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Pneumonia

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Pneumonia

Classification and external resources

A chest X-ray showing a very prominentwedge shaped pneumonia in the right lung.

ICD-10 J12.,J13.,J14.,J15.,J16.,J17.,J18., P23.

ICD-9 480-486, 770.0

DiseasesDB 10166

eMedicine topic list

MeSH D011014

Pneumonia
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Infectious pneumonias

Bacterial pneumoniaViral pneumoniaFungal pneumoniaParasitic pneumoniaAtypical pneumonia

Community-acquiredpneumoniaHealthcare-associatedpneumoniaHospital-acquiredpneumoniaVentilator-associatedpneumoniaSevere acute respiratorysyndrome

Pneumonias caused byinfectious ornoninfectious agents

Aspiration pneumoniaLipid pneumoniaEosinophilic pneumoniaBronchiolitis obliteransorganizing pneumonia

Noninfectious pneumonia

Chemical pneumonia

This box:view talk edit

Pneumonia is an inflammatory condition of the lung.[1] It is often characterizedas including inflammation of the parenchyma of the lung (that is, the alveoli) andabnormal alveolar filling with fluid (consolidation and exudation).[2]

The alveoli are microscopic air filled sacs in the lungs responsible for gasexchange. Pneumonia can result from a variety of causes, including infectionwith bacteria, viruses, fungi, or parasites, and chemical or physical injury to thelungs. Its cause may also be officially described as unknown when infectious

causes have been excluded.
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Typical symptoms associated with pneumonia include cough, chest pain, fever,and difficulty in breathing. Diagnostic tools include x-rays and examination of thesputum. Treatment depends on the cause of pneumonia; bacterial pneumonia istreated with antibiotics.

Pneumonia is common, occurring in all age groups, and is a leading cause ofdeath among the young, the old, and the chronically ill.[3]Vaccines to preventcertain types of pneumonia are available. The prognosis depends on the type ofpneumonia, the treatment, any complications, and the person's underlyinghealth.

Contents[hide]1 Classification1.1 Clinical1.1.1 Community-acquired1.1.2 Hospital-acquired1.1.3 Other types1.2 Other2 Signs and symptoms3 Cause3.1 Viruses3.2 Bacteria3.3 Fungi3.4 Parasites3.5 Idiopathic4 Diagnosis4.1 Investigations4.2 Combining findings4.3 Differential diagnosis4.4 Appearance on X ray5 Prevention6 Treatment6.1 Bacterial6.2 Viral6.3 Aspiration

7 Complications7.1 Respiratory and circulatoryfailure7.2 Pleural effusion, empyema, andabscess8 Prognosis8.1 Clinical prediction rules9 Epidemiology10 History11 Society and culture

12 See also13 References
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Classification

This section needs additional citations for verification.Please help improve this article by adding reliable references.Unsourced material may be challenged and removed. (August 2009)

Pneumonias can be classified in several ways. The primary system ofclassification is the combined clinical classification, which combines factors suchas age, risk factors for certain microorganisms, the presence of underlying lungdisease or systemic disease, and whether the person has recently beenhospitalized.

Other classifications include according to the anatomic changes that can befound in the lungs during autopsies, based on the microbial cause, and aradiological classification.

Clinical

Traditionally, clinicians have classified pneumonia by clinical characteristics,dividing them into "acute" (less than three weeks duration) and "chronic"pneumonias. This is useful because chronic pneumonias tend to be either non-infectious, or mycobacterial, fungal, or mixed bacterial infections caused byairway obstruction. Acute pneumonias are further divided into the classicbacterial bronchopneumonias (such as Streptococcus pneumoniae), the atypicalpneumonias (such as the interstitial pneumonitis ofMycoplasma pneumoniae orChlamydia pneumoniae), and the aspiration pneumonia syndromes.

Chronic pneumonias, on the other hand, mainly include those ofNocardia,Actinomyces and Blastomyces dermatitidis, as well as the granulomatouspneumonias (Mycobacterium tuberculosis and atypical mycobacteria,Histoplasma capsulatum and Coccidioides immitis).[4]

The combined clinical classification, now the most commonly used classificationscheme, attempts to identify a person's risk factors when he or she first comesto medical attention. The advantage of this classification scheme over previoussystems is that it can help guide the selection of appropriate initial treatmentseven before the microbiologic cause of the pneumonia is known. There are two

broad categories of pneumonia in this scheme: community-acquired pneumoniaand hospital-acquired pneumonia. A recently introduced type ofhealthcare-associated pneumonia (in patients living outside the hospital who have recentlybeen in close contact with the health care system) lies between these twocategories.

Community-acquired

Main article: Community-acquired pneumonia

Community-acquired pneumonia (CAP) is infectious pneumonia in a person who

has not recently been hospitalized. CAP is the most common type of pneumonia.The most common causes of CAP vary depending on a person's age, but they
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include Streptococcus pneumoniae, viruses, the atypical bacteria, andHaemophilus influenzae. Overall, Streptococcus pneumoniae is the mostcommon cause of community-acquired pneumonia worldwide. Gram-negativebacteria cause CAP in certain at-risk populations. CAP is the fourth most commoncause of death in the United Kingdom and the sixth in the United States. The

term "walking pneumonia" has been used to describe a type of community-acquired pneumonia of less severity (because the sufferer can continue to "walk"rather than require hospitalization).[5] Walking pneumonia is usually caused bythe atypical bacterium, Mycoplasma pneumoniae.[6]

Hospital-acquired

Main article: Hospital-acquired pneumonia

Hospital-acquired pneumonia, also called nosocomial pneumonia, is pneumoniaacquired during or after hospitalization for another illness or procedure with

onset at least 72 hrs after admission. The causes, microbiology, treatment andprognosis are different from those of community-acquired pneumonia. Up to 5%of patients admitted to a hospital for other causes subsequently developpneumonia. Hospitalized patients may have many risk factors for pneumonia,including mechanical ventilation, prolonged malnutrition, underlying heart andlung diseases, decreased amounts of stomach acid, and immune disturbances.Additionally, the microorganisms a person is exposed to in a hospital are oftendifferent from those at home. Hospital-acquired microorganisms may includeresistant bacteria such as MRSA, Pseudomonas, Enterobacter, and Serratia.Because individuals with hospital-acquired pneumonia usually have underlying

illnesses and are exposed to more dangerous bacteria, it tends to be moredeadly than community-acquired pneumonia. Ventilator-associated pneumonia(VAP) is a subset of hospital-acquired pneumonia. VAP is pneumonia whichoccurs after at least 48 hours ofintubation and mechanical ventilation.

Other types

Bronchiolitis obliterans organizing pneumonia (BOOP)

BOOP is caused by inflammation of the small airways of the lungs. It is alsoknown as cryptogenic organizing pneumonitis (COP).

Eosinophilic pneumonia

Eosinophilic pneumonia is invasion of the lung by eosinophils, a particular kind ofwhite blood cell. Eosinophilic pneumonia often occurs in response to infectionwith a parasite or after exposure to certain types of environmental factors.

Chemical pneumonia

Chemical pneumonia (usually called chemical pneumonitis) is caused bychemical toxicants such as pesticides, which may enter the body by inhalation or

by skin contact. When the toxic substance is an oil, the pneumonia may be calledlipoid pneumonia.
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Aspiration pneumonia

Aspiration pneumonia (or aspiration pneumonitis) is caused by aspirating foreignobjects which are usually oral or gastric contents, either while eating, or afterreflux or vomiting which results in bronchopneumonia. The resulting lung

inflammation is not an infection but can contribute to one, since the materialaspirated may contain anaerobic bacteria or other unusual causes of pneumonia.Aspiration is a leading cause of death among hospital and nursing homepatients, since they often cannot adequately protect their airways and may haveotherwise impaired defenses.

Dust pneumonia

Dust pneumonia describes disorders caused by excessive exposure to duststorms, particularly during the Dust Bowl in the United States. With dustpneumonia, dust settles all the way into the alveoli of the lungs, stopping the

cilia from moving and preventing the lungs from ever clearing themselves.

Necrotizing pneumonia, although overlapping with many other classifications,includes pneumonias that cause substantial necrosis of lung cells, andsometimes even lung abscess. Implicated bacteria are extremely commonlyanaerobic bacteria, with or without additional facultatively anaerobic ones likeStaphylococcus aureus, Klebsiella pneumoniae and Streptococcus pyogenes.[4]

Type 3 pneumococcus is uncommonly implicated.[4]

Opportunistic pneumonia includes those that frequently strikeimmunocompromised victims. Main pathogens are cytomegalovirus,Pneumocystis jiroveci, Mycobacterium avium-intracellulare, invasiveaspergillosis, invasive candidiasis, as well as the "usual bacteria" that strikeimmunocompetent people as well.[4]

Double pneumonia is a historical term for acute lung injury (ALI) or acuterespiratory distress syndrome (ARDS).[7] However, the term was, and is usedstill, especially by lay people, to denote pneumonia affecting both lungs.Accordingly, the term 'double pneumonia' is more likely to be used to describebilateral pneumonia than it is ALI or ARDS.

Severe acute respiratory syndrome (SARS)SARS is a highly contagious and deadly type of pneumonia which first occurred in2002 after initial outbreaks in China. SARS is caused by the SARS coronavirus, apreviously unknown pathogen. Last recorded occurrence was in 2003.

Other

Initial descriptions of pneumonia focused on the anatomic or pathologicappearance of the lung, either by direct inspection at autopsy or by itsappearance under a microscope.
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A lobar pneumonia is an infection that only involves a single lobe, or section, of alung. Lobar pneumonia is often due to Streptococcus pneumoniae (thoughKlebsiella pneumoniae is also possible.)[8]

Multilobar pneumonia involves more than one lobe, and it often causes a more

severe illness.

Bronchial pneumonia affects the lungs in patches around the tubes (bronchi orbronchioles).

Interstitial pneumonia involves the areas in between the alveoli, and it may becalled "interstitial pneumonitis." It is more likely to be caused by viruses or byatypical bacteria.

The discovery of x-rays made it possible to determine the anatomic type ofpneumonia without direct examination of the lungs at autopsy and led to the

development of a radiological classification. Early investigators distinguishedbetween typical lobar pneumonia and atypical (e.g. Chlamydophila) or viralpneumonia using the location, distribution, and appearance of the opacities theysaw on chest x-rays. Certain x-ray findings can be used to help predict thecourse of illness, although it is not possible to clearly determine themicrobiologic cause of a pneumonia with x-rays alone.

With the advent of modern microbiology, classification based upon the causativemicroorganism became possible. Determining which microorganism is causingan individual's pneumonia is an important step in deciding treatment type andlength. Sputum cultures, blood cultures, tests on respiratory secretions, andspecific blood tests are used to determine the microbiologic classification.Because such laboratory testing typically takes several days, microbiologicclassification is usually not possible at the time of initial diagnosis.

Signs and symptoms

Main symptoms of infectious pneumonia
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Crackles

Crackles heard in the lungs of a person withpneumonia using a stethoscope.

Problems listening to this file? See media help.People with infectious pneumonia often have a cough producing greenish oryellow sputum, or phlegm and a high fever that may be accompanied by shakingchills. Shortness of breath is also common, as is pleuritic chest pain, a sharp orstabbing pain, either experienced during deep breaths or coughs or worsened bythem. People with pneumonia may cough up blood, experience headaches, ordevelop sweaty and clammy skin. Other possible symptoms are loss of appetite,fatigue, blueness of the skin, nausea, vomiting, mood swings, andjoint pains or

muscle aches. Less common forms of pneumonia can cause other symptoms; forinstance, pneumonia caused by Legionella may cause abdominal pain anddiarrhea, while pneumonia caused by tuberculosis or Pneumocystis may causeonly weight loss and night sweats. In elderly people, manifestations ofpneumonia are seldom typical. They may develop a new or worsening confusion(delirium) or may experience unsteadiness, leading to falls. Infants withpneumonia may have many of the symptoms above, but in many cases they aresimply sleepy or have a decreased appetite.[9]

Pneumonia fills the lung's alveoli with fluid, keeping oxygen from reaching thebloodstream. The alveolus on the left is normal, while the alveolus on the right isfull of fluid from pneumonia.

Symptoms of pneumonia need immediate medical evaluation. Physicalexamination by a health care provider may reveal fever or sometimes low body
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temperature, an increased respiratory rate, low blood pressure, a high heartrate, or a low oxygen saturation, which is the amount of oxygen in the blood asindicated by either pulse oximetry or blood gas analysis. People who arestruggling to breathe, who are confused, or who have cyanosis (blue-tinged skin)require immediate attention.

Findings from physical examination of the lungs may be normal, but often showdecreased expansion of the chest on the affected side, bronchial breathing onauscultation with a stethoscope (harsher sounds from the larger airwaystransmitted through the inflamed and consolidated lung), and rales (or crackles)heard over the affected area during inspiration. Percussion may be dulled overthe affected lung, but increased rather than decreased vocal resonance (whichdistinguishes it from a pleural effusion).[9] While these signs are relevant, theyare insufficient to diagnose or rule out a pneumonia; moreover, in studies it hasbeen shown that two doctors can arrive at different findings on the same patient.

[10] [11]Cause

This section needs additional citations for verification.Please help improve this article by adding reliable references.Unsourced material may be challenged and removed. (August 2009)
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Upper panel shows a normal lung under a microscope. The white spaces arealveoli that contain air. Lower panel shows a lung with pneumonia under amicroscope. The alveoli are filled with inflammation and debris.

Pneumonia can be caused by microorganisms, irritants and unknown causes.

When pneumonias are grouped this way, infectious causes are the most commontype.

The symptoms of infectious pneumonia are caused by the invasion of the lungsby microorganisms and by the immune system's response to the infection.Although more than one hundred strains of microorganism can causepneumonia, only a few are responsible for most cases. The most common causesof pneumonia are viruses and bacteria. Less common causes of infectiouspneumonia are fungi and parasites.

Viruses

Main article: Viral pneumonia

Viruses have been found to account for between 1828% of pneumonia in a fewlimited studies.[12] Viruses invade cells in order to reproduce. Typically, a virusreaches the lungs when airborne droplets are inhaled through the mouth andnose. Once in the lungs, the virus invades the cells lining the airways and alveoli.

This invasion often leads to cell death, either when the virus directly kills thecells, or through a type of cell controlled self-destruction called apoptosis. Whenthe immune system responds to the viral infection, even more lung damageoccurs. White blood cells, mainly lymphocytes, activate certain chemicalcytokines which allow fluid to leak into the alveoli. This combination of celldestruction and fluid-filled alveoli interrupts the normal transportation of oxygeninto the bloodstream.

As well as damaging the lungs, many viruses affect other organs and thusdisrupt many body functions. Viruses can also make the body more susceptibleto bacterial infections; for which reason bacterial pneumonia may complicateviral pneumonia.[12]

Viral pneumonia is commonly caused by viruses such as influenza virus,

respiratory syncytial virus (RSV), adenovirus, and parainfluenza.[12]Herpessimplex virus is a rare cause of pneumonia except in newborns. People withweakened immune systems are also at risk of pneumonia caused bycytomegalovirus (CMV).

Bacteria

Main article: Bacterial pneumonia
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The bacterium Streptococcus pneumoniae, a common cause of pneumonia,photographed through an electron microscope.

Bacteria are the most common cause of community acquired pneumonia with

Streptococcus pneumoniae the most commonly isolated bacteria.[13] Anotherimportant Gram-positive cause of pneumonia is Staphylococcus aureus, withStreptococcus agalactiae being an important cause of pneumonia in newbornbabies. Gram-negative bacteria cause pneumonia less frequently than gram-positive bacteria. Some of the gram-negative bacteria that cause pneumoniainclude Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli,Pseudomonas aeruginosa and Moraxella catarrhalis. These bacteria often live inthe stomach or intestines and may enter the lungs if vomit is inhaled. "Atypical"bacteria which cause pneumonia include Chlamydophila pneumoniae,Mycoplasma pneumoniae, and Legionella pneumophila.

Bacteria typically enter the lung when airborne droplets are inhaled, but can alsoreach the lung through the bloodstream when there is an infection in anotherpart of the body. Many bacteria live in parts of the upper respiratory tract, suchas the nose, mouth and sinuses, and can easily be inhaled into the alveoli. Onceinside, bacteria may invade the spaces between cells and between alveolithrough connecting pores. This invasion triggers the immune system to sendneutrophils, a type of defensive white blood cell, to the lungs. The neutrophilsengulfand kill the offending organisms, and also release cytokines, causing ageneral activation of the immune system. This leads to the fever, chills, and

fatigue common in bacterial and fungal pneumonia. The neutrophils, bacteria,and fluid from surrounding blood vessels fill the alveoli and interrupt normaloxygen transportation.

Fungi

Main article: Fungal pneumonia

Fungal pneumonia is uncommon, but it may occur in individuals with immunesystem problems due to AIDS, immunosuppresive drugs, or other medicalproblems. The pathophysiology of pneumonia caused by fungi is similar to thatof bacterial pneumonia. Fungal pneumonia is most often caused by Histoplasmacapsulatum, blastomyces, Cryptococcus neoformans, Pneumocystis jiroveci, and
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Coccidioides immitis. Histoplasmosis is most common in the Mississippi Riverbasin, and coccidioidomycosis in the southwestern United States.

Parasites

Main article: Parasitic pneumoniaA variety of parasites can affect the lungs. These parasites typically enter thebody through the skin or by being swallowed. Once inside, they travel to thelungs, usually through the blood. There, as in other cases of pneumonia, acombination of cellular destruction and immune response causes disruption ofoxygen transportation. One type of white blood cell, the eosinophil, respondsvigorously to parasite infection. Eosinophils in the lungs can lead to eosinophilicpneumonia, thus complicating the underlying parasitic pneumonia. The mostcommon parasites causing pneumonia areToxoplasma gondii, Strongyloidesstercoralis, and Ascariasis.

Idiopathic

Main article: Idiopathic interstitial pneumonia

Idiopathic interstitial pneumonias (IIP) are a class ofdiffuse lung diseases. Insome types of IIP, e.g. some types ofusual interstitial pneumonia, the cause,indeed, is unknown or idiopathic. In some types of IIP the cause of thepneumonia is known, e.g. desquamative interstitial pneumonia is caused bysmoking, and the name is a misnomer.

Diagnosis
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Pneumonia as seen on chest x-ray. A: Normal chest x-ray. B: Abnormal chest x-ray with shadowing from pneumonia in the right lung (white area, left side ofimage).

CT of the chest demonstrating right sided pneumonia (left side of the image).

If pneumonia is suspected on the basis of a patient's symptoms and findingsfrom physical examination, further investigations are needed to confirm thediagnosis. Information from a chest X-ray and blood tests are helpful, andsputum cultures in some cases. The chest X-ray is typically used for diagnosis inhospitals and some clinics with X-ray facilities. However, in a community setting(general practice), pneumonia is usually diagnosed based on symptoms and

physical examination alone.[citation needed] Diagnosing pneumonia can bedifficult in some people, especially those who have other illnesses. Occasionally achest CT scan or other tests may be needed to distinguish pneumonia from otherillnesses.

Investigations

An important test for pneumonia in unclear situations is a chest x-ray. Chest x-rays can reveal areas ofopacity (seen as white) which represent consolidation.Pneumonia is not always seen on x-rays, either because the disease is only in itsinitial stages, or because it involves a part of the lung not easily seen by x-ray. In

some cases, chest CT (computed tomography) can reveal pneumonia that is notseen on chest x-ray. X-rays can be misleading, because other problems, like lungscarring and congestive heart failure, can mimic pneumonia on x-ray.[14] Chestx-rays are also used to evaluate for complications of pneumonia (see below.)

If antibiotics fail to improve the patient's health, or if the health care provider hasconcerns about the diagnosis, a culture of the person's sputum may berequested. Sputum cultures generally take at least two to three days, so they aremainly used to confirm that the infection is sensitive to an antibiotic that hasalready been started. A blood sample may similarly be cultured to look for

bacteria in the blood. Any bacteria identified are then tested to see whichantibiotics will be most effective.
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A complete blood count may show a high white blood cell count, indicating thepresence of an infection or inflammation. In some people with immune systemproblems, the white blood cell count may appear deceptively normal. Blood testsmay be used to evaluate kidney function (important when prescribing certainantibiotics) 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 arediseased (SIADH). Specific blood serology tests for other bacteria (Mycoplasma,Legionella and Chlamydophila) and a urine test for Legionella antigen areavailable. Respiratory secretions can also be tested for the presence of virusessuch as influenza, respiratory syncytial virus, and adenovirus. Liver function testsshould be carried out to test for damage caused by sepsis.[9]

Combining findings

One study created a prediction rule that found the five following signs bestpredicted infiltrates on the chest radiograph of 1134 patients presenting to anemergency room:[15]

Fever > 37.8 C (100.0 F)

Pulse > 100 beats/min

Rales/crackles

Decreased breath sounds

Absence of asthma

The probability of an infiltrate in two separate validations was based on thenumber of findings:

5 findings 84% to 91% probability

4 findings 58% to 85%



1 findings 5% to 9%0 findings 2% to 3%

A subsequent study[16] comparing four prediction rules to physician judgmentfound that two rules, the one above[15] and also[17] were more accurate thanphysician judgment because of the increased specificity of the prediction rules.

Differential diagnosis

Several diseases and/or conditions can present with similar clinical features topneumonia. Chronic obstructive pulmonary disease (COPD) or asthma canpresent with a polyphonic wheeze, similar to that of pneumonia. Pulmonaryedema can be mistaken for pneumonia (and vice versa), especially in the elderly,
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due to its similar symptoms and signs. Other diseases to be taken intoconsideration include bronchiectasis, lung cancer and pulmonary emboli.[9]

Appearance on X ray

Normal AP CXR Normal lateral CXR

AP CXR showing leftlower lobe pneumoniaassociated with a smallleft sided pleuraleffusion

AP CXR showingright lower lobepneumonia

A lateral CXRshowing rightlower lobe

pneumonia

AP CXR showingpneumonia of thelingula of the leftlung

Right upper lobepneumonia as markedby the circle.

Prevention

There are several ways to prevent infectious pneumonia. Appropriately treatingunderlying illnesses (such as AIDS) can decrease a person's risk of pneumonia.Smoking cessation is important not only because it helps to limit lung damage,but also because cigarette smoke interferes with many of the body's naturaldefenses against pneumonia.

Research shows that there are several ways to prevent pneumonia in newborninfants. Testing pregnant women for Group B Streptococcus and Chlamydia

trachomatis, and then giving antibiotic treatment if needed, reduces pneumoniain infants. Suctioning the mouth and throat of infants with meconium-stainedamniotic fluid decreases the rate ofaspiration pneumonia.

Vaccination is important for preventing pneumonia in both children and adults.Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae inthe first year of life have greatly reduced the role these bacteria play in causingpneumonia in children. Vaccinating children against Streptococcus pneumoniaehas also led to a decreased incidence of these infections in adults because manyadults acquire infections from children. Hib vaccine is now widely used aroundthe globe. The childhood pneumococcal vaccine is still as of 2009 predominantly

used in high-income countries, though this is changing. In 2009, Rwanda became
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the first low-income country to introduce pneumococcal conjugate vaccine intotheir national immunization program.[18]

A vaccine against Streptococcus pneumoniae is also available for adults. In theU.S., it is currently recommended for all healthy individuals older than 65 and

any adults with emphysema, congestive heart failure, diabetes mellitus, cirrhosisof the liver, alcoholism, cerebrospinal fluid leaks, or those who do not have aspleen. A repeat vaccination may also be required after five or ten years.[19]

Influenza vaccines should be given yearly to the same individuals who receivevaccination against Streptococcus pneumoniae. In addition, health care workers,nursing home residents, and pregnant women should receive the vaccine.[20]When an influenza outbreak is occurring, medications such as amantadine,rimantadine, zanamivir, and oseltamivir can help prevent influenza.[21] [22]

Treatment

In the United States more than 80% of cases of community acquired pneumoniaare treated without hospitalization.[13] Typically, oral antibiotics, rest, fluids, andhome care are sufficient for complete resolution. However, people who arehaving trouble breathing, with other medical problems, and the elderly may needgreater care. If the symptoms get worse, the pneumonia does not improve withhome treatment, or complications occur, then hospitalization may berecommended. Over the counter cough medicine has not been found to behelpful in pneumonia.[23]

Bacterial

Antibiotics improve outcomes in those with bacterial pneumonia.[24] Initiallyantibiotic choice depends on the characteristics of the person affected such asage, underlying health, and location the infection was acquired.

In the UKempiric treatment is usually with amoxicillin, erythromycin, orazithromycin for community-acquired pneumonia.[25] In North America, wherethe "atypical" forms of community-acquired pneumonia are becoming morecommon, macrolides (such as azithromycin), and doxycycline have displacedamoxicillin as first-line outpatient treatment for community-acquired pneumonia.

[13] [26]The use offluoroquinolones in uncomplicated cases is discouraged dueto concerns of side effects and resistance.[13] The duration of treatment hastraditionally been seven to ten days, but there is increasing evidence that shortcourses (three to five days) are equivalent.[27] Antibiotics recommended forhospital-acquired pneumonia include third- and fourth-generationcephalosporins, carbapenems, fluoroquinolones, aminoglycosides, andvancomycin.[28] These antibiotics are often given intravenously and may beused in combination.

Viral

No specific treatments exist for most types ofviral pneumonia including SARScoronavirus, adenovirus, hantavirus, and parainfluenza virus with the exception
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ofinfluenza A and influenza B. Influenza A may be treated with rimantadine oramantadine while influenza A or B may be treated with oseltamivir or zanamivir.

These are beneficial only if they are started within 48 hours of the onset ofsymptoms. Many strains ofH5N1 influenza A, also known as avian influenza or"bird flu," have shown resistance to rimantadine and amantadine.

Aspiration

There is no evidence to support the use of antibiotics in chemical pneumonitiswithout bacterial superinfection. If infection is present in aspiration pneumonia,the choice of antibiotic will depend on several factors, including the suspectedcausative organism and whether pneumonia was acquired in the community ordeveloped in a hospital setting. Common options include clindamycin, acombination of a beta-lactam antibiotic and metronidazole, or anaminoglycoside.[29]Corticosteroids are commonly used in aspirationpneumonia, but there is no evidence to support their use either.[29]

Complications

Sometimes pneumonia can lead to additional complications. Complications aremore frequently associated with bacterial pneumonia than with viral pneumonia.

The most important complications include:

Respiratory and circulatory failure

Because pneumonia affects the lungs, often people with pneumonia havedifficulty breathing, and it may not be possible for them to breathe well enough

to stay alive without support. Non-invasive breathing assistance may be helpful,such as with a bi-level positive airway pressure machine. In other cases,placement of an endotracheal tube (breathing tube) may be necessary, and aventilator may be used to help the person breathe.

Pneumonia can also cause respiratory failure by triggering acute respiratorydistress syndrome (ARDS), which results from a combination of infection andinflammatory response. The lungs quickly fill with fluid and become very stiff.

This stiffness, combined with severe difficulties extracting oxygen due to thealveolar fluid, create a need for mechanical ventilation.
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Pleural effusion. Chest x-ray showing a pleural effusion. The A arrow indicates"fluid layering" in the right chest. The B arrow indicates the width of the rightlung. The volume of useful lung is reduced because of the collection of fluidaround the lung.

Sepsis and septic shock are potential complications of pneumonia. Sepsis occurswhen microorganisms enter the bloodstream and the immune system respondsby secreting cytokines. Sepsis most often occurs with bacterial pneumonia;Streptococcus pneumoniae is the most common cause. Individuals with sepsis orseptic shock need hospitalization in an intensive care unit. They often requireintravenous fluids and medications to help keep their blood pressure fromdropping too low. Sepsis can cause liver, kidney, and heart damage, amongother problems, and it often causes death.

Pleural effusion, empyema, and abscess

Occasionally, microorganisms infecting the lung will cause fluid (a pleuraleffusion) to build up in the space that surrounds the lung (the pleural cavity). Ifthe microorganisms themselves are present in the pleural cavity, the fluidcollection is called an empyema. When pleural fluid is present in a person withpneumonia, the fluid can often be collected with a needle (thoracentesis) andexamined. Depending on the results of this examination, complete drainage ofthe fluid may be necessary, often requiring a chest tube. In severe cases ofempyema, surgery may be needed. If the fluid is not drained, the infection maypersist, because antibiotics do not penetrate well into the pleural cavity.

Rarely, bacteria in the lung will form a pocket of infected fluid called an abscess.Lung abscesses can usually be seen with a chest x-ray or chest CT scan.Abscesses typically occur in aspiration pneumonia and often contain severaltypes of bacteria. Antibiotics are usually adequate to treat a lung abscess, butsometimes the abscess must be drained by a surgeon or radiologist.

Prognosis

With treatment, most types of bacterial pneumonia can be cleared within two tofour weeks.[30] Viral pneumonia may last longer, and mycoplasmal pneumoniamay take four to six weeks to resolve completely.[30] The eventual outcome of

an episode of pneumonia depends on how ill the person is when he or she is firstdiagnosed.[30]

In the United States, about one of every twenty people with pneumococcalpneumonia die. In cases where the pneumonia progresses to blood poisoning(bacteremia), just over 20% of sufferers die.[31]

The death rate (or mortality) also depends on the underlying cause of thepneumonia. Pneumonia caused by Mycoplasma, for instance, is associated withlittle mortality. However, about half of the people who develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia while on a ventilator will die.

[32] In regions of the world without advanced health care systems, pneumonia iseven deadlier. Limited access to clinics and hospitals, limited access to x-rays,
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limited antibiotic choices, and inability to treat underlying conditions inevitablyleads to higher rates of death from pneumonia. For these reasons, the majorityof deaths in children under five due to pneumococcal disease occur indeveloping coutries.[33]

Adenovirus can cause severe necrotizing pneumonia in which all or part of a lunghas increased translucency radiographically, which is called Swyer-JamesSyndrome.[34] Severe adenovirus pneumonia also may result in bronchiolitisobliterans, a subacute inflammatory process in which the small airways arereplaced by scar tissue, resulting in a reduction in lung volume and lungcompliance.[34]

Clinical prediction rules

Clinical prediction rules have been developed to more objectively prognosticateoutcomes in pneumonia. These rules can be helpful in deciding whether or not to

hospitalize the person.

Pneumonia severity index (or PORT Score)[35] online calculator

CURB-65 score, which takes into account the severity of symptoms, anyunderlying diseases, and age[36] online calculator

Epidemiology

Pneumonia is a common illness in all parts of the world. It is a major cause ofdeath among all age groups and is the leading cause of death in children in low

income countries.[24] In children, many of these deaths occur in the newbornperiod. The World Health Organization estimates that one in three newborninfant deaths are due to pneumonia.[37] Over two million children under five dieeach year worldwide and it is estimated that up to 1 million of these (vaccinepreventable) deaths are caused by the bacteria Streptococcus pneumoniae, andover 90% of these deaths take place in developing countries.[38] Mortality frompneumonia generally decreases with age until late adulthood with increasedmortality in the elderly.

In the United Kingdom, the annual incidence of pneumonia is approximately 6cases for every 1000 people for the 1839 age group. For those over 75 years ofage, this rises to 75 cases for every 1000 people. Roughly 2040% of individualswho contract pneumonia require hospital admission of which between 510% areadmitted to a critical care unit. The mortality rate in the UK is around 510%.[9]In the United States community acquired pneumonia affects 5.6 million people ayear making it the 6th leading cause of death.[13]

More cases of pneumonia occur during the winter months than during othertimes of the year. Pneumonia occurs more commonly in males than females, andmore often in Blacks than Caucasians due to differences in synthesizing VitaminD from sunlight. Individuals with underlying illnesses such as Alzheimer's

disease, cystic fibrosis, emphysema, tobacco smoking, alcoholism, or immunesystem problems are at increased risk for pneumonia.[39] These individuals are
http://en.wikipedia.org/wiki/Adenovirushttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Bronchiolitis_obliteranshttp://en.wikipedia.org/wiki/Bronchiolitis_obliteranshttp://en.wikipedia.org/wiki/Bronchioleshttp://en.wikipedia.org/wiki/Fibrosishttp://en.wikipedia.org/wiki/Lung_volumehttp://en.wikipedia.org/wiki/Lung_compliancehttp://en.wikipedia.org/wiki/Lung_compliancehttp://en.wikipedia.org/wiki/Pneumonia_severity_indexhttp://pda.ahrq.gov/clinic/psi/psicalc.asphttp://en.wikipedia.org/wiki/CURB-65http://www.mecriticalcare.net/clinical_criteria/pneumonia_severity_score.phphttp://en.wikipedia.org/wiki/Low_income_countrieshttp://en.wikipedia.org/wiki/Low_income_countrieshttp://en.wikipedia.org/wiki/World_Health_Organizationhttp://en.wikipedia.org/wiki/United_Kingdomhttp://en.wikipedia.org/wiki/Critical_care_unithttp://en.wikipedia.org/wiki/Vitamin_Dhttp://en.wikipedia.org/wiki/Vitamin_Dhttp://en.wikipedia.org/wiki/Alzheimer's_diseasehttp://en.wikipedia.org/wiki/Alzheimer's_diseasehttp://en.wikipedia.org/wiki/Cystic_fibrosishttp://en.wikipedia.org/wiki/Emphysemahttp://en.wikipedia.org/wiki/Tobacco_smokinghttp://en.wikipedia.org/wiki/Alcoholismhttp://en.wikipedia.org/wiki/Immunosuppressionhttp://en.wikipedia.org/wiki/Immunosuppressionhttp://en.wikipedia.org/wiki/Adenovirushttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Bronchiolitis_obliteranshttp://en.wikipedia.org/wiki/Bronchiolitis_obliteranshttp://en.wikipedia.org/wiki/Bronchioleshttp://en.wikipedia.org/wiki/Fibrosishttp://en.wikipedia.org/wiki/Lung_volumehttp://en.wikipedia.org/wiki/Lung_compliancehttp://en.wikipedia.org/wiki/Lung_compliancehttp://en.wikipedia.org/wiki/Pneumonia_severity_indexhttp://pda.ahrq.gov/clinic/psi/psicalc.asphttp://en.wikipedia.org/wiki/CURB-65http://www.mecriticalcare.net/clinical_criteria/pneumonia_severity_score.phphttp://en.wikipedia.org/wiki/Low_income_countrieshttp://en.wikipedia.org/wiki/Low_income_countrieshttp://en.wikipedia.org/wiki/World_Health_Organizationhttp://en.wikipedia.org/wiki/United_Kingdomhttp://en.wikipedia.org/wiki/Critical_care_unithttp://en.wikipedia.org/wiki/Vitamin_Dhttp://en.wikipedia.org/wiki/Vitamin_Dhttp://en.wikipedia.org/wiki/Alzheimer's_diseasehttp://en.wikipedia.org/wiki/Alzheimer's_diseasehttp://en.wikipedia.org/wiki/Cystic_fibrosishttp://en.wikipedia.org/wiki/Emphysemahttp://en.wikipedia.org/wiki/Tobacco_smokinghttp://en.wikipedia.org/wiki/Alcoholismhttp://en.wikipedia.org/wiki/Immunosuppressionhttp://en.wikipedia.org/wiki/Immunosuppression


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also more likely to have repeated episodes of pneumonia. People who arehospitalized for any reason are also at high risk for pneumonia.

History

Hippocrates, the ancient Greek physician known as the "father of medicine"

WPA poster, 1936/1937

The symptoms of pneumonia were described by Hippocrates (c. 460 BC 370BC):
http://en.wikipedia.org/wiki/Hippocrateshttp://en.wikipedia.org/wiki/Works_Progress_Administrationhttp://en.wikipedia.org/wiki/1936http://en.wikipedia.org/wiki/1937http://en.wikipedia.org/wiki/Hippocrateshttp://en.wikipedia.org/wiki/File:WPA_Pneumonia_Poster.jpghttp://en.wikipedia.org/wiki/File:WPA_Pneumonia_Poster.jpghttp://en.wikipedia.org/wiki/File:Hippocrates.jpghttp://en.wikipedia.org/wiki/File:Hippocrates.jpghttp://en.wikipedia.org/wiki/Hippocrateshttp://en.wikipedia.org/wiki/Works_Progress_Administrationhttp://en.wikipedia.org/wiki/1936http://en.wikipedia.org/wiki/1937http://en.wikipedia.org/wiki/Hippocrates


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Peripneumonia, and pleuritic affections, are to be thus observed: If the fever beacute, and if there be pains on either side, or in both, and if expiration be ifcough be present, and the sputa expectorated be of a blond or livid color, orlikewise thin, frothy, and florid, or having any other character different from thecommon... When pneumonia is at its height, the case is beyond remedy if he is

not purged, and it is bad if he has dyspnoea, and urine that is thin and acrid, andif sweats come out about the neck and head, for such sweats are bad, asproceeding from the suffocation, rales, and the violence of the disease which isobtaining the upper hand.[40]

However, Hippocrates referred to pneumonia as a disease "named by theancients." He also reported the results of surgical drainage of empyemas.Maimonides (11381204 AD) observed "The basic symptoms which occur inpneumonia and which are never lacking are as follows: acute fever, sticking[pleuritic] pain in the side, short rapid breaths, serrated pulse and cough."[41]

This clinical description is quite similar to those found in modern textbooks, andit reflected the extent of medical knowledge through the Middle Ages into the19th century.

Bacteria were first seen in the airways of individuals who died from pneumoniaby Edwin Klebs in 1875.[42] Initial work identifying the two common bacterialcauses Streptococcus pneumoniae and Klebsiella pneumoniae was performed byCarl Friedlnder[43] and Albert Frnkel[44] in 1882 and 1884, respectively.Friedlnder's initial work introduced the Gram stain, a fundamental laboratorytest still used to identify and categorize bacteria. Christian Gram's paperdescribing the procedure in 1884 helped differentiate the two different bacteriaand showed that pneumonia could be caused by more than one microorganism.[45]

Sir William Osler, known as "the father of modern medicine," appreciated themorbidity and mortality of pneumonia, describing it as the "captain of the men ofdeath" in 1918, as it had overtaken tuberculosis as one of the leading causes ofdeath in his time. (The phrase was originally coined by John Bunyan with regardto consumption, or tuberculosis.[46]) However, several key developments in the1900s improved the outcome for those with pneumonia. With the advent ofpenicillin and other antibiotics, modern surgical techniques, and intensive care in

the twentieth century, mortality from pneumonia, which had approached 30%,dropped precipitously in the developed world. Vaccination of infants againstHaemophilus influenzae type b began in 1988 and led to a dramatic decline incases shortly thereafter.[47] Vaccination against Streptococcus pneumoniae inadults began in 1977 and in children began in 2000, resulting in a similardecline.[48]

Society and culture

Because of the very high burden of disease in developing countries and becauseof a relatively low awareness of the disease in industrialized countries, the global

health community has declared November 2 to be World Pneumonia Day, a dayfor concerned citizens and policy makers to take action against the disease.[1]
http://en.wikipedia.org/wiki/Maimonideshttp://en.wikipedia.org/wiki/Pulsehttp://en.wikipedia.org/wiki/Middle_Ageshttp://en.wikipedia.org/wiki/Edwin_Klebshttp://en.wikipedia.org/wiki/Carl_Friedl%C3%A4nderhttp://en.wikipedia.org/w/index.php?title=Albert_Fr%C3%A4nkel_(1848%E2%80%931916)&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Albert_Fr%C3%A4nkel_(1848%E2%80%931916)&action=edit&redlink=1http://en.wikipedia.org/wiki/Gram_staininghttp://en.wikipedia.org/wiki/Christian_Gramhttp://en.wikipedia.org/wiki/William_Oslerhttp://en.wikipedia.org/wiki/Penicillinhttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/World_Pneumonia_Dayhttp://en.wikipedia.org/wiki/Maimonideshttp://en.wikipedia.org/wiki/Pulsehttp://en.wikipedia.org/wiki/Middle_Ageshttp://en.wikipedia.org/wiki/Edwin_Klebshttp://en.wikipedia.org/wiki/Carl_Friedl%C3%A4nderhttp://en.wikipedia.org/w/index.php?title=Albert_Fr%C3%A4nkel_(1848%E2%80%931916)&action=edit&redlink=1http://en.wikipedia.org/wiki/Gram_staininghttp://en.wikipedia.org/wiki/Christian_Gramhttp://en.wikipedia.org/wiki/William_Oslerhttp://en.wikipedia.org/wiki/Penicillinhttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/World_Pneumonia_Day


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See also

List of pneumonia victimsReferences

^pneumonia at eMedicine Dictionary

^pneumonia at Dorland's Medical Dictionary

^"Causes of death in neonates and children under five in the world (2004)".World Health Organization.. 2008.http://www.who.int/entity/child_adolescent_health/media/causes_death_u5_neonates_2004.pdf.

^ abcd Table 13-7 in: Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, AbulK.; Fausto, Nelson (2007). Robbins Basic Pa

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