What factors clinical assessment findings are commonly used to diagnose pneumonia?
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Pneumonia is defined as chest infiltrates on chest radiography or chest CT scan associated with fever and an identified infectious etiology. From: Hematology (Seventh Edition), 2018 Fred F. Ferri MD, FACP, in Ferri's Clinical Advisor 2022, 2022 • Antibiotic therapy should be based on clinical, radiographic, and laboratory evaluation. Empiric therapy regimens for severe community-acquired pneumonia are summarized
inTable 5. Macrolides (azithromycin or clarithromycin) or doxycycline can be used for empiric outpatient treatment of CAP as long as the patient has not received antibiotics within the past 3 mo and does not reside in a community in which the prevalence of macrolide resistance is high. Updated guidelines from the American Thoracic Society and Infectious Diseases Society of America3 have added
amoxicillin as a first-line agent for healthy adult outpatients with CAP.Fig. 6 summarizesempiric therapy for CAP. The treatment of choice in suspectedLegionella pneumonia is either a quinolone (e.g., moxifloxacin) or a macrolide (e.g., azithromycin) antibiotic. A beta-lactam antibiotic is usually added to macrolides. In the hospital setting, patients admitted to
the general ward can be treated empirically with a second- or third-generation cephalosporin (ceftriaxone, cefotaxime, or cefuroxime) plus a macrolide (azithromycin or clarithromycin) or doxycycline. An antipseudomonal quinolone (levofloxacin or moxifloxacin) can be substituted in place of the macrolide or doxycycline. Empiric therapy in ICU patients: IV beta-lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam) plus an IV quinolone
(levofloxacin, moxifloxacin) or IV azithromycin. In hospitalized patients at risk forP. aeruginosa infection, empiric treatment should consist of an antipseudomonal beta-lactam (meropenem, doripenem, imipenem, or piperacillin-tazobactam) with or without a second antipseudomonal agent such as an aminoglycoside or an antipseudomonal quinolone. In patients with
suspected methicillin-resistantS. aureus, vancomycin or linezolid is effective. Corticosteroids: Clinical trials evaluating adjunctive use of corticosteroids in severe CAP have produced mixed results. There is no evidence that adjunctive use of corticosteroids improves outcomes in mild to moderate CAP. Guidelines advise against adjunctive treatment of CAP with corticosteroids except in patients with other indications for their
use such as asthma, COPD, an autoimmune disease or CAP with septic shock that is refractory to fluid resuscitation and vasopressor support.4 Duration of antibiotic treatment ranges from 5 to 14 days. Trials have shown that in adults hospitalized with CAP, stopping antibiotic treatment after 5 days in clinically stable patients is reasonable and noninferior to usual care. HematogenousStaphylococcus
infection, abscesses, and cavitary lesions might require prolonged antibiotic therapy, sometimes until radiological resolution is documented. PneumoniaStephen R.C. Howie, ... Stephen M. Graham, in International Encyclopedia of Public Health (Second Edition), 2017 IntroductionPneumonia remains a major contributor to mortality and morbidity worldwide in all age groups and is the leading cause of death in infants and children globally, exceeding the combined mortality of malaria, tuberculosis and HIV infection. The lung is constantly exposed to microorganisms and the combined effects of pathogen, host, and environmental factors determine whether or not the clinical condition known as pneumonia occurs. Pneumonia is generally more prevalent in low- and middle-income countries. Incidence is highest at the extremes of ages such as the elderly and infants. The overwhelming majority of pneumonia deaths in infants and young children occur in low-income settings. There are a number of classifications of pneumonia in use that have implications for etiology, management, and prognosis, such as classification based on the origin of the infection or its severity. The term ‘community-acquired pneumonia’ (CAP) refers to the appearance of infection in a non-hospitalized population with no risk factors for multi-drug-resistant pathogens whereas the term ‘hospital acquired pneumonia’ or ‘nosocomial pneumonia’ is used when there is no evidence that the infection was present or incubating at the time of hospital admission. The latter type of pneumonia is most frequently found in patients receiving mechanical ventilation, hence the term ‘ventilator-associated pneumonia.’ Another classification in common use in children with community-acquired pneumonia in resource-limited settings is based on clinical severity, and is used to guide management decisions such as antibiotic treatment, hospitalization and oxygen therapy. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780128036785003349 Overview of PneumoniaLee Goldman MD, in Goldman-Cecil Medicine, 2020 Noninfectious ConsiderationsMany noninfectious conditions cause patients to present with a syndrome consistent with acute or subacute pneumonia, and 15 to 20% of all patients admitted from the emergency department for suspected pneumonia may not be infected. Pulmonary edema (Chapter 52) is the most common noninfectious cause of a pneumonia syndrome in middle-aged and older patients. The diagnosis should be made based on history, physical examination, and radiographic findings, supported by elevated B-natriuretic peptide levels. Patients with lung cancer (Chapter 182) commonly present with fever and a pulmonary infiltrate, often called postobstructive pneumonia.9 Cavitary lesions may be present. Infection is actually not thought to be present in the majority of cases. Acute respiratory distress syndrome (Chapter 96) in response to a serious nonpulmonary infection is often indistinguishable from pneumonia because it commonly presents with fever, lung crackles, an elevated WBC count, and pulmonary infiltrates. Cryptogenic organizing pneumonia (Chapter 85), acute interstitial pneumonia, eosinophilic pneumonia, sarcoidosis, and other interstitial pneumonias (Chapter 86) are uncommon conditions that are almost always initially misdiagnosed as community-acquired pneumonia. Pulmonary hemorrhage and vasculitis may also cause pulmonary infiltrates and fever. In ANCA-associated granulomatous vasculitis (Chapter 254), these infiltrates may also be associated with cavitary lesions. Attention to the patient’s history may reveal a longer history of symptoms, and careful review of earlier chest radiographs may reveal prior radiographic abnormalities, consistent with a chronic, noninfectious process. Pulmonary emboli with infarction (Chapter 74) can cause pleuritic chest pain and pulmonary infiltrates, with sputum that contains neutrophils but few or no bacteria. Patients with septic pulmonary emboli should be assessed for other foci of infection, such as an infected heart valve or intravascular device. TreatmentHospital AdmissionSeveral scoring systems may help in the decision as to whether a patient should be hospitalized, including the pneumonia severity index (Tables 91-3 and91-4) and SMART-COP (Table 91-5). A corollary decision, whether a patient should be admitted to an intensive care unit (ICU), can be guided by the mortality risks as assessed by the pneumonia severity index or by the SMART-COP algorithim (Table 91-6). Other indicators of overwhelming infection that indicate a need for ICU admission include a WBC count of 6000/µL or lower in bacterial pneumonia (usually seen with increased band forms), thrombocytopenia, hypothermia, or a Po2 less than or equal to 90 in someone who has no underlying lung disease. Supportive therapy should include fluid replacement to maintain blood pressure (e.g., an average of 4.5 liters of fluids with electrolytes are required in the first 24 hours to treat a patient with pneumonia and septic shock [Chapter 100]), oxygen for hypoxemia, and mechanical ventilation if adequate gas exchange cannot otherwise be achieved (Chapter 97). Antibiotic TherapyBased on good evidence that outcomes are worse with prolonged delays, initial antibiotics should be given as soon as the diagnosis of pneumonia is considered likely, regardless of whether that be in a physician’s office or an emergency department.10 Guidelines for the empirical antibiotic therapy of community-acquired pneumonia in outpatients (Table 91-7) focus on common infectious causes of pneumonia and are generally successful because a specific etiologic agent is only infrequently determined.11 However, this approach should not discourage the careful consideration of possible noninfectious causes of fever and pulmonary infiltrates or reasonable attempts to establish a specific infectious diagnosis. Outpatient Antibiotic RegimensFor empirical outpatient therapy,12 guidelines from the Infectious Diseases Society of America and the American Thoracic Society recommend a macrolide, doxycycline, a “respiratory” quinolone (levofloxacin or moxifloxacin, but not ciprofloxacin, which is thought to be slightly less effective against pneumococci), or a β-lactam antibiotic together with a macrolide.12b These recommendations are based on a desire to provide therapy effective for common bacterial causes of pneumonia such asS. pneumoniae (Chapter 273),H. influenzae (Chapter 340),M. catarrhalis (Chapter 284), andLegionella (Chapter 298), as well as infections due toMycoplasma (Chapter 301) orChlamydia (Chapter 302). In contrast, Swedish and UK guidelines recommend outpatient treatment for pneumonia with oral penicillin or amoxicillin. The rationale for this approach is that pneumococcus, which is the most likely potentially dangerous cause of pneumonia, is much better treated by penicillin or amoxicillin than by doxycycline or macrolides (to which a varying proportion of pneumococci are resistant), whereas a patient who fails to respond to penicillin or amoxicillin within a few days can be switched to a macrolide or doxycycline to treat potentialMycoplasma andChlamydia. In the United States, one third ofHaemophilus and the majority ofMoraxella produce β-lactamase, which would make amoxicillin plus clavulanic acid a better choice in patients who have underlying lung disease. Patients with pneumonia and a history of low-grade fever and cough for more than 5 to 6 days should be treated with a macrolide or doxycycline because of the likelihood thatMycoplasma orChlamydia are responsible. In-Hospital Antibiotic RegimensIn a patient who is sick enough to be hospitalized, the physician should make a conscientious effort to determine an etiologic agent. Initial therapy may be empirical, but identifying a causative organism has at least three advantages: (1) therapy can be tailored to an identified causative organism, thereby reducing antibiotic overuse and exposure of patients to antibiotics they do not need; (2) if a patient fails to respond promptly the physician can know whether simply to continue existing antibiotics or which ones to change to; (3) an alternative treatment can be selected appropriately for a patient who has an adverse drug reaction. Recommended initial empirical antibiotic treatment of pneumonia that does not require ICU care (seeTable 91-7) includes a respiratory fluoroquinolone (levofloxacin or moxifloxacin, but not ciprofloxacin) or a β-lactam (cefotaxime, ceftriaxone, ampicillin-sulbactam), together with a macrolide.A3 Either of these regimens will treat pneumonia due toS. pneumoniae, and they will also be effective againstHaemophilus, methicillin-susceptibleS. aureus, Moraxella, Legionella, Mycoplasma, andChlamydia, as well as some less common organisms. Such combination therapy appears to result in more rapid clinical improvementA4 ut not shorter in-hospital length of stay or lower mortalityA5 compared with empirical β-lactam monotherapy. Newer options include lefamulin (150 mg intravenously every 12 hours)A5b,A5c or omadacycline (100 mg intravenously every 12 hours for 2 doses then once daily).A5d To avoid overtreatment, every effort should be made to narrow treatment in accordance with identified pathogens. To avoid undertreatment, the risk of possibleS. aureus infection including MRSA should be considered, especially in patients who may have influenza or a history of injection drug use, chronic renal failure, prior corticosteroid therapy, or progression despite outpatient antibiotics. In such patients, the prevalence of these organisms in the community mandates further consideration of ceftaroline as the β-lactam or the addition of vancomycin or linezolid. The absence of nasal carriage of MRSA on PCR testing greatly reduces the likelihood that this organism is causing pneumonia. ICU Antibiotic RegimensFor patients who require ICU admission, a β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) should be given in combination with either azithromycin or a respiratory fluoroquinolone. WhenPseudomonas is a consideration (e.g., in patients who have pneumonia with predominant gram-negative rods on sputum examination; patients with end-stage COPD, bronchiectasis, or other structural lung disease; or patients who have been treated with glucocorticoids or other immunosuppressive drugs), an antipseudomonal β-lactam or carbapenem (piperacillin-tazobactam, cefepime, imipenem, or meropenem) should be selected. The benefit of adding a second antipseudomonal drug (so-called “double coverage”) has not been proven. A more important principle is that, once a diagnosis of gram-negative pneumonia is established, treatment should be based on the optimal dose of an appropriate antibiotic identified by susceptibility testing. Adjunctive CorticosteroidsData on the efficacy of low-dose corticosteroids (e.g., 30 mg methylprednisolone daily) in treating pneumonia have been conflicting. However, two recent meta-analyses concluded that 3 to 7 days of corticosteroids can reduce morbidity and mortality in patients with severe community-acquired pneumonia.A6,A7 By comparison, patients with severe COVID-19 benefit fromsystemic corticosteroids (e.g., dexamethasone 6 mg daily for up to 10 days or hydrocortisone 200–400 mg intravenously for about 7 days), which can reduce mortality by about one-third (Chapter 342A).A7b Hospital CourseThe value of aggressive attempts to determine the cause of pneumonia becomes obvious during a patient’s hospital course. The expected response to therapy includes defervescence, return of the WBC count to normal, and disappearance of the systemic signs of acute infection within a few days after antibiotics have been begun. Pulmonary infiltrates may resolve slowly, cough may persist for weeks, and fatigue may persist for months, especially in elderly persons. Patients may not respond or may even deteriorate during the first day or two of treatment despite appropriate antibiotic therapy. A further reason to identify the infecting organism is to avoid the temptation to add antibiotics that may provide no further benefit and may have deleterious side effects. For patients who do respond, identification of the causative organism allows broad-spectrum antibiotics to be replaced by a simpler regimen, thereby potentially shortening the hospitalization, reducing the risk for complications such asClostridioides difficile colitis (Chapter 280), and avoiding uncertainty about the culprit medication should an adverse drug reaction occur. Failure to Respond to Antibiotic TherapyThe failure to respond to antibiotic therapy raises a number of concerns (Table 91-8). If the patient simply does not improve, the antibiotic may not be appropriate for the infecting organism. The first step should be to review culture results and antibiotic susceptibilities to ensure that the patient has received an adequate dose of an appropriate antibiotic. When patients show an initial partial response but then have a persistent low-grade fever and leukocytosis, the antimicrobial therapy may have been correct, and the causative organism may be susceptible, but there may be a loculated infection such as empyema (Chapter 92). AMycobacterium or a nonbacterial organism (e.g., a virus12c or a fungus) may be responsible. Alternatively, a noninfectious disease such as lung cancer or pulmonary embolism, or an inflammatory lung condition such as eosinophilic pneumonia or interstitial lung disease (Chapter 86) may explain a newly recognized pulmonary infiltrate that is accompanied by other symptoms of pneumonia, such as fever, cough, and sputum production. When antibiotics have been given empirically and cultures have not been obtained, the lack of a response creates a difficult therapeutic dilemma. For patients with a partial or inadequate response to initial therapy, the physician should aggressively pursue additional diagnostic measures, such as cultures, a chest CT scan, a thoracentesis if an effusion is present, bronchoscopy with bronchoalveolar lavage, and possibly transbronchial biopsy rather than simply changing or adding antibiotics. Duration of TreatmentThe optimal duration of therapy for pneumonia is uncertain. In general, outpatients with community-acquired pneumonia should be treated for 5 to 7 days. Patients who are hospitalized should receive parenteral therapy until they are hemodynamically stable and able to ingest and absorb oral antibiotics, after which oral antibiotics can be given. Three to 5 days of parenteral therapy and a final few days of oral treatment after the patient has become afebrile (temperature <99° F) may be the best approach for pneumococcal pneumonia. Treatment for community-acquired pneumonia of undetermined etiology should generally not exceed a total of 7 days, and 3 days of treatment has been shown to be as effective as 8 days for mild to moderately severe pneumonia if patients are clinically stable after 3 days.A8,A8b In contrast, pneumonia due toS. aureus (Chapter 272) or gram-negative bacilli (Chapters 288,289, and290), which tends to be associated with microabscesses in the lung, probably requires longer treatment (for example, 10 to 14 days, depending upon the rapidity of the response). BacteremicS. aureus pneumonia requires 4 weeks of treatment because of concerns regarding endocarditis, either as a cause or as a result of the pneumonia. For documentedLegionella pneumonia (Chapter 298), the recommendation is 5 to 10 days of treatment with azithromycin, 14 days with a fluoroquinolone, or 3 weeks with either regimen if the patient is immunocompromised. Patients may be discharged from the hospital when they are clinically stable, have no other medical problems requiring continued hospitalization, and have a suitable discharge environment. Reported markers of clinical stability include temperature of 37.8° C or lower, heart rate of 100 beats per minute or lower, respiratory rate of 24 breaths per minute or lower, systolic blood pressure of 90 mm Hg or greater, oxygen saturation of 90% or higher, or Po2 of 60 mm Hg or higher on room air (for patients not previously dependent on supplemental oxygen), and mental status at baseline. Patients are commonly observed in an inpatient setting for up to 24 hours after switching from intravenous to oral therapy, but there is no evidence to support this practice, and it is not necessary for patients who are otherwise stable. Infectious ComplicationsEmpyema (Chapter 92), which is the most common infectious complication of pneumonia, should be considered in patients who have persisting fever and leukocytosis after 4 to 5 days of appropriate antibiotic therapy for pneumonia. A repeat chest radiograph and a CT scan are important diagnostic tools. Other extrapulmonary infections occur when bacteria are carried by the blood stream to bones or joints (especially intervertebral spaces), peritoneal cavity (if peritoneal fluid was present when bacteremia occurred), meninges, heart valves, or even large muscle groups. Such infections will usually declare themselves by causing symptoms, to which the physician must remain attuned in patients whose recovery is not a rapid as was expected. Noninfectious ComplicationsMyocardial infarction (Chapter 64) and new arrhythmias, especially atrial fibrillation (Chapter 58), are each seen in 7 to 10% of patients admitted for community-acquired pneumonia, and worsening of heart failure is even more frequent.13 These cardiac events are associated with substantial increases in morbidity and mortality. PneumoniaM. Esperatti, A. Torres Marti, in International Encyclopedia of Public Health, 2008 Pneumonia is an important cause of morbidity and mortality in adults and children. The most useful classification is based on the site of acquisition: community-acquired (CAP) or hospital-acquired pneumonia (HAP). CAP is caused by a small range of key pathogens and the most important issue in the management of the disease is the care setting: home, general hospital ward, or intensive care unit. Scores assessing severity and risk of death should be used to measure adequate discrimination and treatment. HAP requires an appropriate diagnostic approach given the lack of accuracy of several clinical and laboratory variables. Timely and adequate antibiotic treatment is imperative to improve patient outcomes. Pneumonia is the leading cause of death in children, and more than 95% of all new cases worldwide occur in developing countries. Diagnosis and treatment should be based on clinical findings. A case-management strategy based on a simple algorithm has substantial effect on neonatal, infant, and child mortality and should be incorporated in primary health care. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780123739605006080 PneumoniaRon M. Walls MD, in Rosen's Emergency Medicine: Concepts and Clinical Practice, 2018 Clinical FeaturesThe ED evaluation should focus on establishing the diagnosis of pneumonia and determining the presence of epidemiologic and clinical features that would influence decisions regarding hospitalization and antibiotics. Key components of the history include character of symptoms, setting in which the pneumonia is acquired, recent contact with the health care system, geographic or animal exposures, and host factors that predispose to certain types of infections and are associated with outcome. Pneumonia generally manifests as a cough productive of purulent sputum, shortness of breath, and fever. In most healthy older children and adults, the diagnosis can be reasonably excluded on the basis of history and physical examination, with suspected cases confirmed by chest radiography. The absence of any abnormalities in vital signs or chest auscultation substantially reduces the likelihood of pneumonia as demonstrated by radiography. No single isolated clinical finding, however, is highly reliable in establishing or excluding a diagnosis of pneumonia.12 Older or debilitated patients with pneumonia often have nonspecific complaints, such as acute confusion or a deterioration of baseline function, without classic symptoms. Similarly, older patients may not present with a well-defined infiltrate on radiography. Older patients are more likely to have advanced illness at the time of presentation and may have sepsis in the absence of a previous syndrome suggestive of pneumonia. Occasionally, patients with lower lobe pneumonia have abdominal or back pain as a presenting symptom. Classic teaching divides pneumonia based on clinical patterns into typical pneumonia caused by pyogenic bacteria, such asS. pneumoniae orH. influenzae, and atypical pneumonia caused by organisms such asMycoplasma andChlamydophila spp. This classic teaching is artificial, and a clear differentiation between these two types of pneumonia on clinical grounds alone is impossible. Certain clinical factors may be suggestive of atypical organisms. Factors studied prospectively and found not to help differentiate atypical pneumonias from those with pyogenic bacterial causes include gradual onset, viral prodrome, absence of rigors, nonproductive cough, lower degree of fever, absence of pleurisy or consolidation, normal leukocyte count, and an ill-defined infiltrate on a chest radiograph. Although it is impossible to determine the specific cause of pneumonia with a high degree of certainty without the results of microbiologic or serologic tests, certain clinical factors suggest that a specific pathogen should be considered. Clinical factors suggesting pneumococcal pneumonia include the abrupt onset of a single shaking chill, followed by fever, cough productive of rust-colored sputum, and pleuritic chest pain. Patients with a history of asplenia, sickle cell disease, AIDS, multiple myeloma, or agammaglobulinemia are at increased risk of pneumococcal bacteremia and sepsis, with high mortality rates. Adults with chronic lung disease who develop pneumonia caused byH. influenzae typically demonstrate an insidious worsening of baseline cough and sputum production, and bacteremia is rare.K. pneumoniae may cause severe pneumonia in older or debilitated patients with so-called currant jelly sputum from the necrotizing nature of the infection. Abscess formation, empyema, and bacteremia are common with this organism, and mortality is high. PneumoniaSheila Wilhelm, in xPharm: The Comprehensive Pharmacology Reference, 2007 Signs and SymptomsPneumonia often presents abruptly with fever, chills, dyspnea, and a productive cough. Some bacteria can also cause rust-colored sputum or hemoptysis. On examination, the patient is generally tachypnic and tachycardic with diminished breath sounds on auscultation over the affected area, and inspiratory crackles. To treat the illness most effectively, it is best to determine the most likely causative agent by performing sputum gram stains and cultures. If the patient is immunocompromised, viral or fungal pneumonia may be suspected. Because it may take a week or so to identify a virus, empiric therapy is usually begun in those at risk for viral pneumonia. For bacterial pneumonia, empiric therapy is usually started prior to identification of the causative organism, and is later narrowed to target more specifically the offending organism. Chest radiography is considered the best diagnostic test for pneumonia in symptomatic patients. Findings on chest radiography include lobar consolidation, interstitial infiltrates, and cavitation Donowitz and Mandell (2000), Toltzis et al (1999), Mandell et al (2003). Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780080552323607524 PneumoniaJeffrey S. Wagener MD, in Berman's Pediatric Decision Making (Fifth Edition), 2011 Pneumonia in children typically presents with tachypnea (rapid breathing), fever, and cough. Viral infections are the most frequent cause of childhood pneumonia, particularly in preschool ages; however, bacterial infection and other causes should be considered (Table 1). The care provider can usually diagnose the cause and determine the appropriate therapy based on the history and physical examination, with occasional laboratory assistance. A.History includes duration and degree of symptoms, as well as potential exposure to causative agents. Assess for rapid breathing, fever, and cough. Most pneumonias have a rapid onset unless they represent exacerbations of another underlying chronic condition (i.e., cystic fibrosis, tuberculosis, immune deficiency). Importantly, bacterial pneumonia can represent a complication of a prior viral infection, presenting as a child with a viral upper respiratory infection for 1 to 3 days suddenly developing worsening symptoms with fever and respiratory distress. Higher fevers (≥39° C) are more suggestive of bacterial pneumonias. Cough is not always present, but if productive of sputum is more indicative of a bacterial infection. A “staccato” cough in infants suggests Chlamydia infection, and a paroxysmal cough should always raise concern for pertussis. Other symptoms of pneumonia include poor feeding, lethargy, irritability, risk for aspiration, and occasionally skin rash. History of exposures to other people with similar infections, either at home or in school, helps define cause. Finally, immunization and chronic medication history, as well as information on conditions at home, such as exposure to tobacco smoke, may aid with the diagnosis. B.Individuals at high risk for having a bacterial pneumonia include young infants; patients with chronic illnesses such as cystic fibrosis, malnutrition, or sickle cell anemia; or patients who are immunocompromised. C.Physical examination includes both systemic and lung-specific signs of infection. Tachypnea can be defined as a respiratory rate more than two standard deviations above normal for age (Table 2). In infants, a high respiratory rate often indicates low oxygen, as does cyanosis in any age child. Work of breathing, assessed by high respiratory rate and the presence of nasal flaring and suprasternal and intercostal retractions, is a strong indicator of more severe disease. The child’s activity level also reflects disease severity, and lethargy or poor fluid intake is a particularly concerning sign. Lung examination should include observation (signs of increased work of breathing, hyperinflation, or asymmetry), percussion (particularly looking for complications such as a pleural effusion), and auscultation (crackles are suggestive of bacterial pneumonia, whereas wheezing is more indicative of viral). Localized, decreased breath sounds suggest a complication such as effusion, consolidation, or foreign body aspiration and always necessitate further evaluation. Finally, other body systems should be examined for helpful diagnostic clues including conjunctivitis, otitis media, rhinitis, pharyngitis, cervical adenopathy, cardiac murmur, hepatosplenomegaly, arthritis, digital clubbing, and skin infections or rash. D.Laboratory tests are usually not necessary for the diagnosis of community-acquired pneumonias because most children can be diagnosed using a good history and examination (Table 3). However, additional information may need to be obtained to evaluate for complications or to aid with specific therapy. Oxygen saturation (measured conveniently with a pulse oximeter) is normally 95% or above at sea level (≥93% at 5000 feet). Values less than 88% to 90% indicate more severe pneumonia and the need for supplemental oxygen. Arterial or capillary blood gases can be used to measure carbon dioxide levels in children with an increased work of breathing. A white blood cell (WBC) count with differential, C-reactive protein (CRP) level, and blood culture can be helpful in separating bacterial from viral disease. Sputum cultures are difficult to obtain in children; however, rapid diagnostic tests for some bacteria (group A streptococcus) and many viruses (respiratory syncytial virus, influenza, etc.) can be obtained from throat or nasal swabs. A chest radiograph (both anteroposterior and lateral) is necessary when a complicated pneumonia is suspected and also helps to separate viral and bacterial disease. Diffuse disease with hyperinflation, with or without areas of atelectasis, is typical of viral disease, whereas lobar consolidation and/or pleural effusion are most indicative of bacterial pneumonia. If an effusion is suspected, obtaining a lateral decubitus chest radiograph (with the child lying on the side of the effusion) will help determine whether the fluid is free flowing and can be easily sampled. Obtaining a cell count with differential and a culture with smear from this fluid is extremely valuable for determining therapy. Chest computed tomographic (CT) scanning is rarely, if ever, needed in uncomplicated pneumonia. E.Respiratory distress is indicated by an abnormal respiratory rate, increased work of breathing, intercostal and suprasternal retractions, use of accessory muscle, nasal flaring, grunting, and change in mental status. F.Therapy can be separated by age groups and should be based first on the degree of illness, assessed primarily by the work of breathing, and second on the possible cause (Table 4). Infants younger than 3 weeks should always be admitted to the hospital and treated with intravenous (IV) antibiotics because of the risk for sepsis. Children 3 weeks to 4 months old with possible pneumonia should always be evaluated for fever, low oxygen saturation, and possible bacterial infection, usually requiring hospitalization and close observation. Outpatient management is not recommended for these children if a bacterial pneumonia is suspected (high fever or low oxygen saturation). For children older than 4 months with suspected viral pneumonia (low-grade fever, mild or no increased work of breathing, diffuse lung disease, and able to take fluids well), no therapy other than adequate fluids, observation, and possibly antipyretics for fever are needed. Children older than 4 months with suspected noncomplicated bacterial pneumonia (higher fever but only mild increased work of breathing, localized lung disease [crackles], and able to take fluids well) can be treated with oral antibiotics and watched at home for adequate fluid intake and improving symptoms. Importantly, children with respiratory distress (moderate to severe increased work of breathing), poor fluid intake, excessive irritability, or lethargy should be admitted to the hospital for care and monitoring, unrelated to the cause of the pneumonia. Only children with a suspected bacterial pneumonia, and select patients with influenza infection, require antibiotics (Table 5). Patients with uncomplicated pneumonia do not need follow-up chest radiographs if they have full resolution of respiratory symptoms. G.Complicated pneumonias always need antibiotic therapy, and these patients usually need to be cared for in the hospital, particularly if they have low oxygen saturation or moderate-to-severe increased work of breathing. Pleural effusions should be cultured and always drained if the child is in respiratory distress. Obtaining the culture early, before antibiotic therapy if possible, provides the best opportunity to identify the bacterial causative agent. Video-assisted thoracoscopic surgery can be helpful if the fluid does not layer on the lateral decubitus chest radiograph, but generally is not needed if the effusion is drained early in the course of the pneumonia. Patients with complicated pneumonias need close follow-up and should not be discharged from the hospital until they are clinically improving, are taking adequate nutrition, can complete a minimum 14 days of antibiotics, have an improving chest radiograph, and are assured close follow-up. Long-term follow-up for patients with complicated pneumonia, including a chest radiograph several months later, is valuable for detecting patients at risk for recurrent problems. Prevention of some pneumonias can be achieved through routine immunization for Bordetella pertussis, Haemophilus influenza type b, some strains of Streptococcus pneumoniae, and seasonal influenza. Children at risk for Streptococcus pneumoniae infections should receive additional vaccination after age 2. In addition, premature infants should be considered for passive immunity with palivizumab. Spread of infection can be reduced by proper isolation including good hand washing and avoiding contact with infected patients. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323054058001741 PneumoniaShari L. Platt MD, in Pediatric Emergency Medicine, 2008 Clinical PresentationChildren with pneumonia present with a variety of clinical findings. Early findings are varied, and most cases present initially with symptoms of an upper respiratory infection. These may include low-grade fevers and rhinorrhea. Intermediate and late findings include fever, tachypnea, and cough. Several studies have sought to identify pneumonia based solely on clinical findings. These studies define the “gold standard” for pneumonia diagnosis as the chest radiograph.11,12 Tachypnea was defined based on the WHO definition, as follows: in children less than 2 months old, respiratory rate (RR) greater than 60 breaths/min; in children 2 to 12 months old, RR greater than 50 breaths/min; and children older than 12 months, RR greater than 40 breaths/min.13,14 In 1997, a Canadian task force developed an evidence-based guideline to diagnose pneumonia in children. This guideline states that, although no single clinical finding may accurately diagnose pneumonia, the absence of a cluster of signs, specifically respiratory distress, tachypnea, crackles, and decreased breath sounds, excludes the presence of pneumonia with a sensitivity of 100%.1 These findings were applied to a cohort of 319 children who had a chest radiograph for possible pneumonia, 20% of whom had radiologic findings consistent with pneumonia. The Canadian guideline had a 45% sensitivity and 66% specificity for the diagnosis of pneumonia when applied to this patient cohort. Additionally, tachypnea was only 10% sensitive and 5% specific in this study.15 Despite these findings, several other studies have identified tachypnea as the best clinical indicator. A report on 572 children less than 2 years old, 7% with radiologic signs of pneumonia, defined tachypnea as having a 74% sensitivity and 76% specificity to identify pneumonia.16 In a trial comparing clinical data to chest radiographs in 110 children, of 59 patients diagnosed with pneumonia, 35 had positive findings on chest radiograph. Of all clinical findings, the sensitivity to diagnose pneumonia was best for tachypnea (74%; specificity 67%), followed by retractions (71%) and rales (46%). Combinations of these improved specificity slightly, but did not improve sensitivity to recognize pneumonia. When the cohort was stratified by age, tachypnea was most sensitive: 83% in the youngest infants (<6 months old).17 In a prospective study examining RR cutoffs for pediatric patients hospitalized with pneumonia, a RR greater than 57 in infants 2 to 11 months old, a RR greater than 48 in children 1 to 5 years old, and a RR greater than 36 in children more than 5 years old identified severe pneumonia requiring hospitalization.18 These findings closely parallel the WHO definitions for tachypnea. A prospective study of 570 children ages 1 to 16 years identified the following risk factors to be statistically significant in predicting pneumonia: history of fever, decreased breath sounds, crackles, retractions, grunting, fever, and tachypnea. A multivariate prediction model including fever, decreased breath sounds, crackles, and tachypnea had a sensitivity of 98%, but only an 8% specificity. Of note, fever and tachypnea alone were 93% sensitive for identifying pneumonia in this study.19 This highlights the difficulty in predicting pneumonia based solely on clinical evaluation, though fever and tachypnea seem to strongly suggest the potential for lower respiratory infection and warrant further evaluation. Pulse oximetry has also been examined as a predictor of pneumonia in children. Of 803 children less than 2 years of age who had a chest radiograph performed for respiratory symptoms, 80 (11%) had an opacity suggesting pneumonia. Mean pulse oximetry was not predictive of pneumonia in this cohort.20 The addition of laboratory studies to aid diagnosis has been evaluated in several ways. A study of 154 hospitalized children with CAP, of whom 79% had an identifiable etiology, compared etiologies of pneumonia with respect to clinical and laboratory findings. This analysis revealed that wheezing was most commonly seen in patients with either a viral or an atypical bacterial etiology (41%) compared to patients who had a bacterial etiology (14%). Laboratory studies showed that bacterial etiologies were more likely to be associated with bandemia and elevated serum procalcitonin compared to viral or atypical causes. A multivariate logistic analysis of all variables identified two predictors of bacterial pneumonia: elevated temperature (>38.4° C) less than 72 hours after admission and presence of a pleural effusion, with a sensitivity of 79% and specificity of 59%.7 Of 1248 febrile infants less than 60 days of age, three simple variables—rales, RR greater than 60 breaths/min, and absolute band count less than 1500/mm3—identified 85% of infants with lobar pneumonia (85% sensitivity and 59% specificity).21 It has been reported that, in a cohort of febrile children, leukocytosis as a sole diagnostic finding may indicate pneumonia, despite a lack of supportive clinical findings. A prospective cohort study of 278 febrile (temperature > 39.0° C) children less than 5 years of age with a white blood count (WBC) greater than 20,000/mm3 identified a lobar infiltrate in 26% of patients (36 of 146) who had a radiograph performed and no signs of pneumonia.22 Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9781416000877500611 PneumoniaJean Chastre, ... Alain Combes, in Mechanical Ventilation, 2008 PROGNOSTIC FACTORS AND PREDICTION RULES FOR DETERMINING DISEASE SEVERITYSevere pneumonia can be defined as pneumonia requiring treatment in the intensive care unit (ICU). In general terms, this definition includes patients with pneumonia who require (1) ventilatory support because of acute respiratory failure, inability to clear secretions, deterioration in gas exchange with hypercapnia, or persisting hypoxemia; (2) circulatory support because of hemodynamic instability and signs of peripheral hypoperfusion; or (3) intensive monitoring and treatment of other organ dysfunctions resulting either from a septic component of pneumonia or the underlying disease. In 1993 the American Thoracic Society adopted a statement on the initial management of patients with CAP in which severe illness was defined by the presence of any one of the following features: an admission respiratory rate of more than 30 per minute, a Pao2/Fio2 ratio of less than 250, the need for mechanical ventilation, the presence of bilateral or multilobar infiltrates or rapidly expanding infiltrates, shock, a need for vasopressors, oliguria, or acute renal failure.8 Although this definition was based on factors known to be associated with the need for intensive care, the definition is probably too liberal, and in one study 65% of all patients admitted to the hospital were found to have at least one feature of severe pneumonia present. To improve the specificity of the criteria, one suggestion has been to change the respiratory rate criterion to 35 breaths/min, but it is probable that severe CAP is best defined by patients having at least two of the severe pneumonia criteria mentioned previously. In one more recent study, the nine criteria for severe CAP were divided into five “minor” criteria that could be present on admission and four “major” criteria that could be present on admission or later in the hospital stay.9 The minor criteria included respiratory rate, 30/min; Pao2/Fio2 < 250; bilateral pneumonia or multilobar pneumonia; systolic blood pressure (BP), 90 mm Hg; and diastolic BP, 60 mm Hg. The major criteria included a need for mechanical ventilation, an increase in the size of infiltrates by >50% within 48 hours, septic shock or the need for vasopressors for >4 hours, and acute renal failure (urine output <80 mL in 4 hours or serum creatinine >2 mg/dL in the absence of chronic renal failure). In this retrospective study, the need for ICU admission could be defined using a rule that required the presence of either two of three minor criteria (systolic BP, 90 mm Hg; multilobar disease; Pao2/Fio2 ratio < 250) or one of two major criteria (need for mechanical ventilation or septic shock). When the other criteria for severe illness were evaluated, they did not add to the accuracy of predicting the need for ICU admission. With this rule the sensitivity was 78%, the specificity was 94%, the positive predictive value was 75%, and the negative predictive value was 95%. In the British Thoracic Society (BTS) study, the authors formulated a simple discriminant rule based on the three variables that were consistently associated with death.5 The rule was considered positive when at least two of the following three factors were present: respiratory rate of 30/minute or more, diastolic blood pressure of 60 mm Hg or less, and blood urea nitrogen of more than 7 mmol/L. A positive rule was associated with a 21-fold increase in mortality, with a specificity of 79% and a sensitivity of 88%. However, the positive predictive value was low; only 21 patients of the 108 (19%) who met the rule died. A second rule, in which confusion was used instead of blood urea nitrogen, showed even higher specificity but low sensitivity. The BTS rules have now been validated by two studies, one prospective and one retrospective.10,11 Unfortunately, the positive predictive values of these rules are too low to permit transfer to the ICU of all patients who meet their definition. However, those patients and patients who present with one or more of the other negative prognostic factors have a higher risk for developing severe pneumonia and should be closely monitored for signs of deterioration. This monitoring should include regular checks of vital signs, mental status, fever, and oxygenation, as well as auscultation of the lungs or chest radiography for signs of spread of the pneumonia.7 Although the BTS studies attempted to identify patients with a worse prognosis at the time of admission to the hospital so that they could be targeted for special attention in an ICU, the focus of other studies was just the opposite—namely, to identify those patients with pneumonia who are at lower risk of death and do not need hospital care. Based on the analysis of data collected on 14,199 adult inpatients with pneumonia, Fine and colleagues derived a prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days.12,13 This prediction rule assigns points based on age and the presence of coexisting disease, abnormal physical findings (such as respiratory rate of 30 per minute or temperature of 40°C), and abnormal laboratory findings (such as pH < 7.35, a blood urea nitrogen concentration of 30 mg/dL [11 mmol/L], or a sodium concentration <130 mmol/L) at presentation (Table 56.1). According to this point scoring system, patients 50 years of age or less with none of the five coexisting illnesses and none of the five physical examination abnormalities listed in Table 56.1 are considered class I. Most patient in this class can safely be treated at home, provided they do not have intractable vomiting, a history of noncompliance, or other contraindications to self-care. The prediction rule defines four more treatment classes according to predicted levels of mortality in a logistic regression analysis. Thus physicians can use the rule to estimate the probabilities of death given the presenting clinical features and to suggest where a patient should be treated.3,7 Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780721601861500600 PneumoniaSteven E. Weinberger MD, FACP, ... Jess Mandel MD, FACP, in Principles of Pulmonary Medicine (Fifth Edition), 2008 ETIOLOGY AND PATHOGENESISThe host defenses of the lung are constantly challenged by a variety of organisms, both viruses and bacteria (see Chapter 22). Viruses in particular are likely to avoid or to overwhelm some of the defenses of the upper respiratory tract, causing a transient, relatively mild clinical illness with symptoms limited to the upper respiratory tract. When host defense mechanisms of the upper and lower respiratory tracts are overwhelmed, microorganisms may establish residence, proliferate, and cause a frank infectious process within the pulmonary parenchyma. With particularly virulent organisms, no major impairment of host defense mechanisms is needed; pneumonia may occur even in normal and otherwise healthy individuals. At the other extreme, if host defense mechanisms are quite impaired, microorganisms that are not particularly virulent, that is, unlikely to cause disease in a healthy host, may produce a life-threatening pneumonia. In practice, several factors frequently cause enough impairment of host defenses to contribute to the development of pneumonia, even though individuals with such impairment are not considered “immunosuppressed.” Viral upper respiratory tract infections, ethanol abuse, cigarette smoking, heart failure, and preexisting chronic obstructive pulmonary disease are a few of the contributing factors. More severe impairment of host defenses is caused by diseases associated with immunosuppression (e.g., acquired immunodeficiency syndrome), by various underlying malignancies (particularly leukemia and lymphoma), and by use of corticosteroids and other immunosuppressive or cytotoxic drugs. In these cases associated with impairment of host defenses, individuals are susceptible to both bacterial and more unusual nonbacterial infections (see Chapters 24–26Chapter 242526). Contributing factors for pneumonia in the immunocompetent host are the following: 1.Viral upper respiratory tract infection 2.Ethanol abuse 3.Cigarette smoking 4.Heart failure 5.Chronic obstructive pulmonary disease Microorganisms, especially bacteria, find their way to the lower respiratory tract in two major ways. The first is by inhalation, whereby organisms usually are carried in small droplet particles that are inhaled into the tracheobronchial tree. The second is by aspiration, whereby secretions from the oropharynx pass through the larynx and into the tracheobronchial tree. Aspiration usually is thought of as a process occurring in individuals unable to protect their airways from secretions by glottic closure and coughing. Although clinically significant aspiration is more likely to occur in such individuals, everyone is subject to aspirating small amounts of oropharyngeal secretions, particularly during sleep. Defense mechanisms seem able to cope with this nightly onslaught of bacteria, and frequent bouts of aspiration pneumonia are not experienced. Less commonly, bacteria reach the pulmonary parenchyma through the bloodstream rather than by the airways. This route is important for the spread of certain organisms, particularly Staphylococcus. When pneumonia results in this way from bacteremia, the implication is that a distant, primary source of bacterial infection is present or that bacteria were introduced directly into the bloodstream, for example, as a consequence of intravenous drug abuse. Many individual infectious agents are associated with the development of pneumonia. The frequency with which each agent is involved is difficult to assess and depends to a large extent on the specific population studied. The largest single category of agents probably is bacteria. The other two major categories are viruses and mycoplasma. Of the bacteria, the organism most frequently associated with pneumonia is Streptococcus pneumoniae, in common parlance often called the pneumococcus. It has been estimated that in adults approximately half of all pneumonias serious enough to require hospitalization are pneumococcal in origin. Streptococcus pneumoniae (pneumococcus) is the most common cause of bacterial pneumonia. The polysaccharide capsule is an important factor in its virulence. BACTERIAS. pneumoniae, a normal inhabitant of the oropharynx in a large proportion of adults, is a gram-positive coccus seen in pairs or diplococci. Pneumococcal pneumonia is commonly acquired in the community (i.e., in nonhospitalized patients) and frequently occurs after a viral upper respiratory tract infection. The organism has a polysaccharide capsule that protects the bacteria from phagocytosis and therefore is an important factor in its virulence. There are many antigenic types of capsular polysaccharide, and in order for host defense cells to phagocytize the organism, antibody against the particular capsular type must be present. Antibodies contributing in this way to the phagocytic process are called opsonins (see Chapter 22). Staphylococcus aureus is another gram-positive coccus but usually appears in clusters when examined microscopically. Three major settings in which this organism is seen as a cause of pneumonia are (1) as a secondary complication of respiratory tract infection with the influenza virus; (2) in the hospitalized patient, who often has some impairment of host defense mechanisms and whose oropharynx has been colonized by Staphylococcus; and (3) as a complication of widespread dissemination of staphylococcal organisms through the bloodstream. A variety of gram-negative organisms are potential causes of pneumonia, but only a few of the most important examples from this group of organisms are mentioned here. Haemophilus influenzae, which is a small coccobacillary gram-negative organism, is often found in the nasopharynx of normal individuals and in the lower airways of patients with chronic obstructive lung disease. It can cause pneumonia in children and adults, the latter often with underlying chronic obstructive lung disease as a predisposing factor. Klebsiella pneumoniae, a relatively large gram-negative rod that normally is found in the gastrointestinal tract, has been best described as a cause of pneumonia in the setting of underlying alcoholism. Pseudomonas aeruginosa, which may be found in a variety of environmental sources (especially in the hospital environment), is seen primarily in patients who are debilitated, hospitalized, and, often, previously treated with antibiotics. Factors predisposing to oropharyngeal colonization and pneumonia with gram-negative organisms are the following: 1.Hospitalization or residence in a chronic care facility 2.Underlying disease and compromised host defenses 3.Recent antibiotic therapy The bacterial flora normally present in the mouth are potential etiologic agents in the development of pneumonia. A multitude of organisms (both gram-positive and gram-negative) that favor or require anaerobic conditions for growth are the major organisms composing mouth flora. The most common predisposing factor for anaerobic pneumonia is aspiration of secretions from the oropharynx into the tracheobronchial tree. Patients with impaired consciousness (e.g., as a result of coma, alcohol ingestion, or seizures) and those with difficulty swallowing (e.g., as a result of diseases causing muscle weakness) are prone to aspirate and are at risk for pneumonia caused by anaerobic mouth organisms. In addition, patients with poor dentition or gum disease are more likely to develop aspiration pneumonia because of the larger burden of organisms in their oral cavity. Anaerobes normally found in the oropharynx are the usual cause of aspiration pneumonia. In some settings, such as prolonged hospitalization or recent use of antibiotics, the type of bacteria residing in the oropharynx may change. Specifically, aerobic gram-negative bacilli and S. aureus are more likely to colonize the oropharynx, and any subsequent pneumonia resulting from aspiration of oropharyngeal contents may include these aerobic organisms as part of the process. The two final types of bacteria mentioned here are more recent additions to the list of etiologic agents. The first of these organisms, Legionella pneumophila, was identified as the cause of a mysterious outbreak of pneumonia in 1976 affecting American Legion members at a convention in Philadelphia. Since then it has been recognized as an important cause of pneumonia occurring in epidemics as well as in isolated, sporadic cases. In addition, it seems to affect both previously healthy individuals and those with prior impairment of respiratory defense mechanisms. In retrospect, several prior outbreaks of unexplained pneumonia have been shown to be due to this organism. Although the organism is a gram-negative bacillus, it stains very poorly and is generally not seen by conventional staining methods. The other organism, Chlamydophila pneumoniae, has been recognized in epidemiologic studies as the cause of approximately 5% to 10% of cases of pneumonia. It is an obligate intracellular parasite that appears more related to gram-negative bacteria than to viruses, the category in which it previously had been placed. Diagnosis is rarely made clinically because of the lack of distinguishing clinical and radiographic features, and the organism is not readily cultured. As a result, serologic studies, which are not readily available, serve as the primary means of diagnosis. Many other types of bacteria can cause pneumonia. Because all of them cannot be covered in this chapter, the interested reader should consult some of the more detailed publications listed in the references. VIRUSESAlthough viruses are extremely common causes of upper respiratory tract infections, they are diagnosed relatively infrequently as a cause of frank pneumonia, except in children. In adults, influenza virus is the most commonly diagnosed agent. Outbreaks of pneumonia caused by adenovirus also are well recognized, particularly in military recruits. A relatively rare cause of a fulminant and often lethal pneumonia was described in the southwest United States, but cases in other locations have also been recognized. The virus responsible for this pneumonia, called hantavirus, is found in rodents and previously was described as a cause of fever, hemorrhage, and acute renal failure in other parts of the world. An outbreak of highly contagious and highly lethal pneumonia was reported in 2003 in East Asia and Canada. Termed severe acute respiratory syndrome (SARS), the outbreak was attributed to a novel coronavirus that may have evolved from a type normally found in the civet (a weasel-like mammal found in Chinese markets). MYCOPLASMAMycoplasma appears to be a class of organisms intermediate between viruses and bacteria. Unlike bacteria, they have no rigid cell wall. Unlike viruses, they do not require the intracellular machinery of a host cell to replicate and are capable of free-living growth. Similar in size to large viruses, mycoplasmas are the smallest free-living organisms that have yet been identified. These organisms now are recognized as a common cause of pneumonia, perhaps responsible for a minimum of 10% to 20% of all cases of pneumonia. Mycoplasmal pneumonia occurs most frequently in young adults but is not limited to this age group. The pneumonia is generally acquired in the community, that is, by previously healthy, nonhospitalized individuals, and may occur either in isolated cases or in localized outbreaks. Mycoplasma, the smallest known free-living organism, is a frequent cause of pneumonia in young adults. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9781416050346500269 What is a common assessment finding of pneumonia?
What physical assessment findings might lead to the possible diagnosis of pneumonia?In a prospective study of patients with fever and respiratory complaints, the chest x-ray film was used to diagnose pneumonia. In univariate analysis, the presence of rales, bronchial breath sounds, egophony, decreased breath sounds, and percussion dullness were all significantly (P<.
What clinical features would suggest pneumonia?Fever, sweating and shaking chills. Shortness of breath. Rapid, shallow breathing. Sharp or stabbing chest pain that gets worse when you breathe deeply or cough.
What are three 3 physical assessment findings that are noted with the development of pneumonia?Physical examination of patients with pneumonia is usually remarkable for: shortness of breath, cough, fever, and difficulty breathing.
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