INFECTIOUS DISEASES

Topic: Pneumonia
Lecturer: Dr. Fortuno

INTRODUCTION PHASES OF PNEUMONIA

Pneumonia
Phase Description
 Is an infection of the pulmonary parenchyma
 Initial phase
o The demarcation of the anatomic involvement would be the 1. Edema  Characterized by the presence of exudates and
pulmonary parenchyma bacteria in the alveoli
o If an infection involves the upper respiratory tract  then it  Characterized by erythrocytes in the
cannot be pneumonia BUT it may be the same organism that intraalveolar exudate
had infected the upper respiratory tract 2. Red hepatization  Neutrophil influx is an important standpoint of
 Generally caused by bacteria, fungi, viruses, and protozoa host defense
o Other pathogens include metapneumoviruses, the  Bacteria may occasionally be in the exudates
coronaviruses responsible for Covid-19, severe acute  Cessation of erythrocyte extravasation
respiratory syndrome (SARS) and Middle east respiratory  Degradation of remaining erythrocytes
syndrome, and community-acquired strains of methicillin- 3. Gray hepatization  Neutrophils predominate
resistant Staphylococcus aureus (MRSA)  Abundant fibrin deposition
 Bacteria have disappeared
BASIC PATHOPHYSIOLOGY  Macrophages predominate
 Lower respiratory tract involving the parenchyma  Inflammatory response stops – gives at least 2
4. Resolution
o Pneumonia is an infection of the lower respiratory tract. It has weeks of immunity from another pathogen that
to involve the lung parenchyma could enter the respiratory system
o Sometimes contiguous structure, such as the pleura, may be
affected  leads to pleural effusion Causes of Atypical Pneumonia?
 Due to the invasion and proliferation of the pathogens at the alveolar  Klebsiella pneumoniae – typical
level and subsequent host’s mounted immunologic response Implicated among alcoholics who have high risk
o All the symptoms of pneumonia cannot be explained merely of developing aspiration
by the bacterial infection because most of the time, patients
 Pseudomonas aeruginosa – typical
will be manifesting symptoms secondary to our mounted
Can cause severe pneumonia of the typical type
immunologic response  this is another reason why our
patients expire NOT due to the pathogen BUT due to the host’s
 Staphylococcus aureus – typical
exaggerated immunologic response It is usually spread through hematogenous route
 Aspiration is the most common access of the microbial pathogens coming from a primary focus
o There are different ways for the pathogens to access the
pulmonary parenchyma:  Chlamydophyla pneumonia
 Hematogenous  Legionella species
 Inhalation  Mycoplasma pneumonia atypical
 Aspiration  the most common access  Respiratory syncytial viruses (RSV)
 Adenoviruses
CLINICAL MANIFESTATIONS  Influenza
Typical Pneumonia Manifestations:
 Acute cough or productive cough Risk Factors for CAP in general?
o Cough should be present within the last week  Asthma
Cough that is present for >2 weeks, the possibility of it  Institutionalization
being pneumonia is less. Chronic cough is usually secondary  Alcoholism
to conditions like: TB, Reflux, Allergy  Age > 70 years
 Immunosuppresion
o Always distinguish 1st “when did the cough start?”
 Acute onset – think of pneumonia Community acquired pneumonia  does not necessarily involves
 Present for months or years – think more of allergic streptococcus pneumonia (most common cause of typical pneumonia). In
reactions general means that all of the organisms that causes typical pneumonia could
be a risk factor for CAP
 Abnormal vital signs or tachypnea
All of the listed items are risk factors for CAP
 Tachycardia  Asthma – causes chronic inflammation of the airways
o This may be a “reflex” of the fever because fever can also  Institutionalization – due to proximity to other index patients with
increase out heart rate pneumonia
 Fever  Alcoholism – at the height of their stupor, they may be already
 At least one abnormal chest and lungs PE finding: vomiting and possibility of aspirating their vomitus
o Ronchi  Age > 70 year – due to the theory of wear and tear already becomes
o Crackles weaker in terms of immune mechanisms
o Wheezes  Immunosuppression – like HIV patients, those who chronically use
o Decreased breath sounds steroids, asplenic patients
 Seen in pleural effusion and consolidation

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 INFECTIOUS DISEASES
Topic: Pneumonia
Lecturer: Dr. Fortuno
COMMUNITY ACQUIRED PNEUMONIA (2016 PSMID GUIDELINES)
Clinical Scenario:
 A 72 years male with controlled hypertension and T2DM smoker
presents in the ER because of dyspnea
 Condition started 5 days PTA with productive cough, remittent
fever with a highest temperature of 38.5oC
Remittent fever  the patient’s temperature does not go back
to normal. It may go down a little but it does not reach normal
levels
 There is note of right sided lower chest pain, more pronounced
during coughing and deep inspiration
 RT-PCR and RAT for Covid-19 is (-)
 He tells you that he is asthmatic with his last exacerbation a year
ago controlled by bronchodilator MDI
Physical Examination:
 BP – 140/90 mmHg
 HR – 106/min
 RR – 25/min
 T – 38.9oC
What are your expected PE findings based on the case?
 Inspection
o Retractions of accessory muscles
 Evident on the trapezius muscles
o Retractions of intercostal muscles
 This happens when you ask the patient to inhale
deeply
 During the course of inhaling deeply, normally we
expect the intercostal spaces to expand together with
the deep inhalation
 In retractions, the intercostal spaces retract inward
with the chest wall expanding outward
 Retractions may signify a pulmonary infection
occurring in the patient
o Asymmetry of chest expansion
 Asymmetric side is usually located at the more painful
side
 In the case of the patient, since there is pain on the
right side, asymmetry or “lagging” would be seen on
the right side  the patient will not want to inhale
deeply because there would be pain
 Palpation
o Fremitus
 May be appreciated when there is consolidation
 In the case, it may be appreciated on the right side
o Check for asymmetry
o Check for tenderness
 Percussion
o Dullness
 Confirms the fremitus appreciated on palpation
 Heard usually on areas of the lung with consolidation
 Auscultation
o When using the stethoscope, we primarily use the diaphragm
because the lungs are more deeply situated
o Pattern of auscultation should be from bottom to top
 Because if we do top to bottom  with the number of
deep inhalation that the patient will be doing, by the
time you are already at the lower lung areas, crackles
might already have been cleared up
 Remember also in cases of pneumonia, crackles are
usually found in the lower or more dependent areas.
It is not usually found in the apical areas
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What are the additional questions we have to ask our patient?
 What?
o What are the associated symptoms of the pneumonia?
 E.g. anorexia, body malaise, urination
 Where?
o Where is it more painful/tender?
 When?
o When did it start?
 Why?
o Look for other people within his family or workplace that have
the same symptoms of your patient
 Bacterial pneumonia  attack rate is slower
 Viral pneumonia  attack rate is faster
 How?
o How probably did you acquire this symptoms?
 If a patient tells you that he was exposed to another
person manifesting with the same symptoms:
 5-7 days ago  probably bacterial in origin
 If only one day ago  more of viral in origin
 What else?
o Ask about the control of hypertension and control of diabetes
 Diabetes  already puts a patient in an
immunocompromised state whether or not the blood
sugar is controlled
You informed the patient’s private physician and you were ordered to assess
the patient and admit if needed in accordance with the guidelines of
Community Acquired Pneumonia (CAP) 2016
Risk Factors for Pneumococcal Pneumonia?
 Bronchial asthma
 Smoking
Smoking initially causes discoordinated movement of the cilia
and later on damage to the cilia
Normally, the cilia move in a coordinated manner to push out
any pathogens out of the airways
 HIV infection
 COPD
COPD is worse than bronchial asthma because bronchial asthma
is only episodic, therefore their steroid use is not all the time
COPD patients most of the time use their steroids  steroids
are good in decreasing inflammation but one of its side effects
is to decrease the immunity
Steroids is like a double-edged sword  makes patients feel
very well BUT taking it constantly decreases the immunity
 Seizure disorders
Patients with epilepsy are more prone to develop
pneumococcal pneumonia most probably because of aspiration
Case: 54 yr. old male developed right-sided body weakness and
was found in his bed and could not move. MRI and CT scan
showed he has stroke (infarct on the brain). The patient did not
present any respiratory manifestations but when you did a CXR
 there was infiltrates on the right lung. Why did this happen?
 The patient probably aspirated when he had right-
sided weakness. It will go to the right side of the lungs
because of the position of the bronchus
 CXR showing right-sided lung involvement more than
the left  think of aspiration pneumonia
 CXR showing a balance of right and left lung
involvement  think of CAP
Streptococcus pneumonia is the most common organism to cause
pneumonia in all age groups
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 INFECTIOUS DISEASES
Topic: Pneumonia
Lecturer: Dr. Fortuno

MANAGEMENT OF CAP Low-risk CAP:

Low-risk CAP  Risk here means the risk of dying
 Low-risk CAP  at less risk of dying compared to those in a higher
stratification
 They can be sent home already
 Patient can be seen as outpatient basis and treated accordingly
 Patients who are vomiting  need to be admitted
o Medicine prescribed may be vomited or coughed out

In which subsets of patients should sputum culture be done?

 All patients hospitalized for cough – sputum culture is not done
For cough, they might just be sent home. Remember also that
the most common cause is streptococcus pneumonia for
productive cough so there would be no need for sputum culture

 Presence of neutropenia
 Setting of asplenia or complement deficiency
 Concurrent chronic liver disease
 Severe CAP

Moderate-risk CAP

Case Management
Patient WITHOUT CO-MORBID
ILLNESS presenting with
productive cough  you know
that it is a typical pneumonia Amoxicillin 1 gm TID (or two 500 mg capsules
(commonly caused by TID)
Streptococcus pneumonia)
Azithromycin 500 mg OD or
Clarithromycin 500 mg BID

NOTES:
 Azithromycin is more advantageous because
it is taken only once a day (better for patient
compliance)
Patient WITHOUT CO-MORBID  Clarithromycin maybe given if patient is
ILLNESS presenting with atypical allergic to azithromycin
symptoms  possible organisms  GI upset is a common side effect of
are chalmydophila and azithromycin. So in patients with dyspepsia,
mycoplasma better give clarithromycin

Salt Compositions of Azithromycin:

 Azithromycin Monohydrate
 Given for 5-7 days

 Azithromycin Dihydrate
 Given for 3-5 days
Moderate-risk CAP:
 Risk stratification is the reverse of those of low-risk CAP
Co-amoxiclav 1 gm BID or  BP <90/60  not good because it means that there is more nitric oxide
Sultamicillin 750 mg BID or due to the increase in bacteria
Cefuroxime axetil 500 mg BID
 Included here are those with:
+ o
o
Uncontrolled DM
Active malignancies
Azithromycin 500 mg OD or
Clarithromycin 500 mg BID o Neurologic disease
Patient WITH STABLE CO- NOTES: o CHF (Class 2-4)
MORBID ILLNESS  If patient is allergic to penicillins  do not o Unstable coronary artery disease
give co-amoxiclav or sultamicillin
 Usually complains of easy fatigability and paroxysmal
 If patient is allergic to sulfa-drugs  do not
give sultamicillin nocturnal dyspnea
 Use Cefuroxime as alternative o Renal failure on dialysis
 Since patients have co-morbid illness, we o Uncompensated COPD
need to cover for the atypical organisms  o Decompensated liver disease
reason why we add macrolides
 Azithromycin or clarithromycin  Pathogens:
o Includes those organism in low-risk CAP
o Legionella and anaerobes are added

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 INFECTIOUS DISEASES
Topic: Pneumonia
Lecturer: Dr. Fortuno

Management: High-risk CAP

 Ampicillin-Sulbactam 1.5 gm q6h IV or
If allergic to penicillin then give 2nd generation cephalosporin
(Cefuroxime) or 3rd generation cephalosporin (Ceftriaxone)

 Cefuroxime 1.5 g q8h IV or

 Ceftriaxone 2 g OD

+
 Azithromycin 500 mg OD PO or We always add Macrolides in order
 Clarithromycin 500 mg BID PO or to cover for the atypical organism

 Levofloxacin 500 mg OD PO or Quinolones are option to those who

 Moxifloxacin 400 mg OD PO cannot afford the IV form

Difference of Moderate-risk to Low-risk CAP management:

 Same antibiotics are given BUT the route of administration is
different (Intravenous)

What if the patient does not have any money to afford IV antibiotics?
 We can give a more superior antibiotics which are the quinolones
 Levofloxacin & Moxifloxacin  used for infections that are above
the diaphragm
 Ciprofloxacin  used for infections below the diaphragm

Risk Factor for Legionella Infection?

 Diabetes
 Leukemia
 Breast cancer
 Female gender – not a risk factor
 Alcoholism – not a risk factor
Smoking is a risk factor for legionella BUT NOT alcoholism

Other risk factors for Legionella:

 Smoking
 Ask the patient if he came from a cruise trip (ship)
 Ask the patient if he checked in a hotel
 Does he has HIV
 Male patient

 Moderate-risk patients should be admitted to the ward and treated

accordingly
 If aspiration pneumonia is suspected and, a regimen containing:
o Ampicillin-sulbactam and/or Moxifloxacin
o There is no need to add another antibiotic for additional
anaerobic coverage. If another combination is used may add
Clindamycin to the regimen to cover microaerophilic
streptococci High-risk CAP:
 Patient manifests all the symptoms of moderate-risk CAP together with:
o Sever sepsis
o Septic shock or
o Need for mechanical ventilation
 Pathogens:
o Includes those organisms in both low-risk and moderate-risk
CAP
o Staphylococcus aureus and Pseudomonas aeruginosa is
added

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 INFECTIOUS DISEASES
Topic: Pneumonia
Lecturer: Dr. Fortuno

Management:
Which oral antibiotic are recommended for de-escalation or switch
 If patient has no risk for Pseudomonas:
therapy from parental therapy?
o 3rd generation cephalosporin + IV macrolides or IV quinolones
 If patient is at risk for Pseudomonas:
o 4th generation cephalosporin or Carbapenems + IV macrolides
+ aminoglycosides
 If patient is at risk for MRSA:
o Patients at risk are those with HIV, men having sex with men,
prison inmates, those in long-term care facilities
o Antibiotics listed above + Vancomycin or Clindamycin or
Linezolid

When should Empiric treatment for CAP be initiated?

 Answer: All patients whenever they are diagnosed, should be
started the treatment as soon as possible  Cefuroxime (2nd gen. cephalosporin) has both ORAL and IV form
 Ceftriaxone (3rd gen. cephalosporin) is only given IV (it has NO ORAL
What initial antibiotics should be started for the treatment of CAP? form)
 Answer: All treatment depends upon the risk of the patients and co-  So when you shift ceftriaxone IV to oral form, you give oral
morbidities cefixime instead (also a 3rd gen. cephalosporin)  since
 For Low-risk = Amoxicillin remains the drug of choice. Extended there is no ceftriaxone oral form
macrolides can also be used
 For Moderate-risk = a combination of IV non-antipseudomonal B- How long is the duration of treatment for CAP recommended?
lactam with either of Extended Macrolides and Respiratory
fluoroquinolones
 For High-risk = if without risk of Pseudomonas aeruginosa  a
combination of IV non-antipseudomonal B-lactam (BLIC,
Cephalosporin or Carbapenem) with either of Extended Macrolides
and Respiratory fluoroquinolones
= if with risk of Pseudomonas aeruginosa  a
combination of an IV antipneumococcal, antipseudomonal B-
lactam (BLIC, Cephalosporin or Carbapenem) with an Extended
Macrolides and Aminoglycosides
OR
Combination of an IV antipneumococcal, antipseudomonal B-
lactam and IV Ciprofloxacin or high dose IV Levofloxacin

How can response to initial therapy be assessed?  For Moderate-risk  count the number of days that the patient
 Temperature, respiratory rate, heart rate, blood pressure, was given the antibiotic in the hospital together with the days that
sensorium, oxygen saturation and inspired oxygen concentration you will be prescribing to the patient, once the patient is sent home
should be monitored to assess response to therapy  Patients with Legionalla pneumonia  give for 2-3 weeks (14-21
 Response to therapy is expected within 24-72 hours of initiating days)
treatment. Failure to improve after 72 hours of treatment is an  Patients with Mycoplasma or Chlamydophila pneumonia  give
indication to repeat the chest radiography for 2 weeks (10-14 days)
 Failure to improve after 72 hrs.  need to change empiric
treatment, unless you have the result of the culture (either
When can the Hospitalized patient be Discharged?
sputum or blood)
 In the absence of any unstable coexisting illness or other life
 Primary sample for culture for pneumonia is sputum
threatening complication, clinically stable and once oral therapy is
 If blood culture is requested, inform the laboratory that
started
you are trying to isolate a gram-negative bacteria (for them
 A repeat chest radiography is not needed if the patient is clinically
to use culture medium for gram-negative bacteria)
improving
 Blood culture will be done in patients in a severe state. If
 A repeat chest radiography is recommended after 4-6 weeks (1 and
the patient is only a moderate case, opt for sputum culture
a half month) after discharge during follow up to exclude any
only
Malignancies associated CAP specially in Smoker patient
 Follow-up cultures of blood and sputum are not indicated for
patients who are responding to treatment
What is Updated in 2016 Guidelines?
 Better to start the antibiotic at the same time when diagnosed as
When should de-escalation of empiric antibiotic therapy be done?
CAP
 When we say shift  it is not a shift from one antibiotic to another
 For low risk without co-morbidities, macrolides were
(e.g. from co-amoxiclav to sulbactam). When we say shift, it means
recommended
change in the route of administration (e.g. from IV to Oral)
 For low risk with stable co-morbidities, in case of failure with the 1st
 De-escalation of initial empiric broad-spectrum antibiotic or
line drugs it is recommended 3rd generation oral cephalosphorin
combination parenteral therapy to a single narrow spectrum
 In 2010, Carbapenem was recommended even in the Moderate-risk
parenteral or oral agent based on available lab data is
CAP but now only for High risk
recommended once the patient is clinically improving, is
 Dose of Amoxicillin is increased to 1g TID, previously it was 500mg
hemodynamically stable and has a functioning GI tract
TID
 No need for repeat CXR if patient is clinically improving

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 INFECTIOUS DISEASES
Topic: Pneumonia
Lecturer: Dr. Fortuno

Regarding Clinical Scenario:

 A 46 years Diabetic, Smoker male has presented in the ER with
productive cough for 4 days, fever on/off but febrile since 4 hours with
T=39oC and Right sided lower chest pain and now with Difficulty of
Breathing
 May be Low Risk, Moderate Risk or High Risk
o Prescribing the wrong antibiotics = patient is at risk of dying
o So it is important for future doctors to know the antibiotics and
organism involved for you to know what to correctly prescribe

WHAT ABOUT IMMUNIZATION AGAINST PNEUMONIA?

 IPD
 2 types: PPSV 23 or PCV 13
 Route is intramuscularly (IM)
 Patient population
o High risk population (healthcare workers)
o Elderly (60 yrs. old above)
Give PCV 13 now then PPSV 23 the year after. It is more
prudent for us doctors to give the 2 types of vaccines =
better immunity
Other vaccine you can give: tetanus, flu (quadrivalent),
VZV, pneumococcal, COVID-19

When you tell your patient that he will be immunized for pneumonia, it is not
for CAP but for invasive pneumococcal disease (streptococcus pneumoniae)
 PPSV 23
o Lay people call this the every 5 years vaccine
 PCV 13
o Lifetime vaccine

When do you give your vaccines?

 2 weeks after the patient gets discharged and improved
o 2 weeks  remember that the stage of resolution usually lasts
for 2 weeks. Once the 2 weeks is over, immunity will then wane

Sample Case:
You were administered today with PPSV 23. Will you be required for another
PPSV 23? If yes, when? Or can we give PCV 13, since he was already given the
PPSV 23?
 Either vaccines can be given
 If you are to give another PPSV 23, then you give it after 5 years
 Since PPSV 23 was given today (2021), the next vaccine
would be at 2026
 If you are to give the PCV 13, then you give it after 1 year
 Since PPSV 23 was given today (2021), the next vaccine
would be at 2022

NOTES:
 PCV 13 is only given once. PPSV 23 can be given twice if it purely
PPSV 23 that was given to the patient
 HIV patients are not given with live-attenuated vaccines

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