Community-acquired pneumonia is lung infection that develops in people who are not patients in a hospital, usually in people with a normal (competent) immune system, or in those who are immunocompromised, but pneumonia in people who are immunocompromised is discussed separately.
Many bacteria, viruses, and fungi can cause pneumonia.
The most common symptom of pneumonia is a cough that produces sputum, but chest pain, chills, fever, and shortness of breath are also common.
Doctors diagnose community-acquired pneumonia by listening to the lungs with a stethoscope and by reading x-rays or computed tomography (CT) scans of the chest.
Antibiotic, antiviral, or antifungal medications are used depending on which organism doctors believe has caused the pneumonia.
(See also Overview of Pneumonia.)
Causes of Community-Acquired Pneumonia
Many organisms cause community-acquired pneumonia, including bacteria, viruses, fungi, and parasites. In most cases, the specific microorganism causing the pneumonia is not identified. However, doctors can usually predict which microorganisms are most likely to be causing the pneumonia based on the person’s age and other factors, such as whether the person also has other diseases.
Community-acquired pneumonia can develop in people whose immune systems are normal (also called competent) or in people whose immune systems are impaired (also called immunocompromised people). However, when doctors use the term community-acquired pneumonia, they are generally referring to people whose immune systems are normal. Pneumonia in immunocompromised people is discussed separately (see Pneumonia in Immunocompromised People).
"Walking pneumonia" is a nonmedical term used to describe a mild case of community-acquired pneumonia that does not require bedrest or hospitalization. Some people even feel well enough to go to work and participate in other daily activities.
Bacterial causes of pneumonia
The most common bacterial causes of community-acquired pneumonia are
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Streptococcus pneumoniae (pneumococcus) causes about many hospitalizations in the United States each year. There are over 90 types of pneumococci, but most serious disease is caused by only a small number of types. Pneumococcal pneumonia can be very severe, particularly in young children and older adults.
Haemophilus influenzae pneumonia may occur in adults but is more common among children. However, childhood infection has become much less common since children have been routinely vaccinated against H. influenzae. H. influenzae pneumonia is more common among adults who have underlying chronic lung disorders such as chronic obstructive pulmonary disease (COPD) and bronchiectasis.
Chlamydophila pneumoniae is the second most common cause of lung infections in healthy people aged 5 to 35 years. C. pneumoniae is commonly responsible for outbreaks of respiratory infection within families, in college dormitories, and in military training camps. It causes a pneumonia that is rarely severe and infrequently requires hospitalization. Chlamydia psittaci pneumonia (psittacosis) is a rare infection caused by a different strain of chlamydia and occurs in people who own or are often exposed to birds.
Mycoplasma pneumoniae causes infection very similar to that caused by C. pneumoniae. M. pneumoniae pneumonia is more common among older children and adults younger than 40, especially those living in crowded environments, such as schools, college dormitories, and military barracks. Although the illness is rarely severe, symptoms can last for weeks or even months.
Legionella pneumophila causes pneumonia and flu-like symptoms sometimes called Legionnaires’ disease. It accounts for about 1 to 8% of all pneumonias. Legionella bacteria live in water, and outbreaks have occurred primarily in hotels and hospitals when the organism has spread through the air conditioning systems or water supplies, such as showers. No cases have been identified in which one person directly infected another.
Staphylococcus aureus causes pneumonia that is resistant to some types of antibiotics. This bacteria is known as community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), and it can cause severe pneumonia, primarily in young adults. Since the year 2000, the number of cases of community-acquired pneumonia caused by S. aureus has increased, but the infection is still uncommon.
Pseudomonas aeruginosa is an especially common cause of pneumonia in people with cystic fibrosis and other lung diseases and in those with an impaired immune system.
Viral causes of pneumonia
Common viruses that can cause community-acquired pneumonia include
SARS-CoV-2, the virus that causes COVID-19
Adenoviruses
Influenza viruses
Parainfluenza viruses
Coxsackievirus (rarely)
The virus that causes chickenpox can also cause a lung infection. Hantavirus and severe acute respiratory syndrome (SARS) are also viral causes of pneumonia. Sometimes a bacterial pneumonia can occur after a lung infection caused by a virus.
Fungal causes of pneumonia
Fungal causes of community-acquired pneumonia include
Histoplasma capsulatum (histoplasmosis)
Coccidioides immitis (coccidioidomycosis)
Less common fungal causes of pneumonia include Blastomyces dermatitidis (blastomycosis) and Paracoccidioides braziliensis (paracoccidioidomycosis). Pneumocystis jirovecii commonly causes pneumonia in people who have human immunodeficiency virus (HIV) infection or a weakened immune system (immunocompromise).
Parasites that cause pneumonia
Parasites that cause community-acquired pneumonia in people who live in higher income countries include
Toxocara canis or T. catis (toxocariasis)
Dirofilaria immitis (dirofilariasis)
Paragonimus westermani (paragonimiasis)
Psittacosis: An Unusual Type of Pneumonia
Psittacosis (parrot fever) is a rare pneumonia caused by Chlamydia psittaci, a bacterium present mainly in birds such as parrots, macaws, parakeets, and lovebirds. It is also present in other birds, such as pigeons, finches, chickens, and turkeys. Usually, people are infected by inhaling dust from the feathers or the waste of infected birds. The organism also may be transmitted by a bite from an infected bird and, rarely, from person to person in cough droplets. Psittacosis mainly occurs in bird fanciers or in people who work in pet shops or on poultry farms. About 1 to 3 weeks after being infected, a person develops a fever, chills, fatigue, and loss of appetite. A cough develops, which is initially dry but later brings up greenish sputum (thick or discolored mucus). Fever persists for 2 to 3 weeks and then slowly subsides. The disease may be mild or severe, depending on the person’s age and the extent of lung tissue involved. Blood tests to determine whether the person has a certain type of antibody, suggesting recent infection with Chlamydia psittaci, are the most reliable method for confirming the diagnosis, but doctors usually suspect the infection in people who have a history of exposure to birds. |
Symptoms of Community-Acquired Pneumonia
Symptoms of community-acquired pneumonia include
A general feeling of weakness (malaise)
Cough
Shortness of breath
Fever
Chills
Chest pain
Cough typically produces sputum (thick or discolored mucus) in older children and adults, but the cough is dry in infants, young children, and older people. Shortness of breath usually is mild and occurs mainly during activity. Chest pain is typically worse when breathing in or coughing. Sometimes people have upper abdominal pain.
Symptoms vary at the extremes of age. Symptoms of pneumonia in infants and toddlers may include irritability and restlessness. Older adults may be confused or have a decreased level of consciousness. Older adults and young children may be unable to communicate chest pain and shortness of breath. Fever is common but may not occur in older adults.
Diagnosis of Community-Acquired Pneumonia
Usually a chest x-ray or computed tomography (CT) scan of the chest
No matter what type of pneumonia is suspected, doctors listen to a person’s chest with a stethoscope to make a diagnosis. Chest x-rays or CT scans are usually also done to confirm the diagnosis.
Doctors usually do not need to do additional tests to determine what organism is causing the pneumonia, because most organisms are effectively treated by standard treatment and identifying the organism does not make a difference in treatment success. However, if doctors do need to identify the organism (such as in people whose condition does not improve while taking initial antibiotics), they usually try to grow or identify parts of the organism from a specimen of sputum, blood, or urine. Even when such testing is done, the organism is identified less than half the time.
Sometimes the person's symptoms or risk factors may suggest the cause of the pneumonia. For example, a bird fancier may have psittacosis. So doctors may ask detailed questions about a person's work, hobbies, or recent travel. Certain combinations of risk factors and symptoms may suggest Legionella infection. In people who have first had symptoms typical of influenza or of chickenpox, most pneumonia that develops is actually a bacterial pneumonia that took root in the lungs inflamed by the virus. However, sometimes influenza and chickenpox cause pneumonia directly.
Treatment of Community-Acquired Pneumonia
Antibiotics
Sometimes antiviral or antifungal medications
Doctors evaluate many factors to determine whether people can be safely treated at home or whether they should be hospitalized because of high risk of complications. Some of the factors include the following:
Age
Whether another disorder, such as cancer or a liver, heart, or lung disorder, is also present
Whether there are worrisome findings on physical examination or testing
Whether people are able to care for themselves or have someone to help them
Antibiotics are started as soon as possible. Doctors may prescribe antibiotics based on the severity of the infection and the risk of complications (see table How Is Community-Acquired Pneumonia Treated?). People are also given fluids, medications to relieve fever and pain, and oxygen if needed.
Because the causative organism is difficult to identify, doctors choose antibiotics based on the organisms that are most likely to be causing pneumonia.
With antibiotic treatment, most people with bacterial pneumonia improve. In people who do not improve, doctors look for an alternative diagnosis, unusual organisms, resistance to the antibiotic used for treatment, infection with a second organism, spread of the infection beyond the lungs (for example, into the lining of the lungs [pleura]), or some other disorder (such as a problem with the immune system or a blocked [obstructed] airway) that is delaying recovery.
To treat fungal pneumonia, antifungal medications may be given.
Sometimes doctors do follow-up chest x-rays about 6 weeks after treatment to make sure that any abnormal findings on chest x-ray have resolved. Follow-up may be more important in people who smoke and in older adults to ensure that the abnormal findings seen on chest x-ray represent pneumonia only rather than an underlying cancer with pneumonia.
How Is Community-Acquired Pneumonia Treated?
Severity | Possible Medications | Comments |
|---|---|---|
Mild pneumonia in otherwise healthy people with no risk factors* | Medications are taken by mouth. People are treated at home. | |
Mild pneumonia in people with risk factors* | Medications are usually taken by mouth. Often, more than one medication is taken. People are treated at home. | |
Moderate pneumonia or Pneumonia in people who cannot care for themselves | Medications are usually given intravenously in a hospital. Often, more than one medication is given. | |
Severe pneumonia in people with many risk factors* | Some of the same medications used for moderate pneumonia Piperacillin/tazobactam | Medications are usually given intravenously in an intensive care unit. Usually, more than one medication is given. |
* Risk factors include heart or lung disorders, cancer, alcohol use disorder, age older than 65 years, recent use of antibiotics, and a weakened immune system (for example, because of HIV, organ transplantation, or use of medications that suppress the immune system). | ||
Prognosis for Community-Acquired Pneumonia
Most people with community-acquired pneumonia recover. However, pneumonia can be fatal, most often in infants and in older adults. The death rate is higher in Legionella infections, possibly because people who develop the disease are less healthy even before they become sick.
Prevention of Community-Acquired Pneumonia
Stopping smoking is the best way to prevent pneumonia.
Some pneumonias can be prevented by vaccination
Vaccines to prevent pneumonia
Vaccines are available that offer partial protection against pneumonia caused by
The bacterium Streptococcus pneumoniae
Haemophilus influenzae type b (only in children)
Chickenpox (varicella; only in children)
Respiratory syncytial virus (RSV)
