Clinical Presentation

Patients with pneumonia can present with cough, fever, dyspnea, or malaise. Cough can be productive or nonproductive, and blood tinged or with frank blood. The clinical presentation of pneumonia in otherwise healthy patients often follows one of two patterns that can indicate the cause. A rapid onset of cough and shortness of breath with a high fever can indicate classic bacterial lobar pneumonia such as that produced by a pneumococcus. Physical findings once consolidation occurs include decreased breath sounds, dullness to percussion, and egophony on the affected side. The white blood cell (WBC) count is often elevated (>15,000), with a predominance of neutrophils. A smoldering onset with low-grade fever and fewer constitutional symptoms can indicate an atypical pneumonia, which can be caused by organisms such as respiratory viruses or by Mycoplasma, Chlamydia, or Legionella species.

Patients with new-onset pneumonia can be categorized by whether they are living at home in a community setting or living in a nursing home or other institutional setting. Patients who have had prolonged hospitalizations or who

Table 18-3 Outcomes for Hospital Patients with Pneumonia*

Age Group (yr)

Total Discharges

Length of Stay (mean days)

Aggregate Charges($)

In-Hospital Deaths

All discharges

1,171,546 (100%)

5.4

29,864.341,883

41,273 (3.52%)

<1

33,756 (2.88%)

3.5

491,074,183

1-17

109,351 (9.33%)

3.3

1,665,455,923

213 (0.19%)

18-44

108,599 (9.27%)

4.9

2,835,259,274

997 (0.92%)

45-64

261,175 (22.29%)

5.5

7,328,896,664

5626 (2.15%)

65-84

465,118 (39.70%)

5.9

12,728,150,823

20,142 (4.33%)

85+

192,791 (16.46%)

5.9

4,797,255,969

14,271 (7.40%)

*Except pneumonia caused by tuberculosis or sexually transmitted diseases.

Data from Healthcare Cost and Utilization Project (HCUP). Weighted U.S. estimates from HCUP Nationwide Inpatient Sample, 2007. Agency for Healthcare Research and Quality, Rockville, Md. http://hcupnet.ahrq.gov/.

live in nursing homes may be colonized with gram-negative organisms (e.g., Serratia, Pseudomonas), anaerobes, or multi-drug-resistant bacteria.

Patients with pneumonia can be further categorized by whether they are immunocompetent or immunocompro-mised. Patients with immunodeficiencies (including HIV/ AIDS) can present with opportunistic organisms including Pneumocystis jiroveci (carinii), cryptococci, Coccidioides immi-tis, atypical mycobacteria, and fungi. Alcoholism can predispose patients to lung infections with Haemophilus influenzae or to aspirated anaerobic organisms such as Peptostreptococcus or Bacteroides.

In children, signs of pneumonia can include malaise, cough, chest pain, tachypnea, and intercostal retractions. Children with viral pneumonias have a less toxic appearance, with low-grade fever, wheezing, and cough. Children with bacterial pneumonia appear more acutely ill, with a high-grade fever, chills, cough, and dyspnea. The earliest diagnostic clue in children may be tachypnea disproportionate to degree of fever.

In infants, potential causes of pneumonia are tied to specific periods in the first few months of life. Pneumonia in the newborn is often linked to bacteria that colonize the mother's vaginal flora. Group B streptococcal infections can occur within the first 48 hours of life or appear at 7 to 10 days after birth. Other neonatal infections include gram-negative organisms such as Escherichia coli. Although Chlamydia infections of the eye can appear in newborns at 1 to 2 weeks of age, chlamydial pneumonia is typically diagnosed in infants age 6 to 8 weeks. Other causes of pneumonia in infants age 1 to 3 months include Ureaplasma urealyticum and cytomegalovirus (CMV).

Viral pneumonias are most common in preschool and older children. Viral upper respiratory infections or bron-chiolitis can also predispose to a bacterial pneumonia. Bacterial pathogens are responsible for only 10% to 30% of all cases of infectious pediatric pneumonia. Streptococcus pneumoniae has been the most common bacterial cause of childhood pneumonia, but it is declining in the face of universal pneumococcal vaccination. H. influenzae type B pneumonia is associated with bacteremia and other deep tissue infections (e.g., meningitis, arthritis, cellulitis) but also has declined significantly with universal immunization. Staphy-lococcus aureus causes an aggressive pneumonia that can be complicated by acute respiratory failure, pneumatoceles, or empyema. Staphylococcal pneumonia typically occurs after a staphylococcal skin infection or a systemic viral illness such as varicella (chickenpox) or measles.

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