Summary

• Pneumonia is an infection of the lower respiratory tract affecting the lungs partly or as a whole.
• Pneumonia presents with productive cough, fever and chest pain (on coughing or breathing).

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  The diagnosis is made on history and examination, and can be confirmed by a chest X-ray.
• Sputum can be examined under the microscope and cultured in the laboratory to identify organisms and determine appropriate antibiotic treatment.
• Bacterial, atypical and fungal pneumonia can be treated with antibiotics, but in viral pneumonia antibiotics are no help.
• Pneumonia can be rapidly fatal if not treated early.

What is pneumonia?

Pneumonia often requires hospitalisation for administration of intravenous antibiotics, physiotherapy to clear the lungs of infective secretions, progress monitoring and avoidance of further complications.

What causes pneumonia?

Bacteria most often involved in pneumonia in adults are Streptococcus pneumoniae, anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae, Chlamydia pneumoniae, and other gram-negative bacteria. Mycoplasma pneumoniae is a particularly common cause in older children and young adults. It can also cause complications outside the lungs, including heart muscle inflammation, rashes, meningoencephalitis (inflammation of the brain and its meninges, or membranes), and nausea and vomiting. It tends to occur most often in people living in boarding institutions.

In younger children, pneumonias are usually caused by the following viruses: respiratory syncytial virus, adenovirus, parainfluenza, influenza A and B, varicella, measles and rubella. These agents can also cause pneumonia in adults, but the only potentially serious ones are influenza A and sometimes B.

Other less common agents include fungi (Histoplasma, Coccidioides, etc.) and parasites (Pneumocystis carinii, which occurs commonly in AIDS patients, Toxoplasma gondii, etc.).

Pneumonias develop when the infective organisms are breathed in, for example from infected people. Staphylococcus infection can spread to the lungs via the bloodstream. Pneumonia can spread into the bloodstream and then cause a serious condition called septicaemia.

Aspiration (breathing in) of acid from the stomach results in a very severe pneumonia and has to be prevented at all costs. This is a high risk in unconscious people and they must be positioned on their side, mouth to the side, angling the upper leg forward so the person does not roll over.

Aspiration can occur as a result of alcohol intoxication, injury and stroke, and in elderly, confused and bedridden patients.

Aspiration pneumonia is also the reason why you should not receive anaesthesia if you have eaten in the previous six hours, except in an emergency.

The cause of pneumonia is often difficult to identify. Despite the time-honoured method of identifying bacteria in the sputum, these specimens are often misleading due to other bacteria that come from the mouth or larynx (voice box).

Who gets pneumonia?

What are the risk factors for pneumonia?

• People below one year or over 65 years of age are more likely to develop pneumonia, which can often be fatal in these groups.
• Underlying health problems increase the chance for pneumonia:
• Respiratory tract infections (often influenza or parainfluenza type)
• Alcoholism
• Health problems related to institutionalisation in hospitals or old-age homes
• Cigarette smoking
• Heart failure
• Bronchiectasis (chronic bronchal dilation with a secondary infection)
• Chronic obstructive pulmonary disease
• Bronchial cancer can lead to pneumonia when organisms settle in dead or diseased tissue.
• Debility or stroke
• Immunosuppressive disorders and therapy
• Decreased levels of conciousness for example coma
• Intravenous drug abuse (associated with Staphylococcus aureus infection)
• Problems with swallowing

Aspiration of vomited stomach contents can lead to aspiration pneumonia. This is a problem in unconscious patients or when a general anaesthetic has to be given without prior fasting for at least six hours.

What are the symptoms of pneumonia?

• Sore throat
• Running or blocked nose
• Dry cough, which changes to a cough with sputum production
• Fever

Common symptoms of pneumonia are:

• Fever of 38.5ºC or above
• Cough, which is often productive of sputum from the airways. The colour of the phlegm may be green or rusty, occasionally with blood specks. However, sometimes no sputum is produced.
• Night sweats
• Shallow, rapid breathing
• Chills or shaking
• Chest pain, which is worsened on inhalation or coughing. This may be only on one side and feels deep in the chest. If the pneumonia is complicated, a painful rubbing sensation may be felt with each breath.
• Less movement on the affected side of the chest
• Fast heart rate
• Tiredness, body weakness (general malaise)
• Change in mental status (especially in older people)

Viral pneumonia can have a slower onset and be less severe at first. Sometimes it may go unrecognised because the person may not feel very ill. These symptoms depend on age and other underlying health problems.

In elderly people these symptoms may be much less obvious. Shortness of breath is not easy to spot but may be suspected when talking becomes interrupted and difficult.

In young children these signs may also be less clear, although fever should always arouse suspicions.

Pneumonia caused by less common bacteria and viruses may cause different symptoms. Night sweats, weight loss, malaise and fever can be the dominating problems, rather than coughing. The cough may be non-productive, but in tuberculosis there can be copious amounts of yellow sputum.

How is pneumonia diagnosed?

He or she will confirm this by careful examination, which will include measurement of temperature, pulse, breathing rate and blood pressure.

The doctor will check your skin for cyanosis (blue discoloration), a sign that not enough oxygen is getting into the blood and the tissues. This would indicate that the situation is quite serious.

Confusion can also be a sign of too little oxygen reaching the brain.

The doctor will feel your chest with his or her hands and examine it with a stethoscope.

X-rays of the chest are often the next step to confirm clinical findings and can be very helpful for determining the full extent and severity of the disease.

Your doctor may also take samples for a number of laboratory investigations:

• A full blood count (FBC) can suggest the presence of an infection if the white cell count is high.
• Investigations called C-reactive protein and erythrocyte sedimentation rate can suggest an infection and indicate its seriousness but are not specific for a particular type of infection.
• Looking at the sputum under the microscope and culturing it in the laboratory can indicate the type of organism causing the infection and the appropriate antibiotics. Samples may show the presence of bacteria, viruses (such as the respiratory syncytial virus in young children), parasites or fungi.
• Blood cultures may be taken together with a FBC. Some virus cultures may be obtained. Blood tests for pneumococcus, Mycoplasma and Legionella antibodies may be necessary.
• In a person who may be infected with the HI virus, pneumocystis carinii pneumonia may occur. If this were suspected, an HIV test would be performed.

Depending on the severity of the condition, further tests may be required. If the patient is to be hospitalised, further investigations may be required:

• Pulse oximetry – measurement of blood oxygen levels.
• Determination of arterial blood gases – measurement of blood oxygen and carbon dioxide levels.
• Bronchoscopy – direct visual observation of trachea and bronchi with a probe.
• Lung biopsy – a piece of lung tissue is obtained by inserting a needle through the ribcage into the lungs or via a bronchoscope which is inserted into the lungs through the trachea. The tissue can be examined under a microscope and cultured to obtain exact information about the organism.
• Thoracentesis – drainage of fluid from between lungs and ribcage. If infection (or other factors) causes too much fluid to accumulate in this space, it has to be drained to prevent it compressing the lungs and making breathing difficult or impossible. This is done by inserting a needle. The fluid can be sent for microscopy and culture.

Computerised axial tomography (CAT) scan – may be required to determine the extent of the disease or other possible causes.

Can pneumonia be prevented?

• Hodgkin’s disease and some other cancers
• Liver cirrhosis
• Heart failure
• Kidney failure
• Impaired immune system (HIV infection)
• Chronic lung disease (such as asthma, chronic bronchitis or chronic obstructive pulmonary disease, emphysema, cystic fibrosis, bronchiectasis)
• Sickle cell anaemia
• Alcoholism
• Organ transplant
• Splenectomy (removal of the spleen)

It is probably enough for healthy older adults to be immunised once for lifetime protection but blood tests to check antibody levels are advisable every five years. Patients with underlying medical conditions might benefit from vaccinations every five years. If allergic reactions occur, the immunisations should not be given.

People with impaired immune systems may be predisposed to complications if they contract pneumonia. Immunosuppressed patients should avoid contact with people who have respiratory tract infections. If they have not had measles or chickenpox, they should avoid contact with those illnesses, as pneumonia is a possible complication. Vaccination for those illnesses is probably advisable.

Vaccinations for influenza are given on a yearly basis since new strains develop annually. These are of benefit to those who are at risk of developing pneumonia after bouts of influenza. It may be given at the same time as the pneumococcal vaccine.

To prevent the increasing rate of antibiotic resistance:

• Discard any unused antibiotics. They should not be given to others.
• Always take the whole course of the prescribed antibiotic. Continue even when the infection improves, unless directed otherwise by the doctor.

How is pneumonia treated?

Symptoms usually improve in two to three days. If the patient responds well, this treatment is continued for the full duration: seven to 14 days. Rest and intake of enough fluid are important to aid recovery. If the response is inadequate, sputum cultures should be obtained.

Once antibiotics have been started, culture and sensitivity investigations may become more difficult to do accurately. The medication may prevent the bacteria from growing in the culture, although they may still be active in the patient. X-rays may be repeated.

Hospitalisation

• Older patients, particularly those older than 75 years
• Young infants
• Patients suffering from other significant diseases, such as congestive heart failure or chronic obstructive pulmonary disease
• Those who would not cope at home
• People with severe pneumonia who are too weak to take antibiotics and whose tissues are not receiving enough oxygen
• People who cannot clear the airways properly through coughing because of chest pain

During the hospital stay the following may happen:

• Intravenous antibiotics may be given using a drip - medication is administered directly into the bloodstream via a small plastic tube inserted into a vein.
• Together with the antibiotic, fluids can be infused into the vein. This can be essential if the person is too weak to drink.
• Chest physiotherapy can be given regularly to help clear the lungs of mucus. This is essential to speed up recovery and prevent further complications.
• Oxygen may be required if enough does not reach the blood from the air. It can be given through a nasal tube or face-mask. In children, oxygen is often given with the aid of a tent that fits over the crib.
• Bronchodilators (drugs that counteract wheezing and bronchospasm) can be given through nebulisers.
• X-rays may be repeated and complications diagnosed.
• If there is progressive deterioration, the patient may require intensive care. If the patient is still not getting enough oxygen despite oxygen administered through a nose tube or mask, he or she may require intubation and ventilation with a mechanical ventilator to help force oxygen into the lungs. This is a very serious situation and requires highly skilled personnel and intensive monitoring. Chest drains may be required to remove fluid collecting around the lungs and compressing them.

Home

Rest should be encouraged for at least a few days. Coughing is useful to clear the lungs of the secretions that accumulate due to the infection and should not be suppressed. Steam inhalation at this stage may be less useful.

If there is any doubt about the course of the illness, the doctor who originally started the treatment should be consulted again. It is quite common for chest pain to appear later, but if it worsens, a review is required.

Medication

Amoxicillin, ampicillin and penicillin are baseline antibiotics that have covered most bacterial infections in the past. When people are allergic to penicillin, macrolide antibiotics (such as erythromycin, clarythromycin and azithromycin) or cephalosporins (such as cefalexin, cefaclor and cefpodoxime) are often chosen. Other antibiotics such as trimethoprim/sulfamethoxazole and chloramphenicol may be indicated depending on the organism involved.

Additionally, codeine (for coughing and chest-wall pain) and guaifenesin (to thin mucus) may control some of the symptoms. Inhaled drugs such as salbutamol help when there is wheezing and bronchospasm, and may be given in the surgery once off or on a daily basis. Hospital admission may be more beneficial for regular nebulisations.

When there has not been noticeable improvement in three to seven days, another antibiotic may be required. The sputum might need to be cultured to test for sensitivity so that the appropriate antibiotic can be given.

In cystic fibrosis patients, where Pseudomonas aeruginosa can cause pneumonia, very expensive antibiotics may be required because this bacterium is highly resistant to conventional drugs. Some may be inhaled to act directly in the lungs.

Aspiration pneumonia creates particularly challenging problems due to the intense destructiveness of gastric acid.

Fungal infections (including actinomycosis, nocardiosis, histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis and cryptococcosis), which are rare, are treated with amphotericin B, fluconazole, penicillin, and sulphonamides, depending on the causative organism.

What is the course of pneumonia?

Because many minor illnesses are treated with antibiotics, a population of resistant organisms is being created in the community. Antibiotics should only be used when a definite diagnosis has been made by a doctor. The misuse of antibiotics will decrease their efficacy. Ideally, antibiotics taken by mouth help the person to feel better in a few days, but antibiotics may be required intravenously.

Chest physiotherapy can shorten the illness considerably. Good hospital care may be essential and may even involve intensive care, but even then there is a chance that the patient will succumb.

In young people recovery can take two to three weeks in mild cases, but this can be considerably longer in older patients.

Complications include lung abscesses and empyema. In lung abscess, pus collects locally, filling a cavity in the lungs. When this bursts, a large quantity of purulent (pus-containing) sputum is released. This may enter the airways and be coughed up, or go into the space between the lungs and rib cage, forming an empyema (pus in the space between layers of the membrane enfolding the lungs). This can be a very serious complication.

When to see your doctor

Urgent attention in an emergency department should be sought if:

• Breathing difficulties develop that seem to exhaust the patient – laboured, rapid and shallow breathing with wheezing may indicate a severe episode.
• Chest pains develop that are crushing or burning, increase in intensity and are associated with sweating and nausea.

A doctor should be consulted soon if:

• A cough producing yellow or green sputum has been present for more than two days.
• Cough productive of rust-coloured sputum occurs or blood is coughed up.
• Cough persists for more than seven to 10 days.
• A productive cough is associated with fever of more than 38.5°C.
• Fever over 38.5°C develops.
• Chills develop.
• Chest pains develop and are exacerbated by breathing or coughing.

Visit preparation

• In young patients or elderly patients with memory difficulties, it is useful for the caregiver to accompany them to the doctor to help supply an accurate history of all the symptoms. The history is very important in assessing the seriousness of the situation. Think carefully about all the events that led to this episode of pneumonia. All underlying health problems must be mentioned.
• All drugs taken (for this and other problems) should be known by name and dosage.
• Previous X-rays of the chest and perhaps peak flow measurements are useful and should be taken along.

It is very important to mention whether the patient has been in contact with someone who has tuberculosis.

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