Pneumonia: prevention, diagnosis and treatment

Roughly, pneumonia is divided into community-acquired pneumonia and concerns patients living in the community, hospital-acquired pneumonia and concerns pneumonia that occurs 48 hours after entering the hospital.

Epidemiology
Pneumonia is the 6th leading cause of death worldwide. In 2019, 2,500,000 deaths due to pneumonia were recorded. Mortality in the elderly is 10 times that of adults.

Risk factors:
Patients with coexisting diseases, such as COPD, Bronchiectasis, Heart failure, Diabetes Mellitus, immunosuppression and neurological diseases show a greater risk of developing pneumonia.

Viral infections can lead to primary pneumonia and secondary bacterial pneumonia. Other factors that increase the risk of developing pneumonia are smoking, alcohol, crowded living conditions and age (2% of the elderly are hospitalized with community-acquired pneumonia each year).

Rationale
Depending on the microorganism responsible, pneumonia is divided into:
• typical pneumonias the most common cause is pneumococcus, other causes are Haemophilus influenzae, Staphylococcus aureus, anaerobic aspiration, alcoholism, epilepsy and stroke.
• atypical pneumonias, the most common cause is mycoplasma pneumoniae, other chlamydia, legionella, pneum, coxiela bur.
• viral pneumonias. 50% of all the two pneumonias are viral with the most frequent responsible microorganisms being influenza A and B, others SARS-Cov-2 (Covid 19), parainfluenza, adenoid, respiratory syncytial virus.

Transmission of pneumonia
Pneumonia is transmitted by inhalation of droplets after coughing or sneezing by carriers, by inhalation of droplets during sleep from the pharynx or larynx, or by contact with surfaces recently contaminated with droplets if hygiene measures are not followed of the hands.

This is how microorganisms enter the lungs, settle in the alveoli, where they multiply and create inflammation in the alveoli and the surrounding tissues.

Diagnosis
The diagnosis of pneumonia is based on the clinical picture of the patient, the radiological picture and the laboratory.
Patients usually experience:
• fever with or without chills
• dry or productive cough with purulent or purulent sputum
• pleural pain (localized pain)
• shortness of breath
• hemoptysis
• diarrhea, anorexia, headache
• vomiting, diarrhoea

Many older adults may not have a fever or cough and may have impaired level of consciousness or abdominal discomfort.

Non-musical snoring or bronchial breathing is usually observed on lung auscultation.

The chest x-ray confirms the diagnosis of pneumonia, while the chest x-ray is helpful in case of doubt about the diagnosis (exclusion of malignancy) or in patients who do not respond to treatment as well as for highlighting complications of pneumonia (pleural effusion, abscess, empyema).

Routine laboratory testing includes:
• General blood, a characteristic finding is the increase in white blood cells (the decrease in white blood cells is related to a severe form of the disease or a virus).
• Indicators of inflammation (CRP increase, procalcitonin increase, TKE increase).
• Biochemical testing to assess kidney and liver function.
• Sputum culture and gram staining of sputum, the sensitivity and specificity of the test depends on the responsible microbe and the time of antibiotic administration.
• PCR of respiratory samples for atypical microbes and viruses.
• Pneumococcus and legionella antigen in urine.
• Blood cultures, Arterial blood gases to measure oxygen in the blood.

More invasive methods are bronchoscopy-bronchoalveolar lavage-protected brush done in suspected malignancy, foreign body aspiration in the immunosuppressed and in slowly resolving pneumonia.

Treatment
The decision to treat pneumonia at home or in the hospital is not arbitrary and is related to the severity of the patient’s condition and the judgment of the attending physician.

Various parameters have been defined for this purpose or the simplest is the CURP65 scale (confusion-urea >40mg/dl respiratory rate >30 breaths/min arterial hypertension systolic <90 or even diastolic 65 when there are more than three factors the patient needs hospital treatment).

Initial treatment of pneumonia is empiric. The choice of antibiotic regimen depends on the possible pathogen, the epidemiological data of resistance, the possible administration and type of antibiotic in the last 6 months, the severity of the pneumonia and the coexisting diseases.

A change of antibiotic is recommended in case of deterioration of the patient after 48 hours of receiving treatment or the continuation of fever 72 hours after the start of treatment.

The response of the pneumonia to the treatment is with the clinical improvement (subsidence of the fever, restoration of the drop of oxygen) and the reduction of the indicators of inflammation.

Radiological improvement requires a longer period of time and therefore it is advisable to repeat the radiography after one month, unless complications are suspected.

Prevention
Main means of prevention are vaccination against Covid 19, annual vaccination against seasonal flu, vaccination against pneumococcus recommended in:
1. People >65 years old,
2. Adults with COPD, heart failure, diabetes mellitus, chronic liver disease, smokers, anatomic or functional asplenia congenital or ex-smokers.
3. Immunosuppressed CNA, malignant immunodeficiency

Other strategies to prevent pneumonia are to stop smoking, wash your hands properly and avoid contact with people with respiratory infections.

She writes:
Ferentinou Angeliki
Pulmonologist Tuberculosis
Scientific Associate HEALTH

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