Pneumonia is acute inflammation of the lungs caused by infection. Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and prognosis differ depending on whether the infection is bacterial, mycobacterial, viral, fungal, or parasitic; whether it is acquired in the community or hospital; whether it occurs in a patient treated with mechanical ventilation; and whether it develops in a patient who is immunocompetent or immunocompromised.
(See also Neonatal Pneumonia.)
Millions of people in the United States develop pneumonia (excluding COVID-19 pneumonia) each year. The CDC reported that more that 41,000 people died of pneumonia in 2021 (1). Pneumonia is the most common fatal hospital-acquired infection and the most common overall cause of death in medically underserved countries.
The most common cause of pneumonia in adults > 30 years, in the absence of an ongoing viral pandemic such as COVID-19, is
Bacterial infection
Streptococcus pneumoniae is still the most common pathogen in all age groups, settings, and geographic regions. However, the incidence of S. pneumoniae infection has been declining because of increasing rates of vaccination and development of herd immunity. However, pathogens of every sort, from viruses to parasites, can cause pneumonia. With the availability of sensitive molecular diagnostic methods, viruses are often recognized as a cause of pneumonia, either as a sole pathogen or as a co-pathogen with bacteria.
The airways and lungs are constantly exposed to pathogens in the external environment; the upper airways and oropharynx in particular are colonized with so-called normal flora. Microaspiration of these pathogens from the upper respiratory tract is a regular occurrence, but these pathogens are readily dealt with by lung host defense mechanisms. Pneumonia develops when
Defense mechanisms are compromised
Macro-aspiration leads to a large inoculum of bacteria that overwhelms normal host defenses
A particularly virulent pathogen is introduced
Occasionally, infection develops when pathogens reach the lungs via the bloodstream or by contiguous spread from the chest wall or mediastinum. Another potential pathway of pneumonia development is dysbiosis in the resident microbiome of the lung.
Upper airway defenses include salivary IgA, proteases, and lysozyme; growth inhibitors produced by normal flora; and fibronectin, which coats the mucosa and inhibits adherence.
Nonspecific lower airway defenses, including cough and mucociliary clearance, prevent infection in airspaces. Specific lower airway defenses include various pathogen-specific immune mechanisms, including IgA and IgG opsonization, antimicrobial peptides, anti-inflammatory effects of surfactant, phagocytosis by alveolar macrophages, and T-cell–mediated immune responses. These mechanisms protect most people against infection.
Numerous conditions alter the normal flora (eg, systemic illness, undernutrition, hospital exposure, antibiotic exposure) or impair these defenses (eg, altered mental status, cigarette smoking, nasogastric or endotracheal intubation, disorders or medications that suppress the immune system). Pathogens that then reach airspaces can multiply and cause pneumonia.
Specific pathogens causing pneumonia cannot be found in up to 50% of patients, even with extensive diagnostic investigation, primarily because of the limitations of currently available diagnostic tests and the difficulty of obtaining adequate deep lung (alveolar) samples. But because pathogens and outcomes tend to be similar in patients in similar settings and with similar risk factors, it is clinically useful to categorize pneumonias as
Hospital-acquired (excluding ventilator-associated)
Occurring in immunocompromised patients, including patients with human immunodeficiency virus (HIV) infection (see Pneumocystis jirovecii Pneumonia)
Aspiration pneumonia, which occurs when large volumes of upper airway or gastric secretions enter into the lungs
These categorizations allow treatment to be selected empirically.
Reference
1. Centers for Disease Control and Prevention: National Center for Health Statistics: Fast Stats: Pneumonia. Last reviewed September 19, 2023. Accessed November 27, 2023.
