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Bacterial Pneumonia
Authors

Saud Bin Abdul Sattar1; Sandeep Sharma2.

Affiliations
1 Allama Iqbal Med College, Jinnah Hosp
2
Mery Fitzgerald Hospital
Last Update: February 11, 2019.

Introduction
The word "pneumonia" originates from the ancient Greek word "pneumon" which means "lung," so the word
"penumonia" becomes "lung disease." Medically it is an inflammation of one or both lung's parenchyma that is more
often but not always caused by infections. The many causes of pneumonia include bacteria, viruses, fungi,
and parasites. This article is about bacterial causes of pneumonia as it is the major cause of mortality and morbidity by
pneumonia. According to the new classification of pneumonia, there are four categories: community-acquired (CAP),
hospital-acquired (HAP), healthcare-associated (HCAP) and ventilator-associated pneumonia (VAP). [1][2][3]

Types of Bacterial Pneumonia

CAP: The acute infection of lung tissue in a patient who has acquired it from the community.

HAP: The acute infection of lung tissue that develops 48 hours or longer after the hospitalization of a non-
intubated patient.

VAP: A type of nosocomial infection of lung tissue that usually develops 48 hours or longer after intubation for
mechanical ventilation.

HCAP: The acute infection of lung tissue acquired from healthcare facilities such as nursing homes, dialysis
centres, and outpatient clinics or a patient with hospitalization within the past 3 months (previously included in
HAP but becomes a separate category after some cases presenting as outpatients with pneumonia have been
found to be infected with multidrug-resistant (MDR) pathogens previously associated with HAP).

Some articles include both HAP and VAP under the category of HCAP, so defining HCAP is problematic and
controversial.

Etiology
Etiology of community-acquired pneumonia is an extensive list of agents that include bacteria, viruses, fungi, and
parasites, but this article is about bacterial pneumonia and its causes. Bacteria have classically been categorized into
two divisions on the basis of etiology, "typical" and "atypical" organisms. Typical organisms can be cultured on
standard media or seen on Gram stain, but "atypical" organisms do not have such properties. [4]

Typical pneumonia refers to pneumonia caused by Streptococcus pneumoniae, Haemophilus influenzae, S.

aureus, Group A streptococci, Moraxella catarrhalis, anaerobes and aerobic gram-negative bacteria.

Atypical pneumonia is mostly caused by Legionella spp, Mycoplasma pneumoniae, Chlamydia pneumoniae,
and C. psittaci.

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The most common causes of community-acquired pneumonia (CAP) is S. pneumoniae followed by Klebsiella
pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa. The most common causes of HCAP and HAP
are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. The causative
agents of VAP include both multi-drug resistant (MDR) agents (e.g., S. pneumoniae, other Strep spp, H. influenzae
and MSSA) and non-MDR (e.g., P. aeruginosa, methicillin-resistant Staphylococcus aureus, Acinetobacter spp. and
antibiotic-resistant Enterobacteriaceae) bacterial pathogens.

Epidemiology
The incidence of CAP in the United States is more than 5 million per year; 80% of these new cases are treated as
outpatients with the mortality rate of less than 1%, and 20% are treated as inpatients with the mortality rate of 12% to
40%. The incidence of CAP varies among different genders; for example, it is more common in males and African
Americans than females and other Americans. The incidence rates are higher at extremes of age distribution range; the
adult rate is usually 5.15 to 7.06 cases per 1000 persons per year, but in the population of age less than 4 years and
greater than 60 years, the rate is more than 12 cases per 1000 persons. In 2005, influenza and pneumonia combined
was the eighth most common cause of death in the United States and the seventh Most common cause of death in
Canada. The mortality rate also is variable among different regions at 7.3% for the United States and Canada, 9.1%
for Europe, and 13.3% for Latin America.[5][6]

Pathophysiology
The lower respiratory tract is not sterile, it always is exposed to environmental pathogens. Invasion and propagation of
the above-mentioned bacteria into lung parenchyma at alveolar level causes bacterial pneumonia, and the body's
inflammatory response against it causes the clinical syndrome of pneumonia. To prevent this proliferation of
microorganisms there are a number of host defenses working together in lungs such as mechanical (e.g., hair in
nostrils and mucus on nasopharynx and oropharynx) and chemical (e.g., proteins produced by alveolar epithelial cells
like surfactant protein A and D, which have the intrinsic property of opsonizing bacteria). Another component of the
pulmonary defense system is made up of immune cells such as alveolar macrophages, which work to engulf and kill
proliferating bacteria, but once bacteria overcome the capacity of host defenses, they start proliferation. In this setting,
the alveolar macrophages kickoff the inflammatory response to strengthen the lower respiratory tract defenses. This
inflammatory response is the main culprit of clinical manifestation of bacterial pneumonia. Cytokines are released in
response to the inflammatory reaction and cause the constitutional symptoms, for example, IL-1 (interleukin-1) and
TNF (tumor necrosis factor) causes fever. Chemokine-like IL-8 (interleukin-8) and colony-stimulating factors like
G-CSF (granulocyte colony-stimulating factor) promote chemotaxis and neutrophils maturation respectively, resulting
in leukocytosis on serological lab and purulent secretions. These cytokines are responsible for the leakage of the
alveolar-capillary membrane at the site of inflammation, causing a decrease in compliance and shortness of breath.
Sometimes even erythrocytes cross this barrier and result in hemoptysis.[7][8][9]

Histopathology
Pathologically, lobar pneumonia is the acute exudative inflammation of a lung lobe. It has the following four advanced
stages if left untreated:

1. Congestion: In this stage, pulmonary parenchyma is not fully consolidated, and microscopically, the alveoli
have serous exudates, pathogens, few neutrophils, and macrophages.

2. Red hepatization: Here the lobe is now consolidated, firm, and liver-like. Microscopically, there is an addition
of fibrin along with serous exudate, pathogens, neutrophils, and macrophages. The capillaries are congested, and
the alveolar walls are thickened.

3. Gray hepatization: The lobe is still liver-like in consistency but gray in color due to suppurative and exudative
filled alveoli.

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4. Resolution: After a week, it starts resolving as lymphatic drainage or a productive cough clear the exudate.

History and Physical

The history findings of bacterial pneumonia may vary from indolent to fulminant. Clinical manifestation includes both
constitutional findings and findings due to damage to the lung and related tissue. The following are major history
findings:

Fever with tachycardia and/or chills and sweats.

The cough may be either nonproductive or productive with mucoid, purulent or blood-tinged sputum.

Pleuritic chest pain, if the pleura is involved.

Shortness of breath with normal daily routine work.

Other symptoms include fatigue, headache, myalgia, and arthralgia.

Physical findings also vary from patient to patient and mainly depend on the severity of lung consolidation and
existence or nonexistence of pleural effusion. The following are major clinical findings:

Increased respiratory rate.

Percussion sounds vary from flat to dull.

Tactile fremitus.

Crackles, rales, and bronchial breath sounds are heard on auscultation.

Confusion manifests earlier in older patients. A critically ill patient may present with sepsis or multi-organ failure.

Evaluation
The approach to evaluate and diagnose pneumonia depends on different modalities but primarily it is like a tripod
stand which has 3 legs which are summed up as:

Clinical Evaluation: It includes taking a careful patient history and performing a thorough physical
examination to judge the clinical signs and symptoms mentioned above.

Laboratory Evaluation: This includes lab values such as complete blood count with differentials, inflammatory
biomarkers like ESR and C-reactive protein, blood cultures, sputum analysis or Gram staining and/or urine
antigen testing or polymerase chain reaction for nucleic acid detection of certain bacteria.

Radiological Evaluation: It includes chest x-ray as an initial imaging test and the finding of pulmonary
infiltrates on plain film is considered as a gold standard for diagnosis when the lab and clinical features are
supportive.[10][2]

Treatment / Management
In all patients with bacterial pneumonia, empirical therapy should be started as soon as possible. The first step in
treatment is a risk assessment to know whether the patient should be treated in an outpatient or inpatient setting.
Cardiopulmonary conditions, age, and severity of symptoms affect risk for bacterial pneumonia, especially CAP.[11]
[12][13]

An expanded CURB-65 or CURB-65 pneumonia severity score can be used for risk quantification. It includes C =
Confusion, U = Uremia (BUN greater than 20 mg/dL), R = Respiratory rate (greater than 30 per min), B = B.P (BP
less than 90/60 mmHg) and age greater than 65 years. One point is scored for each previously mentioned risk factor. If

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the total of the score is 2 or more than 2, it indicates hospital admission. If the total is 4 or more than 4, it indicates
ICU admission. Recommended therapy for different settings are as follows:

Outpatient Setting: For patients having comorbid conditions ( e.g., diabetes, malignancy, etc.) the regimen is
"fluoroquinolone" or "beta-lactams + macrolide." For patients with no comorbid conditions, we can use
"macrolide" or "doxycycline" empirically. Testing is usually not performed as the empiric regimen is almost
always successful.

Inpatient Setting (non-ICU): Recommended therapy is fluoroquinolone or macrolide + beta-lactam.

Inpatient setting (ICU): Recommended therapy is beta-lactam + macrolide or beta-lactam + fluoroquinolone.

After getting a culture-positive lab result, therapies should be directed to the culture-specific pathogen.

The patient also can benefit from smoking cessation counseling and influenza and pneumococcal vaccination.

All patients treated at home should be scheduled for a follow-up visit within 2 days to assess any complication of
pneumonia.

Differential Diagnosis
Differential Diagnosis in Children

Asthma or reactive airway disease

Bronchiolitis

Croup

Respiratory distress syndrome

Differential Diagnosis in Adults

Acute and chronic bronchitis

Aspiration of a foreign body

Asthma

Atelectasis

Bronchiectasis

Bronchiolitis

Chronic obstructive pulmonary disease

Fungal

Lung abscess

Pneumocystis jiroveci pneumonia

Respiratory failure

Viral

Prognosis
Prognosis of pneumonia depends on many factors including age, comorbidities, and hospital setting (inpatient or

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outpatient). Patients older than 60 years or younger than 4 years of age have a relatively poorer prognosis than young
adults. Antibiotic resistance, very concerning due to the enhancement of antibiotic regimens, and infectious diseases,
especially those like bacterial pneumonia, can be easily cured.

Complications
The most common complications of bacterial pneumonia are respiratory failure, sepsis, multiorgan failure,
coagulopathy, and exacerbation of preexisting comorbidities. Three distinct complications are metastatic infections,
lung abscess, and complicated pleural effusion.

Enhancing Healthcare Team Outcomes

The management of a pneumonia is multidisciplinary. Besides the administration of antibiotics, these patients often
require chest physical therapy, a dietary consult, physical therapy to help regain muscle mass and a dental consult. The
key is to educate the patient on discontinuation of smoking and abstaining from alcohol. Further, patients should be
encouraged to get the appropriate influenza and pneumococcal vaccines. Finally, it is important to educate the patient
on compliance with antibiotics if they want a complete resolution of the infectious process.[13][14] (Level V)

Outcomes

In healthy people, the outcome after a bacterial pneumonia is excellent. However, in people with advanced age, lung
disease, immunosuppression, infection with aggressive gram-negative organisms (Klebsiella) and other comorbidities,
the outcomes are usually poor. When a pneumonia is left untreated, it carries a mortality in excess of 25%. Pneumonia
can also lead to extensive lung damage and lead to residual impairment in lung function. Other reported complications
of pneumonia that occur in 1-5% of patients include lung abscess, empyema, and bronchiectasis.[15][16] (Level V)

Questions
To access free multiple choice questions on this topic, click here.

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