Pneumonia due to Streptococcus pneumoniae - Clinicals, Diagnosis, and Management

Pulmonology

Clinicals - History

Fact Explanation
Fever and chills Fever occurs due to the pyrogens which usually come from outside the body or released in response to inflamation(cytokines), Pyrogens signals the hypothalamus to increase the temperature set point. When pyrogens signals the hypothalamus to increase the temperature set point, our body begins to shiver; our blood vessels constrict . Fever and chills
Fever occurs due to the pyrogens which usually come from outside the body or released in response to inflamation(cytokines), Pyrogens signals the hypothalamus to increase the temperature set point. When pyrogens signals the hypothalamus to increase the temperature set point, our body begins to shiver; our blood vessels constrict .
Productive cough with sputum Bacteria can enter the lungs mainly via inhalation of airborne bacteria, less commonly- microaspiration of organisms that colonize the naso/oropharynx, bacteremic seeding of blood-borne bacteria in septicemic patients and direct extension of an adjacent infection. Cough reflex, mucociliary transport and pulmonary macrophages try to protect the body against the infection.The invading organism starts to multiply and release damaging toxins that cause inflammation and edema of the lung parenchyma. This action leads to accumulation of cellular debris and exudes within the lungs.
This produces cough with either white or yellow sputum.
Productive cough with sputum
Bacteria can enter the lungs mainly via inhalation of airborne bacteria, less commonly- microaspiration of organisms that colonize the naso/oropharynx, bacteremic seeding of blood-borne bacteria in septicemic patients and direct extension of an adjacent infection. Cough reflex, mucociliary transport and pulmonary macrophages try to protect the body against the infection.The invading organism starts to multiply and release damaging toxins that cause inflammation and edema of the lung parenchyma. This action leads to accumulation of cellular debris and exudes within the lungs.
This produces cough with either white or yellow sputum.
Difficulty in breathing Airways are blocked with inflammatory exudate and gas exchange is impaired at alveolar level. Difficulty in breathing
Airways are blocked with inflammatory exudate and gas exchange is impaired at alveolar level.
Pleuritic chest pain Inflammation of the pleura can cause pain which increases on inspiration. Pleuritic chest pain
Inflammation of the pleura can cause pain which increases on inspiration.
Lethrgy ,malaise, loss of apetite Complex signaling circuits are activated by bacterial contact with airway epithelial cells that initiate chemokine expression to recruit phagocytes to the region of infection. Pneumolysin, a multifunctional virulence factor, related to streptococcus pneumoniae, activates complement, leading to ongoing production of cytokines.Patient is unwell due to the production of cytokines. Lethrgy ,malaise, loss of apetite
Complex signaling circuits are activated by bacterial contact with airway epithelial cells that initiate chemokine expression to recruit phagocytes to the region of infection. Pneumolysin, a multifunctional virulence factor, related to streptococcus pneumoniae, activates complement, leading to ongoing production of cytokines.Patient is unwell due to the production of cytokines.
Headache Less common symptom. Headache
Less common symptom.
Altered mental state Confusion is a marker of severity of the disease Altered mental state
Confusion is a marker of severity of the disease
Risk factors:-History of immunosuppression Immunosuppression is a risk factor for pneumonia specially for pneumococcal pneumonia. Acquired Immuno-defficiency syndrome, malnutrition, diabetes, malignancy, chemotherapy and long-term use of steroids are some of these conditions that increased the risk of getting pneumonia due to immunosuppresion. Risk factors:-History of immunosuppression
Immunosuppression is a risk factor for pneumonia specially for pneumococcal pneumonia. Acquired Immuno-defficiency syndrome, malnutrition, diabetes, malignancy, chemotherapy and long-term use of steroids are some of these conditions that increased the risk of getting pneumonia due to immunosuppresion.
Risk factors:-History of underlying lung disease Patients with underlying abnormalities in the lung structure and function are also vulnerable for pneumonia. Conditions like bronchiectasis, chronic obstructive pulmonary disease, cystic fibrosis and lung cancer increase the risk of getting pneumonia.
Patients with respiratory failure who are on mechanical ventilators are more prone to pneumonia.
Risk factors:-History of underlying lung disease
Patients with underlying abnormalities in the lung structure and function are also vulnerable for pneumonia. Conditions like bronchiectasis, chronic obstructive pulmonary disease, cystic fibrosis and lung cancer increase the risk of getting pneumonia.
Patients with respiratory failure who are on mechanical ventilators are more prone to pneumonia.
Risk factors:-History of co-morbidities Patients who are having diabetes mellitus, renal diseases and heart diseases have an increased risk of mortality due to pneumonia. Risk factors:-History of co-morbidities
Patients who are having diabetes mellitus, renal diseases and heart diseases have an increased risk of mortality due to pneumonia.
Risk factors-History of smoking Smoking decreases the body's natural defenses against infection, making individual vulnerable for infections. Risk factors-History of smoking
Smoking decreases the body's natural defenses against infection, making individual vulnerable for infections.
History of excessive use of alcohol Excessive use of alcohol associated with leucopenia increases the risk of complications due to pneumonia. This can lead to alcoholic leukopenic pneumococcal sepsis that has a high mortality. History of excessive use of alcohol
Excessive use of alcohol associated with leucopenia increases the risk of complications due to pneumonia. This can lead to alcoholic leukopenic pneumococcal sepsis that has a high mortality.
Age At both extremes of age,there is increased risk of getting pneumonia. This increased risk relates in part to impaired immunity. In some countries individuals older than age
65 account for most of the deaths
from pneumonia.
Age
At both extremes of age,there is increased risk of getting pneumonia. This increased risk relates in part to impaired immunity. In some countries individuals older than age
65 account for most of the deaths
from pneumonia.
If complicated with; pleural effusion Often results when the pneumonia is close to the chest wall and causes inflammation of the pleura surrounding the lung. Patient presents with difficulty in breathing and pleuritic chest pain. If complicated with; pleural effusion
Often results when the pneumonia is close to the chest wall and causes inflammation of the pleura surrounding the lung. Patient presents with difficulty in breathing and pleuritic chest pain.
If complicated with; empyema If complicated with empyema , patient with a resolving pneumonia develops recurrent fever. If complicated with; empyema
If complicated with empyema , patient with a resolving pneumonia develops recurrent fever.
If complicated with; lung abscess Inadequately treated pneumonia can develop into a lung abscess. Swinging fever, purulent cough, pleuritic chest pain and hemoptysis are some of the symptoms. If complicated with; lung abscess
Inadequately treated pneumonia can develop into a lung abscess. Swinging fever, purulent cough, pleuritic chest pain and hemoptysis are some of the symptoms.
If complicated with; hypotension This may be either due to dehydration or sepsis. Patient nay be experiencing faintishness or even collapse if in a state of shock. If complicated with; hypotension
This may be either due to dehydration or sepsis. Patient nay be experiencing faintishness or even collapse if in a state of shock.
If complicated with; sepsis This is due to spread of bacteria from lung tissue to the blood stream. Pneumococcal Surface Protein C is an important virulence factor that contributes to the sepsis. If complicated with; sepsis
This is due to spread of bacteria from lung tissue to the blood stream. Pneumococcal Surface Protein C is an important virulence factor that contributes to the sepsis.

Clinicals - Examination

Fact Explanation
Febrile Pyrogens signals the hypothalamus to increase the temperature set point making patient febrile. Febrile
Pyrogens signals the hypothalamus to increase the temperature set point making patient febrile.
Tachypnoea Respiratory rate >30/min indicates severe pneumonia. Tachypnoea
Respiratory rate >30/min indicates severe pneumonia.
Cyanosis This indicates severe pneumonia where the alveolar gas exchange is impaired. Cyanosis
This indicates severe pneumonia where the alveolar gas exchange is impaired.
Reduced chest expansion Inflammation and edema of the lung parenchyma leads to accumulation of cellular debris and exudes within the lungs. Soon the airless state of the lungs is changed to a consolidated state due to the fluid and exudate filling up(with polymorphonuclear leucocytes and fibrin). Due to this consolidation, there is reduced chest expansion on the affected side. Reduced chest expansion
Inflammation and edema of the lung parenchyma leads to accumulation of cellular debris and exudes within the lungs. Soon the airless state of the lungs is changed to a consolidated state due to the fluid and exudate filling up(with polymorphonuclear leucocytes and fibrin). Due to this consolidation, there is reduced chest expansion on the affected side.
Reduced chest moments Due to the consolidation , there is reduced air entry and lung expansion. Reduced chest moments
Due to the consolidation , there is reduced air entry and lung expansion.
Dull percussion note Percussion note is dull over the areas of consolidation. Dull percussion note
Percussion note is dull over the areas of consolidation.
Increased vocal fremitus/resonance Due to the consolidation , sound waves travel better over this part of the lung. Increased vocal fremitus/resonance
Due to the consolidation , sound waves travel better over this part of the lung.
Reduced breath sounds The alveoli are filled with exudate due to inflammation where the normal air entry mechanism can not be happened. Reduced breath sounds
The alveoli are filled with exudate due to inflammation where the normal air entry mechanism can not be happened.
Added sounds eg:- crepitations Crepitations are generated when
an abnormally closed airway opens during inspiration or closes at the end of expiration. Crepitations in pneumonia are caused by the opening of small airways and alveoli collapsed by fluid and exudate.
Added sounds eg:- crepitations
Crepitations are generated when
an abnormally closed airway opens during inspiration or closes at the end of expiration. Crepitations in pneumonia are caused by the opening of small airways and alveoli collapsed by fluid and exudate.
Added sounds eg:-Bronchial breathing Bronchial breathing is heard over areas of consolidation, as solid lung conducts the sound of turbulence in main airways to peripheral areas without filtering. Added sounds eg:-Bronchial breathing
Bronchial breathing is heard over areas of consolidation, as solid lung conducts the sound of turbulence in main airways to peripheral areas without filtering.
Added sounds eg:- Pleural rub It is caused by friction between the pleural membranes as a result of loss of lubrication and indicates an inflammatory process inside the lungs. If the normal layer of lubrication is reduced or disappears because of inflammation, friction builds up and the pleural membranes rub or grate against each other. Added sounds eg:- Pleural rub
It is caused by friction between the pleural membranes as a result of loss of lubrication and indicates an inflammatory process inside the lungs. If the normal layer of lubrication is reduced or disappears because of inflammation, friction builds up and the pleural membranes rub or grate against each other.
If complicated with; pleural effusion This can be a complication of pneumonia. Reduced chest expansion and chest moments, stony dull percussion note, decreased vocal fremitus/resonance and reduced breath sounds and bronchial breathing over the upper margin of the pleural effusion are the signs of pleural effusion. If complicated with; pleural effusion
This can be a complication of pneumonia. Reduced chest expansion and chest moments, stony dull percussion note, decreased vocal fremitus/resonance and reduced breath sounds and bronchial breathing over the upper margin of the pleural effusion are the signs of pleural effusion.
If complicated with; empyema Serotype 1 pneumococcus is the primary serotype associated with empyema. Examination signs are same as for pleural effusion. If complicated with; empyema
Serotype 1 pneumococcus is the primary serotype associated with empyema. Examination signs are same as for pleural effusion.
If complicated with; lung abscess Clubbing, anaemia, crepitations are some of the common signs. If complicated with; lung abscess
Clubbing, anaemia, crepitations are some of the common signs.
If complicated with; respiratry failure It is type-1 respiratory failure that occurs in pneumonia. Signs of hypoxia such as dyspnoea, agitation, central cyanosis and signs of hypercapnia such as tachycardia, bounding pulse, papiledema, confusion can be seen. If complicated with; respiratry failure
It is type-1 respiratory failure that occurs in pneumonia. Signs of hypoxia such as dyspnoea, agitation, central cyanosis and signs of hypercapnia such as tachycardia, bounding pulse, papiledema, confusion can be seen.
If complicated with; Hypotension Systolic blood pressure of <90mmHg and/or diastolic blood pressure of <60mmHg is a marker of severity under 'curb 65' criteria. If complicated with; Hypotension
Systolic blood pressure of <90mmHg and/or diastolic blood pressure of <60mmHg is a marker of severity under 'curb 65' criteria.
If complicated with; sepsis Diagnostic criteria for sepsis include 2 or more of the following criteria together with an infection. (Temperature >38.3º (101.0) or <36º (96.8), Systolic Blood Pressure < 90 or > 40 point SBP decrease from baseline, heart rate > 90 /min, resp Rate > 20/min or PaCO2<32 mmHg, altered Mental Status, hyperglycemia with glucose > 140 mg/dL in the absence of diabetes, lactic Acid > 1.2, Urine Output < 0.5 ml / kg / hr x 8 hours, leukocytes >12,000; <4,000) If complicated with; sepsis
Diagnostic criteria for sepsis include 2 or more of the following criteria together with an infection. (Temperature >38.3º (101.0) or <36º (96.8), Systolic Blood Pressure < 90 or > 40 point SBP decrease from baseline, heart rate > 90 /min, resp Rate > 20/min or PaCO2<32 mmHg, altered Mental Status, hyperglycemia with glucose > 140 mg/dL in the absence of diabetes, lactic Acid > 1.2, Urine Output < 0.5 ml / kg / hr x 8 hours, leukocytes >12,000; <4,000)
Confusion, coma Confusion is a marker of severity under 'curb 65' criteria. May be due to hypoxia or hypercapnoea. Confusion, coma
Confusion is a marker of severity under 'curb 65' criteria. May be due to hypoxia or hypercapnoea.

Investigations - Diagnosis

Fact Explanation
Chest X-ray Chest X-rays, to confirm the presence of pneumonia and determine the extent and location of the infection. Homogeneous parenchymal lobar opacity involving one, or less commonly, multiple lobes and characteristic air bronchogram (usually in right lower lobe, but may vary in aspiration pneumonia) signify the streptococcal pneumonia. But X-rays can be misleading, because problems, like lung scarring and congestive heart failure, can mimic pneumonia on x-ray. Chest x-rays are also used to evaluate for complications of pneumonia such as pleural effusion. Chest X-ray
Chest X-rays, to confirm the presence of pneumonia and determine the extent and location of the infection. Homogeneous parenchymal lobar opacity involving one, or less commonly, multiple lobes and characteristic air bronchogram (usually in right lower lobe, but may vary in aspiration pneumonia) signify the streptococcal pneumonia. But X-rays can be misleading, because problems, like lung scarring and congestive heart failure, can mimic pneumonia on x-ray. Chest x-rays are also used to evaluate for complications of pneumonia such as pleural effusion.
Sputum gram stain and culture This can be used to demonstrate the causative organism. In gram stain streptococci appear as gram positive cocci. Sputum gram stain and culture
This can be used to demonstrate the causative organism. In gram stain streptococci appear as gram positive cocci.
Full blood count (FBC) High white blood cell count, indicating the presence of an infection or inflammation. In some people with immune system problems, the white blood cell count may appear deceptively normal. As the patient presents with the fever, FBC is also important to look for the platelet count, as it might be a viral infection. Full blood count (FBC)
High white blood cell count, indicating the presence of an infection or inflammation. In some people with immune system problems, the white blood cell count may appear deceptively normal. As the patient presents with the fever, FBC is also important to look for the platelet count, as it might be a viral infection.
C reactive protein Increased, indicating an inflammation. C reactive protein
Increased, indicating an inflammation.
Pleural fluid culture A fluid sample is taken from the pleural area and analyzed to help determine the type of infection. Pleural fluid culture
A fluid sample is taken from the pleural area and analyzed to help determine the type of infection.
Chest Computer Tomography Pneumonia is not always seen on x-rays, either because the disease is only in its initial stages, or because it involves a part of the lung not easily seen by x-ray. In some cases, chest CT can reveal pneumonia that is not seen on chest x-ray. Consolidation appear as increased lung opacity on a chest CT. Chest Computer Tomography
Pneumonia is not always seen on x-rays, either because the disease is only in its initial stages, or because it involves a part of the lung not easily seen by x-ray. In some cases, chest CT can reveal pneumonia that is not seen on chest x-ray. Consolidation appear as increased lung opacity on a chest CT.

Investigations - Management

Fact Explanation
Chest X-ray Arrange a chest X-ray after 6 weeks for people over 50 years of age that smoke, and for people with persistent symptoms or signs of pneumonia.Monitoring a favorable disease process by routine follow-up chest radiographs seems to have no additional value above following a patient's clinical course.
Follow up chest x-ray indicated in children only if it is recurrent.
Chest X-ray
Arrange a chest X-ray after 6 weeks for people over 50 years of age that smoke, and for people with persistent symptoms or signs of pneumonia.Monitoring a favorable disease process by routine follow-up chest radiographs seems to have no additional value above following a patient's clinical course.
Follow up chest x-ray indicated in children only if it is recurrent.
Renal function tests ( Serum creatinine, serum electrolytes and blood urea) Evaluation of kidney function is important when prescribing certain antibiotics or to look for low blood sodium. Low blood sodium in pneumonia is thought to be due to extra anti-diuretic hormone produced when the lungs are diseased (SIADH). Renal function tests ( Serum creatinine, serum electrolytes and blood urea)
Evaluation of kidney function is important when prescribing certain antibiotics or to look for low blood sodium. Low blood sodium in pneumonia is thought to be due to extra anti-diuretic hormone produced when the lungs are diseased (SIADH).
Liver function tests To have a base line value, specially there can be abnormalities in liver functions if there is a organ failure associated with sepsis. Liver function tests
To have a base line value, specially there can be abnormalities in liver functions if there is a organ failure associated with sepsis.
C Reactive protein (CRP) Is increased due to the inflammation. C Reactive protein (CRP)
Is increased due to the inflammation.
Bronchoscopy This is used to check any obstruction in the airways or whether something else is contributing to your pneumonia. Bronchoscopy
This is used to check any obstruction in the airways or whether something else is contributing to your pneumonia.
Blood culture May be needed if the condition of the patient is worsening, to exclude the complications such as sepsis. Blood culture
May be needed if the condition of the patient is worsening, to exclude the complications such as sepsis.
Renal function tests ( Serum creatinine, serum electrolytes and blood urea) Blood urea more than 7mmol/l is a marker of severe pneumonia. Renal function tests ( Serum creatinine, serum electrolytes and blood urea)
Blood urea more than 7mmol/l is a marker of severe pneumonia.
Pulse oxymetry SaO2 <92% is an indicator of severe pneumonia. Pulse oxymetry
SaO2 <92% is an indicator of severe pneumonia.
Chest ultrasonograpgy Used to evaluate the suspected parapneumonic effusions. Chest ultrasonograpgy
Used to evaluate the suspected parapneumonic effusions.

Management - Supportive

Fact Explanation
Assessment of the severity Severity is based on the criteria of 'CURB 65'-C- Confusion, U- Urea >7mmol/l, R-Respiratory rate >30/min, B-Systolic blood pressure<90mmHg and 65-Age >65 years. If 0-1 score is present, patient can be managed at home. If it is 2, hospital management and 3 or more, admission to a intensive care unit is needed..
If patient is having shock, hypercapnia or uncorrected hypoxia, consider admission to a intensive care unit.
Assessment of the severity
Severity is based on the criteria of 'CURB 65'-C- Confusion, U- Urea >7mmol/l, R-Respiratory rate >30/min, B-Systolic blood pressure<90mmHg and 65-Age >65 years. If 0-1 score is present, patient can be managed at home. If it is 2, hospital management and 3 or more, admission to a intensive care unit is needed..
If patient is having shock, hypercapnia or uncorrected hypoxia, consider admission to a intensive care unit.
Oxygen To keep PaO2 >k8Pa and saturation >94%. Oxygen
To keep PaO2 >k8Pa and saturation >94%.
Adequate fluid supplimentation Drinking sufficient fluids is important to prevent dehydration. Sometimes IV fluids may be needed as patient is having anorexia, dehydration and even shock.
Observation of the frequency and colour of their urine is important as fluid intake has to be increased if there is reduced urine output.
Adequate fluid supplimentation
Drinking sufficient fluids is important to prevent dehydration. Sometimes IV fluids may be needed as patient is having anorexia, dehydration and even shock.
Observation of the frequency and colour of their urine is important as fluid intake has to be increased if there is reduced urine output.
Analgesia Use paracetamol 1g 6H as required to reduce temperature and symptoms of malaise and pleurisy. Analgesia
Use paracetamol 1g 6H as required to reduce temperature and symptoms of malaise and pleurisy.
Monitoring Clinical symptoms and chest signs are monitored for improvement. CRP should be checked as it may be persistently high in a case of poor progression. Close monitoring of vital parameters is required if the condition of the patient is worsening. Monitoring
Clinical symptoms and chest signs are monitored for improvement. CRP should be checked as it may be persistently high in a case of poor progression. Close monitoring of vital parameters is required if the condition of the patient is worsening.
Looking for the complications Pleural effusion, lung absess, septicaemia, respiratory failure, pericarditis,myocarditis,brain abscess are some of the possible complications and patient should be carefully monitored for them. Looking for the complications
Pleural effusion, lung absess, septicaemia, respiratory failure, pericarditis,myocarditis,brain abscess are some of the possible complications and patient should be carefully monitored for them.
Pneumococcal vaccine A vaccine against ''Streptococcus pneumoniae'' is also available for high risk groups such as persons with emphysema, congestive heart failure, diabetes mellitus, cirrhosis of the liver, alcoholism, cerebrospinal fluid leaks, or those who had splenectomy. A repeat vaccination may also be required after five or ten years. Pneumococcal vaccine
A vaccine against ''Streptococcus pneumoniae'' is also available for high risk groups such as persons with emphysema, congestive heart failure, diabetes mellitus, cirrhosis of the liver, alcoholism, cerebrospinal fluid leaks, or those who had splenectomy. A repeat vaccination may also be required after five or ten years.

Management - Specific

Fact Explanation
Antibiotics for mild disease Oral amoxicillin 500mg-1g 8H
or clarithromycin 500mg 12H
or doxycycline 200mg followed by 100mg 12H
Antibiotics for mild disease
Oral amoxicillin 500mg-1g 8H
or clarithromycin 500mg 12H
or doxycycline 200mg followed by 100mg 12H
Antibiotics for moderate disease Empirical treatment is with β-lactams, macrolides, or fluoroquinolones. Oral amoxicillin 500mg-1g 8H+ clarithromycin 500mh 12H or doxycycline 200mg followed by 100mg 12H. If IV required amoxicillin 500mg-1g 8H+clarithromycin 500mh 12H. Macrolide antibiotics, particularly azithromycin, are unique as anti-infective agents, have potent anti-inflammatory properties and confer a mortality advantage in community acquired pneumonia irrespective of the causative pathogen.
In an attempt to prevent the emergence of resistance , it has been recommended that the new fluoroquinolones not be used routinely as first-line agents in the treatment of community-acquired pneumonia; and these agents should be reserved for patients who are allergic to the commonly used beta-lactam agents, for infections known to be or suspected of being caused by highly resistant strains, and for patients in whom initial therapy has failed.
Antibiotics for moderate disease
Empirical treatment is with β-lactams, macrolides, or fluoroquinolones. Oral amoxicillin 500mg-1g 8H+ clarithromycin 500mh 12H or doxycycline 200mg followed by 100mg 12H. If IV required amoxicillin 500mg-1g 8H+clarithromycin 500mh 12H. Macrolide antibiotics, particularly azithromycin, are unique as anti-infective agents, have potent anti-inflammatory properties and confer a mortality advantage in community acquired pneumonia irrespective of the causative pathogen.
In an attempt to prevent the emergence of resistance , it has been recommended that the new fluoroquinolones not be used routinely as first-line agents in the treatment of community-acquired pneumonia; and these agents should be reserved for patients who are allergic to the commonly used beta-lactam agents, for infections known to be or suspected of being caused by highly resistant strains, and for patients in whom initial therapy has failed.
Antibiotics for severe disease Co amoxiclav 1.2g 12H iv or cefuroxime 1.5g 8H IV and clarithromycin 500mg12H IV. Antibiotics for severe disease
Co amoxiclav 1.2g 12H iv or cefuroxime 1.5g 8H IV and clarithromycin 500mg12H IV.
Antibiotics for aspiration pneumonia due to streptococcus pneumoniae Cefuroxime 1.5g 8H IV + Metronidazole 500mg 8H IV. Antibiotics for aspiration pneumonia due to streptococcus pneumoniae
Cefuroxime 1.5g 8H IV + Metronidazole 500mg 8H IV.

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