Pneumonia

Adult Gerontology Acute Care 2

Dr. Cynthia Shields
Bree Doran
7.27.2020
 Definition Incidence
 Acute febrile inflammatory disorder of the lung  One of the most common serious lung
associated with cough and exertional dyspnea conditions
 Infection that creates inflammation of the lower  Accounts for 10% of admissions
respiratory tract as microorganisms grow after
 1.3 million visits to ER for pneumonia as
gaining access via inhalation or aspiration
primary diagnosis (2017)
 Microorganisms responsible include bacteria,
 49,157 deaths in US (2017)
viruses, Fungi and Parasites
 Comorbidities that contribute to high
mortality: COPD, HF, DM, CKD and Liver
disease
Infection and
inflammation
Variations in Disease Rates
affect the alveoli  More common in men and African American
populations
 More common in winter months
 Elderly at higher risk due to decreased immune
response and increased weakness causing inadequate
airway clearance
 Children also at high risk
 Clearance vs. Colonization
Microorganisms are constantly entering the respiratory
tract; they either come to stay or don’t make it out alive
Clearance Colonization
Factors that prevent colonization Factors that influence colonization
 Mucus entrapment  Ciliary clearance disruption
• Airway obstruction (COPD, CF, Neoplasm)
 Ciliary clearance • Ciliary dysfunction (Smoking)
 Immune surveillance  Inoculation events
 Intact epithelial barrier • Dysphagia
• Intubation
• AMS
• Debilitation
• Bacteremia
 Epithelial barrier disruption
• Injury (intubation, Pulmonary edema)
• Infection (viral infection)
 Decreased immune response
• Immunosuppression (transplant, HIV)
• age
 Pneumonia Classifications
v
Community-Acquired Ventilator-Acquired (VAP)
•
(CAP )
pneumonia that is acquired from exposure • Occurs 48-72 hours after intubation
within the community – outside a healthcare • Pseudomonas most common cause
facility • Result of poor oral care – Initiate
• Presents in hospital setting within 48 hours of VAP bundle (chlorohexidine,
admission aspiration precautions)
• 25% hospitalized, 10-12% mortality

Hospital-Acquired (HAP) Healthcare-Associated

(HCAP)
• Occurs 48 hours or more after admission • Any patient hospitalized in an acute care
(not incubating at the time of admission) setting for 2 or more days within 90 days
• Strep Pneumoniae, Staph Aureus and H. of the infection
Influenzae most common • LTAC or Nursing Home Patient
• higher cases of Staph Aureus and
pseudomonas, as well as Klebsiella
 Community-Acquired Pneumonia (CAP)
CAP Organisms
Bacterial Viral Fungal/Parasitic
 Typical  Influenza viruses  Most common in
• More serious and severe  Respiratory syncytial virus immunocompromised patients
• Fever, chills, leukocytosis, cough,  Adenovirus  Endemic or Opportunistic
sputum  Rhinovirus  Pneumocystis pneumonia
• Strep pneumoniae most common**  COVID-19 (PCP)
• H. Influenzae  Human metapneumovirus  Aspergillosis
• M. Catarrhalis  Histoplasmosis
• Respond to cell-wall active
antibiotics
 Atypical (20-30% of CAP)
• Mild illness – vary in presentation
• No cell wall – gram stain poorly
• Mycoplasma pneumoniae –
walking pneumonia
• Chlamydia pneumoniae
• Legionella pneumoniae
 Clinical Manifestations
 Pulmonary symptoms
• Tachypnea
• Dyspnea
• Pleuritic chest pain – sharp, knife-like, worse with inspiration
• Adventitious breath sounds
• Crackles
• Rhonchi
• Tactile fremitus
• Egophony
 Fever
 Malaise
 Chills
 Hypoxemia
 Tachycardia
 Elderly may have AMS, confusion
Pneumonia Evaluation

 Historical information provided by patient

 Physical assessment
 Labs
• CBC with differential
• Blood cultures
• Urine for strep pneumoniae and legionella SPP
• Sputum culture with gram stain – if
• Respiratory Panel for Viruses
• ABGs – if respiratory failure expected
• Procalcitonin – aids in confirmed bacterial
diagnosis and helps antibiotic therapy course
 Pneumonia Evaluation
 Diagnostics
• CXR – check for existing or new
infiltrates
 Lobar – entire lobe consolidation
 Interstitial – patchy
 Aspiration – follows gravitational Lobar
flow of aspirated contents – Aspiration
usually right middle lobe
 Diffuse – patchy opacities,
cavitation
 Atypical pneumonia more diffuse
and involve more than one lung
segment or both lungs
Interstitial
Diffus
e
 m a Complications
mp ye
E Sep
 Purulent exudate within s is
pleural space
 Bacteria makes its way into the
 Necrosis/breakdown of pleura
blood stream infecting the
and/or spread of infection to
pleura may occur D S circulating blood

Pleur AR
a l Effu
s i on s
 Inflammation leads to
exudation leaking into pleural
space
 Management
Overzealous treatment of mild respiratory infections can
contribute to the development antimicrobial drug resistance
Community-Acquired
Treating Strep Pneumoniae, H. Influenzae, M. Catarrhalis, Legionella,
Mycoplasma and Chlamydia pneumoniae

OUTPATIENT
Mild CAP Moderate CAP
Healthy, no antibiotics in last 3 months Comorbidities OR antibiotics in last 3 months
 Azithromycin 500 mg x 1 day then 250 mg  Levaquin 750 mg daily for 5 days
daily for 4 days
OR OR
 Doxycycline 100 mg BID for 7 days  Augmentin 2000 mg BID for 7 days PLUS
Azithromycin 500 mg x 1 day then 250 mg
daily for 4 days
 Management
Community-Acquired

INPATIENT
 Inpatient initial treatment, IV recommended but switch to PO once improvement
occurs
 Mild to Moderate Hospital Inpatient
• First Choice: Respiratory Fluoroquinolone (Levofloxacin)
• Second Choice: 2nd or 3rd Generation Cephalosporin (Rocephin)+ Macrolide
(Azithromax)
 Severe ICU Inpatient
• First Choice: Antipseudomonal fluoroquinolone (ciprofloxacin)+
Antipseudomonal β-lactam (Zosyn, cefepime, Merrem)
• Second Choice: Triple therapy - Antipseudomonal β-lactam + aminoglycosides
(gentamicin) + macrolides
 Management
Hospital-Acquired
Treating E. Coli, Enteric Gram-Negative bacilli,
Klebsiella, H, Influenzae, Staph Aureus, Pseudomonas,
Acinetobacter
 Mild to Moderate Hospital Inpatient  Severe ICU Inpatient
• NO Unusual Risk Factors • Aminoglycoside (Gentamicin)or
 Cephalosporin (Ancef, Ceftin, Rocephin) Ciprofloxacin plus one of the
 2nd Generation or antipseudomonal 3rd following:
generation β-lactam/ β-lactamase inhibitor  β-lactam/ β-lactamase
(Zosyn, Unasyn) inhibitor (Zosyn, Unasyn)
• With Risk factors  Linezolid
 Antibiotics above with the addition of:  Possibly Vancomycin
• Vancomycin (until MRSA excluded)
• Linezolid
• Clindamycin
 Management

Viral Fungal
Treating PCP, Aspergillosis, Histoplasmosis
 No treatment necessary – and others
will resolve on own  Amphotericin β, Itraconazole
 If known influenza A & B  PCP pneumonia resistant to most
• Zanamivir (Relenza) – antifungals – Bactrim is First Line,
10 mg inhalation BID if no improvement second line is
• Oseltamivir (Tamiflu) – Primaquine with Clindamycin
75 mg oral BID
 Management
Non-Pharmacological Management

 Oxygen Therapy
 Chest Vest/Chest physiotherapy
 Postural Drainage Positioning
 Incentive Spirometry
 Fluid balance
 Rest
 Disposition
Once a diagnosis of pneumonia is
reached, use the CURB-65 to
determine the need for hospital
admission or Outpatient treatment
Differential Diagnosis

 Acute Bronchitis
 COPD Exacerbation
 Asthma
 Congestive Heart Failure
 Lung Cancer
 Pertussis
 Pulmonary Emboli
 Review Question 1
You are treating an 87-year-old male nursing home resident who was
admitted with shortness of breath and fever. His temperature on
admission was 102°F. On physical exam, the gentleman is toxic looking
and has crackles at the right base. The chest Xray shows an infiltrate at
the right lower lobe. What’s the most likely causative organism?

(A) Streptococcus pneumoniae

(B) Legionella pneumophila
(C) Viral pneumonia
(D) Staphylococcus Aureus

 D. A nursing home resident is likely to have a healthcare-associated pneumonia

caused by Gram-negative bacteria, such as Klebsiella pneumoniae, or
by Staphylococcus aureus. 
 Review Question 2
Which organism is responsible for the diagnosis of “walking pneumonia”?

(A) Legionella
(B) Pneumocytitis pneumonia
(C) Mycoplasma pneumoniae
(D) Staphlyococcus aureus

C. Mycoplasma pneumoniae
 Review Question 3
A 77-year-old woman is hospitalized for treatment of community-acquired
pneumonia. She lives at home alone. Two months ago, she had a urinary tract
infection that was treated with ciprofloxacin. She had an upper respiratory tract
infection seven days ago and developed left-sided pleuritic chest pain and chills
one day before admission.

Which antibiotics would be most appropriate in this situation?

(A) Oral Telithromycin

(B) IV Rocephin plus Azithromycin
(c) IV levofloxacin
(D) IV Vancomycin Plus Rocephin

B. IV Rocephin PLUS Azithromycin

 Review Question 4
Which is NOT a factor that helps prevent organisms from colonizing within
the respiratory tract?

(A) Mucus Entrapment

(B) Epithelial Barrier
(c) Immune Surveillance
(D) Alveolar Macrophages
(E) Ciliary Dysfunction

E. Ciliary Dysfunction
 Review Question 5
A 72-year-old male smoker with chronic obstructive pulmonary disease was hospitalized two
days ago because of patchy left lower lobe pneumonia accompanied by fever, cough, and
dyspnea. WBC count was 18.600. Intravenous levofloxacin was started.

On hospital day 4, he has been afebrile for the past 18 hrs. He has good oral intake, his cough
has decreased, and he is no longer dyspneic. WBC now 8.700. A repeat CXR shows no
change in left lower lobe infiltrate.

Which of the following is most appropriate?

(A) ADD IV Rocephin
(B) Consult Pulmonary for Bronch
(c) CT Chest
(D) Change IV Levofloxacin to PO Levaquin

D. Change IV Levofloxacin to PO Levaquin

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