Bacterial Pneumonia

Practice Essentials

Bacterial pneumonia is caused by a pathogenic infection of the lungs and may present as a primary disease processor as the final, fatal disorder in an individual who is already debilitated.

Essential update: Telavancin approved for bacterial pneumonia

The US Food and Drug Administration (FDA) recently approved the antibiotic telavancin (Vibativ) for the treatment ofpatients with hospital-acquired or ventilator-associated pneumonia (HAP or VAP) caused by the bacteriumStaphylococcus aureus. Telavancin, which was approved in 2009 to treat complicated skin and skin structure

infections, is meant for use in HAP/VAP only when there is no suitable alternative treatment.[71] :

Approval was based on 2 clinical trials involving a total of 1532 patients who were randomly assigned to treatment withtelavancin or vancomycin. Among patients positive for S aureus at baseline, all-cause mortality rates between the 2treatments were comparable at 28 days. An exception, however, was found among patients with preexisting kidneyproblems, with mortality being higher among those who were treated with telavancin.

Signs and symptoms

Cough, particularly cough productive of sputum, is the most consistent presenting symptom of bacterial pneumoniaand may suggest a particular pathogen, as follows:

Streptococcus pneumoniae: Rust-colored sputumPseudomonas, Haemophilus, and pneumococcal species: May produce green sputumKlebsiella species pneumonia: Red currant-jelly sputumAnaerobic infections: Often produce foul-smelling or bad-tasting sputum

Signs of bacterial pneumonia may include the following:

Hyperthermia (fever, typically >38°C)[29] or hypothermia (< 35°C)Tachypnea (>18 respirations/min)Use of accessory respiratory musclesTachycardia (>100 bpm) or bradycardia (< 60 bpm)Central cyanosisAltered mental status

Physical findings may include the following:

Adventitious breath sounds, such as rales/crackles, rhonchi, or wheezesDecreased intensity of breath soundsEgophonyWhispering pectoriloquyDullness to percussionTracheal deviationLymphadenopathyPleural friction rub

Examination findings that may indicate a specific etiology include the following:

Bradycardia: May indicate a Legionella etiologyPeriodontal disease: May suggest an anaerobic and/or polymicrobial infection

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Bacterial Pneumonia

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Bullous myringitis: May indicate Mycoplasma pneumoniae infectionCutaneous nodules: May suggest Nocardia infectionDecreased gag reflex: Suggests risk for aspiration

See Clinical Presentation for more detail.

Diagnosis

Severity assessment

Tools to assess the severity of disease and risk of death include the PSI/PORT (ie, pneumonia severity index/PatientOutcomes Research Team score), the CURB-65 (ie, confusion, urea, respiratory rate, blood pressure, and age >65years) system, and the APACHE (ie, acute physiology and chronic health evaluation), among others.

The following laboratory tests are also useful for assessing illness severity:

Serum chemistry panelArterial blood gas (ABG) determinationVenous blood gas determination (central venous oxygen saturation)Complete blood count (CBC) with differentialSerum free cortisol valueSerum lactate level

Sputum evaluation

Sputum Gram stain and culture should be performed before initiating antibiotic therapy. A single predominant microbeshould be noted at Gram staining, although mixed flora may be observed with anaerobic infections.

Imaging studies

Chest radiography: The criterion standard for pneumonia diagnosisChest computed tomography scanningChest ultrasonography

Bronchoscopy

Lung tissue can be visually evaluated and bronchial washing specimens can be obtained with the aid of a fiberopticbronchoscope. Protected brushings and bronchoalveolar lavage (BAL) can be performed for fluid analysis andcultures.

Thoracentesis

This is an essential procedure in patients with a parapneumonic pleural effusion. Analysis of the fluid allowsdifferentiation between simple and complicated effusions.

Pathogen-specific tests

Urine assaysSputum, serum, and/or urinary antigen testsImmune serologic tests

Histologic examination

Histologic inflammatory lung changes vary according to whether the patient has lobar pneumonia, bronchopneumonia,or interstitial pneumonia.[56]

See Workup for more detail.

Management

The mainstay of drug therapy for bacterial pneumonia is antibiotic treatment. First-line antimicrobials for Spneumoniae, the most prevalent cause of bacterial pneumonia, are, for the penicillin-susceptible form of thebacterium, penicillin G and amoxicillin. For the penicillin-resistant form of S pneumoniae, first-line agents are chosenon the basis of sensitivity.

Bacterial Pneumonia




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Supportive measures include the following:

Analgesia and antipyreticsChest physiotherapyIntravenous fluids (and, conversely, diuretics), if indicatedPulse oximetry with or without cardiac monitoring, as indicatedOxygen supplementationPositioning of the patient to minimize aspiration riskRespiratory therapy, including treatment with bronchodilators and N-acetylcysteineSuctioning and bronchial hygieneVentilation with low tidal volumes (6 mL/kg of ideal body weight) in patients requiring mechanical ventilation

secondary to bilateral pneumonia or acute respiratory distress syndrome (ARDS)[16]

Systemic support: May include proper hydration, nutrition, and mobilization

See Treatment and Medication for more detail.

Image library

Bacterial pneumonia. Radiographic images in a patient with right upper lobe pneumonia. Note the increased anteroposterior chestdiameter, which is suggestive of chronic obstructive pulmonary disease (COPD).

Bacterial Pneumonia



Contributor Information and DisclosuresAuthorNader Kamangar, MD, FACP, FCCP, FCCM, FAASM Associate Professor of Clinical Medicine, University ofCalifornia, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine,Olive View-UCLA Medical Center; Associate Program Director, Multi-Campus Pulmonary and Critical CareFellowship Program, Cedars-Sinai/West Los Angeles Veterans Affairs/Los Angeles Kaiser Permanente/OliveView-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM, FAASM is a member of the following medical societies: AmericanAcademy of Sleep Medicine, American Association of Bronchology, American College of Chest Physicians,American College of Physicians, American Lung Association, American Medical Association, American ThoracicSociety, Association of Pulmonary and Critical Care Medicine Program Directors, Association of SpecialtyProfessors, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, and World Association forBronchology and Interventional Pulmonology

Disclosure: Nothing to disclose.

Coauthor(s)Annie Harrington, MD Fellow in Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center

Annie Harrington, MD is a member of the following medical societies: Alpha Omega Alpha and American College ofChest Physicians


Chief EditorZab Mosenifar, MD Director, Division of Pulmonary and Critical Care Medicine, Director, Women's GuildPulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai MedicalCenter, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians,American College of Physicians, American Federation for Medical Research, and American Thoracic Society


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Additional ContributorsPaul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, MaricopaMedical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College ofEmergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association,and Arizona Medical Association


Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, ProgramDirector for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve UniversitySchool of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, AmericanAcademy of Emergency Medicine, American College of Chest Physicians, American College of EmergencyPhysicians, American College of Physicians, American Heart Association, American Thoracic Society, ArkansasMedical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for AcademicEmergency Medicine


Ryland P Byrd Jr, MD Professor, Department of Internal Medicine, Division of Pulmonary Medicine and CriticalCare Medicine, Program Director of Pulmonary Diseases and Critical Care Medicine Fellowship, East TennesseeState University, James H Quillen College of Medicine; Medical Director of Respiratory Therapy, James H QuillenVeterans Affairs Medical Center

Ryland P Byrd Jr, MD is a member of the following medical societies: American College of Chest Physicians andAmerican Thoracic Society


Christina Rager, MD Resident Physician, Internal and Emergency Medicine, Olive View-University of California atLos Angeles Medical Center

Christina Rager, MD is a member of the following medical societies: American College of Physicians, AmericanMedical Student Association/Foundation, and Phi Beta Kappa


Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine,University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine,American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine,American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada,Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association


Dana A Stearns, MD Assistant Director of Undergraduate Education, Department of Emergency Medicine,Massachusetts General Hospital; Assistant Professor of Surgery, Harvard Medical School

Dana A Stearns, MD is a member of the following medical societies: American College of Emergency Physicians


James M Stephen, MD, FAAEM, FACEP Assistant Professor, Tufts University School of Medicine; AttendingPhysician, Director of Medical Informatics and Graduate Education, Department of Emergency Medicine, TuftsMedical Center

James M Stephen, MD, FAAEM, FACEP is a member of the following medical societies: American Academy ofEmergency Medicine and American College of Emergency Physicians



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Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center Collegeof Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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