also Staph. Aureus, including MRSA-forms (multidrug resistant)

19. Hospital-acquired pneumonia management A third generation cephalosporin (cefotaxime) + an aminoglycoside (gentamicin)or Imipenemor A monocyclic beta-lactam (aztreonam) + flucloxacillin

20. Aspiration pneumonia management Co-amoxiclav 1,2 g 8-hourly + Metronidazole 500 mg 8-hourly iv