What is pneumonia?
Pneumonia is an infection of one or both lungs which is usually
caused by bacteria, viruses, or fungi. Prior to the discovery of antibiotics,
one-third of all people who developed pneumonia subsequently died from the
infection. Currently, over 3 million people develop pneumonia each year in the
United States. Over a half a million of these people are admitted to a hospital
for treatment. Although most of these people recover, approximately 5% will die
from pneumonia. Pneumonia is the sixth leading cause of death in the United
States.
What are pneumonia
symptoms and signs?
Most people who
develop pneumonia initially have symptoms of a cold (upper
respiratory infection, for example, sneezing,sore
throat, cough), which are then followed by a high fever ,shaking chills,
and a cough with sputum production. The sputum is usually discolored and
sometimes bloody. Depending on the location of the infection, certain symptoms
are more likely to develop. When the infection settles in the air passages,
cough and sputum tend to predominate the symptoms. In some, the spongy tissue
of the lungs that contain the air sacs is more involved. In this case,
oxygenation of the blood can be impaired, along with stiffening of the lung,
which results in shortness
of breath. At times, the individual's skin color may change and become
dusky or purplish (a condition known as "cyanosis")
due to their blood being poorly oxygenated.
The only pain fibers
in the lung are on the surface of the lung, in the area known as the pleura.
Chest pain may develop if the outer aspects of the lung close to the pleura are
involved in the infection. This pain is usually sharp and worsens when taking a
deep breath and is known as pleuritic pain or pleurisy.
In other cases of pneumonia, depending on the causative organism, there can be
a slow onset of symptoms. A worsening cough, headaches, and muscle aches may be
the only symptoms.
Children and babies
who develop pneumonia often do not have any specific signs of a chest infection
but develop a fever, appear quite ill, and can become lethargic. Elderly people
may also have few symptoms with pneumonia.
How is pneumonia diagnosed?
Your doctor will ask you about
your symptoms and do a physical exam. He or she may order a chest X-ray and a blood test.
This is usually enough for your doctor to know if you have pneumonia. You may
need more tests if you have bad symptoms, are an older adult, or have other
health problems. In general, the sicker you are, the more tests you will have.
Pneumonia may be suspected when the doctor examines the patient
and hears coarse breathing or crackling sounds when listening to a portion of
the chest with a stethoscope. There may be wheezing or the sounds of breathing may be faint in
a particular area of the chest. A chest X-ray is usually ordered to confirm the
diagnosis of pneumonia. The lungs have several segments referred to as lobes,
usually two on the left and three on the right. When the pneumonia affects one
of these lobes, it is often referred to as lobar pneumonia. Some pneumonias
have a more patchy distribution that does not involve specific lobes. In the past,
when both lungs were involved in the infection, the term "double
pneumonia" was used. This term is rarely used today.
Sputum samples can be collected and examined under the
microscope. Pneumonia caused by bacteria or fungi can be detected by this examination.
A sample of the sputum can be grown in special incubators, and the offending
organism can be subsequently identified. It is important to understand that the
sputum specimen must contain little saliva from the mouth and be delivered to
the laboratory fairly quickly. Otherwise, overgrowth of noninfecting bacteria
from the mouth may predominate. As we have used antibiotics in a broader
uncontrolled fashion, more organisms are becoming resistant to the commonly
used antibiotics. These types of cultures can help in directing more
appropriate therapy.
A blood test that measures white blood cell count (WBC)
may be performed. An individual's white blood cell count can often give a hint
as to the severity of the pneumonia and whether it is caused by bacteria or a
virus. An increased number of neutrophils, one type of WBC, is seen in most
bacterial infections, whereas an increase in lymphocytes, another type of WBC,
is seen in viral infections, fungal infections, and some bacterial infections
(like tuberculosis).
Bronchoscopy is a procedure in which a thin, flexible,
lighted viewing tube is inserted into the nose or mouth after a local
anesthetic is administered. Using this device, the doctor can directly examine
the breathing passages (trachea and bronchi). Simultaneously, samples of sputum
or tissue from the infected part of the lung can be obtained.
Sometimes, fluid collects in
the pleural space around the lung as a result of the inflammation from
pneumonia. This fluid is called a pleural effusion. If a significant amount of fluid
develops, it can be removed. After numbing the skin with local anesthetic a
needle is inserted into the chest cavity and fluid can be withdrawn and
examined under the microscope. This procedure is called a thoracentesis. Often ultrasound is used to prevent complications from this
procedure. In some cases, this fluid can become severely inflamed
(parapneumonic effusion) or infected (empyema) and may need to be removed by
more aggressive surgical procedures. Today, most often, this involves surgery
through a tube or thoracoscope. This is referred to as video-assisted
thoracoscopic surgery or VATS.
What are some of the organisms
that cause pneumonia? What is the treatment for pneumonia? Can pneumonia be
prevented?
The most common cause of a bacterial pneumonia is Streptococcus pneumoniae.
In this form of pneumonia, there is usually an abrupt onset of the illness with
shakingchills, fever, and
production of a rust-colored sputum. The infection spreads into the blood in
20%-30% of cases (known assepsis), and if
this occurs, 20%-30% of these patients die.
Two vaccines are available to prevent pneumococcal
disease: the pneumococcal conjugate vaccine (PCV13) and the pneumococcal
polysaccharide vaccine (PPV23; Pneumovax). The pneumococcal conjugate vaccine
is part of the routine infant immunization schedule in the U.S. and is
recommended for all children < 2 years of age and children 2-4 years of age
who have certain medical conditions. The pneumococcal polysaccharide vaccine is
recommended for adults at increased risk for developing pneumococcal pneumonia
including the elderly, people who havediabetes, chronic heart, lung, or
kidney disease, those with alcoholism, cigarette smokers,
and in those people who have had their spleen removed. This vaccination should
be repeated every five to seven years, whereas the flu vaccine is given annually.
Antibiotics often used in the
treatment of this type of pneumonia includepenicillin, amoxicillin and clavulanic
acid (Augmentin,
Augmentin XR), and macrolide antibiotics including erythromycin (E-Mycin, Eryc, Ery-Tab, PCE,
Pediazole, Ilosone), azithromycin (Zithromax, Z-Max), and clarithromycin(Biaxin).
Penicillin was formerly the antibiotic of choice in treating this infection.
With the advent and widespread use of broader-spectrum antibiotics, significant
drug resistance has developed. Penicillin may still be effective in treatment
of pneumococcal pneumonia, but it should only be used after cultures of the
bacteria confirm their sensitivity to this antibiotic.
Klebsiella
pneumoniae and Hemophilus influenzae are bacteria that often cause
pneumonia in people suffering from chronic obstructive pulmonary
disease (COPD) or
alcoholism. Useful antibiotics in this case are the second- and
third-generation cephalosporins, amoxicillin and clavulanic
acid, fluoroquinolones (levofloxacin [Levaquin], moxifloxacin-oral [Avelox], and sulfamethoxazole/trimethoprim [Bactrim, Septra]).
Mycoplasma
pneumoniae is a
type of bacteria that often causes a slowly developing infection. Symptoms
include fever, chills, muscle aches,diarrhea, and rash. This
bacterium is the principal cause of many pneumonias in the summer and fall
months, and the condition often referred to as "atypical pneumonia."
Macrolides (erythromycin, clarithromycin, azithromycin, and fluoroquinolones)
are antibiotics commonly prescribed to treat Mycoplasma pneumonia.
Legionnaire's disease is caused by the bacterium Legionella pneumoniaethat is
most often found in contaminated water supplies and air conditioners. It is a
potentially fatal infection if not accurately diagnosed. Pneumonia is part of
the overall infection, and symptoms include high fever, a relatively slow heart
rate, diarrhea, nausea, vomiting,
and chest pain. Older men, smokers, and people whose immune systems are
suppressed are at higher risk of developing Legionnaire's disease. Fluoroquinolones
(see above) are the treatment of choice in this infection. This infection is
often diagnosed by a special urine test looking for specific antibodies to the
specific organism.
Mycoplasma, Legionnaire's, and another infection, Chlamydia pneumoniae, all cause
a syndrome known as "atypical pneumonia." In this syndrome, the chest
X-ray shows diffuse abnormalities, yet the patient does not appear severely
ill. In the past, this condition was referred to as "walkingpneumonia,"
a term that is rarely used today. These infections are very difficult to
distinguish clinically and often require laboratory evidence for confirmation.
Recently, a study performed in
the Netherlands demonstrated that adding a steroid medication, dexamethasone (Decadron), to antibiotic therapy
shortens the duration of hospitalization. This medication should be used with
caution in patients whom are critically ill or already have a compromised
immune system.
Pneumocystis carinii (now known as Pneumocystis jiroveci) pneumonia is another form of
pneumonia that usually involves both lungs. It is seen in patients with a
compromised immune system, either from chemotherapy forcancer, HIV/AIDS, and those
treated with TNF (tumor necrosis factor),
such as for rheumatoid arthritis.
Once diagnosed, it usually responds well to sulfa-containing antibiotics.
Steroids are often additionally used in more severe cases.
Viral pneumonias do not
typically respond to antibiotic treatment. These infections can be caused by
adenoviruses, rhinovirus, influenza virus (flu),respiratory syncytial virus (RSV), and parainfluenza virus (that also causescroup). These
pneumonias usually resolve over time with the body's immune system fighting off
the infection. It is important to make sure that a bacterial pneumonia does not
secondarily develop. If it does, then the bacterial pneumonia is treated with
appropriate antibiotics. In some situations, antiviral therapy is helpful in
treating these conditions. More recently, H1N1, swine-origin influenza A, has
been associated with very severe pneumonia often resulting in respiratory
failure. This disease often requires the use of mechanical ventilation for
breathing support. Death is not uncommon when this infection involves the
lungs.
Fungal infections that can lead
to pneumonia include histoplasmosis,
coccidiomycosis, blastomycosis, aspergillosis, and cryptococcosis.
These are responsible for a relatively small percentage of pneumonias in the
United States. Each fungus has specific antibiotic treatments, among which are
amphotericin B, fluconazole (Diflucan), penicillin, and
sulfonamides.
Major concerns have developed
in the medical community regarding the overuse of antibiotics. Most sore
throats and upper respiratory infections are caused by viruses rather than
bacteria. Though antibiotics are ineffective against viruses, they are often prescribed.
This excessive use has resulted in a variety of bacteria that have become
resistant to many antibiotics. These resistant organisms are commonly seen in
hospitals and nursing homes. In fact, physicians must consider the location
when prescribing antibiotics (community-acquired pneumonia, or CAP, versus
hospital-acquired pneumonia, or HAP).
The more virulent organisms
often come from the health-care environment, either the hospital or nursing
homes. These organisms have been exposed to a variety of the strongest
antibiotics that we have available. They tend to develop resistance to some of
these antibiotics. These organisms are referred to as nosocomial bacteria and
can cause what is known as nosocomial pneumonia when the lungs become infected.
Recently, one of these resistant organisms from the hospital has
become quite common in the community. In some communities, up to 50% of Staph aureus infections are due to organisms
resistant to the antibiotic methicillin. This organism is referred to as MRSA (methicillin-resistant Staph aureus) and requires special antibiotics when it
causes infection. It can cause pneumonia but also frequently causes skin
infections. In many hospitals, patients with this infection are placed in
contact isolation. Their visitors are often asked to wear gloves, masks, and
gowns. This is done to help prevent the spread of this bacteria to other
surfaces where they can inadvertently contaminate whatever touches that
surface. It is therefore very important to wash your hands thoroughly and
frequently to limit further spread of this resistant organism. The situation
with MRSA continues to evolve. The community-acquired strain of MRSA tends to
be responsive to some of the more commonly used antibiotics whereas the
hospital-acquired strains require stronger, more aggressive antibiotic
therapies. As this evolution occurs, patients are arriving in the hospital with
the community-acquired strains as well as a previous hospital-acquired strain.
This further necessitates performing bacterial cultures to determine the best
course of action.
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