Pneumonia is an inflammation in alveolar tissue, most often caused by a microbial agent. Inhalation is the commonest route of infection. The most frequent inhalational pneumonia is the community acquired pneumonia (CAP), which is most commonly caused by Streptococcus pneumoniae(typical). Nosocomial pneumonia is likely to be caused by gram-negative bacilli or Staph aureus. Aspiration pneumonia, is polymicrobial including anaerobes. Age is an important predictor of infecting agent

Features:

·       Sudden onset of fever, productive cough, chest pain, shortness of breath and in some cases pleuritic chest pain; systemic symptoms like headache, body ache and delirium are more severe with atypical pneumonia

·       New focal signs on physical examination of the chest

·       In contrast, the elderly patients differ in their presentation.

·       The atypical pneumonia syndrome is characterized by a more gradual onset, a dry cough, SOB and prominence of extrapulmonary symptoms (myalgia, headache, fatigue, sore throat, nausea, vomiting and diarrhoea) and abnormalities on chest Xray despite minimal signs of pulmonary involvement (other than rales)

·       The “primary atypical pneumonia” caused by M pneumoniae results in a violent, episodic cough with small mucoid sputum preceded by fever with or without chills and maybe accompanied by profound weakness

·       Confirmation of the etiological diagnosis is by blood culture/sputum culture and/or molecular diagnostic methods

Treatment:

CURB65 score for the initial severity assessment and treatment of pneumonia. Antibiotics are the mainstay of treatment. The choice maybe modified based on response and sputum culture

CURB65 severity score (1 point for each feature)

·       C=confusion

·       U=Urea>7mmol/l

·       R=Respirator rate=30/min

·       B=BP<90or DBP=60mmHg

·       Age=65 years

Plan A: Outpatient treatment-previously healthy without risk factors Cap Azithromycin 500 mg once daily OR Cap Doxycycline 200 mg OD for 10 days

Plan B: Presence of comorbidities like chronic heart/lung/liver/renal disease/diabetes/alcoholic liver/malignancies/use of immunosuppressant drugs etc.,

1.      Inj. Amoxycillin 1G 8 hourly IM/IV OR Cap Amoxycillin+Clavulunate 2G BD OR Inj. Ceftriaxone 2G IV OD OR Tab Cefpodoxime 200 mg BD

2.      Cap Azithromycin 500mg OD for 5 days OR Cap Clarithromycin 500 mg BD for 10 days OR Cap Doxycycline 200mg loading dose followed by 100 mg OD for 10 days

Plan C: Inpatient, non-ICU treatment

1.     Inj. Cefotaxime 1-2G IV 8-12 hourly OR Inj. Ceftriaxone 2G IV OD OR Inj. Ampicillin 1g IV 8 hourly. Patients allergic to penicillin, Levofloxacin 750mg OD may be given

2.     Inj. Azithromycin 500mg IV OD OR Clarithromycin 500 mg IV BD

3.     For selected patients, Inj. Ertapenem 1g daily IV plus Inj. Azithromycin 500 mg IV OD or Clarithromycin 500mg BD or Doxycycline 200mg loading dose followed by 100 mg OD for 10 days. Monitor with C- reactive protein concentration in patients with community-acquired pneumonia on admission to hospital and repeat after 48-72 hours, if clinical progress is uncertain

Plan D: Inpatient, ICU treatment

1.      A Beta lactam (cefo/ceftria) plus Azithromycin OR Inj. Levofloxacin 750 mg by slow IV infusion over 90 minutes every 24 hours

2.      If pseudomonas is suspected:

Inj. Piperacillin + Tazobactam 4.5g IV/IM 6 hrly or Inj. Cefepime 1-2g IV 8 hrly or Inj. Imipenem 500 mg IV 8 hrly or Meropenem 500 mg-1g IV 8 hourly

Supportive treatment:

1.     Concomitant use of bronchodilators (salbutamol, terbutaline) is beneficial for bronchospasm

2.     Analgesic for fever and body ache

3.     Noninvasive/ invasive ventilator