Review articles
 

By Mr. Chen K Ming , Ms. Jayne Lim C Ying , Ms. Nur Sobah B Mohd Shafie , Ms. Ong G Tian , Ms. Tey W Ni , Prof. Mohd Zaini Asmawi
Corresponding Author Prof. Mohd Zaini Asmawi
Universiti Sains Malaysia, - Malaysia
Submitting Author Mr. Chen K Ming
Other Authors Mr. Chen K Ming
Universiti Sains Malaysia, - Malaysia

Ms. Jayne Lim C Ying
Universiti Sains Malaysia, - Malaysia

Ms. Nur Sobah B Mohd Shafie
Universiti Sains Malaysia, - Malaysia

Ms. Ong G Tian
Universiti Sains Malaysia, - Malaysia

Ms. Tey W Ni
Universiti Sains Malaysia, - Malaysia

LUNG

A Very Brief Introduction to Pneumonia

Ming CK, Ying JC, Mohd Shafie NB, Tian OG, Ni TW, Asmawi M. Pneumonia. WebmedCentral LUNG 2011;2(12):WMC002697
doi: 10.9754/journal.wmc.2011.002697

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
No
Submitted on: 18 Dec 2011 11:48:18 AM GMT
Published on: 19 Dec 2011 03:43:52 PM GMT

Abstract


Pneumonia is a type of lung infection which can be caused by bacteria, virus or fungi. It is very common among children especially those under 5 years old. Basically, pneumonia can be classified into hospital-acquired pneumonia and community-acquired pneumonia. Bacterial pneumonia, viral pneumonia, fungal pneumonia and aspiration pneumonia are some types of pneumonia classified according to the type of disease-causing agent. The common signs and symptoms of pneumonia are chest pain, shortness of breath, shaking chills and cough. However, different types of pneumonia do show specific signs and symptoms. Diagnosis of pneumonia can be done in several ways. Different type of pneumonia needs different treatment. In order to prevent pneumonia, personal hygiene and vaccination is a must.

Introduction


What is pneumonia?
Pneumonia is a type of respiratory disease in which the lungs are infected by bacteria, viruses or fungi. It makes our lungs not to be able to function properly and thus can cause many unwanted, severe problems such as respiratory difficulties. Besides that, pneumonia may lead to other diseases such as meningitis, etc. (American Lung Association 2011)
Pneumonia is a very common disease among children less than 5 years old in developing nations as it cause up to 5 million deaths among them each year. According to National Health and morbidity survey 1996 -1997 Report 1997, there were estimated to be total of 12.9 million deaths in the whole world in 1990 in children under 5 years old and over 3.6 million (28%) of the number was caused by pneumonia. Besides children, adults especially the elderly can also get pneumonia. (Maimunah AH, Patmanathan I 1987) (Maimumah et al. 1997)
Types of pneumonia(American Lung Association 2011)(Pneumonia: Classification of Pneumonia 2011)(Is pneumonia contagious n.d.)
Basically, pneumonia can be classified as hospital-acquired pneumonia (nosocomial) and community-acquired pneumonia. As the name suggests, hospital-acquired pneumonia is acquired when someone is staying at hospital while community-acquired pneumonia is acquired when someone is staying outside the hospital. Hospital-acquired pneumonia is more serious and dangerous than community-acquired pneumonia as the germs in hospital are more resistant to the drugs given.
There are several types of pneumonia which are bacterial pneumonia, viral pneumonia, fungal pneumonia and also aspiration pneumonia. Pneumonia is divided into these several types based on the agents causing this disease.
Bacterial pneumonia is a type of pneumonia caused by bacteria. Pneumonia-causing bacteria can be divided into typical bacteria and atypical bacteria. Typical bacteria include Streptococcus pneumonia, Staphylococcus pneumonia and Haemophilus influenza while atypical bacteria include Mycoplasma pneumonia, Legionella pneumonia and Chlamydia pneumonia. All of them can cause pneumonia.
Viral pneumonia
Besides bacteria, viruses may also cause pneumonia among human being. In fact, viruses are believed to cause about 50% of the pneumonia cases although viruses-causing pneumonia is less serious than bacteria-causing pneumonia. Viral pneumonia causes most of the pneumonia infection in very young people. Different type of viruses such as flu virus, herpes simplex virus, rhinovirus, cytomegalovirus, etc can cause pneumonia. Cytomegalovirus-causing pneumonia is very common among immune-suppressed patients such as those undergoing transplant processes and AIDS patients.
Fungal Pneumonia
Other than bacteria and viruses, fungi may also cause pneumonia which is a very rare case. Fungal infections such as actinomycosis, cryptococcosis, aspergillosis, histoplasmosis, coccidiomycosis, blastomycosis and nocardiosis may lead to pneumonia. The most common pneumonia-causing fungus is Pneumocytosis carinii. Pneumocytosis carinni is generally present in our surroundings and is very common among immune-suppressed patients such as AIDS patients and cancer patients. AIDS patients are more often to be infected by this type of fungus.
What is pneumonia?
Pneumonia is a type of respiratory disease in which the lungs are infected by bacteria, viruses or fungi. It makes our lungs not to be able to function properly and thus can cause many unwanted, severe problems such as respiratory difficulties. Besides that, pneumonia may lead to other diseases such as meningitis, etc. (American Lung Association 2011)
Pneumonia is a very common disease among children less than 5 years old in developing nations as it cause up to 5 million deaths among them each year. According to National Health and morbidity survey 1996 -1997 Report 1997, there were estimated to be total of 12.9 million deaths in the whole world in 1990 in children under 5 years old and over 3.6 million (28%) of the number was caused by pneumonia. Besides children, adults especially the elderly can also get pneumonia. (Maimunah AH, Patmanathan I 1987) (Maimumah et al. 1997)
Types of pneumonia(American Lung Association 2011)(Pneumonia: Classification of Pneumonia 2011)(Is pneumonia contagious n.d.)
Basically, pneumonia can be classified as hospital-acquired pneumonia (nosocomial) and community-acquired pneumonia. As the name suggests, hospital-acquired pneumonia is acquired when someone is staying at hospital while community-acquired pneumonia is acquired when someone is staying outside the hospital. Hospital-acquired pneumonia is more serious and dangerous than community-acquired pneumonia as the germs in hospital are more resistant to the drugs given.
There are several types of pneumonia which are bacterial pneumonia, viral pneumonia, fungal pneumonia and also aspiration pneumonia. Pneumonia is divided into these several types based on the agents causing this disease.
Bacterial pneumonia is a type of pneumonia caused by bacteria. Pneumonia-causing bacteria can be divided into typical bacteria and atypical bacteria. Typical bacteria include Streptococcus pneumonia, Staphylococcus pneumonia and Haemophilus influenza while atypical bacteria include Mycoplasma pneumonia, Legionella pneumonia and Chlamydia pneumonia. All of them can cause pneumonia.
Viral pneumonia
Besides bacteria, viruses may also cause pneumonia among human being. In fact, viruses are believed to cause about 50% of the pneumonia cases although viruses-causing pneumonia is less serious than bacteria-causing pneumonia. Viral pneumonia causes most of the pneumonia infection in very young people. Different type of viruses such as flu virus, herpes simplex virus, rhinovirus, cytomegalovirus, etc can cause pneumonia. Cytomegalovirus-causing pneumonia is very common among immune-suppressed patients such as those undergoing transplant processes and AIDS patients.
Fungal Pneumonia
Other than bacteria and viruses, fungi may also cause pneumonia which is a very rare case. Fungal infections such as actinomycosis, cryptococcosis, aspergillosis, histoplasmosis, coccidiomycosis, blastomycosis and nocardiosis may lead to pneumonia. The most common pneumonia-causing fungus is Pneumocytosis carinii. Pneumocytosis carinni is generally present in our surroundings and is very common among immune-suppressed patients such as AIDS patients and cancer patients. AIDS patients are more often to be infected by this type of fungus.
Aspiration Pneumonia
Although pneumonia is more commonly caused by bacteria, viruses and fungi, it can also occur when people inhale any foreign materials such as food, drinks, dust and secretions from mouth or stomach, etc within lung area.
Aspiration pneumonia occurs when someone has inflammation of bronchial tubes after he inhales foreign materials within the lungs. Pus will be formed in the lungs, leading to pneumonia. The more acidic the inhaled foreign materials, the more serious the pneumonia caused.
People who having dental problems, old age, having sedative drugs, being alcoholic, coma, and anesthesia are more easily to get this type of pneumonia. (Bible Health 2011)
Who are at risk?
People at high risk getting pneumonia include the elderly (above 65 years old) and the very young. Those having health problems such chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure, asthma and sickle cell anemia may easily get pneumonia too.
Besides that, the immune-suppressed patients such as AIDS patients and patients undergoing transplant processes are very vulnerable to pneumonia. Lastly, people practicing unhealthy lifestyle such as smokers are also more likely to get pneumonia. (American Lung Association 2011) (How do you get pneumonia n.d.)


Signs and Symptoms


Different types of pneumonia might show some specific signs and symptoms. This is can be seen by the pneumonia caused by different microorganisms which show different signs and symptoms. (Baum et al. 2009, chapter 184)
Despite those specific signs and symptoms, all types of pneumonia do share the common symptoms such as chest pain, shortness of breath, shaking chills, and cough. Chest pain experienced by pneumonia patients is caused by the inflammation of lungs and it occurs adjacently to the infected area. (Watkins RR, Lemonovisch 2011).
Normally, a pneumonia patient will experience shortness of breath when he is doing some light exercise or climbing a stair. In other words, a pneumonia patient feel tired easily and is lack of breath as compared to usual people. However, different symptoms appear in different ages of patients. For instances, cough usually occur in older children and adults and dry occurs in infants, young children and the elderly. (John G. Barlett, MD 2008)
A pneumonia patient may show signs such as fever, dullness to percussion[1], egophony[2], tachycardia[3], tachypnea[4] and are fairly sensitive for pneumonia patient. (Watkins RR, Lemonovisch 2011).
Often, the elderly does not develop fever while the infants commonly will have nasal flaring[5] and cyanosis[6]. (John G. Barlett, MD 2008) A pneumonia patient may have some rare signs of pneumonia such as asymmetric breath sounds and pleural rubs.
Viral pneumonia shares some similar signs and symptoms with bacterial pneumonia which are fever, lethargy and rapid heartbeat or breathing. (Bible Health 2010)
On the other hand, fungal pneumonia is a rare disease. Fungal pneumonia has the same sign as bacterial pneumonia which may include fever and increase in heartbeat. (Drager: Technology for Life n.d.)
Aspiration pneumonia is a result of inhalation of foreign materials. Sometimes it may take a few days for symptoms of aspiration pneumonia to begin. Common signs and symptoms include frequent coughing, fever, chest pain, dizzy or trouble in swallowing. (Is pneumonia contagious n.d.)
[1] The act of striking a part with short, sharp blows as an aid in diagnosing the condition of the underlying parts by the sound obtained
[2] Increased resonance of voice sounds, with a high-pitched bleating quality, heard especially over lung tissue compressed by pleural effusion
[3] Abnormal rapid heart beat
[4] Very rapid respiration
[5] The enlargement of the opening nostrils during breathing
[6] A bluish discoloration of skin and mucous membranes due to excessive concentration of reduced hemoglobin in the blood.

Diagnosis


Knowing the signs and symptoms only is not enough to treat the pneumonia. Diagnosis should be done in further to choose the right and more effective treatment.
Understanding the patient’s medical and personal history is important before making a pneumonia diagnosis. It is because pneumonia may be caused by chronic diseases such as lung disease and the treatment will be totally different from those who have no chronic diseases or any medical history.
Diagnosis of pneumonia is typically based on chest x-ray, consideration of pulmonary embolism and sometimes identification of pathogen. (Watkins RR, Lemonovisch TL 2011)
Chest radiography or chest x-ray is the most common way to diagnose pneumonia. It is used to check which part of lungs is infected and it can show the abnormal fluid collection in the lungs which leads to pneumonia. Chest x-ray is recommended to the patients showing complicated signs and symptoms. However, the x-ray findings may be different for different types of pneumonia. (John G. Bartlett, MD. 2008)
Besides that, tests such as laboratory tests and listening to heart and lungs through stethoscope are also some common diagnosis for pneumonia patients. (Drager: Technology for Life n.d.) Laboratory testing such as white blood cells count, serum electrolytes, blood tests and creatinine testing are recommended for hospitalized-acquired pneumonia patients to test the severity of disease. (Kathleen L. DePippo, MS et al. 1992) Blood test is carried out to see whether the patients’ immune system is working to fight against the pneumonia or not. The tests are conducted to see how severe the pneumonia is.
However, for aspiration pneumonia patient, tests such as swallowing studies or special tests of throat or esophagus might work better. (Kathleen L. DePippo, MS et al. 1992) (Hoeve L.J., Rombout J., Pot D.J. 2007)
Other than that, sputum cultures can also be carried out to identify the microorganism that causes pneumonia. (Drager: Technology for Life n.d.) It is advisable to identify a pathogen in patients who are showing therapeutic failure or are critically ill. Pathogen identification is important as different pathogen-causing pneumonia needs different treatment. For example, antibiotics are prescribed for bacterial pneumonia but not viral pneumonia. Besides the type of pneumonia, different type of bacteria-causing pneumonia may need different antibiotics. (Baum SG et al. n.d.)
Other investigations like urea and electrolytes examination and liver function tests are also recommended for patients with non-severe community acquired pneumonia. (Baum SG et al. n.d.)

Preventions


As idiom goes “prevention is better than cure”, prevention of pneumonia is always important before someone suffering painfully from it and it may lead to death at the end if proper treatment is not undertaken.
The best way to prevent pneumonia is to practice healthy lifestyle.
Avoid and stop smoking
As smoking can seriously damage our lungs’ natural defence against infection, we will have a higher chance to get pneumonia if we smoke (University of Maryland Medical Syatem n.d.). So, don’t smoke and stop smoking today to have healthier lungs and to have lower chance to get pneumonia.
Get enough rest and stay fit
There are some types of pneumonia that invade immunosuppressed patients. In other words, they attack people who have low immune system. So, in order to prevent this type of pneumonia, strengthening of immune system is a must. Getting enough rest, doing exercise frequently and eating healthy diet including plenty of fat-free dairy products, fruits, vegetables and whole grains can help to boost up our immune system.(Mayoclinic n.d.)
Hygiene
Since pneumonia is an infectious disease that can be transmitted from one to another especially during hot weather, maintaining good personal hygiene is a must to prevent someone from getting the transmitted pneumonia. Usually, pneumonia is caused by flu and cough that are transmitted from one to another through shaking hands. Thus, washing hands frequently after coming back from outside and before meals with soaps or to be more effective by antibacterial soaps can prevent the transmission of pneumonia.
As an infectious disease, pneumonia can also be transmitted through the wounds. Hence, proper handling and care of wounds are needed. A wound should be cleaned and covered with dry plasters or clothing. Besides that, sharing of personal items such as toothbrush, towel and razor should be strictly restricted (University of Maryland Medical Syatem n.d.).
Hospital settings
The best way to prevent someone from getting hospital-acquired pneumonia is to stay away from hospital. As hospitals are full of bacteria, children and the elderly are advised not to go to hospital as they have weaker immune system than usual people.
However, it is impossible for people working at hospital such as doctor, physician, nurses, hospital pharmacist and the hospitalised patients from staying away from the hospitals. Hence, education should be given to those who cannot stay away from hospital on how to reduce the transmission of bacteria. For example, sharing of personal items among the hospitalised patients is strictly forbidden. Besides that, the shared medical equipments and patients’ bed-sheets should be cleaned frequently. The proper of handling patient’s wound should also be given to the hospital’s staff so that the chance for them to get the transmitted disease from the patients is reduced to a safe level.
Vaccines
Another way to prevent pneumonia is to get vaccination. Vaccine helps someone to get immuned to pneumonia by stimulating the body to make antibodies against pneumonia and hence the chance for him to get pneumonia is greatly reduced.
Generally, there are two types of pneumonia vaccines which are for the children and the adults respectively. The vaccine for children is called the 7-valent pneumococcal conjugate vaccine (Prevnar, PCV7). More than one dose is given to the children younger than 2 years old but the children older than 2 years old just need 1 dose of the vaccine. (Gross PA et. Al 1995)(Secretariat n.d.)Similarly, there is vaccine for adults called the 23-valent pneumococcal polysaccharide vaccine (Pneumovax, Pnu-Immune). Only one dose of vaccine is needed for this type of vaccination.
Vaccination is recommended for the people of this following:
People aged 65 and over
People who smoke
People who have serious chronic diseases such as lung disease which may lead to pneumonia eventually.
People who have weaker immune system including those receiving organ transplant, AIDS patients and cancer patients
The young children
People staying at hospital for long period of time (George C. Schiffman, MD, FCCP n.d.)
Besides vaccines for pneumonia, other vaccine which can prevent common diseases that may lead to pneumonia is also available such as viral flu vaccine.

Treatments


The treatments for pneumonia depend on the type of pneumonia and the severity of the condition.
The most common type of pneumonia is community-acquired pneumonia. Normally, people who have community-acquired pneumonia will be treated at home provided his condition is not very serious.
The treatment plan must be followed and all medicines must be taken as prescribed and ongoing medical care should be seeked. The doctor may want to have a chest x ray on the patient to make sure the pneumonia is gone thus follow up is necessary. Fatigue can persist for up to a month or more though the patients may start to feel better after a few days or weeks. People who are treated in the hospital may need minimum 3 weeks before they resume normal routines. (National Heart Lung and Blood Institute 2011)
Most people can be treated at home by following these steps:
Drinking plenty of fluids to help loosen secretions and bring up the phlegm.
Resting alone.
Cough medicines may make it harder for your body to cough up the extra sputum. Thus, do not take cough medicines without consulting the doctor first.
Controlling fever with acetaminophen, aspirin or non-steroidal anti-inflammatory drugs. But never give aspirin to children. (National Heart Lung and Blood Institute 2011)
Bacterial Pneumonia
In order to cure this type of pneumonia, antibiotics will be a wise choice to kill the bacteria.
Streptococcus pneumonia
Antibiotics including penicillin such as amoxicillin in combination with clavulanic acid and macrolide antibiotics such as erythromycin, azithromycin and clarithromycin are used to treat this type of pneumonia. Macrolide is used for penicillin-resistant Streptococcus pneumonia.
oral fluoroquinolones is used in the treatment of mild to moderate community-acquired pneumonia. However, overuse of fluoroquinolones as a single agent may promote quinolone resistance.
Besides that, for elderly patient, combination therapy with a beta-lactam and macrolide may give a better outcome in hospitalised patients. (Neralla S, Meyer KC 2009)
Klebsiella pneumonia
The antibiotics that can be used are second and third generation cephalosporins, amoxicillin in combination with clavulanic acid, fluoroquinolones (levofloxacin), oral moxifloxacin, and trimethoprim in combination with sulfamethoxazole.(Smego RA et. Al 2001) Besides that, tigecycline can be used too but its significance side effect (empyema recurrence) should be considered first before giving the treatment. (Daly MW et. Al 2007)
Mycoplasma pneumonia
Macrolides such as erythromycin, clarithromycin and azithromycin is the first line of therapy use in the treatment of community-acquired pneumonia that is not responsive to beta-lactam antibiotics alone. (Averbuch D et. al 2010) (Lung DC et. al 2010) (Waites KB, Talkington DF 2004) Tetracycline and fluoroquinolone are groups of antimicrobials that can be used to treat this disease too.
However, both tetracyclines and fluoroquinolones are not recommended for use in children. Fluoroquinolones are not recommended for use in children younger than 18 years of age due to their potential for damaging cartilage whereas tetracyclines is limited to children older than 8 years due to their liability to cause permanent dental discolouration. (Lung DC et. al 2010)
Legionella pneumophila pneumonia
Macrolides and fluoroquinolones are the monotherapy in the treatment of L. pneumophila pneumonia whereas rifampin-based combination therapy is used for severe community-acquired Legionella pneumophila pneumonia. However, rifampin therapy should be considered only for patients with severe disease or significant comorbid conditions such as uncontrolled diabetes, smoking, or obstructive lung disease, immunocompromised hosts and those patients who are refractory to conventional monotherapy regimens. It is due to its significant adverse drug events and drug-drug interactions. (Varner TR 2011)
Chlamydia pneumonia
Most Chlamydia Pneumonia infections in children and young adults are generally quite mild and do not require hospitalization. (Mesothelioma-Asbestosis 2010) Severe cases of Chlamydia Pneumonia most probably will happen in elderly people with other pre-existing health complications. Chlamydia Pneumonia treatment includes tetracyclines (eg. doxycycline) which is usually not for pregnant women, macrolides( eg. trythromycin) and in some cases fluoroquinolones are used. (Oba Y 2011)
Staphylococcus aureus pneumonia
Vancomycin and linezolid can be used to treat this type of pneumonia. Besides that, ?-cyclodextrin derivative (IB201) is use to treat Staphylococcus aureus pneumonia too. It provides a high level of protection against lethal disease caused by both methicillin-sensitive and methicillin-resistant clinical isolates. Early treatment with IB201 is required to prevent mortality from Staphylococcus aureus pneumonia. (Ragle BE, Karginov VA and Wardenburg JB 2010).
Treatment of multidrug-resistant pneumonia
A patient will usually get multidrug-resistant pneumonia from a hospital and thus multidrug resistant pneumonia is always related to hospital-acquired pneumonia. Several drugs can be used to treat this type of pneumonia.
Penicillin-resistant and cephalosporin-resistant pneumococcal pneumonia
Patients with mild/moderate pneumococcal pneumonia may be treated with oral amoxicillin whereas patient with severe pneumonia may be successfully treated with intravenous ceftriaxone, cefotaxime, or amoxicillin-clavulanic acid. Imipenem and vancomycin should not be widely used for the treatment of pneumococcal pneumonia except for well-selected patients. (Pallares R 1999)
Methicillin- resistant staphylococcus aureus (MRSA) pneumonia
MRSA is resistant to all classes of beta-lactam antibiotics. Vancomycin is the only antibiotic that consistently shows activity against MRSA. (Johnston BL 1994) Besides that, ceftaroline, teicoplanin and linezolid are the alternative therapy to treat MRSA. (Jorgenson MR, Depestel DD, Carver PL 2011) Linezolid shows a better efficacy than vancomycin because of its better pharmacokinetics and pharmacodynamics index. (Martinez-Olondris P et al. 2001)
Teicoplanin is another glycopeptide antibiotic available in Europe for the treatment of MRSA. (Linezolid is superior treatment for drug-resistant pneumonia n.d.) Other than that, tigecycline is useful in the salvage therapy after linezolid failure. (Martinez-Olondris P et al. 2001)
Macrolide-resistant pneumoniaThe ketolides represent a new class of macrolide-like antibacterials that are highly effective in vitro against macrolide-resistant pneumococci. (Neralla S, Meyer KC 2009) Alternative therapy for pediatric pneumonia including tetracyclines and fluoroquinolones should be considered in children experiencing treatment failure although they are currently not approved for this indication. (Lung DC, Chan YH Kwong L Que TL 2010)
Fluoroquinolone (levofloxacin)-resistant pneumonia
Cephalosporins can be used with or without the co-drug to treat this disease. Combinations of potent parenteral cephalosporins (cefepime and ceftriaxone) and some newer fluoroquinolones (gatifloxacin, gemifloxacin, and moxifloxacin) have the greatest initial empiric coverage. These treatments are less effective than vancomycin or quinupristin and dalfopristin, but these latter agents possess narrower spectrums of overall activity and higher associated toxicity. (Jones RN, Fritsche TR, Sader HS 2011)
Trimethoprim-sulfamethoxazole (TMP-SMX) resistant pneumonia
The combination of clindamycin and primaquine is use to treat this disease. It is likely to be more effective than intravenous pentamidine. (Smego RA et al. 2001)
Viral Pneumonia(Viral Pneumonia Treatment and Management n.d.)
Pneumonia caused by virus can be treated with antiviral agent which inhibits DNA synthesis and viral replication by competing for viral DNA polymerase with deoxyguanosine triphosphate. For example amantadine, rimantadine, zanamivir, oseltamivir, ribavirin, acyclovir, ganciclovir, and foscarnet are used as antiviral agent.
Amantadine and Rimantadine prevent penetration of the virus into the host by inhibiting uncoating of influenza A. However during influenza season in 2005-2006, resistance to Rimantadine has emerged.Zanamivir and Oseltamivir inhibit a glycoprotein on the surface of the influenza virus called neuraminidase that destroys the infected cell's receptor for viral hemagglutinin. The release of viruses from infected cells is reduced and the spreading of virus is controlled through the inhibition of neuraminidase. Similarly to Rimantadine, resistant strains of seasonal influenza and H1N1 to Oseltamivir have been reported.
Ribavirin inhibits DNA and RNA synthesis and thus preventing viral replication. It has shown in vitro antiviral properties against RSV, parainfluenza, hantavirus, measles, and many other. Acyclovir has affinity for viral thymidine kinase and it causes DNA chain termination when phosporylated when acted on by DNA polymerase. Thus it has inhibitory activity of both HSV-1 and HSV-2 when it is used within 24-48 hours of rash onset, patients experience less pain and faster resolution of HSV or VZV lesions.
Ganciclovir is an acyclic nucleoside analog of 2'-deoxyguanosine and is a synthetic guanine derivative. It inhibits replication of herpesviruses both in vitro and in vivo and is active against CMV, HSV, HHV-6, and HHV-8. The level of ganciclovir-triphosphate could reach 100-fold greater in CMV-infected cells than in uninfected cells, possibly due to preferential phosphorylation of ganciclovir in virus-infected cells.
Valganciclovir is an oral prodrug of Ganciclovir that is available now. For the treatment of CMV pneumonia, high-dose intravenous immunoglobulin has been used successfully in conjunction with ganciclovir. Through anti-idiotypic antibodies, immune globulin IV neutralizes circulating myelin antibodies. It down-regulates proinflammatory cytokines; blocks Fc receptors on macrophages; suppresses inducer T cells and B cells; amplify suppressor T cells; stops the complement cascade, encourages remyelination, and may increase CSF IgG levels (10%).
Foscarnet is an organic analog of inorganic pyrophosphate that inhibits viral replication at pyrophosphate-binding sites on virus-specific DNA polymerases of known herpesviruses, including CMV, HSV-1, and HSV-2. Viral resistance may occur and this is shown if there is poor clinical response or persistent viral excretion during therapy.
Fungal pneumonia
Pneumonia caused by fungi is treated using antifungal agent.Against Cryptococcus neoformans, it is recommended that a regimen for induction therapy is Amphotericin B plus flucytosine for at least 2 weeks followed by consolidation therapy with fluconazole (400 mg daily) for 8 weeks, and then maintenance therapy with fluconazole (200 mg daily) for life or until the CD4 cell count rises above 200 cells/?L for at least 6 months as a result of antiretroviral therapy. (Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America (HIVMA/IDSA) MMWR 2009)
Amphotericin B (liposomal) is also recommended as first-line treatment for disseminated histoplasmosis caused by Histoplasma capsulatumand, disseminated coccidioidomycosis caused by Coccidioides immitis and Coccidioides posadasii and for cases of diffuse pneumonia. (Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America (HIVMA/IDSA) MMWR 2009)
Patients with histoplasmosis and coccidioidomycosis should be treated with Amphotericin B until clinical improvement (usually at least 2 weeks). This is followed by itraconazole (200 mg three times daily for 3 days, then 200 mg twice daily) for a total of at least 12 months. Persons with severe disseminated histoplasmosis or CNS involvement and those who relapse despite appropriate therapy should receive itraconazole (200 mg daily) probably for life. (Viral Pneumonia Treatment and Management n.d.)

Conclusion


Pneumonia can be fatal if proper treatment is not adopted immediately especially among children below 5 years old. Treatment such as taking antibiotics or antifungal agents can be helpful in treating pneumonia. However, pneumonia-causing agents, patients factor such as ages, history of allergies, pregnancy and drug factors should be taken into consideration when choosing the type of treatment. As prevention is always better than cure, practice of the ways to prevent pneumonia should be done by every single individual including the healthcare professionals as well. Education on practicing personal hygiene, leading a healthy lifestyle and vaccination should be given to the public by the authorities to reduce the cases of pneumonia.

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WebmedCentral Article: Pneumonia

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