PNEUMONIA

INTRODUCTION
 6th leading cause of death; mortality 1%, increased in elderly and underlying dz
 Definition = inflammation of the lung w/ clinical or Xray signs of consolidation

PATHOPHYSIOLOGY
 Pulmonary Defenses are normally VERY GOOD
 Three general reasons why pneumonia develops:
 Large inoculum that overwhelmes immune response
 Abnormal immune response or clearance of the lungs
 Particularly virulent organism
 Normal defenses of the airway and lung to prevent pneumonia
 Epiglottic and cough reflexes
 Tracheobrochial secretions and and bacteria are cleared bymucociliary
transport
 Cell mediated immunity
 Humoral immunity
 Risk Factors for Pneumonia
 Immunodeficiency
- Chemotherapy
- Cancers: leukemia, lymphoma, etc
- HIV/AIDS
- Chronic steroids
- Alcoholics
 Abnormal lung or chest structure
- COPD
- Bronchiectasis
- Bronchial obstruction: tumor, FB, adenopathy, TB
- Severe scoliosis, kyphosis, myopathy
 Decreased ability for mucociliary clearance
- Smoking
- Immotile cilia syndrome
 Abnormal airway reflexes and aspiration
- Coma, sz, alcoholic, overdoses
- Dementia, strokes, cerebral palsy, MS
- Debilitation: alcoholisms, extremes of life, neoplasia,
immunosuppresion
 Chronic disease
- Hem: leukemia, lymphoma, Hbpathy
- CV: CAD, CHF, CM
- CRF
- Diabetes
 Procedure
- Bronchoscopy, intubation, ventilation, needles
 Hospitalization/institutionalization/animals/travel change the bugs

PNEUMONIA SYNDROMES
 Typical vs atypical
 Community Acquired Pneumonia
 Hospital Acquired Pneumonia
 Nursing Home Acquired Pneumonia
 Aspiration pneumonia

TYPICAL PNEUMONIA ATYPICAL PNEUMONIA

HISTORY - productive cough, fever, dyspnea, - nonproductive cough, less fever,

sudden onset of chills, pleuritic chest
pain more common
- usu no constitutional symptoms
less dyspnea, less chills, pleuritic
CP not as common, no response
to abx
- constitutional symptoms very
common (myalgias, arthralgias,
H/A, rhinitis)
- usually community acquired

PHYSICAL - more respiratory distress - less resp distress

- higher fever - less fever
- consolidation findings - no consolidation: rales only

CXR - CXR: lobar, segmental or bronch - - CXR: diffuse, patchy, bilateral

INVEST pneumonia involvement that actually looks
- increased wbc more common worse than pt; atelectasis and
- positive sputum gram stain and volume loss
culture - less inc wbc and sputum/culture -ve

ETIOLOGY Gram Positives Bacteria

- pneumococcus - Mycoplasma
- Group A strep - Legionella
- Staph aureus - Coxiella burnetti
Gram Negatives - Chlamydia pneumonia/TWAR/
- Klebsiella Psittaci/trachomatis
- Psuedomonas
- H.flu Viral
- Enterobacter - influenza, parainfluenza, rhino,
Anerobes RSV, VZV, adenovirus, entero
- Fusobacterium, peptococcus, - Hanta virus
bacteroides, Other
peptostreptococcus - CMV
- PCP

 Is this useful?
 Exact bacteriologic identification is difficult even with extensive testing
 CXR is actually not very predictive of particular bugs
 This doesn’t really change management as you generally cover for both

COMMUNITY ACQUIRED PNEUMONIA

 Large multicenter trial of hospitalized CAP
Typical bugs (Pneumococcus, Morax, and Hflu) 25%
 Viral agents (Influenza, parainfluenza) 17%
Atypical bugs (Mycoplasma, chlamydia, Legionella) 15%
Unidentified Remainder
 Severe CAP pneumonia requiring ICU
 Pneumococcus is MCC
 Staph aureus is relatively more common
 Legionella is relatively more common
 Less severe CAP treated as outpatient
 Viral relatively more common
 Mycoplasma relatively more common
 Pneumococcus
 DM
 Cardiovascular disease
 Alchoholics
 Sickle cell anemia
 Asplenia or functional asplenia
 Cancers
 Immunosuppressed
 Resistant pneumococcus (Levofloxacin, vancomycin)
 > 65yo
 Comorbidities
 Immunosuppressed
 Abx w/i 3 months
 Contact with kids from day cares
 Nursing homes
 Pseudomonas (Ceftazidime, Ciproflox, Gent/tobra, Piptazo)
 Bronchiectasis
 Immunodeficiency
 Nursing homes
 Recent hospitalization
 Abx therapy for prior 7 days
 Gram -ves (Ceftriaxone, Cipro, Cefuroxime)
 Elderly
 Comorbidities and chronic dz
 Alcoholics
 COPD
 Diabetics
 Anerobes (Aspiration) (Flagyl, Clinda, Pip/Tazo)
 Alcoholics
 Strokes
 Dysphagia
 Dental dz
 GERD

 Staph (Vancomycin, Ancef, Clinda)

 Nursing homes
 Recent hospitalization
 Post influenza
 IVDU
 PCP (Septra, Pentamidine)
  AIDS
 Immunosuppressed
 Cancers
 TB (PIR)
 Immunosuppressed
 Homeless
 AIDS
 Exposure
 Aboriginal
 Night sweats, wt loss
 Prior TB exposure

EXAM QUESTION: LIST 10 UNIQUE PATIENTS/DISEASES THAT WOULD ALTER YOUR

USUAL CAP THERAPY AND LIST WHAT DRUG YOU WOULD USE/ADD
o Aspiration Anaerobes Flagyl
o Nursing home Staph Vancomycin
o Post influenza Staph Vanco
o AIDS PCP Septra
o Bronchiectasis Pseudomonas Ceftaz,cipro, pip/tazo
o Immunodef Pseudomonas Ceftaz, cipro, pip/tazo
o Comorbidities Resistant pneumoc Levoflox
o Elderly Resistant pneumoc Levoflox
o Nursing home Resistant pneumoc Levoflox

APPROACH TO PATIENT WITH PNEUMONIA

 ABCs, supportive, and resuscitation as appropriate
 Oxygen --------> intubation
 Intubation for respiratory failure: Pa02 < 70 mmHg with Fi02 at least 70%,
A - a gradient > 350 mmHg (normal 15, up to 37 w/ age), PaCO2 > 60 in
non-COPD
 Fluids, pressors for sepsis
 Bronchodilators for asthma/COPD
 General approach
 Stabilize, innitial tx, initial invetigations then Hx, PE, investigation
 URTI versus LRTI versus other ddx
 Typical vs atypical
 Setting: community acquired, institution acquired, aspiration,
immunocompro
 Identify risk factors R/O immunocompromised
 Isolation: for high risk of TB or suggestive hx
 Empiric Rx based on Inpatient vs Outpt management and RFs
 History
 Cough + Fever + Dyspnea are the cardinal symptoms of pneumonia
 Sputum color, amount, consistency, odor
 Ask about risk factors and clues to etiology: travel, immunizations,
immunedeficiency, infectious contacts, institutional vs community, animal
exposure (birds, deer mice, goats/sheep/birthing cats), alcohol/drugs,
preceeding URTI, diarrhea, pleuritic chest pain, rash, hemoptysis, TB
contacts or hx, occupational exposure, preceeding viral infection
 PMHx: immunodef, AIDS, CF, lung dz, asplenia, sickle cell, MM etc
  NB: elderly can present with delirium, sepsis
 Peds: presents with lethargy, irritability, poor feeding, grunting
 Specific Associations
Bordetella (kennel cough): sick dogs
 Histoplasmosis: bat caves
 Actinomyces: sulphur granules
 Tularemia: rabbit/fox/squirrel meat, tic/fly bites
 Brucellosis: farm animals, vets
 Anthrax: farm animal, vets
 Rodococcus equi: horses
 EtoH: aspiration, gram -ves and anaerobes
 Elderly: gram -ves
 Asplenic: pneumococcus, Hflu
 Preceeding viral syndrome: staph
 Predominant upper AW symptoms: mycoplasma
 Elderly, constitutional symptoms, diarrhea: legionella
 Physical Examination
 Gen: dehydrated, cyanotic, cachectic, anemic, jaundiced
 Vitals: RR, HR, BP, Sa02, temp
 Tacchycardia: expect 10 bpm/degree elevation; pulse temp deficit with
atypical pneumonias
 Resp: retractions, AMU, cyanosis, consolidation, wheezing, crackles
 ENT: bullous myringitis, herpes labialis w/ pneumococcus
 Skin: EN or EM
INVESTIGATIONS
 CBC and differential
 Not reliable
 Neutrophilia and left shift w/ bacteria (typicals)
 Lymphocytosis w/ viral, chlamydial, pertussis (atypicals)
 May be low in severe sepsis
 Sputum
 Hx: rusty (pneumococcus), current jelly (klebsiella), salmon color (staph),
scant/watery/thin (atypicals), foul smelling (anaerobes)
 Gram stain quality: > 25 PMNs per hpf and < 10 epithelial cells per hpf
 Gram stain bugs: grm +ve or -ve, diplococci, chains, clusters, cocobacilli,
etc
 Culture: often difficult to interpret, many false -ves, high contamination
rate
 DO NOT rely on sputum
 Blood cultures and CAP
Outpatients 5% positive
Inpatients 10% positive
Contamination rate 50%
Change abx therapy 1%
 Other Samples
 Nasopharyngeal aspirates for GS, AFB, culture
 Transtracheal aspirates
 Bronchoscopy brush, BAL
 Lung bx (gold standard)
 Thoracentesis
 ABG in severe case
 Hypoxemia due to shunt and V/Q mismatch
  Only req’d in severe cases
 CXR
 Indication for CXR: risk factors, underlying dz, failure of Rx,
immunodeficient, clinically moderate to severe disease
 Typical Bacterial Pneumonia: Consolidation, air-bronchograms,
atelectasis (volume loss) minimal, silouhette sign
 Atypical Pneumonia: diffuse interstitial infiltrates, hyperinflation,
peribronchial thickening, atelectasis (volume loss)
 Typical vs Atypical is not very reliable in microbiologic studies
 Pneumatoceles: think staph aureus, H.flu
 Empyema + pthx: think staph aureus
 Abscess: staph, anaerobes, TB, funhgal, gram -ves
 Pleural effusion: think pneumococcus, H.flu, staph
 Unilateral or paratracheal adenopathy: think TB
 Focal infiltrate, RLL: think foreign bd and order insp and exp films
 Upper lobes, suspected aspiration: think gram -ves, may be due to GER
 Bulging fissures: think klebsiella
 Mimicers: infarction, cancer, effusion, poor film, scarring, pleural
thickened, atelectasis, edema
 Hilar, mediastinal lymphadenopathy: TB, Ca, fungi

Pneumonia is a CLINICAL DIAGNOSIS

and a chest Xray does NOT r/o
pneumonia

HOW OFTEN IS THE EXACT BUG

IDENTIFIED?

Only 25% will have bug identified with

extensive testing and rarely does it
change abx therapy

 Rapid Tests
 Nasopharyngeal aspirates for RSV
 Bedside Cold Agglutinins
- found in 75% of mycoplasma infections (75% sensitive)
- not very specific (also +ve in CMV, EBV, adenovirus,
influenza, chlamydia)
- correlates w/ titer > 1:64
- drop blood into blue tube and put on ice for 30 sec; positive
test is when the blood agglutinates in the tube
 Serology
 Can do mycoplasma, chlamydia, and viral titers
 Not very helpful in acute situation
COMPLICATIONS
 Bacteremia
 Sepsis
 Resp failure, death
 Abcess, empyema
 pneumothroax
 Pleural effusion
 Pneumatocele
 Bronchietasis
 Precipitate MI, CVA, CHF, COPD

DIFFERENTIAL DIAGNOSIS
 Spontaneous pneumo: young
 FB aspiration in young
 ARDS
 Subdiaphragmatic abcess
 Pulmonary embolism
 Pneumonia + PE
 COPD exacerbation
 CHF
 Atelectasis (post op, recent hospitalizn)
 Inflammatory: silicosis, chloride/ammonia fumes, pulmonary toxins (bleomycin), radiation
pneumonitis, thermal injury
 Immunologic: sarcoidosis, goodpastures’s, coll. vasc. dz, farmer’s lung
 ARDS: see end
 Mendelson’s syndrome

ASPIRATION
 NOT equal to pneumonia
 Disturbs surfactant, atelectasis, hypoxemia, +/- ARDS, may develop pneumonia later
 NO evidence for steroids with acute aspiration
 Debatable evidence for prophylaxis of abx with acute aspiration
 Start abx for pneumonic features, clinical deterioration, progression of CXR infiltrate at
36hrs

HIV AND PNEUMONIA

 Etiology
 Pneumocystis carini: MCC
 Regular CAP bugs: pneumococus, Hflu, viral, GNBs, mycoplasma,
legionella
 TB: much increased risk
 Mycobacterium avum complex
 Cryptococcus
 Karposi’s sarcoma looking like pneumonia
 Other fungi
 Pneumocystis carinii pneumonia
 PCP is the MC opportunistic infection in AIDS
 80% of patients with AIDS have PCP at some time
 PCP is the initial opportunistic infection in 60%
  Morphology actually resembles a fungus
 CXR: diffuse interstitial infiltrate is the MC finding but may show nothing,
asymmetric infiltrates, lobar infultrates, pulmonary nodules, cavitations, or
bullae
 Classic CXR: bilateral perihilar infiltrates
 Gallium scanning of the chest may be positive when CXR is negative
 Sputum staining with monoclonal antibodies can make the dx
 Diagnosis traditionally made by bronchoscopy and BAL
 ED treatment will have to be done on spec
 Elevated LDH 85% sensitive, 85% specific for PCP vs non-PCP
pneumonia
 Clinical risk of PCP score
- Diffuse or perihilar infiltrate
- Presence of thrush or oral hairy leukoplakia
- LDH > 220
- ESR > 50
- 2/4 50%, 1/4 10%, 0/4 0% Treatment = septra first line,
pentamidine second line

 Clinical clues to PCP

- Profound hypoxemia (sats 50-60%) and cyanosis with
minimal resp distress and relatively unimpressive CXR
- Desaturation on exertion (road test!)
 TMP-SMX: 20 mg/kg/day of trimethoprima nd 100 mg/kg/day of
sulfamethoxazole (Bactrim DS tables two q8hr)
 Add STEROIDS if Pa02 < 70 mmHg or A-a > 35 (prednisone 40 mg po
bid with a taper over 3 weeks)
 Treatment generally for 3 weeks
 Many do not clear the infection
 Adverse effects of septra 20Xs more common in AIDS patients: N/V, rash,
neutropenia, thrombocytopenia, hyponatremia, hepatitis
 PCP prophylaxis: recommended when CD4 < 200; Bactrim one DS tab po
od or bid (pentamidine or dapsone can also be used)

DISPOSITION
 Patient factors: comorbidities, older, immunosuppressed, extremes of age
 Social factors: no home, no follow up, non-compliant, can’t easily return
 Disease factors
 Vomiting
 Dehydration
 Sepsis, shock
 Hypoxemia requiring oxygen therpay
 Respiratory distress or failure: RR > 20, DBP < 60, severe hypoxemia
 Complications: pneumothorax, empyema, abscess, etc
 PORT Score = FINE Score
 MEDIS group derivation cohort: rule was derived on data from 14,000
inpatients with CAP
 MEDIS group validation cohort: rule was retrospectively validated on data
from 38,000 inpatients with CAP
  PORT validation cohort: rule was retrospectively validated on 2287
patients (1300 inpatients and 944 outpatients)
 Fine. NEJM 1997. Compared the results from the derivation cohort,
retrospective MEDIS cohort and the prospective PORT cohort. They were
all very similar.
 Scoring system based on demographics, comorbidities, signs, labs
 NB: Pa02 is included but sats aren’t
 Scored into five categories and looked at mortality
Category Approximate Mortality
I (<50yo, no Rfs) 0.1%
II (<70) 0.7%
III (71-90) 2.0%
IV (91-130) 8%
V (>130) 30%
Recommendations
Class I, II, III (<90) D/c home
Class IV, V Admit
 NOTE THREE IMPORTANT EXCLUSIONS
- HIV/AIDS
- Immunocompromised
- Hospitalized for pneumonia in previous 7 days

GENERAL MANAGEMENT OF PNEUMONIA

 Antipyretics for patient comfort
 Fluids and hydration are important as most are dry
 A pleural effusion requires thoracentesis to r/o empyema “Don’t let the sun go down
on a pleural effusion with a pneumonia”
 Empyemas must be drained with a chest tube
 Follow up CXR is indicated at 8 weeks in (i) all adults >50yo and (ii) smokers
 Exhaustive attempts at microbiologic diagnosis is not warranted as 50% + won’t be
identified
 Consider foreign bodies in pediatrics
 The CXR is not 100% accurate: false +ves and false -ves exist
 The early CXR may not be as impressive as the later CXR (after hydration)
 Early antibiotic therapy more important than antibiotic choice
 Start with broad spectrum agents
 The sicker the patient the more broad spectrum abx should be chosen
 Delirium is a very common feature of NAP
 Rigors are generally predictive of bacteremia
 Elderly are less likely to have a fever: (i) lower baseline body temperatures (ii) less ability
to mount a febrile response (iii) relatively immunosuppressed
 Pneumovax 8 weeks post pneumonia if (i) never recieved and (ii) > 65yo (iii)
comorbidities
 Influenza vaccination recommended if > 65yo or comorbidities
 Canadian CAP guidelines recommend
 BC for ward patients and ICU patients
 Sputum studies for ICU patients
 Legionella urinary antigen for admitted patients
 Duration = 10 days (except azithro)
EMPIRIC ANTIBIOTIC GUIDELINES
 Absolute guidelines are not possible
 Microbiology varies per geographic location
 Microbiology varies per patient factors
 Resistance patterns vary per geographic location
 Guidelines list many options
 Guidelines are tainted by conflicts of interest
 There are soo many guidelines
 Canadian Thoracic Society
 Canadian ID Society
 Standford’s
 Alberta Medical Association
 American Thoracic Society
 American ID Society
 American Society of CAP

EMPIRIC ANTIBIOTIC THERPAY FOR CAP:

CHR GUIDELINES (Based on the Canadian
Guidelines for CAP: Can Inf Diseases 2000)
OUTPATIENT THERAPY
 No Modifying Factors
 No factors listed below
 Azithro/Clarithro/Erythro first line (doxycycline 2nd line)
 Bugs: pneumococcus, mycoplasma, chlamydia
 Modifying Factors
 Smoker, COPD, DM, alcoholic, CRF, hepatic failure, CHF, recent steroid
use, recent abx, malnutrition, lung cancer, hospitalization w/i 3 months
- Azithro/Clarithro or Levofloxacin
- Better coverage of resistant pneumococcus
- Better coverage of Hflu (COPD)
 Suspected aspiration
- Add clavulin (clinda, flagyl) to above
- Adds anaerobic coverage
 Nursing home
- Levofloxacin
- Adds gram -ve/HFlu, staph, anaerobe coverage, resistant
pneumococcus coverage

INPATIENT WARD THERAPY

 Levofloxacin first line (Cefuroxime/Ceftriaxone + Azithromycin second line)
 Bugs: Pneumococcus, Hflu, gram -ves, Chlamydia, legionella, Mycoplasma
 Suspected aspiration: Add clavulin/clinda/flagyl

ICU THERAPY
 Levofloxacin iv + Ceftriaxone iv
 Bugs: double coverage of resistant pneumococcus, gram -ve, atypicals, some anaerobic
coverage
 Suspected aspiration: Add clavulin/clinda/flagyl
 Suspected pseudomonas: Ciprofloxacin iv + Ceftazidime iv
 Cystic fibrosis
 Bronchiectasis
 Recent hospitalization with abx therapy

TYPICAL BACTERIAL PNEUMONIA

PNEUMOCOCCUS
 Microbiology/Epidemiology
 Streptococcus pneumoniae
 Gram +ve diplococcus, lancet shaped
 Alpha hemolytic on agar
 40% of healthy population has in nasopharynx
 Risks: asplenia, sickle cell dz, etoh, Ca, immunodef
 MCC of typical pneumonia
 Winter and spring are most common times
 30% mortality w/o abx, 5% with
 Clinical
 Preceeding URTI, single rigor (not recurrent), rusty sputum 75%, pleuritic
chest pain are characteristics
 Bacteremic in 30%, effusions common, empyemas rare
 Empiric Abx: ceftriaxone/cefuroxime +/- macrolad
(erythro/clarithro/azithro)
 Resistant pneumococcus: vanco, levofloxacin

GROUP A STREP
 Microbiology
 Streptococcus pyogenes
 Gram +ve cocci in chains
 Rare but high mortality
 Usu sticks to pharyngitis
 Clinical
 Flu-like illness + pharyngitis
 Can give toxic shock syndrome
 Can lead to postinfectious nephritis syndrome GN
 Empyemas in 80%
 Specific Abx: penicillin G 10 million units/d
 Chest tube drainage of empyema

STAPHYLOCOCCUS
 Microbiology
 Staphylococcus aureus
 Gram +ve cocci in grape like clusters or pairs
 1% of bacterial pneumonias
 Clinical
 30% nasal carriage
  Preceeding URTI, influenza, measles, IVDAs, hospitalized and debilitated
all at increased risk of staph aureus pneumonia
 Salmon pink sputum
 Pt looks toxic
 CXR: cavitation, pneumatoceles, empyema common
 Specific Abx: cloxacillin 4 - 8 mg/day iv X 14/7 (Cefazolin or vancomycin if
pen allergic); naficillin, oxacillin alternatives

KLEBSIELLA (Friedlander’s pneumonia)

 Gram -ve rod (fat)
 MC gram -ve community acquired pneumonia
 Hemoptysis common; currant jelly sputum
 MC in RUL, necrotizing lobar pneumonia w/ 20% empyema
 Rx: must have grm -ve coverage (aminoglycoside): gentamycin, tobramycin

PSEUDOMONAS
 Gram -ve rod (slim)
 Aspiration vs bacteremic pathogenesis
 Increased risk in institutions, underlying diseases, especially CF, immunocompromised,
ventilators
 Always use two antibiotics that cover pseudomonas
 Ceftazidime, piperacillin, tobramycin, piperacillin + tazobactam, amakacin, imipenim

HEMOPHILUS INFLUENZA
 Pleomorphic grm -ve cocobacillus
 Children get H.flu type B, adults get H.flu nontypable
 Risks: alcoholism, COPD, aspiration, asplenia, sickle cell, malnourished, Ca, DM
 Cefuroxime, Cefotaxime

ANAEROBES
 Mixed infections most common
 Aspiration is most common setting: altered mentation, alcohol
 High carriage of anaerobes in mouth, especially w/ bad dentition
 Necrotizing, high mortality, often mixed infections, abcesses and empyemas common
 Clues: abcesses, putrid smelling sputum, subacute or chronic presentation
 Grm stain: mixed flora
 Bld culture usually usually -ve
 Sputum anaerobic cultures?
 Abx must cover anaerobes if you suspect them: abx should be iv
 Imipenum
 Metronidazole
 Amikacin
 Clindamycin

ATYPICAL PNEUMONIA
MYCOPLASMA
 Epidemiology
  20% or more of all community acquired pneumonias
 Predominantly affects 5 - 25 yo
 Peaks in summer and early fall (up to 50% of all CAP)
 True epidemics occur: military, colleges, schools, families
 Mycoplasma pneumoniae
 Clinical
 Mild febrile illness, cough, consitutional s/s, insidious onset, incubation
3wks
 Tracheobronchitis is most commonw/ mild pulmonary infiltrates
 Consitutional s/s in 95%: H/A, sore throat, chills, scant sputum,
hoarseness, rhinitis, mild fever, malaise, muscle aches: sounds viral,
think mycoplasma
 Bullous myringitis rare but pathognomonic
 WBC mild elevation
 High ESR
 NORMAL gram stain and cultures of sputum: KEY TO DIAGNOSIS
 Can do serological testing
 Cold agglutins a/f 1 wk very sensitive but not specific (viral, TB, collagen
vascular dz, cancer, lymphoma)
 Complications
 Derm: EN, EM, urticatia, TEN/SJS
 Hem: thrombocytopenia, hemolytic anemai, pancytopenia, DIC
 Neuro: GBS, aseptic meningitis, myelitis, cerebellar ataxia
 Cardiac: myocarditis, pericarditis, heart block, CHF (may see on ECG)
 Other: pancreatitis, glomerulonephritis, tubo-ovarian abcess
 Antibiotics
 Macrolides
 No penicillin b/c it does not undergo cell wall synthesis
 Tetracycline alternative

LEGIONELLA
 Epidemiology
 Pontiac Fever: non-pneumonic flu-like illness
 Legionnaire’s disease: water delivery devices; air conditioners, water
towers, showers, water sprayers, whirl pools, respiratory therapy devices,
heat exchangers
 Institutional outbreaks
 Risk: alcoholics, construction, prisoners, institusions, smokers, DM
 True outbreaks occur
 NOT transmitted person-to-person
 Clinical
 Initially mild cough, scant sputum production, with fever/malaise/headache
 Chest pain: pleuritic and mimics PE
 Watery diarrhea, nausea, vomiting in 40% is unique
 Hyponatremia and hypophosphatemia unique
 Neurologic, GI, hematologic complications similar to mycoplasma less
common but posible
 Gram stain may show grm -ve rods
 Antibiotics
 Macrolads or tetracycline or rifampin; Erythromycin 0.5 - 1.0 g q6h

CHLAMYDIA
 Psittacosis
 Chlamydia psittaci
 Avian pneumonia causes by inhalation of dried bird crap; Any bird: turky,
pigeon, parrots; Decreasing b/c of tetracycline in bird feeds
 Severe headache, dry cough, splenomegaly
 Hepatosplenomegaly is a unique feature
 Tx: tetracycline 500 mg q6h
 TWAR
 Causes pharyngitis an atypical pneumonia
 Epidemics from dorms, barracks, prisons
 COMMON: up to 10% of CAP
 Tx: tetracycline
 Trachomatis
 Neonatal; acquired from female genital tract
 Tx: erythromycin 50 mg/kg/d X 3/52

COXIELLA
 Goats, cattle, sheep, parturient cats (Poker player’s pneumonia), cattle
 Animal exposure is only clue
 Fever, headache in 75%
 Tx: tetracyline

VIRAL PNEUMONIAS
 Many bugs: influenza, parainfluenza, RSV common
 Look for secondary bacterial infections: staph aureus, pneumococcus, H.flu common
 Difficult to make dx: serology may show retrospective dx
 Adenovirus causes 10 - 40 % of all atypical pneumonias
 Management
 Bed rest, analgesia, antipyretic, hydration especially in elderly,
Bronchodilators for AWO, Antibiotics for secondary bacterial infection,
ventilation if sick
 Influenza: amantidine reduces duration and symptoms if started w/i 24 hr;
100 - 200 mg/day, recommend for high risk patient; vacination if indicated
 HSV: acyclovir
 RSV: ?ribavirin

CMV/PCP
 AIDS or immunodeficient community acquired pneumonia
 PCP does occur in non-HIV patients
 CXR may be normal
 CMV: gangyclovir and PCP: septa (pentamidine)

HANTAVIRUS
 Exposure to mice, especially deer mice
 Outbreaks occur
 Prodrome of malaise, headache, fever several days b/f acute respiratory distress
 Acute febrile illness, capillary leak syndrome, ARDS, resp failure, shock
 Think of in rapid deterioration acute respiratory distress + shock + farmer
 Can crash quickly; Farmer/outdoorsmen, pneumonia, sick, think hantavirus
 Lab: decreased platelets, increased Hb, atypical lymphs
 CXR: bilateral infiltrates looks like ARDS

OTHER
 Bordetella: sick dogs with kennel cough
 Rodococcus equi: horses
 Anthrax: farm animals, vets
 Brucellosis: farm animals, vets
 Histoplamosis: bat caves
 Actinomyces: sulphur granules
 Coccidiomyocosis: arizona, mexico, california, texas
 Plague
 Squirrel, rabbit, gopher, rodent
 Fleas from above
 Sputum, hemoptysis, fever, adenopathy (bubo)
 Tularemia
 Rabbit, hare, fox, squirrel meat or tick/fly bites
 Fever, malaise, wt loss, +/- dry cough
 CXR with patchy infiltrates

BRONCHITIS
INTRODUCTION
 Inflammation of the bronchial tree
 Almost alway viral
 Prolonged cough is common
 45% cough for 2 weeks
 25% cough for 3 weeks
 5% cough for 4 weeks

CLINICAL FEATURES
 Cough
 Purulent sputum (Purulent sputum NOT predictive of bacterial infection)
 Fever (brief)
 Chest discomfort
 NO features of pneumonia
 Sustained fever (Fever > 5 days suggest pneumonia)
 Hypoxemia
 Chest crackles
 Chest wheezing
 Chest consolidation
 Chest dulness

INVESTIGATIONS
 None
 CXR only for signs of pneumonia or suspicion of pneumonia
 R/O asthma
 PFTs have been done on patients without asthma with bronchitis and have shown
changes similar to mild asthma

MANAGMENT
 NO antibiotics: severe studies showing no benefit
 Tylenol prn
 Fluids
 Ventolin: only thing to show decrease cough
 Antitussives not proven
 Warn them about prolonged cough
 Macrolide if suggestion of pertusis
 Severe bouts of coughing followed by whoop or cough