History

Fact Explanation
Fever and chills [1] Fever [1] occurs due to the pyrogens which usually come from outside the body or released in response to inflamation(cytokines), Pyrogens signals the hypothalamus to increase the temperature set point. When pyrogens signals the hypothalamus to increase the temperature set point, our body begins to shiver; our blood vessels constrict .
Productive cough with sputum [1] Bacteria can enter the lungs mainly via inhalation of airborne bacteria, less commonly- microaspiration of organisms that colonize the naso/oropharynx, bacteremic seeding of blood-borne bacteria in septicemic patients [13] and direct extension of an adjacent infection. Cough reflex, mucociliary transport and pulmonary macrophages try to protect the body against the infection.The invading organism starts to multiply and release damaging toxins that cause inflammation and edema of the lung parenchyma. This action leads to accumulation of cellular debris and exudes within the lungs. This produces cough with either white or yellow sputum.
Difficulty in breathing [1] Airways are blocked with inflammatory exudate and gas exchange is impaired at alveolar level. [8]
Pleuritic chest pain [1] Inflammation of the pleura can cause pain which increases on inspiration. [1]
Lethrgy ,malaise, loss of apetite Complex signaling circuits are activated by bacterial contact with airway epithelial cells that initiate chemokine expression to recruit phagocytes to the region of infection. Pneumolysin, a multifunctional virulence factor, [4] related to streptococcus pneumoniae, activates complement, leading to ongoing production of cytokines.Patient is unwell due to the production of cytokines.
Headache[1] Less common symptom. [1]
Altered mental state Confusion [6] is a marker of severity of the disease
Risk factors:-History of immunosuppression Immunosuppression is a risk factor for pneumonia specially for pneumococcal pneumonia. Acquired Immuno-defficiency syndrome, [10] malnutrition, diabetes, malignancy, chemotherapy and long-term use of steroids are some of these conditions that increased the risk of getting pneumonia due to immunosuppresion.
Risk factors:-History of underlying lung disease Patients with underlying abnormalities in the lung structure and function are also vulnerable for pneumonia. [10] Conditions like bronchiectasis, chronic obstructive pulmonary disease, cystic fibrosis and lung cancer increase the risk of getting pneumonia. Patients with respiratory failure who are on mechanical ventilators are more prone to pneumonia.
Risk factors:-History of co-morbidities Patients who are having diabetes mellitus, [12] renal diseases and heart diseases [11] have an increased risk of mortality due to pneumonia.
Risk factors-History of smoking Smoking decreases the body's natural defenses against infection, making individual vulnerable for infections. [5]
History of excessive use of alcohol Excessive use of alcohol associated with leucopenia [9] increases the risk of complications due to pneumonia. This can lead to alcoholic leukopenic pneumococcal sepsis that has a high mortality. [9]
Age At both extremes of age,there is increased risk of getting pneumonia. [6] This increased risk relates in part to impaired immunity. In some countries individuals older than age 65 account for most of the deaths from pneumonia.
If complicated with; pleural effusion Often results when the pneumonia is close to the chest wall and causes inflammation of the pleura surrounding the lung. [3] Patient presents with difficulty in breathing and pleuritic chest pain.
If complicated with; empyema If complicated with empyema [7], patient with a resolving pneumonia develops recurrent fever.
If complicated with; lung abscess Inadequately treated pneumonia can develop into a lung abscess. [7] Swinging fever, purulent cough, pleuritic chest pain and hemoptysis are some of the symptoms.
If complicated with; hypotension This may be either due to dehydration or sepsis. [6] Patient nay be experiencing faintishness or even collapse if in a state of shock.
If complicated with; sepsis This is due to spread of bacteria from lung tissue to the blood stream. Pneumococcal Surface Protein C is an important virulence factor that contributes to the sepsis. [2]
References
  1. KANG CI, BAEK JY, JEON K, KIM SH, CHUNG DR, PECK KR, LEE NY, SONG JH. Bacteremic Pneumonia Caused by Extensively Drug-Resistant Streptococcus pneumoniae J Clin Microbiol [online] 2012 Dec, 50(12):4175-4177 [viewed 22 September 2014] Available from: doi:10.1128/JCM.01642-12
  2. IANNELLI F, CHIAVOLINI D, RICCI S, OGGIONI MR, POZZI G. Pneumococcal Surface Protein C Contributes to Sepsis Caused by Streptococcus pneumoniae in Mice Infect Immun [online] 2004 May, 72(5):3077-3080 [viewed 22 September 2014] Available from: doi:10.1128/IAI.72.5.3077-3080.2004
  3. STORM HK, KRASNIK M, BANG K, FRIMODT-MøLLER N. Treatment of pleural empyema secondary to pneumonia: thoracocentesis regimen versus tube drainage. Thorax [online] 1992 Oct, 47(10):821-824 [viewed 22 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC464066
  4. RUBINS JB, CHARBONEAU D, PATON JC, MITCHELL TJ, ANDREW PW, JANOFF EN. Dual function of pneumolysin in the early pathogenesis of murine pneumococcal pneumonia. J Clin Invest [online] 1995 Jan, 95(1):142-150 [viewed 22 September 2014] Available from: doi:10.1172/JCI117631
  5. MOHSEN A, PECK R, MASON Z, MATTOCK L, MCKENDRICK M. Lung function tests and risk factors for pneumonia in adults with chickenpox Thorax [online] 2001 Oct, 56(10):796-799 [viewed 22 September 2014] Available from: doi:10.1136/thorax.56.10.796
  6. CURTAIN JP, SANKARAN P, KAMATH AV, MYINT PK. The Usefulness of Confusion, Urea, Respiratory Rate, and Shock Index or Adjusted Shock Index Criteria in Predicting Combined Mortality and/or ICU Admission Compared to CURB-65 in Community-Acquired Pneumonia Biomed Res Int [online] 2013:590407 [viewed 22 September 2014] Available from: doi:10.1155/2013/590407
  7. YU J, SALAMON D, MARCON M, NAHM MH. Pneumococcal Serotypes Causing Pneumonia with Pleural Effusion in Pediatric Patients J Clin Microbiol [online] 2011 Feb, 49(2):534-538 [viewed 22 September 2014] Available from: doi:10.1128/JCM.01827-10
  8. SARA AG, HAMDAN AJ, HANAA B, NAWAZ KA. Bronchiolitis obliterans organizing pneumonia: Pathogenesis, clinical features, imaging and therapy review Ann Thorac Med [online] 2008, 3(2):67-75 [viewed 22 September 2014] Available from: doi:10.4103/1817-1737.39641
  9. ALRAIYES AH, SHAHEEN K, ALRAIES MC. Alcoholic leukopenic pneumococcal sepsis Avicenna J Med [online] 2013, 3(2):53-55 [viewed 22 September 2014] Available from: doi:10.4103/2231-0770.114133
  10. ONYANGO D, KIKUVI G, AMUKOYE E, OMOLO J. Risk factors of severe pneumonia among children aged 2-59 months in western Kenya: a case control study Pan Afr Med J [online] :45 [viewed 22 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3542783
  11. SADOH W, OSAROGIAGBON W. Underlying congenital heart disease in Nigerian children with pneumonia Afr Health Sci [online] 2013 Sep, 13(3):607-612 [viewed 22 September 2014] Available from: doi:10.4314/ahs.v13i3.13
  12. VALDEZ R, NARAYAN KM, GEISS LS, ENGELGAU MM. Impact of diabetes mellitus on mortality associated with pneumonia and influenza among non-Hispanic black and white US adults. Am J Public Health [online] 1999 Nov, 89(11):1715-1721 [viewed 22 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1508989
  13. SEIFERT HARALD. The Clinical Importance of Microbiological Findings in the Diagnosis and Management of Bloodstream Infections. CLIN INFECT DIS [online] 2009 May, 48(s4):S238-S245 [viewed 22 September 2014] Available from: doi:10.1086/598188

Examination

Fact Explanation
Febrile Pyrogens signals the hypothalamus to increase the temperature set point making patient febrile. [5]
Tachypnoea Respiratory rate >30/min indicates severe pneumonia. [2]
Cyanosis This indicates severe pneumonia where the alveolar gas exchange is impaired.[4]
Reduced chest expansion Inflammation and edema of the lung parenchyma leads to accumulation of cellular debris and exudes within the lungs. Soon the airless state of the lungs is changed to a consolidated state due to the fluid and exudate filling up(with polymorphonuclear leucocytes and fibrin). Due to this consolidation, there is reduced chest expansion on the affected side. [3]
Reduced chest moments Due to the consolidation [3] , there is reduced air entry and lung expansion.
Dull percussion note Percussion note is dull over the areas of consolidation. [3]
Increased vocal fremitus/resonance Due to the consolidation [5] , sound waves travel better over this part of the lung. [3]
Reduced breath sounds The alveoli are filled with exudate due to inflammation where the normal air entry mechanism can not be happened.[3]
Added sounds eg:- crepitations Crepitations are generated when an abnormally closed airway opens during inspiration or closes at the end of expiration. Crepitations in pneumonia are caused by the opening of small airways and alveoli collapsed by fluid and exudate. [3]
Added sounds eg:-Bronchial breathing Bronchial breathing is heard over areas of consolidation, as solid lung conducts the sound of turbulence in main airways to peripheral areas without filtering.[3]
Added sounds eg:- Pleural rub It is caused by friction between the pleural membranes as a result of loss of lubrication and indicates an inflammatory process inside the lungs. If the normal layer of lubrication is reduced or disappears because of inflammation, friction builds up and the pleural membranes rub or grate against each other. [3]
If complicated with; pleural effusion This can be a complication of pneumonia. [6] Reduced chest expansion and chest moments, stony dull percussion note, decreased vocal fremitus/resonance and reduced breath sounds and bronchial breathing over the upper margin of the pleural effusion are the signs of pleural effusion.
If complicated with; empyema Serotype 1 pneumococcus is the primary serotype associated with empyema. [6] Examination signs are same as for pleural effusion.
If complicated with; lung abscess Clubbing, anaemia, crepitations are some of the common signs. [6]
If complicated with; respiratry failure It is type-1 respiratory failure that occurs in pneumonia. [5] Signs of hypoxia such as dyspnoea, agitation, central cyanosis and signs of hypercapnia such as tachycardia, bounding pulse, papiledema, confusion can be seen.
If complicated with; Hypotension Systolic blood pressure of <90mmHg and/or diastolic blood pressure of <60mmHg is a marker of severity under 'curb 65' criteria. [2]
If complicated with; sepsis Diagnostic criteria for sepsis [1] include 2 or more of the following criteria together with an infection. (Temperature >38.3º (101.0) or <36º (96.8), Systolic Blood Pressure < 90 or > 40 point SBP decrease from baseline, heart rate > 90 /min, resp Rate > 20/min or PaCO2<32 mmHg, altered Mental Status, hyperglycemia with glucose > 140 mg/dL in the absence of diabetes, lactic Acid > 1.2, Urine Output < 0.5 ml / kg / hr x 8 hours, leukocytes >12,000; <4,000)
Confusion, coma Confusion [2] is a marker of severity under 'curb 65' criteria. May be due to hypoxia or hypercapnoea.
References
  1. AHL JONAS, LITTORIN NILS, FORSGREN ARNE, ODENHOLT INGA, RESMAN FREDRIK, RIESBECK KRISTIAN. High incidence of septic shock caused by Streptococcus pneumoniae serotype 3 - a retrospective epidemiological study. Array [online] 2013 December [viewed 03 June 2014] Available from: doi:10.1186/1471-2334-13-492
  2. LIM W, VAN DER EERDEN MM, LAING R, BOERSMA W, KARALUS N, TOWN G, LEWIS S, MACFARLANE J. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study Thorax [online] 2003 May, 58(5):377-382 [viewed 15 September 2014] Available from: doi:10.1136/thorax.58.5.377
  3. SARA AG, HAMDAN AJ, HANAA B, NAWAZ KA. Bronchiolitis obliterans organizing pneumonia: Pathogenesis, clinical features, imaging and therapy review Ann Thorac Med [online] 2008, 3(2):67-75 [viewed 16 September 2014] Available from: doi:10.4103/1817-1737.39641
  4. AYIEKO P, ENGLISH M. Case Management of Childhood Pneumonia in Developing Countries Pediatr Infect Dis J [online] 2007 May, 26(5):432-440 [viewed 16 September 2014] Available from: doi:10.1097/01.inf.0000260107.79355.7d
  5. KANG CI, BAEK JY, JEON K, KIM SH, CHUNG DR, PECK KR, LEE NY, SONG JH. Bacteremic Pneumonia Caused by Extensively Drug-Resistant Streptococcus pneumoniae J Clin Microbiol [online] 2012 Dec, 50(12):4175-4177 [viewed 22 September 2014] Available from: doi:10.1128/JCM.01642-12
  6. YU J, SALAMON D, MARCON M, NAHM MH. Pneumococcal Serotypes Causing Pneumonia with Pleural Effusion in Pediatric Patients J Clin Microbiol [online] 2011 Feb, 49(2):534-538 [viewed 22 September 2014] Available from: doi:10.1128/JCM.01827-10

Differential Diagnoses

Fact Explanation
Chronic obstructive pulmonary disease (COPD) Pneumonia is different from an acute exacerbation of COPD, which is another disease that can cause fever, cough, chest pain, and shortness of breath. There is a progressive deterioration of the respiratory function with obstruction of pulmonary airways. [4] Bronchitis is caused by inflammation of the bronchi leading to the alveoli. [4] Patients with COPD, usually have a history of chronic cough with intermittent exacerbations and long term smoking. [4] On examination, they are wasted, and features of hyperinflation of the chest may be present. Sometimes they can go into cor-pulmonale, where they develop features of heart failure. Chest X-ray also shows features of hyperinflation in COPD patients.
Bronchiectasis In bronchiectasis, there is an abnormal and permanent dilatation of conducting airways. [3] Bronchiectasis patients often have a long-term history of cough and daily mucopurulent sputum production. [2] In an acute exacerbation, they usually develops hemoptysis [2] from airway damage, thick foul smelling sputum and increased sputum production over the baseline. In pneumonia, the sputum production is acute in onset and it may be rusty sputum.On examination they have wasting, crackles, [2] pallor and clubbing. These patients are also vulnerable to get infections of the lung.
Lung cancer These patients have a history of smoking/ exposure to asbestos and other chemicals(such as arsenic, chromium and nickel), [1] loss of appetite, loss of weight, increasing shortness of breath,persistent chest pain, haemoptysis and intermittent fever. Features of paraneoplastic syndrome and metastases(bone pain, headache) may also be present. On general examination, wasting, pallor may be present. Chest examination will show same features of consolidation as in pneumonia. Chest X-ray reveals an abnormal mass. CT scan reveals small lesions, which are not detected on an X-ray. Sputum cytology sometimes reveals the presence cancer cells. Tissue sample (biopsy) and bronchoscopy may also be helpful in diagnosis.
Lung abscess Lung abscess is a collection of pus in the lung with inflammation and tissue destruction. Unlike pneumonia, most of the these infections are produced by anaerobes.[9] History of pneumonia, aspiration, periodontal disease and poor oral hygiene may be present. [10] Unlike in pneumonia, chest X-ray will show a thick-walled cavity surrounded by solid tissue. There is often a visible air-fluid level.
Tuberculosis These patients presents with a history of cough for 2 weeks or longer accompanied by weight loss, night sweats and low grade fever. [6] But in the pneumonia, it is of acute onset, and usually high grade fever. Clinical or radiological differentiation may be difficult in some cases. Mantoux test will be positive in patients with tuberculosis, which may still not be positive in patients with immunosuppression. [5]
Adult respiratory distress syndrome(ARDS) There will be a history of significant aetiological factors such as pneumonia, aspiration, toxic inhalation, near-drowning, or lung contusion; as well as indirect mechanisms, such as sepsis, burn, pancreatitis. [13] Severe shortness of breath is the main symptom of ARDS. Other features include, unusually rapid breathing, confusion and low blood pressure. PaO2/F iO2 ≤200 mmHg . [13]
Pulmonary edema The aetiology may be mostly cardiac and less commonly pneumonia. Extreme shortness of breath that worsens on lying down, gasping for breath, restlessness, excessive sweating, palpitations and cough that produces frothy sputum [11] that may be tinged with blood are the symptoms that makes it different from pure pneumonia. Chest X-ray shows cardiomegaly, alveolar edema, haziness of vascular margins and peri hilar bat wing appearance. [12]
Sepsis Risk factors may be present in the history (eg:- immunosuppression, diabetes, AIDS, cirrhosis, burns or severe injuries, infections such as pneumonia, meningitis, cellulitis, urinary tract infection) [7,8] Patients with severe pneumonia can mimics sepsis. Diagnostic criteria for sepsis include 2 or more of the following criteria together with an infection. (Temperature >38.3º (101.0) or <36º (96.8), Systolic Blood Pressure < 90 or > 40 point SBP decrease from baseline, heart rate > 90 /min, resp Rate > 20/min or PaCO2<32 mmHg, altered mental Status, hyperglycemia with glucose > 140 mg/dL in the absence of diabetes, lactic Acid > 1.2, Urine Output < 0.5 ml / kg / hr x 8 hours, leukocytes >12,000; <4,000)
References
  1. MOLINA JR, YANG P, CASSIVI SD, SCHILD SE, ADJEI AA. Non-Small Cell Lung Cancer: Epidemiology, Risk Factors, Treatment, and Survivorship Mayo Clin Proc [online] 2008 May, 83(5):584-594 [viewed 22 September 2014] Available from: doi:10.4065/83.5.584
  2. HABESOGLU MA, UGURLU AO, EYUBOGLU FO. Clinical, radiologic, and functional evaluation of 304 patients with bronchiectasis Ann Thorac Med [online] 2011, 6(3):131-136 [viewed 22 September 2014] Available from: doi:10.4103/1817-1737.82443
  3. CLARK NS. Bronchiectasis in Childhood Br Med J [online] 1963 Jan 12, 1(5323):80-88 [viewed 22 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2122600
  4. ZAMARRóN C, PAZ VG, MORETE E, DEL CAMPO MATíAS F. Association of chronic obstructive pulmonary disease and obstructive sleep apnea consequences Int J Chron Obstruct Pulmon Dis [online] 2008 Dec, 3(4):671-682 [viewed 22 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2650593
  5. SANDHU GK. Tuberculosis: Current Situation, Challenges and Overview of its Control Programs in India J Glob Infect Dis [online] 2011, 3(2):143-150 [viewed 22 September 2014] Available from: doi:10.4103/0974-777X.81691
  6. SMITH I. Mycobacterium tuberculosis Pathogenesis and Molecular Determinants of Virulence Clin Microbiol Rev [online] 2003 Jul, 16(3):463-496 [viewed 22 September 2014] Available from: doi:10.1128/CMR.16.3.463-496.2003
  7. REMICK DG. Pathophysiology of Sepsis Am J Pathol [online] 2007 May, 170(5):1435-1444 [viewed 22 September 2014] Available from: doi:10.2353/ajpath.2007.060872
  8. LEVER A, MACKENZIE I. Sepsis: definition, epidemiology, and diagnosis BMJ [online] 2007 Oct 27, 335(7625):879-883 [viewed 22 September 2014] Available from: doi:10.1136/bmj.39346.495880.AE
  9. HAGAN JL, HARDY JD. Lung abscess revisited. A survey of 184 cases. Ann Surg [online] 1983 Jun, 197(6):755-762 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352910
  10. Lung abscess. West J Med [online] 1976 Jun, 124(6):476-482 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1130102
  11. Treatment of Pulmonary Oedema Br Med J [online] 1956 Dec 29, 2(5008):1531-1533 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2036040
  12. BOWSER B JR, STINSON JM. Spontaneous Unilateral Pulmonary Edema J Natl Med Assoc [online] 1986 Sep, 78(9):882-886 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2571366
  13. LUH SP, CHIANG CH. Acute lung injury/acute respiratory distress syndrome (ALI/ARDS): the mechanism, present strategies and future perspectives of therapies J Zhejiang Univ Sci B [online] 2007 Jan, 8(1):60-69 [viewed 17 September 2014] Available from: doi:10.1631/jzus.2007.B0060

Investigations - for Diagnosis

Fact Explanation
Chest X-ray Chest X-rays, to confirm the presence of pneumonia and determine the extent and location of the infection. Homogeneous parenchymal lobar opacity involving one[6], or less commonly, multiple lobes [3] and characteristic air bronchogram (usually in right lower lobe, but may vary in aspiration pneumonia) signify the streptococcal pneumonia. But X-rays can be misleading, because problems, like lung scarring and congestive heart failure, can mimic pneumonia on x-ray. Chest x-rays are also used to evaluate for complications of pneumonia such as pleural effusion.
Sputum gram stain and culture This can be used to demonstrate the causative organism. In gram stain streptococci appear as gram positive cocci.[4]
Full blood count (FBC) High white blood cell count, indicating the presence of an infection or inflammation. In some people with immune system problems, the white blood cell count may appear deceptively normal. As the patient presents with the fever, FBC is also important to look for the platelet count, as it might be a viral infection.[5]
C reactive protein Increased, indicating an inflammation.[5]
Pleural fluid culture A fluid sample is taken from the pleural area and analyzed to help determine the type of infection.[4]
Chest Computer Tomography[6] Pneumonia is not always seen on x-rays, either because the disease is only in its initial stages, or because it involves a part of the lung not easily seen by x-ray. In some cases, chest CT can reveal pneumonia that is not seen on chest x-ray. Consolidation appear as increased lung opacity on a chest CT.[3]
References
  1. POGODINA VV. Elizaveta Nilolaevna Levkovich-75th birthday. Acta Virol [online] 1975 Nov, 19(6):509 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2002
  2. WACHTER RF, BRIGGS GP, PEDERSEN CE JR. Precipitation of phase I antigen of Coxiella burnetii by sodium sulfite. Acta Virol [online] 1975 Nov, 19(6):500 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2000
  3. VIRKKI R, JUVEN T, RIKALAINEN H, SVEDSTROM E, MERTSOLA J, RUUSKANEN O. Differentiation of bacterial and viral pneumonia in children Thorax [online] 2002 May, 57(5):438-441 [viewed 16 September 2014] Available from: doi:10.1136/thorax.57.5.438
  4. BAESMAN RK, STRAND CL. Detection of Streptococcus pneumoniae in lower respiratory tract specimens by anaerobic culture technique. J Clin Microbiol [online] 1984 Apr, 19(4):550-551 [viewed 16 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC271117
  5. HOPSTAKEN RM, MURIS JW, KNOTTNERUS JA, KESTER AD, RINKENS PE, DINANT GJ. Contributions of symptoms, signs, erythrocyte sedimentation rate, and C-reactive protein to a diagnosis of pneumonia in acute lower respiratory tract infection. Br J Gen Pract [online] 2003 May, 53(490):358-364 [viewed 16 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314594
  6. REYNOLDS JH, MCDONALD G, ALTON H, GORDON SB. Pneumonia in the immunocompetent patient Br J Radiol [online] 2010 Dec, 83(996):998-1009 [viewed 16 September 2014] Available from: doi:10.1259/bjr/31200593

Investigations - Fitness for Management

Fact Explanation
Renal function tests ( Serum creatinine, serum electrolytes and blood urea) [2] Evaluation of kidney function [2] is important when prescribing certain antibiotics or to look for low blood sodium. Low blood sodium in pneumonia is thought to be due to extra anti-diuretic hormone produced when the lungs are diseased (SIADH).
Liver function tests[2] To have a base line value, specially there can be abnormalities in liver functions if there is a organ failure associated with sepsis. [2]
C Reactive protein (CRP) [1] Is increased due to the inflammation. [1]
References
  1. VIRKKI R, JUVEN T, RIKALAINEN H, SVEDSTROM E, MERTSOLA J, RUUSKANEN O. Differentiation of bacterial and viral pneumonia in children Thorax [online] 2002 May, 57(5):438-441 [viewed 16 September 2014] Available from: doi:10.1136/thorax.57.5.438
  2. AYIEKO P, ENGLISH M. Case Management of Childhood Pneumonia in Developing Countries Pediatr Infect Dis J [online] 2007 May, 26(5):432-440 [viewed 16 September 2014] Available from: doi:10.1097/01.inf.0000260107.79355.7d

Investigations - Followup

Fact Explanation
Chest X-ray Arrange a chest X-ray after 6 weeks for people over 50 years of age that smoke, and for people with persistent symptoms or signs of pneumonia.Monitoring a favorable disease process by routine follow-up chest radiographs seems to have no additional value above following a patient's clinical course.[1] Follow up chest x-ray indicated in children only if it is recurrent.[2]
References
  1. BRUNS AH, OOSTERHEERT JJ, EL MOUSSAOUI R, OPMEER BC, HOEPELMAN AI, PRINS JM. Pneumonia Recovery; Discrepancies in Perspectives of the Radiologist, Physician and Patient J Gen Intern Med [online] 2010 Mar, 25(3):203-206 [viewed 16 September 2014] Available from: doi:10.1007/s11606-009-1182-7
  2. DAVIES HD. Community-acquired pneumonia in children Paediatr Child Health [online] 2003 Dec, 8(10):616-619 [viewed 16 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2795279

Investigations - Screening/Staging

Fact Explanation
Bronchoscopy[3] This is used to check any obstruction in the airways or whether something else is contributing to your pneumonia. [3]
Blood culture May be needed if the condition of the patient is worsening, to exclude the complications such as sepsis. [5]
Renal function tests ( Serum creatinine, serum electrolytes and blood urea) Blood urea more than 7mmol/l is a marker of severe pneumonia. [1,4]
Pulse oxymetry[1] SaO2 <92% is an indicator of severe pneumonia. [4]
Chest ultrasonograpgy[2] Used to evaluate the suspected parapneumonic effusions. [2]
References
  1. LIM W, VAN DER EERDEN MM, LAING R, BOERSMA W, KARALUS N, TOWN G, LEWIS S, MACFARLANE J. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study Thorax [online] 2003 May, 58(5):377-382 [viewed 15 September 2014] Available from: doi:10.1136/thorax.58.5.377
  2. HILLIARD T, HENDERSON A, HEWER S. Management of parapneumonic effusion and empyema Arch Dis Child [online] 2003 Oct, 88(10):915-917 [viewed 16 September 2014] Available from: doi:10.1136/adc.88.10.915
  3. Aspiration Pneumonia Br Med J [online] 1951 Oct 27, 2(4738):1018-1019 [viewed 16 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2070256
  4. KANG CI, BAEK JY, JEON K, KIM SH, CHUNG DR, PECK KR, LEE NY, SONG JH. Bacteremic Pneumonia Caused by Extensively Drug-Resistant Streptococcus pneumoniae J Clin Microbiol [online] 2012 Dec, 50(12):4175-4177 [viewed 22 September 2014] Available from: doi:10.1128/JCM.01642-12
  5. IANNELLI F, CHIAVOLINI D, RICCI S, OGGIONI MR, POZZI G. Pneumococcal Surface Protein C Contributes to Sepsis Caused by Streptococcus pneumoniae in Mice Infect Immun [online] 2004 May, 72(5):3077-3080 [viewed 22 September 2014] Available from: doi:10.1128/IAI.72.5.3077-3080.2004

Management - General Measures

Fact Explanation
Assessment of the severity[4] Severity is based on the criteria of 'CURB 65'-C- Confusion, U- Urea >7mmol/l, R-Respiratory rate >30/min, B-Systolic blood pressure<90mmHg and 65-Age >65 years. [7] If 0-1 score is present, patient can be managed at home. If it is 2, hospital management and 3 or more, admission to a intensive care unit is needed.. If patient is having shock, hypercapnia or uncorrected hypoxia, consider admission to a intensive care unit.
Oxygen [2] To keep PaO2 >k8Pa and saturation >94%. [6]
Adequate fluid supplimentation[2] Drinking sufficient fluids is important to prevent dehydration. [2] Sometimes IV fluids may be needed as patient is having anorexia, dehydration and even shock. Observation of the frequency and colour of their urine is important as fluid intake has to be increased if there is reduced urine output.
Analgesia[2] Use paracetamol 1g 6H as required to reduce temperature and symptoms of malaise and pleurisy. [2]
Monitoring[2] Clinical symptoms and chest signs are monitored for improvement. [2] CRP should be checked as it may be persistently high in a case of poor progression. Close monitoring of vital parameters is required if the condition of the patient is worsening. [6]
Looking for the complications[2] Pleural effusion, lung absess, septicaemia, respiratory failure, [6] pericarditis,myocarditis,brain abscess are some of the possible complications and patient should be carefully monitored for them.
Pneumococcal vaccine [5] A vaccine against ''Streptococcus pneumoniae'' is also available for high risk groups such as persons with emphysema, congestive heart failure, diabetes mellitus, cirrhosis of the liver, alcoholism, cerebrospinal fluid leaks, or those who had splenectomy. [8] A repeat vaccination may also be required after five or ten years.
References
  1. AHL JONAS, LITTORIN NILS, FORSGREN ARNE, ODENHOLT INGA, RESMAN FREDRIK, RIESBECK KRISTIAN. High incidence of septic shock caused by Streptococcus pneumoniae serotype 3 - a retrospective epidemiological study. Array [online] 2013 December [viewed 03 June 2014] Available from: doi:10.1186/1471-2334-13-492
  2. BARTLETT JG. Managing Community-acquired Pneumonia J Gen Intern Med [online] 2001 Sep, 16(9):642-643 [viewed 16 September 2014] Available from: doi:10.1046/j.1525-1497.2001.016009640.x
  3. EMMI V. [Guidelines for treatment of pneumonia in intensive care units]. Infez Med [online] 2005:7-17 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16801748
  4. LIM WS. Severity assessment in community-acquired pneumonia: moving on Thorax [online] 2007 Apr, 62(4):287-288 [viewed 16 September 2014] Available from: doi:10.1136/thx.2006.073700
  5. WHITE RT. Pneumococcal vaccine. Thorax [online] 1988 May, 43(5):345-348 [viewed 16 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC461242
  6. KANG CI, BAEK JY, JEON K, KIM SH, CHUNG DR, PECK KR, LEE NY, SONG JH. Bacteremic Pneumonia Caused by Extensively Drug-Resistant Streptococcus pneumoniae J Clin Microbiol [online] 2012 Dec, 50(12):4175-4177 [viewed 22 September 2014] Available from: doi:10.1128/JCM.01642-12
  7. KIM HI, KIM SW, CHANG HH, CHA SI, LEE JH, KI HK, CHEONG HS, YOO KH, RYU SY, KWON KT, LEE BK, CHOO EJ, KIM DJ, KANG CI, CHUNG DR, PECK KR, SONG JH, SUH GY, SHIM TS, KIM YK, KIM HY, MOON CS, LEE HK, PARK SY, OH JY, JUNG SI, PARK KH, YUN NR, YOON SH, SOHN KM, KIM YS, JUNG KS. Mortality of Community-Acquired Pneumonia in Korea: Assessed with the Pneumonia Severity Index and the CURB-65 Score J Korean Med Sci [online] 2013 Sep, 28(9):1276-1282 [viewed 22 September 2014] Available from: doi:10.3346/jkms.2013.28.9.1276
  8. WHITE RT. Pneumococcal vaccine. Thorax [online] 1988 May, 43(5):345-348 [viewed 22 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC461242

Management - Specific Treatments

Fact Explanation
Antibiotics for mild disease Oral amoxicillin 500mg-1g 8H or clarithromycin 500mg 12H or doxycycline 200mg followed by 100mg 12H [1]
Antibiotics for moderate disease [3] Empirical treatment is with β-lactams, macrolides, or fluoroquinolones. [4] Oral amoxicillin 500mg-1g 8H+ clarithromycin 500mh 12H or doxycycline 200mg followed by 100mg 12H. If IV required amoxicillin 500mg-1g 8H+clarithromycin 500mh 12H. Macrolide antibiotics, particularly azithromycin, are unique as anti-infective agents, have potent anti-inflammatory properties and confer a mortality advantage in community acquired pneumonia irrespective of the causative pathogen. In an attempt to prevent the emergence of resistance [4] , it has been recommended that the new fluoroquinolones not be used routinely as first-line agents in the treatment of community-acquired pneumonia; and these agents should be reserved for patients who are allergic to the commonly used beta-lactam agents, for infections known to be or suspected of being caused by highly resistant strains, and for patients in whom initial therapy has failed.
Antibiotics for severe disease[3] Co amoxiclav 1.2g 12H iv or cefuroxime 1.5g 8H IV and clarithromycin 500mg12H IV. [3]
Antibiotics for aspiration pneumonia due to streptococcus pneumoniae[2] Cefuroxime 1.5g 8H IV + Metronidazole 500mg 8H IV. [2]
References
  1. GAVALDà J, CAPDEVILA JA, ALMIRANTE B, OTERO J, RUIZ I, LAGUARDA M, ALLENDE H, CRESPO E, PIGRAU C, PAHISSA A. Treatment of experimental pneumonia due to penicillin-resistant Streptococcus pneumoniae in immunocompetent rats. Antimicrob Agents Chemother [online] 1997 Apr, 41(4):795-801 [viewed 15 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC163797
  2. KOENIG SM, TRUWIT JD. Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention Clin Microbiol Rev [online] 2006 Oct, 19(4):637-657 [viewed 16 September 2014] Available from: doi:10.1128/CMR.00051-05
  3. AYIEKO P, ENGLISH M. Case Management of Childhood Pneumonia in Developing Countries Pediatr Infect Dis J [online] 2007 May, 26(5):432-440 [viewed 16 September 2014] Available from: doi:10.1097/01.inf.0000260107.79355.7d
  4. KANG CI, BAEK JY, JEON K, KIM SH, CHUNG DR, PECK KR, LEE NY, SONG JH. Bacteremic Pneumonia Caused by Extensively Drug-Resistant Streptococcus pneumoniae J Clin Microbiol [online] 2012 Dec, 50(12):4175-4177 [viewed 22 September 2014] Available from: doi:10.1128/JCM.01642-12