Pneumonia in adults

The problem in Africa

• For many decades pneumonia has ranked
second only to malaria as a cause of admission
to adult medical wards across Africa
• However, in the last 25 years the pattern of
hospital admissions has changed, reflecting
the dominance of HIV-related problems.
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• The two commonest reasons for admission
among HIV-infected adults are
a) tuberculosis and
b) pneumonia ,
so pneumonia continues to present a
considerable burden to hospital services
across the continent.
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• Although mortality is higher in the elderly, the
majority of pneumonia-related deaths in
hospital occur among young adults, less `than
40 years old.
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• Furthermore, among survivors, 60 per cent of
pneumonia patients have not recovered
sufficiently to return to work 3 weeks after
their admission
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• Pneumoniais usually straightforward to
diagnose and treat.
• The challenges in management are
1) identifying the severely ill patient,
2) predicting the aetiology of disease,
3) dealing with resistance among respiratory
pathogens and
4) anticipating complications
 Aetiology of acute community acquired
pneumonia
• The insensitivity of gold-standard diagnostic
methods, e.g. blood culture, and the poor
specificity of accessible diagnostic procedures
such as sputum culture limit our knowledge of
pneumonia aetiology.
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• Across the globe, studies of pneumonia fail to
identify an aetiology in 10–50 per cent of all
presenting cases, yet empiric treatment
guidelines rely on the assumption that the
undiagnosed portion is composed of similar
organisms to the diagnosed portion.
 Respiratory viruses
1) Influenza and Parainfluenza viruses,
2) Adenovirus and
3) Respiratory Syncytial Virus.
• One-third of the patients have no aetiological
diagnosis and potential causes of these cases
include
1) Pneumocystis jiroveci,
2) Klebsiella pneumoniae,
3) Escherichia coli,
4) Pseudomonas aeruginosa,
5) anaerobic bacteria,
6) Chlamydia psittaci,
7) Legionella pneumophila,
8) Coxiella burnetti,
9) Histoplasma capsulatum,
10) Aspergillus species,
11) Paragonimus species or
12) other migrating parasite
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• However, even among patients with no
defined aetiology, Streptococcus pneumoniae
is likely to be the commonest causative
organism and, where multiple diagnostic
methods have been combined in aetiological
studies, 46–70 per cent of inpatient
pneumonias have been attributable to the
pneumococcus.
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• This remains the rationale for primary empiric
treatment with penicillin.
 Bacterial pneumonia
Streptococcus pneumoniae
• This Gram-positive coccus commonly colonizes
the nasopharynx of healthy individuals,
especially young children, and is transmitted
by airborne droplet spread and direct contact
with infected nasal mucus on hands and
fomites.
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• Human immunity is serotype specific, i.e.
determined by antibodies to variants of the
bacterial polysaccharide capsule, of which
more than 91 serologically distinct types have
been identified.
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• Among African adults 80 per cent of episodes
of pneumonia are caused by only nine
serotypes.
 Especial risk of
pneumococcal pneumonia
1) HIV infection,
2) hypogammaglobulinaemia,
3) asplenia,
4) nephrotic syndrome and
5) sickle cell anaemia .
 Pneumococcal pneumonia is typically

1) lobar,
2) multi-lobar or
3) segmental and
4) only rarely causes diffuse
bronchopneumonia.
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• An accompanying pleural effusion occurs in 20
per cent of patients, but empyema is rare in
patients treated with antibiotics.
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• The pneumococcus does not often lead to
cavitation, but can produce a destructive
pneumonia, leading to necrosis of lung
parenchyma and fibrotic healing in rare cases
 Haemophilus influenzae
• This Gram-negative cocco bacillus is
responsible for 3 to 5 per cent of episodes of
pneumonia in adults.
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• It exists in both encapsulated and non-
capsulated forms and both are capable of
causing pneumonia in adults .
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• As with the pneumococcus,serotyping is based
on the serological differentiation of reactions
to the capsule; most pathogenic isolates are of
serotype b, the non-encapsulated forms are
‘non-typable’.
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• Widespread introduction of Haemophilus
influenzaetype b (Hib) vaccine for children has
made Hib pneumonia uncommon.
 Staphylococcus aureus

• S. aureusis a Gram-positive coccus causing 1–2

per cent of adult pneumonia episodes.
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• The incidence of S. aureus pneumonia, and
the proportion of cases of pneumonia caused
by S. aureus, have been shown to rise
coincidentally with epidemics of influenza,
suggesting it has a particular role as a cause of
secondary bacterial pneumonia.
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• The bacterium colonizes the nose and the
prevalence of colonization is 15–30 per cent in
healthy individuals and 50 per cent in hospital
workers.
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• It may also spread to the lung from existing
foci of infection in skin, wounds or via
intravenous devices and needles.
• Staphylococcal pneumonia tends to be severe
and cavitation, abscess formation and
empyema are all common.
• Haematogenous infection may lead to
multiple lung abscesses.
 Gram-negative bacilli
• Collectively, Gram-negative bacilli account for
approximately 5 per cent of all episodes of
pneumonia.
• Klebsiella pneumoniae is the most frequently
isolated and is a particular problem in
intensive care unit patients in South Africa.
• E. coli, and bacteria from the genera
Pseudomonas, Enterobacter, Serratia,
Acinetobacter, Citrobacter and Proteus all
cause pneumonia
 Atypical pneumonia
• Pneumonias caused by the bacteria
a) Legionella pneumophila,
b) Mycoplasma pneumoniae,
c) Chlamydia psittaci and
d) the Rickettsia Coxiella burnetti
are collectively described as atypical
 Legionella pneumophila
• In Europe and North America Legionella
pneumophila causes outbreaks of severe
pneumonia frequently associated with a
common source of contaminated aerosolised
water
 Fungal pneumonia
• Cryptococcus neoformans pneumonia occurs
in HIV-infected adults, but is usually found in
the context of other pulmonary infections.
• Aspergillus fumigatus is geographically
widespread and causes four distinct patterns
of respiratory illness:
(i) exacerbated asthma,
(ii) allergic bronchopulmonary aspergillosis, a
condition characterized by recurrent episodes
of cough, wheeze and fever with mucus
plugging, atelectasis and collapse, eventually
leading to proximal bronchiectasis,
(iii) aspergilloma, which is a large fungal culture
loosely inhabiting an existing lung cavity
following, for example, tuberculosis,
(iv) severe invasive Aspergillus pneumonia