**3.4. Complications of CAP and prevention**

syncytial (RSV), rhinovirus, and parainfluenza as the most encountered. Fungal infection mainly affects immunocompromised patients and parasitic infections are mainly endemic [50]. Clinical syndrome of condensation and radiological alveolar syndrome occur in few days. Pathogens implicated in nosocomial infection include a larger panel with methicillin-resistant staphylococcus aureus (MRSA), Enterobacteriaceae, and different types with a potential of resistance and

Patient with CAP mainly complaints of cough, fever, shivers, pleuritic chest pain of abrupt onset. Dyspnea may occur when the involved pulmonary sector is large. Sputum production is not rare, of purulent aspect or blood stained. Physical examination may reveal a condensation syndrome with focal crackles. It is of great importance to consider also extrathoracic signs

History should be extended to demographic and behavioral considerations (age, gender, style and site of living) and comorbidities. CRB65, which is a clinical score for assessment of CAP is recommended in many guidelines. It includes data about confusion, respiratory rate, blood pressure, and age ≥ 65 years. A CRB65n score of 0 seems a patient at low risk of death and not

Additional investigations are required to guide the diagnosis setting, such as inflammatory markers (leukocytosis and differential counts, ESR, CRP) and etiological identification of pathogens through conventional microbiological analyses of samples (sputum, nasotracheal aspirates, bronchoalveolar lavage), the latter could be positive in only 15% of cases. The quality of the specimen to be examined by gram stain is a prerequisite, and the sputum should contain more than 10–25 polymorphonuclear cells by microscopic screening to be suitable. Culturebased techniques are widely used for the diagnosis of pneumonia. That is the case of blood, sputum cultures, or endotracheal aspirates, which can allow pathogen identification and antibiotic sensitivity tests. Urinary antigen tests are helpful for *S. pneumoniae* and *L. pneumophila*. Molecular diagnosis tools are currently more and more used for diagnosis of infectious diseases. CRP, an acute-phase protein during acute inflammation has not proven to be accurate in differential diagnosis between bacterial or viral infections; it is nevertheless an indicator of response to the treatment. Other biomarkers are being developed, such as procalcitonin, a prohormone elevated in response to bacterial infections. Studies using this biomarker have not provided sufficient probes for large clinical use [51]. Otherwise, both biomarkers are useful in

the assessment of response to treatment and suitability of the antibiotic prescribed.

Serological tests find applicability in the diagnosis of pneumonia due to atypical pathogens such as Chlamydia, Mycoplasma, and viral infections, not easy to identify by current culture-

Molecular techniques are now developed ensuring an early diagnosis and sensitivity tests for resistance to treatment. Dried blood spots have been used for bacterial identification and have proven to be a useful and easily accessible tool for molecular diagnosis in poor resources countries [46]. Urinary antigen tests are available for *S. pneumoniae* and *L. pneumophila*.

difficult to treat infections.

42 Contemporary Topics of Pneumonia

**3.3. Diagnosis of CAP**

(mouth, nose, ear).

based techniques.

normally requiring hospitalization.

CAP mortality remains high despite the development of new antibiotics and new tools for early-onset diagnosis. Main complications are sepsis and respiratory failure, but about 50% of CAP mortality in the first month is due to comorbidities [53]. Respiratory infections through hypoxemia and oxidative stress are a potential determinant of cardiovascular adverse events. The underlying atherosclerosis as shown by the increased rate of inflammatory biomarkers (fibrinogen, CRP, cytokines) in infectious status may impact on prothrombotic vascular conditions and subsequent cardiovascular ischemic diseases [54, 55]. The prognosis of acute myocardial infarction, cardiac arrhythmias, and heart failure is often worsened by respiratory infections according to few previous studies [55–57].

CAP is not simply a local but systemic inflammatory response as expressed by the measurable increase in serum biomarkers such as IL-6, IL-8, and TNF-alpha. To improve patients' outcomes, preventive measures are strongly recommended such as smoking cessation interventions and accurate screening of comorbidities. About a half of CAP mortality within the first month is due to the comorbidities such as cardiovascular complications, cancer, chronic lower respiratory diseases renal failure, and infections, mainly involving the elderly [58, 59]. Cardiovascular mortality contributes for almost 30% of deaths after CAP; that is the case of myocardial infarction in a multicenter study by Lichtman et al. reporting a 7.2% of CAP in patients admitted to the hospital with an acute myocardial infarction [60]. Cardiac arrhythmias are also observed sometimes induced by the use of macrolides alone or in combination therapy [61]. Respiratory infections were more frequent (19 vs. 6%) in a comparison study of stroke patients and control [62], suggesting the comorbidity of this condition.

Empyema is a harmful complication of pneumonia occurring mostly in more vulnerable subjects (comorbidities, immune disorders).

Preventive measures through behavioral changes such as smoking cessation and vaccination in vulnerable populations such as drepanocytosis patients, COPD, renal insufficiency patients with influenza, and pneumococcal vaccines need to be largely implemented to reduce the mortality rate.

#### **3.5. Treatment of CAP**

Severity assessment is a prerequisite to an accurate decision for the place of care (ICU or not). Empirical antibiotic therapy is widely used in the treatment of CAP and should include pneumococcal coverage. The promptitude of the treatment (less than 8 h from diagnosis) has been shown to improve mortality rate. Few recommendations by the American Thoracic Society (ATS) emphasize the relevance of some conditions such as the severity of the pneumonia, the previous health status of the patient, the comorbidities, and a previous use of antibiotic therapy less than 3 months. The combination therapy or the monotherapy is regularly questioned, but evidence shows the superiority of the combination therapy in severe patients [57, 63, 64]. The use of pneumonia severity index and CURB 65 will help to improve the outcomes of CAP, by a relevant orientation of the patients. In ambulatory patients with mild to moderate disease, monotherapy, and mainly by oral route is a common practice. The empirical choice is the class of β-lactamases (amoxicillin) or macrolides in case of allergy to the former. Fluoroquinolones in monotherapy, even recommended in some developed countries such as the North America should be discouraged in the settings where TB is a great concern, because of the influence of these drugs on the delay of TB diagnosis and the lack of alternative diagnosis tools for smear-negative tuberculosis. Macrolides and doxycycline are suitable when mycoplasma or chlamydia are the suspected etiologic agents. A previous history of antibiotic therapy in the latter 3 months guides the choice for a not yet used antibiotic by the patient. This is to minimize the emergence of resistance to antibiotics. In hospitalized patients, a part from taking care of the comorbidities, monotherapy using amoxicillin-clavulanic acid may be a choice according to the severity of the illness; combination therapy of the latter with advanced macrolides (clarithromycin, azithromycin) is often recommended. In case of a risk of aspiration pneumonia (Dementia, Alzheimer, Diphtheria), the clindamycin should be added. Patients admitted in ICU need combination therapy as first choice and G3-cephalosporins; or carbapenems are regularly prescribed. The emergence of resistance is nevertheless a threat in these critically ill subjects. Adjunctive therapies in hospitalized patients include oxygen suppliance if necessary, low doses corticosteroids in suspected adrenal insufficiency following the bacteremia phase may be added to improve outcomes. Nonsevere CAP could be treated ambulatory with a 7-day monotherapy with oral antibiotics. The use of pneumonia severity index and CURB 65 or serum biomarkers may improve the prognosis of the illness. Among the biomarkers, the procalcitonin has been assessed in the decision of initiation or discontinuation of antibiotic therapy in adults. The discontinuation may be applied if the PCT level after 3 days is lower than 0.25 ng/mL or as decreased by more than 80–90% relative to the initial value [65].

**Author details**

Kinshasa, DR Congo

**References**

Jean-Marie Ntumba Kayembe1

\*Address all correspondence to: dr12jmkayembe@yahoo.com

2 Ecom-Alger, University of Kinshasa, DR Congo

2013. Lancet. 2015;**385**:1990-2013

Diseases. 2009;**22**:143-147

compreped-10273

2005;**310**:456-460

BP622Pneumo.pdf [Accessed: January 16, 2016]

\* and Harry-César Ntumba Kayembe2

Pneumonia: A Challenging Health Concern with the Climate Change

http://dx.doi.org/10.5772/intechopen.71609

45

1 Pneumology Unit, Department of Internal Medicine, Faculty of Medicine, University of

[1] UNICEF The State of the World's Children 2016. Available from: https://www.unicef.

[2] GBD Collaborators. Global, regional and national levels of age-specific mortality and 240 causes of death. 1990-2013: A systematic analysis for the Global burden of Disease Study

[3] Tong N. Background Paper 6.22 Pneumonia 2013. http://www.who.int/medicines/

[4] Marcos MA, Esperatti M, Torres A. Viral pneumonia. Current Opinion in Infectious

[5] Rudan I, Boschi-Pinto C, Biloglav Z, et al. Epidemiology and etiology of childhood pneumonia. Bulletin of the World Health Organization. 2008;**86**:408-416. DOI: 10.2471/BLT.07.048769

[6] Boloursaz MR, Lotfian F, Aghahosseini F, et al. Epidemiology of lower respiratory tract infections in children. Journal of Comprehensive Pediatrics. 2013;**4**:93-98. DOI: 10.17795/

[7] Overpeck JT, Otto-Bliesner BL, Miller GH, Muhs DR, Alley RB, Kiehl JT. Paleoclimatic evidence for future ice-sheet instability and rapid sea-level rise. Science. 2006;**311**:1747-1750

[8] Alley RB, Clark PU, Huybrechts P, Joughin I. Ice-sheet and see-level changes. Science.

[9] Biggar KK, Storey KB.New approaches to comparative and animal stress biology research in the post-genomic era: A contextual overview. Computational and Structural Biotechnology

[10] Mirsaeidi M, Motahari H, Khamesi MT, Sharif A, Campos M, Schraufnagel DE. Climate change and respiratory infections. Annals of the American Thoracic Society.

[11] Bayard V, Kitsutani PT, Barria EO, Rueda LA, Tinnin DS, Mnoz C, de Mosca IB, Guerrero G, Kant R, Garcia A, *et al*. Outbreak of hantavirus pulmonary syndrome, Los Santos,

Journal. 2014;**30**:138-146. DOI: 10.1016/j. csbj.2014.09.006 eCollection 2014 Sep

2016;**13**(8):1223-30. DOI: 10.1513/AnnalsATS.201511-729PS

Panama,1999-2000. Emerging Infectious Diseases. 2004;**10**:1635-1642

org/publications/files/UNICEF\_SOWC\_2016.pdf [Accessed: 2017-07-01]

#### **4. Conclusion**

Pneumonia remains a global threat despite the development of newer antibiotics. Early diagnosis tools need to be widely available, including easily accessible molecular analyzes. The empirical antibiotic treatment should relay on site of care, severity index of the disease, comorbidities, cost effectiveness, but also on identifications of new risk factors challenging the outcomes of patients such as climate changes.
