Bacterial Infections
Pneumonia
Tuberculosis
Pneumonia
Pathophysiology and
Clinical Manifestations
DR. ELVIRISTO K. REYES
PULMONOLOGIST
• Pneumonia is an infection of the lungs caused by bacteria, viruses or
fungi.
• Pneumonia causes lung tissue to swell (inflammation) and can cause
fluid or pus in the lungs. Bacterial pneumonia is usually more severe
than viral pneumonia, which often resolves on its own.
• Pneumonia can affect one or both lungs. Pneumonia in both of the
lungs is called bilateral or double pneumonia.
What’s the difference between viral and bacterial
pneumonia?
Bacterial pneumonia
Viral pneumonia
tends to be more common and more
severe than viral pneumonia.
causes flu-like symptoms and is more
likely to resolve on its own
require a hospital stay
don’t need specific treatment for viral
pneumonia.
antibiotics
Lower respiratory and pleural disease
Pneumonia -- infection of alveoli
(viral or bacterial)
vs. Pneumonitis -- immune-mediated
inflammation of alveoli
Empyema: purulent
exudate in the pleural
cavity
Bronchitis -- inflammation of
bronchi, may be immunemediated, e.g. asthma,
COPD, or infectious (usually
viral but can be bacterial)
Abscess: circumscribed
collection of pus within the
lung parenchyma
Bronchiolitis: inflammation
of bronchioles (often viral but
can be bacterial)
5
PNEUMONIA:
CLEARANCE vs. COLONIZATION
Microbes constantly enter airways but
many factors prevent colonization:
• mucous entrapment
• ciliary clearance
• immune surveillance
• intact epithelial barrier
• secreted factors such as:
‒ secretory IgA
‒ surfactant proteins (SP-a, SP-d)
‒ defensins
Disrupting or overwhelming these defense mechanisms can allow microbes to colonize the lungs, resulting in
PNEUMONIA
6
Factors favoring colonization
Disruption of
mucociliary
clearance:
• airway obstruction
(CF, COPD, chronic
bronchitis,
neoplasm)
• ciliary dysfunction
(Kartagener,
smoking, ciliostatic
factors)
Disruption of intact
epithelial barrier:
• injury (e.g.
pulmonary edema,
intubation) or
infection (e.g. viral
respiratory
infection such as
influenza)
Increasing
“inoculation” events:
• altered
consciousness
• debility
• dysphagia
• intubation
• bacteremia
Decreasing immune
function:
• immune
suppression
(transplant, HIV)
• evading host
immunity (IgA
proteases,
encapsulation)
Effects and patterns of microbial colonization:
wh ere and how inflammation appears can be informative
Alveolar
Interstitial
• In alveolar lumen
• Purulent exudate of
RBCs and PMNs
• Mostly in alveolar wall
• Mononuclear WBCs
• Fibrinous exudate
Lobar pneumonia
• lobar distribution
• “typical” CAP
• S. pneumo, H. flu.
Bronchopneumonia
• patchy distribution
• aspiration, intubation,
bronchiectasis
• Staph, enterics,
Pseudomonas
Atypical pneumonia
• diffuse infiltrate w/ perihilar concentration
• Mycoplasma, Chlamydophila, Legionella
• Respiratory viruses, e.g. influenza
8
What are the types of pneumonia?
Types of
pneumonia
Community-acquired pneumonia (CAP)
 pneumonia outside of a healthcare facility
Bacteria: Infection with Streptococcus
pneumoniae bacteria, also called
pneumococcal disease, is the most common
cause of CAP. Pneumococcal disease can
also cause ear infections, sinus infections
and meningitis. Mycoplasma pneumoniae
bacteria causes atypical pneumonia, which
usually has milder symptoms. Other bacteria
that cause CAP include Haemophilus
influenza, Chlamydia
pneumoniae and Legionella (Legionnaires’
disease).
Viruses: Viruses that cause the common
cold, the flu (influenza), COVID-19 and
respiratory syncytial virus (RSV) can
sometimes lead to pneumonia.
Fungi (molds): Fungi,
like Cryptococcus, Pneumocystis
jirovecii and Coccidioides, are uncommon
causes of pneumonia. People with
compromised immune systems are most at
risk of getting pneumonia from a fungus.
Protozoa: Rarely, protozoa
like Toxoplasma cause pneumonia.
Hospital-acquired
(HAP)
pneumonia
 hospital or healthcare facility
for another illness or procedure.
 more serious than communityacquired pneumonia because
it’s often caused by antibioticresistant
bacteria,
like
methicillinresistant
Staphylococcus
aureus (MRSA)
 HAP can make you sicker and
be harder to treat.
Types of pneumonia
Healthcare-associated pneumonia
(HCAP)
• long-term care facility (such as a
nursing home) or outpatient,
extended-stay clinics.
• caused by antibiotic-resistant bacteria.
Ventilator-associated pneumonia
(VAP)
• respirator or breathing machine in the
hospital (usually in the ICU)
• The same types of bacteria as
community-acquired pneumonia, as
well as the drug-resistant kinds that
cause hospital-acquired pneumonia,
cause VAP.
Aspiration pneumonia
Types of
pneumonia
• Aspiration is when solid
food, liquids, spit or vomit
go down to the trachea
(windpipe) and into the
lungs.
How can I tell if
I have
pneumonia
versus the
common cold
or the flu?
It can be difficult to tell the difference between the
symptoms of a cold, the flu and pneumonia, and only
a healthcare provider can diagnose you. As
pneumonia can be life-threatening, it’s important to
seek medical attention for serious symptoms that
could be signs of pneumonia, such as:
• Congestion or chest pain.
• Difficulty breathing.
• A fever of 102 degrees Fahrenheit (38.88 degrees
Celsius) or higher.
• Coughing up yellow, green or bloody mucus or spit.
History
• Previously healthy with sudden onset of fever and shortness of breath
Physical signs and symptoms
• fever
• tachycardia
• tachypnea
• productive cough with purulent sputum and possible hemoptysis
• pallor and cyanosis
• localized:
− dullness to percussion
− decreased breath sounds
− crackles, ronchi, egophony (“E-to-A” change)
Investigations
•
CXR showing lobar consolidation
•
CBC showing leukocytosis w/ left shift
•
Sputum sample contains neutrophils, RBCs; Gram stain may be
positive depending on organism
Sample Case
• 32 YO healthy patient – one week of low
grade fever, sore throat, and intractable
cough
• Minimal sputum production
• Able to continue to work
• No sick contacts, recent travel, or
evidence of altered immune system
• PE reveals a mildly ill-appearing patient with
diffuse wheezes on lung exam
• Primary care physician prescribes empiric
antibiotics for CAP with complete resolution
• “Walking pneumonia” syndrome
Complications of pneumonia
• inflammation leads to exudation of fluid into pleural
space
• can compromise lung function
• purulent exudate in pleural space
• necrosis/breakdown of visceral pleura and/or spread
of infection into pleura
• Pleural adhesions, lung fibrosis
Complications of pneumonia
• Abscess / cavitary lesion
• circumscribed focus of liquefactive
necrosis within lung tissue
• associated with necrotizing Staph
or Strep infections or Gram-neg
rods (e.g. aspiration)
Who is most
at risk of
getting
pneumonia?
•Are over the age of 65 and or under the age of 2.
•Are living with a lung or heart condition. Examples
include cystic fibrosis, asthma, chronic obstructive
pulmonary disease, emphysema, pulmonary fibrosis
or sarcoidosis.
•Are living with a neurological condition that makes
swallowing difficult. Conditions like dementia,
Parkinson’s disease and stroke increase your risk of
aspiration pneumonia.
•hospital or at a long-term care facility.
•Smoke.
•pregnant.
•have a weakened immune system.
DIAGNOSIS AND TESTS
What tests
will be done
to diagnose
pneumonia?

Imaging: Your provider can
use chest X-ray or CT scan to take
pictures of your lungs to look for
signs of infection.

Blood tests: Your provider can use
a blood test to help determine what
kind of infection is causing your
pneumonia.


Sputum test: You’re asked to
cough and then spit into a container
to collect a sample for a lab to
examine. The lab will look for signs
of an infection and try to determine
what’s causing it.
Pulse oximetry: A sensor measures
the amount of oxygen in your blood
to give your provider an idea of
how well your lungs are working.

Pleural fluid culture: Your
provider uses a thin needle to
take a sample of fluid from
around your lungs. The sample
is sent to a lab to help determine
what’s causing the infection.

Arterial blood gas test: Your
provider takes a blood sample
from your wrist, arm or groin to
measure oxygen levels in your
blood to know how well your
lungs are working.

Bronchoscopy: In some cases,
your provider may use a thin,
lighted
tube
called
a
bronchoscope to look at the
inside of your lungs. They may
also take tissue or fluid samples
to be tested in a lab.
MANAGEMENT
AND TREATMENT
Treatment for pneumonia depends on the cause — bacterial, viral
or fungal — and how serious the case is.



Treatment

Antibiotics: Antibiotics treat bacterial pneumonia. They can’t
treat a virus but a provider may prescribe them if you have a
bacterial infection at the same time as a virus.
Antifungal medications: Antifungals can treat pneumonia
caused by a fungal infection.
Antiviral medications: Viral pneumonia usually isn’t treated
with medication and can go away on its own. A provider may
prescribe antivirals such
as oseltamivir (Tamiflu®), zanamivir (Relenza®)
or peramivir (Rapivab®) to reduce how long you’re sick and
how sick you get from a virus.
Oxygen therapy: If you’re not getting enough oxygen, a
provider may give you extra oxygen through a tube in your
nose or a mask on your face.

IV fluids: Fluids delivered directly to your vein (IV) treat or
prevent dehydration.

Draining of fluids: If you have a lot of fluid between your
lungs and chest wall (pleural effusion), a provider may drain it.
This is done with a catheter or surgery.
How to
manage the
symptoms of
pneumonia?
Over-the-counter medications and other at-home treatments can help you
feel better and manage the symptoms of pneumonia, including:

Pain relievers and fever reducers: Your provider may recommend
medicines like ibuprofen (Advil®) and acetaminophen (Tylenol®) to
help with body aches and fever.

Cough suppressants: Check with your healthcare provider before
taking cough suppressants for pneumonia. Coughing is important to
help clear your lungs.

Breathing treatments and exercises: Your provider may prescribe
these treatments to help loosen mucus and help you to breathe.

Using a humidifier: Your provider may recommend keeping a small
humidifier running by your bed or taking a steamy shower or bath to
make it easier to breathe.

Drinking plenty of fluids.
How soon
after
treatment for
pneumonia
will I begin to
feel better?
How soon you’ll feel better depends on:
Your age.
The cause of your pneumonia.
The severity of your pneumonia.
If you have other health conditions or
complications.
Physical and respiratory therapist
treatment
Respiratory physiotherapy is a core
specialty within the physiotherapy
profession and occupies a key role in the
management and treatment of patients
with respiratory diseases.
It aims to unclog the patient’s airways
and help them return to physical activity
and exertion. The respiratory
physiotherapist employs many diverse
interventions, including pulmonary
rehabilitation, early mobilization, and
airway clearance techniques, all having
beneficial effects on the symptoms
associated with in this case pneumonia.
Physical and respiratory management
PREVENTION
Vaccines for pneumonia
• There are two types of vaccines (shots) that prevent pneumonia caused by pneumococcal bacteria.
Similar to a flu shot, these vaccines won’t protect against all types of pneumonia, but if you do get
sick, it’s less likely to be severe.
• Pneumococcal vaccines: Pneumovax23® and Prevnar13® protect against pneumonia bacteria. They’re
each recommended for certain age groups or those with increased risk for pneumonia. Ask your
healthcare provider which vaccine would be appropriate for you or your loved ones.
• Vaccinations against viruses: As certain viruses can lead to pneumonia, getting vaccinated against
COVID-19 and the flu can help reduce your risk of getting pneumonia.
• Childhood vaccinations: If you have children, ask their healthcare provider about other vaccines they
should get. Several childhood vaccines help prevent infections caused by the bacteria and viruses that
can lead to pneumonia.
What Is
Tuberculosis?
DR. ELVIRISTO K. REYES
PULMONOLOGIST
Factors
Contributing
to the
Increase in
TB Cases
HIV epidemic
Increased
immigration
from highprevalence
countries
Transmission of
TB in congregate
settings (e.g.,
correctional
facilities, long
term care)
Deterioration of
the public health
care
infrastructure
History
The development in the 1940s of
streptomycin, the first antibiotic to effectively
cure TB, dramatically lowered the number of
cases of tuberculosis seen in developed
countries.
Tuberculosis,
or TB
an infectious disease
caused by the
bacteria
Mycobacterium
tuberculosis
bacteria spreads
through the air from
person to person and
mainly attacks the
lungs, and can affect
other areas of the
body
human history,
becoming particularly
deadly at times,
researchers can trace
tuberculosis back to
early Egypt, more
than 5,000 years ago.
biblical books of
Deuteronomy and
Leviticus under the
Hebrew word
schachepheth, and
Hippocrates describes
it in his writings as
"phthisis."
Signs and Symptoms of Tuberculosis
three stages:
• Primary TB Infection This is when the bacteria first enters your body. In many people this
causes no symptoms, but others may experience fever or pulmonary symptoms. Most
people with a healthy immune system will not develop any symptoms of infection, but in
some people the bacteria may grow and develop into an active disease. Most primary TB
infections are asymptomatic and followed by a latent TB infection, according to the Centers
for Disease Control and Prevention (CDC).
• Latent TB Infection The bacteria is in your body and can be found through tests,but is not
active. During this stage you don’t experience symptoms and can’t spread the disease to
others.
• Active Disease The TB bacteria are active and multiplying
Pulmonary TB occurs in
the lungs
Sites of TB
Disease
Extrapulmonary TB
occurs in places other
than the lungs, including
the:
•Larynx
•Lymph nodes
•Brain and spine
•Kidneys
•Bones and joints
85% of all TB cases are
pulmonary
Miliary TB occurs when
tubercle bacilli enter the
bloodstream and are
carried to all parts of the
body
Causes and Risk Factors of Tuberculosis
The bacteria do not live on surfaces, so you
can’t get TB by:

Shaking hands

Using a toilet

Sharing drinking glasses or eating
utensils

Touching other surfaces
Risk factors for TB include:
 Poverty
 HIV infection
 Homelessness
 Being in jail or prison (where close contact can spread
infection)
 Substance abuse
 Taking medication that weakens the immune system
 Kidney disease and diabetes
 Organ transplants
 Working in healthcare
 Exposure to air pollution
 Cancer
 Smoking tobacco
 Pregnancy
 Age, specifically babies, young children, and elderly
people
Diagnostic tests used for active TB include:
How Is
Tuberculosis
Diagnosed?
• Sputum Samples Sputum is the mucus that comes
up when you cough. Samples of sputum can be
directly examined in a lab for M. tuberculosis.
• Molecular Tests These can be used to detect the
bacteria's genetic material and help identify which
antibiotics will work best.
• Biopsy A biopsy of the lungs, lymph nodes, or
other tissues may be cultured to grow the bacteria
and make it easier to see under a microscope.
Imaging
tests used
for active
TB include:
• X-Rays Chest X-rays
may be done to look
for signs of TB in the
lungs.
• Computerized
Tomography (CT)
Scans CT scans may
be used to look for TB
in the spine or to get
better views of the
lungs if X-ray images
are unclear.
• Magnetic
Resonance Imaging
(MRI) An MRI of the
spine or brain may be
done if doctors think
the tuberculosis
infection has spread
to those areas.
• Bone Scans These
can be used to tell
the difference
between cancerous
lesions and those
caused by TB.
Duration of Tuberculosis
A person can have latent TB for
years, without having symptoms or
becoming sick. But if the bacteria is
detected, a course of treatment over
three to four months.
Treatment for active TB disease can
take six to nine months. It's vital that
people with TB disease complete
their full course of medication
exactly as prescribed. Otherwise, the
disease can return and be more
resistant to treatment.
Keeping your immune system healthy and avoiding exposure to someone with
active TB is the best way to prevent a TB infection.
Prevention
of
Tuberculosis
Identifying and treating cases of latent TB, before the disease can become active, is
also important, particularly in high-risk populations.
To prevent the transmission of tuberculosis in healthcare settings, the CDC’s
guidelines recommend that all healthcare personnel be screened for tuberculosis
when they’re hired. Other steps toward preventing the spread of TB include:
Improving ventilation in indoor spaces so there are fewer bacteria in the air
Using germicidal UV lamps to kill airborne bacteria in buildings where there are
people at high risk of TB
Using directly observed therapy (DOT), in which people taking medication for TB are
monitored by their healthcare providers, to raise the likelihood of successful
treatment
Complications of Tuberculosis
Loss of appetite
Nausea or vomiting
Yellowing of skin or
eyes (a sign of liver
damage)
Dark-colored urine
Pain the in the
abdominal area
Tingling in the
fingers or toes
Dizziness
Muscle weakness
or aching joints
Fever that lasts
longer than three
days
Fatigue
Feeling itchy with
no known cause
Rash on the skin
Changes in vision
Changes in
hearing, like
hearing loss or
ringing in the ears
most commonly used drugs are:
Treatment
and
Medication
Options for
Tuberculosis
• Rifapentine
• Moxifloxacin
• Isoniazid
• Pyrazinamide
• Rifampin
• Myambutol (ethambutol)
TB infection and disease is
treated with these drugs:
• Isoniazid (Hyzyd®).
• Rifampin (Rifadin®).
• Ethambutol (Myambutol®).
• Pyrazinamide (Zinamide®).
• Rifapentine (Priftin®).
RECAP