Atypical Bacterial

Pneumonia
 Why it is called “Atypical”???

 The atypical organisms cannot be cultured on standard

media, nor can they be seen on Gram’s stain.

 Have atypical presentation

 Often cause extrapulmonary manifestations

 Intrinsically resistant to all β-lactam agents as most of

the atypical pathogens do not have a bacterial cell wall
 Causes of Atypical pneumonia
 Bacteria  Respiratory tract viruses
 Influenza, adenovirus,
 Mycoplasma (M. respiratory syncytial virus,
pneumoniae) parainfluenza virus
 Chlamydophila (C. psittaci,
C. pneumoniae)  Other viral agents
 Legionella  Varicella-zoster, measles,
 F. tularensis Epstein-Barr virus, CMV,
 Y. pestis metapneumovirus, Hantavirus
 B. anthracis
 Fungi
 Rickettsia  Histoplasma, Blastomyces,
Coccidioides, Pneumocystis
 C. burnetii (Q fever)
 Epidemiology
 Atypical CAPs represent approximately 15% of all
CAPs.

Legionella
 Sources of infection include domestic hot and cold water
systems, wet cooling systems, natural spas, humidifiers,
ultrasonic mist machines, respiratory therapy equipment.
- The attack rate is higher in:
 the elderly
 tobacco smokers, alcoholism
 those with chronic lung disease
 diabetes mellitus
 ICH
 Mycoplasma (M. pneumoniae)
The organism is spread by droplet aerosol

Chlamydophila (C. psittaci, C. pneumoniae)

 C. psittaci may be hosted by many avian species

 Psittacine infection is an occupational hazard of
veterinarians, pet-shop workers, zoo staff and poultry
workers.
 Clinical Presentation
 Fever, chills, pleuritic chest pain

 Cough: non-productive or productive of mucoid

sputum only.

 Dyspnea

 Physical findings of consolidation

 Pleural friction rub

Typical and Atypical Presentation of
CAP:
Extrapulmonary Manifistations

Bradycardia
Hyponatremia
Legionella Diarrhea: 20%
Mental confusion
Glomerulonephritis

Bullous myringitis (painful haemorrhagic

blisters on the ear-drum and external auditory canal)
Mycoplasma
Splenomegaly
Lymphadenopathy
Maculopapular skin rash
 Hepatitis
Palpable splenomegaly
Chlamydia Endocarditis
Stevens–Johnson syndrome
Erythema nodosum
Bullous myringitis
Steven Johnson Syndrome
Erythema nodosum
Radiology
 Patchy reticular or reticulonodular opacities.

 Subsegmental and sometimes segmental atelectasis.

  Hilar adenopathy

  Pleural effusion
Severe Legionella pneumonia. Chest radiograph shows dense
consolidation in both lower lobes.
Legionella pneumonia
Mycoplasma Pneumonia
Chlamydia pneumonia. CXR shows multifocal, patchy
consolidation in the right upper, middle, and lower lobes
 Investigations
Sputum microscopy:

 The absence of large numbers of organisms in an

adequate sputum sample raises the possibility of
Legionella pneumophila, Mycoplasma
pneumoniae, Coxiella burnetii or a viral
pneumonia.
Sputum culture

 Legionella spp. → selective charcoal yeast extract

medium. Result is relatively slow, taking about 3
days.

Urine Antigen detection

 Legionella spp.
Standard acute and convalescent serological
testing

 Complement-fixing antibody levels in the blood

 Enzyme-linked immunosorbent assay (ELISA)
 Immunofluorescent tests

PCR
Haematological and biochemical
measurements

 White cell count: normal or increased (Legionella )

 ESR : raised.
 Mild abnormalities of liver and renal function
including proteinuria and microscopic haematuria
 Raised LDH and creatine kinase (Legionella )
 Hyponatraemia (Legionella )
 IgM cold agglutinins: Mycoplasma

This test is usually done by combining the patient’s

serum with type O red cells in the laboratory. If
clumping is noted, the serum is serially diluted and
the test repeated, the titre reported being the highest
dilution at which clumping occurs at 4°C
 complications
Legionella Mycoplasma Chlamydia
respiratory failure √√ rare rare
Empyema, cavitation rare √
Cardiac: pericarditis, myocarditis and √√ √√ √√
endocarditis
Neurological :confusion, memory √√ √√ √√
impairment, cerebellar ataxia, GBS
Pancreatitis √√
Cellulitis √√
Renal failure √√ √√
Autoimmune hemolytic anaemia √√
SIADH √√ √√
Steven Johnson Syndrome √√ √√
 Treatment

Can we use
B-LACTAM
ANTIBIOTICS
to treat Atypical
Pneumonia????
Antibiotics:
 Macrolides
 Doxycycline
 Quinolone

Add on therapy
 Rifampicin (legionella, chlamydia)
 Steroids (mycoplasma)
Doses

Erythromycin 500 mg/ 6-hours

Azithromycin 500 mg/24 hours
Doxycycline 200 mg for the first dose
Followed by 100 mg / 12-hours
Ciprofloxacin 400mg/8 hours IV
OR
750 mg orally /12 hours
Levofloxacin 750 mg/24 hours
Moxifloxacin 400 mg/24 hours
Rifampicin 600 mg /12 hours
Duration

 It is recommended that treatment is continued for

2–3 weeks for fear that shorter periods may

result in delayed resolution or relapse,
particularly in those who are immunosuppressed or
who have extensive disease.
Prevention of Legionella pneumonia

 Identification of the sources where epidemics or

case clustering have occurred.

 Hot water supplies are usually decontaminated by

hyperchlorination, or by superheating water
supplies to 70–80°C, and by the removal of
rubber washers from shower fittings.