Source: Blackford MG, Glover ML,
Reed MD. Lower Respiratory Tract Infections. In: DiPiro, JT, Talbert RL,
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Accessed July 12, 2012.
- Lung inflammation caused by bacterial or viral infection
- Majority of cases in otherwise healthy adults caused byS. pneumoniae (pneumococcus)
- Aypical pathogens include:
- M. pneumoniae
- C. pneumoniae
- Staphylococcus aureus and Gram-negative
rods causative agents in elderly nursing home patients and in association
with alcoholism and other debilitating conditions.
- Microorganisms gain access to lower respiratory tract
by 3 routes:
- Inhaled as aerosolized particles
- Via bloodstream from extrapulmonary site of infection
- Aspiration of oropharyngeal contents
- Viral lung infections suppress bacterial clearing activity
of lung by impairing alveolar macrophage function and mucociliary
clearance, setting stage for secondary bacterial pneumonia.
- Most common infectious cause of death in United States.
- Occurs in persons of all ages, although clinical manifestations
most severe in very young, elderly, and chronically ill.
- Polyvalent polysaccharide vaccines available for S. pneumoniae and H.
- Influenza vaccine
prevent primary influenza pneumonia and secondary bacterial pneumonia
- Annual administration
to those ≥65 years, residents of long-term care
facilities, or underlying cardiopulmonary disease
- Age ≥65 years
- Underlying cardiopulmonary disease
- Clinical appearance similar regardless of etiology
- Abrupt onset of:
- Productive cough
- Rust-colored sputum or hemoptysis
- Pleuritic chest pain
- Dullness to percussion
- Increased tactile fremitus, whispered pectoriloquy, and egophony
- Chest wall retractions and grunting respirations
- Diminished breath sounds
- Inspiratory crackles during lung expansion
Means of Confirmation
- Chest radiograph
- Sputum examination and culture
- Sputum Gram stain and culture
- Complete blood count (CBC)
- Leukocytosis with
predominance of polymorphonuclear cells
- Arterial blood gas
- Chest radiograph: dense lobar or segmental infiltrate
- Sputum induction and bronchoscopy for patients who cannot
provide expectorated samples
- Eradicate offending organism.
- Achieve complete clinical cure.
- Minimize associated morbidity (e.g., renal, pulmonary, or
- Evaluate adequacy of respiratory function.
- Determine signs of systemic illness, specifically dehydration,
or sepsis with resulting circulatory collapse.
- Mechanical ventilation
- Fluid resuscitation
- Nutritional support
- Fever control
- Chest physiotherapy with postural drainage if secretions retained
- Administer bronchodilators (albuterol) if bronchospasm
concentrations in respiratory secretions in excess of pathogen minimum
inhibitory concentration (MIC) are necessary.
- Initial empiric treatment with broad-spectrum antibiotic(s)
- Narrow therapy based on culture results
- Adult recommendations in Table 1
- Pediatric recommendations in Table 2
- Doses to treat pneumonia in Table 3
Table 1. Evidence-Based
Empiric Antimicrobial Therapy for Pneumonia in Adultsa