AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Bacterial pneumonia is caused by a pathogenic infection of the lungs and may present as a primary disease process or as the final coup de grace in the individual who is already debilitated. Pneumonia may be further categorized into community-acquired pneumonia (CAP), or hospital- or institutional-acquired pneumonia (HAP or IAP, respectively).

William Henry Harrison, the ninth president of the United States, contracted pneumonia during his inauguration in 1841 and died after being in office for only 31 days. Ronald Reagan, 40th US president, died of pneumonia after years of debilitation from Alzheimer disease. Other notable persons to succumb to pneumonia include Sir Francis Bacon (1626), who died after stuffing chickens with snow while conducting freezing experiments, and Thomas Stonewall Jackson (1863), whose arm required amputation after he was shot by one of his own sentries.

Pathophysiology

Bacteria from the upper airways or, less commonly, from hematogenous spread, find their way to the lung parenchyma. Once there, a combination of factors (including virulence of the infecting organism, status of the local defenses, and overall health of the patient) may lead to bacterial pneumonia. The patient may be made more susceptible to infection because of an overall impairment of the immune response (eg, HIV infection, chronic disease, advanced age) and/or dysfunction of defense mechanisms (eg, smoking, chronic obstructive pulmonary disease [COPD], tumors, inhaled toxins, aspiration). Poor dentition or chronic periodontitis is another predisposing factor.

Frequency

United States

More than 3 million cases occur annually in the United States. Pneumonia is more prevalent during the winter months and in colder climates. This condition is most likely from viral upper and lower respiratory infections, which increase in winter and result in impaired host defenses to bacterial superinfection.

Mortality/Morbidity

Left untreated, pneumonia may have an overall mortality rate of more than 30%. The individual's risk of mortality is dependent on the particular infectious agent and host response. Even with appropriate treatment, the risk of mortality may be high if the host is ill or infirm.

The Pneumonia Severity Index (PSI) may be used as a guide to determine a patient's mortality risk, but it tends to overestimate the actual risk in many cases.

Particularly virulent organisms, such as Klebsiella and Legionella species, may confer a higher mortality rate.

• Morbidity may include destruction of lung tissue from infection, with subsequent scarring. Affected areas may be incapable of gas exchange, reducing respiratory reserve.
• In a patient with preexisting respiratory disease, onset of bacterial pneumonia may result in a downward spiral of infections, further impairment of respiratory status, and repeated infections owing to reduced local and systemic immune responses.
• Bronchiectasis may be a sequela of bacterial pneumonia. Infections with Staphylococcus and Klebsiella organisms result in subsequent bronchiectasis, especially if treatment is delayed.
• Destroyed alveoli and small-to-medium airways may be replaced by dilated blind saccules filled with purulent material. Ongoing, chronic inflammation usually occurs in the surrounding area and may destroy local adjacent lung tissue over time.
• Empyema and lung abscess may occur as direct complications of bacterial pneumonia.
• Pneumonia has been associated with increased incidence of placental abruption in pregnant patients.

Sex

Incidence is greater in males than in females.

Age

In general, advanced age increases the risk of contracting the disease and mortality. In patients who are elderly, comorbidity and a diminished immune response and defense against aspiration increase the risk of bacterial pneumonia. In a 20-year US study, the average overall mortality rate in pneumococcal pneumonia with bacteremia was 20.3%; patients older than 80 years had the highest mortality rate, which was 37.7%.¹

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

The clinical presentation varies from the mildly to extremely ill patients.

• Although not diagnostic of a particular causative agent, the characteristics of the sputum produced may suggest the presence of one bacterium instead of another.
• • Pneumococci may produce bloody or rust-colored sputum.
  • Pseudomonas, Haemophilus, and pneumococcal species may produce green sputum.
  • Anaerobic infections may produce foul-smelling sputum.
  • Klebsiella and type 3 pneumococci may produce sputum resembling currant jelly.
• Rigors or severe shaking chills may be observed in any infectious process. For unclear reasons, the presence of rigors may suggest pneumococcal pneumonia more often than pneumonia caused by other bacterial pathogens.
• The patient also may have headache, malaise, nausea, vomiting, and diarrhea. Although these symptoms may be observed in any systemic illness, their presence with bacterial pneumonia is suggestive of infection with Legionella species.
• Other findings include the following:
• • Malaise
• • Myalgias
  • Exertional dyspnea (dyspnea at rest with progressive disease)
  • Pleuritic chest pain
  • Abdominal pain
  • Anorexia and weight loss
• Sudden onset of symptoms and rapid illness progression are associated with bacterial pneumonias.

Physical

• Findings at physical examination may include the following:
• • Fever
  • Tachypnea
  • Tachycardia or bradycardia
  • Cyanosis
  • Decreased breath sounds
  • Wheezes, rhonchi, and rales
  • Egophony on auscultation
  • Pleural friction rub
  • Dullness to percussion
  • Altered mental status

Causes

Causes for the development of pneumonia are extrinsic or intrinsic, and various bacterial causes exist.

• Extrinsic factors include exposure to a causative agent, exposure to pulmonary irritants, or direct pulmonary injury.
• • Most authors categorize bacterial pneumonias by their infectious agents, which include pneumococcal agents; Haemophilus influenzae; Klebsiella, Staphylococcus, and Legionella species; gram-negative organisms; and aspirated materials.
  • Inhalation of infectious aerosols probably is the most common mode of infection. Some agents, notably Staphylococcus species, may be spread hematogenously.
• Intrinsic factors are related to the host.
• • Loss of protective upper airway reflexes allows aspiration of contents from the upper airways into the lung. Various causes for this loss include altered mental status due to intoxication and other metabolic states and neurologic causes, such as stroke and endotracheal intubation.
  • Local lung pathologies (eg, tumors, COPD, bronchiectasis) are predisposing factors. Smoking also impairs resistance to infection. Chronic gingivitis and periodontitis also are associated with increased risk of pneumonia.
• Bacterial pneumonia caused by Streptococcus pneumoniae remains the most common cause of all bacterial pneumonias.
• Pneumonia from H influenzae most commonly arises in the winter and early spring.
• • This pneumonia more often is associated with hosts who are debilitated.
  • Asthma, COPD, smoking, and a compromised immune system are risk factors for H influenzae infection.
• Klebsiella pneumonia results in an aggressive necrotizing lobar pneumonia. Patients with chronic alcoholism, diabetes, or COPD are at increased risk.
• Staphylococcus aureus pneumonia is observed in intravenous drug abusers and other individuals with debilitations. In patients who abuse intravenous drugs, the infection probably is spread hematogenously to the lungs from contaminated injection sites.
• Legionella pneumophila infections tend to occur sporadically and in local epidemic clusters. Legionella pneumonia was named after an outbreak in 1976 that affected more than 180 members of the American Legion who were staying at the same hotel for an annual convention. Twenty-nine legionnaires died, and the organism was not identified until 1977. These infections usually arise in the summer and fall and may be found in the water condensed from air conditioning systems. L pneumophila seems to have the following 2 forms:
• • Pontiac fever has a viruslike presentation, with malaise, fever and/or chills, myalgias, and headache. This form of Legionella pneumonia usually subsides without sequelae.
  • Frank Legionella pneumonia, the second form of the disease, is very aggressive, with a mortality rate as high as 75% unless treatment begins rapidly. It occurs in individuals who are elderly and debilitated, as well as in smokers and those with COPD, alcoholism, immunocompromise, or trauma.
  • Unlike other pneumonias, Legionella pneumonia has GI symptoms associated with its infection more than 50% of the time. GI manifestations may include anorexia, nausea, vomiting, and diarrhea.
• Gram-negative pneumonias are observed in individuals who are debilitated, immunocompromised, or recently hospitalized.
• • Causative organisms include Escherichia coli and Pseudomonas, Enterobacter, and Serratia species.
  • Individuals living in long-term care facilities where other residents are intubated also are at risk for these infections.
• Any individual with an altered sensorium (eg, seizures, alcohol or drug intoxication) or CNS impairment (eg, stroke) may have a reduced gag reflex, which allows aspiration of stomach or oropharyngeal contents and which enables aspiration pneumonias.
• Causative organisms may include Moraxella catarrhalis and Bacteroides, Peptostreptococcus, and Fusobacterium species.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Empyema
Lung abscess

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Leukocytosis with a left shift may be observed in any bacterial infection; however, its absence, particularly in patients who are elderly, should not cause the clinician to discount the possibility of a bacterial infection.
• Leukopenia (usually defined as a WBC count <5000) may be an ominous clinical sign of impending sepsis.
• Assess ABGs for hypoxia and respiratory acidosis.
• Blood cultures show poor sensitivity in pneumonia. Even in pneumococcal pneumonia, results are often negative. Their yield may be better in patients with more severe cases. The use of blood cultures only rarely dictates a change in antibiotic use.
• Hyponatremia (sodium level <130 mEq/L) and microhematuria may be associated with Legionella pneumonia.
• • Sputum examination may be supplemented by using a Legionella-specific fluorescent antibody. However, this technique has a high false-negative rate.
  • Urinary antigen testing for Legionella serogroup 1 organisms is accurate. However, as many as 30% of infections are not caused by serogroup 1 organisms.
  • Pneumococcal antigen tests for serum, urine, and saliva samples have been developed.
  • A Legionella serum antibody titer of 1:128 or more is suggestive of the diagnosis.
  • Antigen-antibody testing has little clinical effect in the ED, although it may help in recalcitrant or unclear cases.
• Culture pleural effusions or frank empyema fluid, and perform Gram staining.
• A pulse oximetry finding of <95% indicates significant hypoxia.
• Consider using the patient's Pneumonia Severity Index (PSI) score as a guide for inpatient care and mortality risk. Note that PSI score may underestimate the patient's need for admission (ie, a young otherwise healthy patient who is vomiting or has social factors that precludes him or her taking the medicine). Conversely, the PSI score tends to overestimate the mortality in the higher risk patients. See PSI calculator.

Imaging Studies

• Chest radiography
• • Air bronchograms may be observed in the presence of S pneumoniae. Frank consolidation and air bronchograms have been associated with a higher incidence of bacteremia.
  • Cavitary lesions and bulging lung fissures may be observed with Klebsiella pneumoniae infection.
  • Cavitation and associated pleural effusions are observed in cases of S aureus infection, anaerobic infections, gram-negative infections, and tuberculosis.
  • Legionella has a predilection for the lower lung fields.
  • Klebsiella has a tendency to occur in the upper lobes.
• In unclear cases, high-resolution CT scanning of the lungs may aid in the diagnosis.

Other Tests

• Sputum examination may be performed.
• • An adequate specimen must have fewer than 10 oral squamous epithelial cells per low-power field.
  • The WBC count should be more than 25 per low-power field.
  • A single predominant microbe should be noted at Gram staining, although mixed flora may be observed with anaerobic infections.
  • Often, patients cannot produce an adequate specimen. Many specimens produced are so contaminated by oral materials that they are unusable.
  • Cultures of the sputum have similar limitations. To be accurate, only specimens that have been examined microscopically and that have satisfied the criteria above should be submitted for culturing.
• Blood cultures have limited value.
• • Positive findings correlate well with the causative agent.
  • Findings are positive in approximately 40% of cases. (This rate is true even in pneumococcal pneumonia, which has the highest association with positive culture findings.)
  • Cultures require 24 hours (minimum) to incubate.
  • Findings probably have minimal clinical effect in treating bacterial pneumonia.
• Urine assays are available for the rapid detection of Legionella and pneumococcal antigens. These fast card-type assays have been developed recently, may be performed at the bedside, and may be useful in unclear cases or when the choices for antimicrobial therapy are limited.
• An elevated international normalized ratio has been associated with more severe illness. This finding may herald the development of disseminated intravascular coagulation.
• An elevated C-reactive protein level may be predictive of more serious disease. It is has not been clearly shown to differentiate bacterial versus viral illness.

Procedures

• Bronchoscopy
• Transtracheal aspiration for culturing
• Thoracentesis

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Prehospital Care

• For patients with mild shortness of breath, only supplemental oxygen may be required for ventilatory support.
• Patients in respiratory failure may require endotracheal intubation and ventilation. An alternative to intubation may be use of a CPAP mask.
• Patients with hypotension and/or tachycardia may benefit from an intravenous crystalloid bolus in the field.
• Many individuals with pneumonia also have volume depletion. In elderly patients with underlying cardiac disease, take care to avoid aggressive fluid administration, which may cause volume overload.

Emergency Department Care

• Mild dyspnea may resolve with oxygen administered with a nasal cannula.
• Moderate dyspnea requires high oxygen concentrations, such as those provided by a Venti-mask or partial rebreathing face mask. Use these masks with caution in patients with COPD.
• Patients with COPD who need high oxygen concentrations may require intubation.
• Administer ventilatory support when simple supplemental oxygen is not sufficient or when the patient cannot cope with the work of breathing.
• Use of a CPAP mask may be an alternative to intubation in some cases. Patients who are awake and can tolerate mask application may avoid intubation. Nasal CPAP usually is not as well tolerated as a full mask (which covers both the nose and mouth) in the emergent situation.
• Other treatments may include the following:
• • Empiric antimicrobial therapy
• • Hydration
  • Correction of electrolyte levels
  • Chest physiotherapy

Consultations

• Consultation with infectious disease and/or pulmonary specialists may be of benefit in unclear or difficult cases.
• Critical care specialists may aid in the treatment of admitted patients who require a CPAP mask or intubation.
• Pharmacy and/or infection control may provide information about typical resistance patterns observed in hospitalized patients.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

The mainstay of drug therapy for bacterial pneumonia is antibiotic treatment. The choice of agent is based on the severity of the patient's illness, host factors (eg, comorbidity, age), and the presumed causative agent. Although intravenous penicillin G is currently not favored, doses in the range of 20-24 million U/d result in serum levels that exceed minimum inhibitory concentration levels of most resistant pneumococci. Second-generation cephalosporins maintain the gram-positive activity of first-generation cephalosporins, and they add activity against Proteus mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis. Third-generation cephalosporins have wider activity against most gram-negative bacteria (eg, Enterobacter, Citrobacter, Serratia, Neisseria, Providencia, Haemophilus species), including beta-lactamase–producing strains.

The role of glucocorticoids in acute bacterial pneumonia is not yet clear. Classic teaching warns that the use of glucocorticoids in infection may impair the immune response. However, findings show that local pulmonary inflammation may be reduced with systemic glucocorticoids. In the future, these drugs may be a useful adjunct in the immunocompetent patient.

Outpatients are given oral agents, and, for the most part, parenteral medications are given to admitted patients. This rationale does not preclude the clinician from giving an initial intravenous dose of antibiotics in the ED and then sending the patient home on oral agents, if the patient's condition warrants such action. The patient's condition, infection severity, and microorganism susceptibility should determine the proper dose and route of administration.

A rational approach may be to administer an oral extended-spectrum macrolide or amoxicillin and clavulanate (Augmentin) to those with mild, outpatient disease. Oral fluoroquinolone may be substituted if a comorbidity or allergy to the first-line agents is present or for good dosing compliance. Admitted patients should receive intravenous therapy, a third-generation cephalosporin alone or with a macrolide. An alternative regimen would be intravenous fluoroquinolones.

Drug Category: Antibiotics

The best initial antibiotic choice is thought to be a macrolide. Macrolides provide the best coverage for the most likely organisms in community-acquired bacterial pneumonia. Macrolides have effective coverage for gram-positive, Legionella, and Mycoplasma organisms. Azithromycin administered intravenously may be an alternative to intravenous erythromycin.

Macrolides, as a class, have the potential disadvantage of causing GI upset. Compared with erythromycin, newer agents have fewer GI adverse effects and drug interactions, although all macrolides have the potential for drug interactions similar to those of erythromycin. Newer macrolides offer improved compliance because of reduced dosing frequency, improved action against H influenzae, and coverage of Mycoplasma species (unlike cephalosporins). The main disadvantage is cost.

Macrolides are primarily recommended for the treatment of community-acquired pneumonia in patients younger than 60 years who are nonsmokers without comorbidity. Give special consideration to recommendations for antibiotic use in patients with comorbidity or those with community-acquired pneumonia who are older than 60 years. While patients in this group are still susceptible to S pneumoniae, they should receive treatment for broader coverage that includes Haemophilus, Moraxella, and other gram-negative organisms. Therefore, a prudent course of action for empiric outpatient therapy is to include (1) one of the macrolide agents described previously plus a second- or third-generation cephalosporin or amoxicillin and clavulanate or (2) trimethoprim and sulfamethoxazole as a single agent.

Second-generation cephalosporins also provide good coverage against Haemophilus and Moraxella species and provide adequate activity against gram-positive organisms. Of these agents, cefprozil, cefpodoxime, and cefuroxime seem to have better in vitro activity against S pneumoniae. Second-generation cephalosporins are not effective against Legionella or Mycoplasma species. These drugs generally are well tolerated, but cost may be a factor. Oral second-generation and third-generation cephalosporins offer increased activity against gram-negative agents and may be effective against ampicillin-resistant S pneumoniae.

The combination of trimethoprim and sulfamethoxazole may be used in the patient with pneumonia and a history of COPD or smoking. It may be used as a single agent in younger patients in whom a Haemophilus species is the suspected agent. It is well tolerated and inexpensive. Allergic reactions more often are associated with drugs in this class than with other antibiotics. Reactions span the spectrum from simple rash (most likely) to Steven-Johnson syndrome and toxic epidermal necrolysis (rare). Many potential drug interactions exist.

Patients who have moderate clinical impairment or comorbidity are best treated with parenteral agents and, unless a particular agent is strongly suspected, broad coverage should be afforded. Regimens for this use include a macrolide plus a second- or third-generation cephalosporin, (as single agents) amoxicillin and sulbactam (Unasyn), piperacillin and tazobactam (Zosyn), or ticarcillin and clavulanate (Timentin). These last 3 are not described in detail here. Please consult the Sanford Guide for more information.

Intravenous cephalosporins may be combined with a macrolide agent. They broaden the gram-negative coverage, and in the case of third-generation agents, they may be effective against resistant S pneumoniae. Also, some third-generation agents are effective against Pseudomonas, whereas second-generation agents are not.

When a severely ill patient has features of sepsis and/or respiratory failure, and/or when neutropenia is known or suspected, treatment with an intravenous macrolide is combined with an intravenous third-generation cephalosporin and vancomycin. An alternative regimen may include imipenem, meropenem, or piperacillin and tazobactam plus a macrolide and vancomycin. A fulminant course also must raise the suspicion of infection with Legionella or Mycoplasma species, Hantavirus, psittacosis, or Q fever.

Fluoroquinolones, including levofloxacin, moxifloxacin, and gatifloxacin, may also be used. They are available in oral and parenteral forms and have convenient dosing regimens, which allow easier conversion to oral therapy that results in good patient compliance. Note that a warning was issued from the FDA regarding risk of tendonitis and tendon rupture in July 2008.²

All agents discussed above are for use in persons older than 5 years. In children younger than 5 years, initial treatment of pneumonia includes intravenous ampicillin or nafcillin plus gentamicin or cefotaxime (for neonates), and ceftriaxone or cefotaxime can be administered as a single agent (for >28 d to 5 y). An alternative regimen includes a penicillinase-resistant penicillin plus an antipseudomonal aminoglycoside.

Outpatient treatment of mild-to-moderate pneumonias in children usually involves agents similar to those used for acute otitis media. Most of the pneumonias in these patients probably have a viral cause. In children who have features suggesting a bacterial etiology (eg, an infiltrate on chest radiograph and/or positive findings at sputum Gram staining), the administration of antibiotics may be good clinical practice. In these cases, many clinicians begin empiric therapy with amoxicillin, but its spectrum of activity is lacking because children in this group who do not have nonviral pneumonia usually have an infection caused by S pneumoniae and Mycoplasma species.

H influenzae type B has been less common since the introduction of the HIB vaccine. Children younger than 2 years may still be at risk for H influenzae type B infection because their immune response is not sufficient, as it is in older children. A typical regimen for outpatient therapy may include a new macrolide agent or a second- or third-generation cephalosporin. Cost is a potential drawback for all agents.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Inpatient Care

• Direct the use of antibiotic agents based on laboratory data as well as clinical response.
• Unresponsive cases of pneumonia may require fiberoptic bronchoscopy or open lung biopsy for definitive diagnosis.
• Administer adequate respiratory support (eg, as simple as low-flow oxygen or as complex as assisted ventilation), as the patient's clinical situation dictates.
• Pulmonary toilet may include active suction of secretions, chest physiotherapy, positioning to promote dependent drainage, and incentive spirometry to enhance elimination of purulent sputum and to avoid atelectasis.
• Systemic support may include proper hydration, nutrition, and mobilization to create a positive host milieu to fight infection and speed recovery. Early mobilization of patients, with encouragement to sit, stand, and walk when tolerated, speeds recovery.

Further Outpatient Care

• When treated as an outpatient, the patient must undergo adequate follow-up evaluations.
• A follow-up chest radiograph should be obtained in about 6 weeks to ensure clearing of the infiltrate and to assess persistent abnormality of the lung parenchyma (eg, scarring, bronchiectasis).
• In patients in whom a precipitating factor was tumoral obstruction of an airway, the infiltrate may fail to clear, or the tumor may be depicted on a chest radiograph. CT scans may be of benefit in unclear cases.

In/Out Patient Meds

• Antibiotic therapy is the mainstay of treatment of bacterial pneumonia. However, patients who have bronchospasm with infection benefit from inhaled bronchodilators, administered by means of a nebulizer metered-dose inhalers.

Transfer

• Transfer, if needed, is safe for a patient in otherwise stable condition who is being admitted for antibiotic therapy and pulmonary toilet.
• Patients who are severely ill and those with signs of respiratory failure, sepsis, and/or neutropenia must be stabilized prior to transfer.

Deterrence/Prevention

• Cessation of smoking
• Immunization
• • Administration of influenza vaccine decreases fall and/or winter risk of viral influenza, which decreases the risk of bacterial superinfection. This vaccine is especially important in patients who are elderly and in those with comorbidity.
  • Pneumococcal vaccines are effective but underused. Administer these to asplenic, transplant, and renal patients; administration in patients who are elderly and in those with comorbidity may not be unreasonable.

Complications

Complications of pneumonia include the following:

• Local destruction of lung tissue due to infection (may occur, with subsequent scarring)
• Frank cavitation
• Bronchiectasis
• Empyema
• Pulmonary abscess
• Respiratory failure
• Acute respiratory distress syndrome
• Ventilator dependence
• Superinfection
• Death

Prognosis

• The prognosis generally is good in the otherwise healthy patient with uncomplicated pneumonia.
• These factors, alone or in combination, increase morbidity and mortality: advanced age, aggressive organisms (eg, Klebsiella species, Legionella species, resistant S pneumoniae), comorbidity, respiratory failure, neutropenia, and features of sepsis.

Patient Education

• Encourage cessation of smoking and heavy use of alcohol.
• Encourage keeping teeth in good repair.
• Instruct patients at risk to receive appropriate influenza immunization.
• Patients, particularly elderly and debilitated patients, with symptoms such as dyspnea or fever and rigors should seek prompt care.
• For excellent patient education resources, visit eMedicine's Pneumonia Center. Also, see eMedicine's patient education article Bacterial Pneumonia.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Use caution in patients who are elderly or debilitated. If bacteremia is present in persons with pneumococcus who are older than 80 years, the mortality rate remains approximately 40%, even with treatment.
• Empiric therapy for the hospitalized patient should be initially broad and cover the likely causative organisms.
• Always consider the possibility of Legionella infection because delayed treatment significantly increases mortality.
• Remember that the most prevalent causative organism is pneumococcus regardless of the host; empiric therapy must be selected with this in mind.
• Many regions have guidelines for evaluation and treatment of community-acquired pneumonia. This usually includes a minimum time from door to antibiotic of 4 hours or less. Failure to abide by these time parameters may be associated with poor outcome. When in doubt, administer the first antibiotic dose.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Lateral image in a patient with right upper lobe pneumonia. Note the increased anteroposterior chest diameter, which is suggestive of chronic obstructive pulmonary disease (COPD).
	View Full Size Image
Media type:  X-RAY

Media file 2:  Lateral image in a patient with bilateral lower lobe pneumonia. Note the spine sign, or loss of progression of radiolucency of the vertebral bodies.
	View Full Size Image
Media type:  X-RAY

Media file 3:  Early right middle lobe pneumonia.
	View Full Size Image
Media type:  X-RAY

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

1. Mufson MA, Stanek RJ. Bacteremic pneumococcal pneumonia in one American City: a 20-year longitudinal study, 1978-1997. Am J Med. Jul 26 1999;107(1A):34S-43S. [Medline].
2. Kelly C. FDA Requests Boxed Warnings on Fluoroquinolone Antimicrobial Drugs. US Food and Drug Administration; July 2008. [Full Text].
3. Arnold FW, Ramirez JA, McDonald LC, Xia EL. Hospitalization for community-acquired pneumonia: the pneumonia severity index vs clinical judgment. Chest. Jul 2003;124(1):121-4. [Medline].
4. Brown K. Pneumonia. In: Pediatric Emergency Medicine: A Comprehensive Study Guide. 2^nd ed. 2002:219-25.
5. Bryan CS. Treatment of pneumococcal pneumonia: the case for penicillin G. Am J Med. Jul 26 1999;107(1A):63S-68S. [Medline].
6. Dwyer R, Ortqvist A, Aufwerber E, et al. Addition of a macrolide to a ss-lactam in bacteremic pneumococcal pneumonia. Eur J Clin Microbiol Infect Dis. Aug 2006;25(8):518-21. [Medline].
7. Flanders WD, Tucker G, Krishnadasan A, et al. Validation of the pneumonia severity index. Importance of study-specific recalibration. J Gen Intern Med. Jun 1999;14(6):333-40. [Medline].
8. Flood RG, Badik J, Aronoff SC. The utility of serum C-reactive protein in differentiating bacterial from nonbacterial pneumonia in children: a meta-analysis of 1230 children. Pediatr Infect Dis J. Feb 2008;27(2):95-9. [Medline].
9. Foo RL, Graham SM, Suthisarnsuntorn U, Parry CM. Detection of pneumococcal capsular antigen in saliva of children with pneumonia. Ann Trop Paediatr. Jun 2000;20(2):161-3. [Medline].
10. Getahun D, Ananth CV, Peltier MR, et al. Acute and chronic respiratory diseases in pregnancy: associations with placental abruption. Am J Obstet Gynecol. Oct 2006;195(4):1180-4. [Medline].
11. Gilbert DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy. 38^th ed. 2008:35-6.
12. Gowardman J, Trent L. Severe community acquired pneumonia: a one-year analysis in a tertiary referral intensive care unit. N Z Med J. May 12 2000;113(1109):161-4. [Medline].
13. Khashab MM, Xiang J, Kahn JB. Comparison of the adverse event profiles of levofloxacin 500 mg and 750 mg in clinical trials for the treatment of respiratory infections. Curr Med Res Opin. Oct 2006;22(10):1997-2006. [Medline].
14. Klugman KP, Madhi SA, Feldman C. HIV and pneumococcal disease. Curr Opin Infect Dis. Feb 2007;20(1):11-5. [Medline].
15. Moffa DA, Emerman CL. Bronchitis, pneumonia & pleural empyema. In: Emergency Medicine: A Comprehensive Study Guide. 6^th ed. 2004:446-51.
16. Molinos L, Fernandez R, Gullon JA, et al. [Community-acquired pneumonia (CAP) with hospital treatment. The value of the clinical picture and complementary exams in predicting its etiology]. Arch Bronconeumol. May 1997;33(5):230-4. [Medline].
17. Monton C, Ewig S, Torres A, et al. Role of glucocorticoids on inflammatory response in nonimmunosuppressed patients with pneumonia: a pilot study. Eur Respir J. Jul 1999;14(1):218-20. [Medline].
18. Mundy LM, Leet TL, Darst K, et al. Early mobilization of patients hospitalized with community-acquired pneumonia. Chest. Sep 2003;124(3):883-9. [Medline].
19. Musher DM, Alexandraki I, Graviss EA, et al. Bacteremic and nonbacteremic pneumococcal pneumonia. A prospective study. Medicine (Baltimore). Jul 2000;79(4):210-21. [Medline].
20. Reinert RR, Lutticken R, Lemperle M, Bryskier A. A comparative study of the in-vitro activity of levofloxacin against Streptococcus pneumoniae. J Antimicrob Chemother. Jun 1999;43 Suppl C:5-8. [Medline].
21. Rittenhouse BE, Stinnett AA, Dulisse B, et al. An economic evaluation of levofloxacin versus cefuroxime axetil in the outpatient treatment of adults with community-acquired pneumonia. Am J Manag Care. Mar 2000;6(3):381-9. [Medline].
22. Ruiz-Gonzalez A, Falguera M, Vives M, et al. Community-acquired pneumonia: development of a bedside predictive model and scoring system to identify the aetiology. Respir Med&#