Problem‑Solving for Acute and Critical Care

CME Article

Acute management of pneumonia in adult patients

high (e.g. ≥90%). Similarly, for a test to be useful in ruling in
Opening Vignette
a diagnosis/aetiology, its specificity should be high (e.g. ≥90%).
A 40‑year‑old woman presented to her general practitioner’s
For low‑risk community‑acquired pneumonia which is managed
clinic with 3 days of cough, yellow phlegm, dyspnoea and
on an outpatient basis, routine blood cultures have low yield.
fever. She had diabetes mellitus, which was under good
Depending on clinical suspicion, rapid antigen or molecular
control with insulin and metformin. She had no sick contacts
tests for severe acute respiratory syndrome coronavirus 2
and was fully vaccinated for COVID‑19. Vital signs were as
(SARS‑CoV‑2) or sputum testing for tuberculosis may be
follows: temperature 39°C, respiratory rate 25 breaths/min,
considered. Nonetheless, even without any chest imaging or
heart rate 120 beats/min, blood pressure 80/50 mmHg
microbiological testing, presumed pneumonia based on clinical
and peripheral oxygen saturation of 89% in room air.
features alone needs prompt attention from frontline clinicians.
Physical examination additionally revealed right‑sided lung
crepitations. Frontline clinicians would encounter pneumonia often
[Table 2]. Pneumonia is a leading infectious cause of disease
and death globally, with >2 million deaths reported from lower
IDENTIFICATION AND DIFFERENTIAL DIAGNOSIS respiratory tract infections in 2016.[11] Pneumonia can also
OF PNEUMONIA occur within healthcare settings like nursing homes, hospital
The patient has clinical features of pneumonia, marked by wards and intensive care units. Patients with pneumonia
a combination of cough, phlegm production, fever and lung may also present repeatedly if the disease is non‑resolving.
crepitations, which suggest infection of the lung parenchyma. Guidelines for pneumonia have been published in the USA[12,13]
Not all of these clinical features may be present; for and the UK.[14] The principles of management as outlined in this
example, fever may be absent in older adults. Radiological article are consistent with these guidelines. Additionally, while
confirmation of pneumonia requires demonstration of some guidelines differentiate between community‑acquired
consolidation on chest radiography. In the absence of chest and hospital‑acquired pneumonia,[13,14] the clinical impact of
radiography, point‑of‑care lung ultrasound may be used such classification seems to be minimal compared to local
to identify consolidation that abuts the visceral pleura, epidemiology.[12]
though consolidation that does not reach the pleura may Determination of pneumonia depends on the clinical criteria
be missed. Besides consolidation, other ultrasonographic and does not seem to benefit from more complicated scoring
signs of pneumonia include hepatisation of the lung, methods (e.g. Clinical Pulmonary Infection Score for diagnosis
dynamic air bronchograms and shred sign (irregular junction of ventilator‑associated pneumonia).[13] It is important to avoid
between consolidated and aerated lung). For the diagnosis diagnostic closure, and the general approach to pneumonia
of community‑acquired pneumonia, lung ultrasonography in adult patients requires consideration of differential
in the hands of non‑imaging specialists (e.g. emergency diagnoses [Figure 1]. Mimics of pneumonia can present
physicians, internal medicine physicians, intensivists) achieved with the same constellation of respiratory symptoms, but
a sensitivity of 68%–100% and a specificity of 61%–99%, require other specific treatment. For instance, extrapulmonary
compared to a chest computed tomography reference infection can seed the lungs via haematogenous spread and
standard.[1] Blood and sputum cultures — preferably before requires either intensified antibiotic dosing in the case of
antibiotic administration — can help identify the pathogen and infective endocarditis or pus drainage in the case of liver
streamline antimicrobial therapy. Additionally, genotyping for abscess. Non‑infective pneumonia (e.g. organising pneumonia,
the detection of antibiotic resistance‑related mutations may eosinophilic pneumonia) responds well to steroids, while
be available, though culture remains an important reference pulmonary embolism requires anticoagulation.
standard for drug susceptibility testing.
Chest radiography, computed tomography and culture‑based RISK STRATIFICATION OF PNEUMONIA
tests are often taken as the reference tests for pneumonia The relatively high prevalence and mortality burden of
diagnosis, particularly for severe pneumonia. Beyond pneumonia has driven development of several early warning
these reference tests, other tests are available to diagnose and risk stratification systems. If available, machine learning
pneumonia and its aetiology, with widely varying sensitivities can continuously draw upon big data to accurately identify
and specificities [Table 1].[1‑10] For a test to be useful in and prognosticate pneumonia. Nonetheless, such a complex
ruling out a diagnosis/aetiology, its sensitivity should be approach may not be accessible or necessary for frontline

© 2023 Singapore Medical Journal | Published by Wolters Kluwer - Medknow 209

 See and Lau: Pneumonia in adults

Table 1. Selected diagnostic test characteristics and requirements.

Diagnostic test Diagnostic outcome Test characteristics
Lung ultrasound by non‑imaging specialists, Presence of CAP Sensitivity: 68%–100%
looking for subpleural or alveolar consolidation[1] Specificity: 57%–100%
Serum CRP>10 mg/L[2] Presence of CAP Sensitivity: 90% (CI 52%–99%)
Specificity: 48% (CI 27%–70%)
Serum PCT>0.5 mcg/L[2] Presence of CAP Sensitivity: 28% (CI 11%–53%)
Specificity: 96% (CI 80%–99%)
Serum PCT>0.5 mcg/L[3] Bacterial CAP Sensitivity: 10%–78%
(vs. viral CAP) Specificity: 47%–100%
Serum mycoplasma IgM Ab[4] Mycoplasma LRTI Sensitivity: 85% (CI 63%–95%)
Specificity: 90% (CI 75%–97%)
Urine streptococcal antigen[4] Pneumococcal LRTI Sensitivity: 70% (CI 60%–79%)
Specificity: 83% (CI 63%–93%)
Urine Legionella antigen[6] Legionellosis Sensitivity: 74% (CI 68%–81%)
(mostly serotype 1) Specificity: 99% (CI 98%–99.7%)
Sputum bacterial culture[7] Non‑TB bacteria Streptococcus pneumoniae
Sensitivity: 59% (CI 56%–62%)
Specificity: 87% (CI 86%–89%)
Haemophilus influenzae
Sensitivity: 78% (CI 72%–84%)
Specificity: 96% (CI 94%–97%)
Staphylococcus aureus
Sensitivity: 72% (CI 53%–87%)
Specificity: 97% (CI 95%–99%)
Gram‑negative bacilli
Sensitivity: 64% (CI 49%–77%)
Specificity: 99% (CI 97%–99%)
Direct sputum smear for TB[8] Pulmonary TB Sensitivity: 31%–80%
Specificity: 93%–100%
Immunochromatographic assay for influenza A/B Influenza LRTI Sensitivity: 69% (CI 64%–74%)
Ag using respiratory samples[4] Specificity: 97% (CI 96%–98%)
TB PCR test using sputum[9] Pulmonary TB Smear‑negative, culture‑positive
Sensitivity: 78% (CI 68%–86%)
Specificity: 96% (CI 93%–98%)
Smear‑positive, culture‑positive
Sensitivity: 99% (CI 98%–100%)
Specificity: 100%
Pneumococcus PCR test using respiratory Pneumococcal LRTI Sensitivity: 96% (CI 93%–98%)
samples[4] Specificity: 91% (CI 71%–98%)
Mycoplasma PCR using respiratory samples[4] Mycoplasma Sensitivity: 87% (CI 73%–95%)
pneumoniae LRTI Specificity: 98% (CI 97%–99%)
Chlamydia PCR using respiratory samples[4] Chlamydophila Sensitivity: 83% (CI 58%–94%)
pneumoniae LRTI Specificity: 99% (CI 96%–100%)
COVID‑19 quantitative PCR test on respiratory COVID‑19 infection Sensitivity: 93% (CI 88%–96%)
samples[10] Specificity: 93% (CI 87%–96%)
Influenza A/B PCR test using respiratory samples[4] Influenza LRTI Sensitivity: 94% (90%–96%)
Specificity: 98% (97%–99%)
Pneumocystis PCR using BAL or induced sputum[5] PCP Sensitivity: 94%–99%
Specificity: 89%–91%
Pneumocystis cytology using BAL or induced PCP Sensitivity: 55–90% (lower in
sputum[5] HIV‑negative patients)
Specificity: 100%
Ab: antibody, Ag: antigen, BAL: bronchoalveolar lavage, CAP: community‑acquired pneumonia, CI: 95% confidence interval, COVID‑19: coronavirus
disease 2019, CRP: C‑reactive protein, LRTI: lower respiratory tract infection, PCP: Pneumocystis jirovecii pneumonia, PCR: polymerase chain
reaction (also known as nucleic acid amplification test), PCT: procalcitonin, TB: tuberculosis

210 Singapore Medical Journal ¦ Volume 64 ¦ Issue 3 ¦ March 2023

 See and Lau: Pneumonia in adults

Suspected, confirmed, non-resolving

or progressive pneumonia

Consider differential Risk stratify e.g. using

diagnosesa DS-CRB-65b

Treat pathogen and Prompt source Provide organ Treat related

consider steroidsc control support conditionsd

Bacteria including
Empyema Haemodynamics Anatomical
tuberculosis

Viruses
Respiratory
(e.g. influenza, Lung abscess Neurological
system
coronaviruses)

Fungi including
Extrapulmonary
Pneumocystis Renal system Immunological
abscess
jirovecii

Figure 1: Chart shows the approach to pneumonia in adult patients. aDifferential diagnoses of pneumonia: extrapulmonary infection (e.g. infective
endocarditis, liver abscess), heart failure, cancer, interstitial lung disease, non‑infective pneumonia (e.g. organising pneumonia, eosinophilic pneumonia),
pulmonary embolism. bDS‑CRB‑65: D‑criterion (comorbid diseases) defined as the presence of one or more of the following: congestive heart failure,
chronic renal disease, chronic liver disease, cerebrovascular disease, other chronic neurological disease or active malignancy; S‑criterion defined
as oxygen saturation of <90% measured by pulse oximetry at admission or on first physician contact without oxygen supplementation; C‑criterion
defined as confusion; R‑criterion defined as respiratory rate ≥30/min; B‑criterion defined as systolic blood pressure <90 mmHg or diastolic blood
pressure ≤60 mmHg; and 65‑criterion defined as age ≥65 years. cConsider steroids for (a) patients with an ongoing need for vasopressor therapy;
(b) patients with Pneumocystis jirovecii pneumonia who have arterial oxygen partial pressure <70 mmHg or peripheral oxygen saturation of <92%
in room air and (c) patients with COVID‑19 pneumonia who require either invasive mechanical ventilation or oxygen. dRelated conditions leading
to pneumonia: (a) anatomical (e.g. oral hygiene, head/neck cancer, tracheoesophageal fistula, endobronchial obstruction, abdominal distension);
(b) neurological (e.g. stroke, neuromuscular disease, alcohol/drug intoxication); and (c) immunological (e.g. poorly controlled diabetes mellitus,
acquired immunodeficiency syndrome, leucopenia, immunoglobulin deficiency).

clinicians to provide good care. Rapid triaging of pneumonia S‑criterion defined as oxygen saturation of <90% as measured
can be done with one of several risk scores (e.g. Pneumonia by pulse oximetry at admission or on first physician contact
Severity Index, CURB‑65 and the Infectious Diseases Society without oxygen supplementation; C‑criterion defined as
of America/American Thoracic Society [IDSA/ATS] 2007 confusion; R‑criterion defined as respiratory rate ≥30/min;
criteria).[15,16] It must be emphasised that risk stratification B‑criterion defined as systolic blood pressure <90 mmHg or
using any score is imperfect[15‑18] and requires clinician gestalt diastolic blood pressure ≤60 mmHg; and 65‑criterion defined
as a safety net. Additionally, risk stratification by itself works as age ≥65 years. With wider availability of home‑based
only when its result is promptly linked to appropriate treatment pulse oximetry and digital blood pressure monitors, this
and disposition. score may even be applied via telemedicine. CRB‑65 ≥1
Examples of risk stratification tools for pneumonia that can be or DS‑CRB‑65 ≥2 predicts increased 30‑day mortality and
used without the need for laboratory testing are the CRB‑65[19] necessitates closely monitored management, most commonly
and the DS‑CRB‑65[20] scores [Table 3]. One point is assigned in an inpatient or, more recently, in a hospital‑at‑home setting.
to each of the following six criteria for the DS‑CRB‑65 score:
D‑criterion (comorbid diseases) defined as the presence of one ANTIMICROBIAL CHOICE FOR PNEUMONIA
or more of the following — congestive heart failure, chronic Pneumonia is caused by one or more pathogens which can
renal disease, chronic liver disease, cerebrovascular disease, directly damage the lung tissue. Early administration of
other chronic neurological disease or active malignancy; antimicrobials reduces the microbial load and blunts direct

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 See and Lau: Pneumonia in adults

Table 2. Selected clinical scenarios for pneumonia in adult patients.

Clinical scenario Patient characteristics Pathogen considerations
Immunocompetent Absence of immunosuppressive conditions and Pneumococcus; Mycoplasma; Legionella; influenza; SARS‑CoV‑2;
medications Pseudomonas (especially for severe pneumonia); Melioidosis
(especially for severe pneumonia in the tropics); tuberculosis
Immunocompromised Poorly controlled diabetes mellitus; solid‑organ transplant; Melioidosis; tuberculosis; Pneumocystis jirovecii; Aspergillosis;
haematopoietic stem cell transplant; high‑dose steroids moulds; Cytomegalovirus
and other immunosuppressive drugs; chemotherapy HIV
patients with low CD4 counts
Previous and recent exposure to Patients can be from the community or from healthcare‑ Methicillin‑resistant; Staphylococcus aureus; drug‑resistant
broad‑spectrum antimicrobials associated settings (e.g. nursing home and hospitals) Pseudomonas
Large volume aspiration Impaired consciousness; cardiac arrest; neurological Polymicrobial infection including anaerobes; check for
(macroaspiration) disorders with bulbar dysfunction; head‑and‑neck cancer; concomitant foreign body aspiration, which would need removal
poor cough; impaired cough reflex; aspiration pneumonitis via interventional bronchoscopy; for mild illness due to chemical
affects the most dependent regions of the lung and pneumonitis, antibiotics may be withheld and the patient reviewed
secondary bacterial infection may then set in in 48 h
Postoperative Inadequate fasting leading to aspiration risk; premature For mild illness due to chemical pneumonitis, antibiotics may be
extubation before return of protective airway reflexes withheld and the patient reviewed in 48 h
Ventilator acquired Invasive mechanical ventilation >48 h, via endotracheal Methicillin‑resistant S. aureus; Acinetobacter; Pseudomonas;
tube or tracheostomy Stenotrophomonas
HIV: human immunodeficiency virus, SARS‑CoV‑2: severe acute respiratory syndrome coronavirus 2

pathogenic attack. Empirical broad‑spectrum antimicrobials tuberculosis spread. At the same time, in such countries,
should be administered based on best available data. Such empirical use of respiratory fluoroquinolones (e.g. levofloxacin,
data include knowledge on local epidemiology and hospital moxifloxacin) should be avoided as these medications are also
antibiograms. used to treat tuberculosis. Using a single antituberculosis agent
leads to drug resistance and delays culture positivity should
Studies conducted before the coronavirus disease 2019
subsequent sputum testing be done.
(COVID‑19) pandemic in the Asia‑Pacific showed that
community‑acquired bacterial pneumonia was predominantly Immunocompromised patients are susceptible to myriad
d u e t o S t re p t o c o c c u s p n e u m o n i a e , M y c o p l a s m a pathogens. For example, patients with poorly controlled
pneumoniae, Haemophilus influenzae, Chlamydophila diabetes mellitus living in the tropics may be infected
pneumoniae and Staphylococcus aureus, though by melioidosis. Patients with human immunodeficiency
community‑acquired methicillin‑resistant S. aureus remained virus (HIV) and low CD4 counts may get Pneumocystis jirovecii
uncommon.[21] For severe cases, Klebsiella pneumoniae, pneumonia. In non‑HIV patients on long‑term steroids and
Burkholderia pseudomallei and severe influenza pneumonia other immunomodulatory agents (e.g. biological agents), both
were additional aetiologic considerations. Therefore, to tuberculosis and P. jirovecii pneumonia should be considered.
empirically treat community‑acquired bacterial pneumonia, Highly immunocompromised patients, like those who have
β‑lactam and macrolide combination therapy would generally recently undergone haematopoietic stem cell transplantation,
be sufficient, with broader gram‑negative cover and an may even be infected by fungi/moulds (e.g. Candida,
anti‑influenza agent also required for severe cases.[12] Aspergillus, Mucor) and parasites (e.g. Strongyloides).
During the COVID‑19 pandemic, many cases of
community‑acquired pneumonia were due to SARS‑CoV‑2. STEROID USE FOR PNEUMONIA
While treatment with antibiotics is commonly recommended The immune response to infection is an overlap of proinflammatory
for bacterial pneumonia, it would not be necessary in most and anti‑inflammatory processes, and the net effect could be
instances of mild‑to‑moderate COVID‑19 pneumonia. Another hyperinflammatory or immunosuppressive.[23] Apart from
instance where antibiotics may be withheld is mild aspiration direct pathogenic attack, excessive inflammation can also lead
pneumonia due to chemical pneumonitis.[22] to organ damage. Steroids and other anti‑inflammatory agents
(e.g. interleukin‑6 inhibitors) may have a role to mitigate
Certain clinical scenarios deserve special consideration
infection‑induced inflammation. However, these drugs are
to guide the identification of possible pathogens and drug
double‑edged swords. Excessive anti‑inflammatory agent use raises
resistance [Table 2]. In countries with mid‑to‑high tuberculosis
secondary infection risk and worsens overall clinical outcomes,
prevalence, careful attention to the chest radiograph is required
especially with concurrent infection‑induced immunosuppression.
to look for active pulmonary tuberculosis. The presence of
patchy infiltrates or cavitation in the upper lobes necessitates Nonetheless, appropriate patient selection and steroid dosing
early referral for sputum testing. This not only benefits the can improve clinical outcomes. A recommended indication for
patient clinically, but also improves public health by limiting steroids is pneumonia with refractory septic shock;[12] patients

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 See and Lau: Pneumonia in adults

onset), benefited from intravenous dexamethasone 20 mg once

Table 3. Prognostic scores (not requiring blood tests) for
daily (days 1–5), followed by 10 mg once daily (days 6–10),
pneumonia in adult patients.
which decreased 60‑day mortality.[27]
Condition Score components Interpretation
CRB‑65 C: Score 1 if confusion is present Total score SOURCE CONTROL AND ORGAN SUPPORT FOR
R: Score 1 if the respiratory rate 0: Low risk
is≥30/min 1–2: Intermediate risk PNEUMONIA
B: Score 1 if the systolic blood 3–4: High risk In most cases of pneumonia, a short course of antibiotics
pressure is<90 mmHg or
diastolic blood pressure is
Mortality over~30 days in over 5–7 days[12,13] brings about clinical improvement and
hospital‑based studies
≤60 mmHg eventual resolution of symptoms over the next 2–3 weeks.
Low risk: 2.4%
65: Score 1 if age is≥65 years
Intermediate risk: 13.3% Complicated forms of pneumonia respond less favourably to
High risk: 34.3% short courses of antibiotics alone. Pneumonia with abscess
Mortality over~30 days in formation, which can be diagnosed using computed tomography,
community-based studies requires an extended course over 4–6 weeks. For cases of
Low risk: 0%
parapneumonic effusion or empyema, source control with
Intermediate risk: 1.6%
High risk: 18.5%
drainage of infected pleural collections may be most expediently
DS‑CRB‑65 D: Score 1 if one or more Total score
done using ultrasound‑guided chest tube drainage. Poorly
comorbid diseases is present. 0–1: Low risk draining pleural collections may be due to viscous pus or
Comorbid diseases include 2: Intermediate risk pleural septations, which can be overcome by intrapleural dual
congestive heart failure, chronic
kidney disease, chronic liver
3–6: High risk lysis (comprising DNase and tissue plasminogen activator) or by
disease, cerebrovascular disease, Mortality over~30 days in video‑assisted thoracic surgery. Occasionally, pneumonia may
hospital–based studies
other chronic neurological be secondary to spread from an extrapulmonary source, such
diseases or active malignancy Low risk: 0–1%
Intermediate risk: 5% as from infective endocarditis or liver. Infective endocarditis
S: Score 1 if oxygen saturation
is <90% measured by pulse High risk: 10%–50% requires prolonged high‑dose antibiotics, while large liver
oximetry at admission or on first abscesses may require percutaneous or surgical drainage.
physician contact without oxygen
supplementation In patients with pneumonia, support of key organs involves
C: As in CRB‑65 reversal of shock, acute respiratory failure and acute kidney
R: As in CRB‑65 failure. Shock is most readily identified by delayed capillary
B: As in CRB‑65
refill >3 s and necessitates a rapid fluid challenge, even in the
65: As in CRB‑65
absence of hypotension (i.e. shock can exist even if the mean
arterial pressure is <65 mmHg, where the mean arterial pressure is
with an ongoing need for vasopressor therapy should receive the sum of one‑third of the systolic blood pressure and two‑thirds
200 mg/day of intravenous hydrocortisone, which speeds up of the diastolic blood pressure). Concomitant hypotension, if not
shock resolution.[24] For P. jirovecii pneumonia with hypoxaemia improved by fluid challenge, usually requires administration of
(arterial oxygen partial pressure <70 mmHg or peripheral vasopressors, for example, noradrenaline starting at a dose of
oxygen saturation <92% in room air), adjunctive corticosteroid 0.05 mcg/kg/min or dopamine starting at 5 mcg/kg/min. Acute
has mortality benefit for HIV‑positive patients (admittedly less respiratory failure can be readily detected by a peripheral oxygen
so for HIV‑negative patients).[25] The usual steroid regimen for saturation of <90% using routine pulse oximetry. Supplemental
P. jirovecii pneumonia with hypoxaemia consists of prednisolone oxygen using nasal prongs or face masks should be quickly
40 mg twice daily (days 1–5), followed by 40 mg/day (days 6–10) instituted pending further investigation (e.g. arterial blood
and then 20 mg/day (days 11–21). gas analysis) and before more advanced forms of respiratory
More recently, another accepted indication for steroids is support are used (e.g. non‑invasive or invasive mechanical
COVID-19 pneumonia. Patients with COVID-19 pneumonia ventilation). Renal failure may not be apparent initially
who require either invasive mechanical ventilation or and may be demonstrated clinically by oliguria (i.e. urine
supplemental oxygen benefit from oral or intravenous production <0.5 mL/kg body weight/h). Blood urea should be
dexamethasone 6 mg once daily for up to 10 days, which measured, and kidney replacement therapy is indicated when the
decreases 28‑day mortality.[26] In the DEXA‑ARDS trial, blood urea exceeds 39.9 mmol/L or if oliguria persists for >72 h.[28]
which requires further validation, non-COVID‑19 patients
with persistent moderate‑to‑severe acute respiratory distress RELATED CONDITIONS LEADING TO PNEUMONIA
syndrome (ARDS) (defined by a ratio of partial pressure When pneumonia is confirmed, identification and treatment of
of arterial oxygen to the fraction of inspired oxygen [FiO2] underlying causes can help reduce recurrence. Bacterial burden
of ≤200 mmHg assessed with a positive end‑expiratory is increased with poor oral hygiene, which is readily apparent.
pressure of ≥10 cmH2O and FiO2 of ≥0.5 at 24 h after ARDS Aspiration risk is increased in the presence of anatomical

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 See and Lau: Pneumonia in adults

or neurological anomalies. Anatomical anomalies include could develop despite appropriate antibiotics, and the patient
head/neck cancer (before or after treatment with radiotherapy), may require further chest imaging and drainage.
tracheoesophageal fistula (e.g. due to oesophageal cancer) and
endobronchial obstruction (e.g. due to foreign body aspiration TAKE‑HOME MESSAGES
or endobronchial cancer). For the latter, a fixed and localised 1. Pneumonia is a clinical diagnosis marked by a combination
wheeze may be detected on physical examination. Neurological of cough, phlegm production, fever and lung crepitations,
anomalies affecting bulbar function (e.g. stroke, neuromuscular which suggest infection of the lung parenchyma.
disease, alcohol/drug intoxication) can present with audible 2. Even without any chest imaging or microbiological
gurgling. testing, presumed pneumonia based on clinical features
alone needs prompt attention from frontline clinicians.
Both anatomical and neurological anomalies exist in
3. The general approach to pneumonia in adult patients requires
post‑operative pneumonia, which occurs after 0.5%–28% of consideration of differential diagnoses, risk stratification,
general surgical operations and 2%–54% of cardiothoracic appropriate antimicrobials, source control, organ
surgical procedures.[29] High‑risk patients may be identified support and treating related conditions (e.g. anatomical,
before non‑cardiothoracic surgery using a variety of clinical neurological and immunological conditions).
tools.[30,31] Anatomically, abdominal splinting due to ascites or 4. Rapid triaging of pneumonia can be done with one of
bowel obstruction may result in macroaspiration if not adequately several risk scores (e.g. CRB-65, DS-CRB-65).
decompressed. Neurologically, post‑operative analgesia may 5. Patients with uncomplicated pneumonia should complete
impair cough and secretion clearance, leading to atelectasis and a short course of antibiotics, typically over 5–7 days.
pneumonia in patients undergoing prolonged bedrest.
Closing Vignette
Immunological suppression not only makes the patient The patient was diagnosed with community‑acquired
vulnerable to pneumonia, but also increases the chance pneumonia. Based on her low blood pressure of 80/50 mmHg
of less‑common infections. Some conditions leading to and peripheral oxygen saturation of 89% in room air, her
immunological suppression are modifiable. Poorly controlled DS‑CRB‑65 score was 2. Intravenous normal saline 500 mL
diabetes mellitus requires glucose control while avoiding and supplemental oxygen via nasal prongs were administered.
hypoglycaemia, and a glucose target range of 7.8–10 mmol/L is An ambulance was called to bring her to the nearest emergency
reasonable in critically ill diabetic patients with pneumonia.[32] department. Her blood pressure improved to 120/90 mmHg
Acquired immunodeficiency syndrome requires early institution after a further 1,000 mL of normal saline was administered.
of antiretroviral therapy. Leucopenia may be reversed using She was also given intravenous amoxicillin–clavulanic acid
granulocyte colony‑stimulating factor, while immunoglobulin and oral azithromycin and admitted to the general ward. Her
deficiency may be overcome with immunoglobulin infusion. initial chest X‑ray showed right‑sided consolidation and no
pleural effusion. Blood cultures did not have any bacterial
FOLLOW‑UP AFTER THE ACUTE EPISODE OF growth. Polymerase chain reaction tests for COVID‑19,
PNEUMONIA influenza and tuberculosis were negative. Her fever resolved on
Patients who receive appropriate therapy for pneumonia should the third day of hospitalisation, and she was discharged from
improve clinically within 48–72 h,[12,14] though complete
the hospital with another 4 days of oral amoxicillin–clavulanic
acid. Follow‑up chest X‑ray at 2 months showed complete
disease resolution takes a longer time. Post‑pneumonia cough
resolution of the right‑sided consolidation.
may persist for several weeks. Decreased physical function
may continue for months, necessitating graduated return
Financial support and sponsorship
to pre‑illness exercise levels. Radiological resolution takes
Nil.
2–3 months for most patients, and follow‑up chest radiographs
may be done then.[33] Persistent radiological abnormalities Conflicts of interest
should prompt consideration of pulmonary tuberculosis, which See KC is the handling editor of the PACC series.
is endemic in Singapore, and alternative diagnoses like lung
Kay Choong See1, MRCP, MPH, Yie Hui Lau2, MBBS, MMed (Anaes)
cancer in a patient with risk factors (e.g. smoking/elderly). 1
Division of Respiratory and Critical Care Medicine, Department of Medicine,
Patients who improve clinically should complete a short National University Hospital, 2Department of Anaesthesiology, Intensive Care
and Pain Medicine, Tan Tock Seng Hospital, Singapore
course of antibiotics, typically over 5–7 days.[12‑14] If culture
results are available, these should be used to de‑escalate Correspondence: Dr. Kay Choong See,
broad‑spectrum antibiotics. Patients who do not improve Division of Respiratory and Critical Care Medicine, Department of Medicine,
within 48–72 h of receiving appropriate empirical treatment National University Hospital, 1E Kent Ridge Road,
NUHS Tower Block Level 10, 119228, Singapore.
should be re‑evaluated for differential diagnoses and for the E‑mail: [email protected]
development of complications of pneumonia. The concepts
outlined in Figure 1 can be revisited. For instance, empyema Received: 27 Mar 2022  Accepted: 31 Jul 2022  Published: 28 Feb 2023

214 Singapore Medical Journal ¦ Volume 64 ¦ Issue 3 ¦ March 2023

 See and Lau: Pneumonia in adults

REFERENCES factors for mortality due to pneumonia among adults from different
age groups in Singapore and mortality predictions based on PSI and
1. Strom JJ, Haugen PS, Hansen MP, Graumann O, Jensen MBB, CURB‑65. Singapore Med J 2018;59:190‑8.
Aakjaer Andersen C. Accuracy of lung ultrasonography in the hands 19. McNally M, Curtain J, O’Brien KK, Dimitrov BD, Fahey T. Validity
of non‑imaging specialists to diagnose and assess the severity of of British Thoracic Society guidance (the CRB‑65 rule) for predicting
community‑acquired pneumonia in adults: A systematic review. BMJ the severity of pneumonia in general practice: Systematic review and
Open 2020;10:e036067. meta‑analysis. Br J Gen Pract 2010;60:e423‑33.
2. Ebell MH, Bentivegna M, Cai X, Hulme C, Kearney M. Accuracy of 20. Dwyer R, Hedlund J, Henriques‑Normark B, Kalin M. Improvement of
biomarkers for the diagnosis of adult community‑acquired pneumonia: CRB‑65 as a prognostic tool in adult patients with community‑acquired
A meta‑analysis. Acad Emerg Med 2020;27:195‑206. pneumonia. BMJ Open Respir Res 2014;1:e000038.
3. Kamat IS, Ramachandran V, Eswaran H, Guffey D, Musher DM. 21. Song JH, Huh K, Chung DR. Community‑acquired pneumonia in the
Procalcitonin to distinguish viral from bacterial pneumonia: A systematic Asia‑Pacific Region. Semin Respir Crit Care Med 2016;37:839‑54.
review and meta‑analysis. Clin Infect Dis 2020;70:538‑42. 22. Mandell LA, Niederman MS. Aspiration pneumonia. N Engl J Med
4. Gentilotti E, De Nardo P, Cremonini E, Gorska A, Mazzaferri F, 2019;380:651‑63.
Canziani LM, et al. Diagnostic accuracy of point‑of‑care tests in acute 23. Hotchkiss RS, Monneret G, Payen D. Sepsis‑induced
community‑acquired lower respiratory tract infections. A systematic immunosuppression: From cellular dysfunctions to immunotherapy. Nat
review and meta‑analysis. Clin Microbiol Infect 2022;28:13‑22. Rev Immunol 2013;13:862‑74.
5. Salzer HJF, Schafer G, Hoenigl M, Gunther G, Hoffmann C, 24. Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM,
Kalsdorf B, et al. Clinical, diagnostic, and treatment disparities between French C, et al. Surviving sepsis campaign: International guidelines
HIV‑infected and non‑HIV‑infected immunocompromised patients with for management of sepsis and septic shock 2021. Intensive Care Med
pneumocystis jirovecii pneumonia. Respiration 2018;96:52‑65. 2021;47:1181‑247.
6. Shimada T, Noguchi Y, Jackson JL, Miyashita J, Hayashino Y, 25. Lemiale V, Debrumetz A, Delannoy A, Alberti C, Azoulay E. Adjunctive
Kamiya T, et al. Systematic review and metaanalysis: Urinary antigen steroid in HIV‑negative patients with severe Pneumocystis pneumonia.
tests for legionellosis. Chest 2009;136:1576‑85. Respir Res 2013;14:87.
7. Del Rio‑Pertuz G, Gutierrez JF, Triana AJ, Molinares JL, 26. Group RC, Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, et al.
Robledo‑Solano AB, Meza JL, et al. Usefulness of sputum gram stain Dexamethasone in hospitalized patients with Covid‑19. N Engl J Med
for etiologic diagnosis in community‑acquired pneumonia: A systematic 2021;384:693‑704.
review and meta‑analysis. BMC Infect Dis 2019;19:403. 27. Villar J, Ferrando C, Martinez D, Ambros A, Munoz T, Soler JA, et al.
8. Steingart KR, Ng V, Henry M, Hopewell PC, Ramsay A, Cunningham J, Dexamethasone treatment for the acute respiratory distress syndrome:
et al. Sputum processing methods to improve the sensitivity of smear A multicentre, randomised controlled trial. Lancet Respir Med
microscopy for tuberculosis: A systematic review. Lancet Infect Dis 2020;8:267‑76.
2006;6:664‑74. 28. Gaudry S, Palevsky PM, Dreyfuss D. Extracorporeal kidney‑replacement
9. Zifodya JS, Kreniske JS, Schiller I, Kohli M, Dendukuri N, therapy for acute kidney injury. N Engl J Med 2022;386:964‑75.
Schumacher SG, et al. Xpert ultra versus xpert MTB/RIF for 29. Chughtai M, Gwam CU, Mohamed N, Khlopas A, Newman JM, Khan R,
pulmonary tuberculosis and rifampicin resistance in adults with et al. The epidemiology and risk factors for postoperative pneumonia.
presumptive pulmonary tuberculosis. Cochrane Database Syst Rev J Clin Med Res 2017;9:466‑75.
2021;2:CD009593. doi: 10.1002/14651858.CD009593.pub4. 30. Laporta ML, Kruthiventi SC, Mantilla CB, Johnson RL,
10. Au WY, Cheung PPH. Diagnostic performances of common nucleic Sprung J, Portner ER, et al. Three risk stratification tools and
acid tests for SARS‑CoV‑2 in hospitals and clinics: A systematic review postoperative pneumonia after noncardiothoracic surgery. Am Surg
and meta‑analysis. Lancet Microbe 2021;2:e704‑14. 2021;87:1207‑13.
11. Collaborators GBDLRI. Estimates of the global, regional, and national 31. Kokotovic D, Degett TH, Ekeloef S, Burcharth J. The ARISCAT score
morbidity, mortality, and aetiologies of lower respiratory infections in is a promising model to predict postoperative pulmonary complications
195 countries, 1990‑2016: A systematic analysis for the Global Burden after major emergency abdominal surgery: An external validation in a
of Disease Study 2016. Lancet Infect Dis 2018;18:1191‑210. Danish cohort. Eur J Trauma Emerg Surg 2022;48:3863‑7.
12. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, 32. See KC. Glycemic targets in critically ill adults: A mini‑review. World J
et al. Diagnosis and treatment of adults with community‑acquired Diabetes 2021;12:1719‑30.
pneumonia. An official clinical practice guideline of the American 33. Bruns AH, Oosterheert JJ, Prokop M, Lammers JW, Hak E,
Thoracic Society and Infectious Diseases Society of America. Am J Hoepelman AI. Patterns of resolution of chest radiograph abnormalities
Respir Crit Care Med 2019;200:e45‑67. in adults hospitalized with severe community‑acquired pneumonia. Clin
13. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Infect Dis 2007;45:983‑91.
Palmer LB, et al. Management of adults with hospital‑acquired and
ventilator‑associated pneumonia: 2016 Clinical practice guidelines by
the Infectious Diseases Society of America and the American Thoracic This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
Society. Clin Infect Dis 2016;63:e61‑111.
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
14. Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Le Jeune I,
is given and the new creations are licensed under the identical terms.
et al. BTS guidelines for the management of community acquired
pneumonia in adults: Update 2009. Thorax 2009;64(Suppl 3):iii1‑55.
15. Noguchi S, Yatera K, Kawanami T, Fujino Y, Moro H, Aoki N, et al. Access this article online
Pneumonia severity assessment tools for predicting mortality in patients Quick Response Code:
with healthcare‑associated pneumonia: A systematic review and Website:
meta‑analysis. Respiration 2017;93:441‑50. https://journals.lww.com/SMJ
16. Chalmers JD, Mandal P, Singanayagam A, Akram AR, Choudhury G,
Short PM, et al. Severity assessment tools to guide ICU admission in
community‑acquired pneumonia: Systematic review and meta‑analysis. DOI:
Intensive Care Med 2011;37:1409‑20. 10.4103/singaporemedj.SMJ-2022-050
17. Chalmers JD, Singanayagam A, Akram AR, Mandal P, Short PM,
Choudhury G, et al. Severity assessment tools for predicting mortality in
hospitalised patients with community‑acquired pneumonia. Systematic
review and meta‑analysis. Thorax 2010;65:878‑83. How to cite this article: See KC, Lau YH. Acute management of pneumonia
18. Zhang ZX, Yong Y, Tan WC, Shen L, Ng HS, Fong KY. Prognostic in adult patients. Singapore Med J 2023;64:209-16.

Singapore Medical Journal ¦ Volume 64 ¦ Issue 3 ¦ March 2023 215

 See and Lau: Pneumonia in adults

SMC CATEGORY 3B CME PROGRAMME

Online Quiz: https://www.sma.org.sg/cme‑programme
Deadline for submission: 6 pm, 10 April 2023

Question True False

1. In the absence of chest radiography, point‑of‑care lung ultrasound may be used to diagnose pneumonia.
2. G
 enotyping for the detection of antibiotic resistance‑related mutations may replace culture as the reference
standard for drug susceptibility testing.
3. F or a test to be useful in ruling out a diagnosis/aetiology, its specificity should be high (e.g. ≥90%).
4. R
 isk scores such as Pneumonia Severity Index, CURB‑65 and the Infectious Diseases Society of America/
American Thoracic Society (IDSA/ATS) 2007 criteria require laboratory testing.
5. In countries with mid‑to‑high tuberculosis prevalence, empirical use of respiratory fluoroquinolones for
pneumonia should be avoided.
6. A recommended indication for steroids is pneumonia with refractory septic shock.
7. Adjunctive steroids can improve survival for all patients with Pneumocystis jirovecii pneumonia.
8. Adjunctive steroids can improve survival for all patients with COVID‑19 pneumonia.
9. Most cases of bacterial pneumonia can be successfully treated with 5–7 days of antibiotics.
10. P
 neumonia with abscess formation, which can be diagnosed using computed tomography, requires an extended
course over 4–6 weeks.
11. Treatment of lung abscesses generally requires percutaneous drainage or surgery.
12. P
 oorly draining pleural collections, which may be due to viscous pus or pleural septations, can be treated with
intrapleural dual lysis (comprising DAase and tissue plasminogen activator).
13. F or adult patients with pneumonia, kidney replacement therapy is indicated when the blood urea exceeds
39.9 mmol/L or if oliguria persists for >72 h.
14. A
 glucose target range of 4.4–6.1 mmol/L is reasonable in critically ill diabetic patients with pneumonia.
15. Patients who receive appropriate therapy for pneumonia should improve clinically within 48–72 h.
16. Radiological resolution of pneumonia takes 2–3 weeks for most patients.
17. S
 erum C‑reactive protein >10 mg/L is more specific than sensitive for diagnosis of community‑acquired
pneumonia.
18. S
 erum procalcitonin >0.5 mcg/L is more specific than sensitive for diagnosis of community‑acquired
pneumonia.
19. Serum mycoplasma IgG Ab may be used to diagnose acute mycoplasma lower respiratory tract infection.
20. Influenza A/B polymerase chain reaction test using respiratory sample is highly sensitive and specific for the
diagnosis of influenza lower respiratory tract infection.

216 Singapore Medical Journal ¦ Volume 64 ¦ Issue 3 ¦ March 2023