Pneumonia

Pneumonia is an acute respiratory infection that affects the lungs, primarily involving the
alveolar spaces. It is characterized by inflammation and consolidation of lung tissue due to
microbial infection, leading to symptoms such as cough, fever, and difficulty breathing.
Pneumonia can range from mild to life-threatening, particularly in vulnerable populations such
as the elderly, immunocompromised individuals, and young children. It remains a leading cause
of morbidity and mortality worldwide, with significant healthcare burdens.

Characterization/Symptoms of the Disease

Common Symptoms:

• Respiratory symptoms:

• Cough (productive or dry) • Sputum production (~30%)

(~75%) • Chest pain (~30%)
• Dyspnea (shortness of
breath) (~65%)
• Systemic symptoms:

•Fever, chills, rigors • Confusion (especially in

•Fatigue, myalgia (muscle older adults)
pain)
Severe Symptoms (indicating hospitalization/ICU need):

• Hypoxemia (low oxygen levels)

• Tachypnea (rapid breathing)
• Hemodynamic instability (low blood pressure)
• Sepsis or septic shock

Atypical Presentations:

• Immunocompromised patients may present with subtle or absent fever.

• Elderly patients may exhibit non-respiratory symptoms (e.g., falls, weakness, altered
mental status).

Causes
Pneumonia is caused by various pathogens, including:

A. Community-Acquired Pneumonia (CAP):

Bacterial:

• Streptococcus • Staphylococcus
pneumoniae (most aureus (including MRSA)
common) • Legionella pneumophila
• Haemophilus influenzae
 • Mycoplasma • Chlamydia
pneumoniae (atypical) pneumoniae (atypical)

• Viral:

• Influenza virus • SARS-CoV-2 (COVID-19)

• Respiratory syncytial virus • Adenovirus
(RSV)
B. Hospital-Acquired Pneumonia (HAP) & Ventilator-Associated Pneumonia (VAP):

• Pseudomonas aeruginosa • Methicillin-

• Acinetobacter baumannii resistant Staphylococcus
• Klebsiella pneumoniae aureus (MRSA)

C. Immunocompromised Hosts:

• Pneumocystis jirovecii (in • Cytomegalovirus (CMV)

HIV/AIDS) • Mycobacterium tuberculosis
• Fungal (Aspergillus, Cryptococcus)

Risk Factors:

• Age >65 or <2 years • Immunosuppression (HIV,

• Chronic diseases (COPD, diabetes, chemotherapy)
heart disease) • Aspiration risk (stroke, neurological
• Smoking, alcohol abuse disorders)

Diagnosis
A definitive diagnosis combines:

1. Clinical Assessment:

• Symptoms (cough, fever, dyspnea)

• Physical exam (crackles, dullness to percussion)

2. Imaging:

• Chest X-ray (CXR): Gold standard for consolidation detection.

• CT scan: More sensitive, used if CXR is inconclusive.
• Lung Ultrasound: Emerging for rapid bedside diagnosis.

3. Microbiological Testing:

• Sputum Gram stain & culture

• Blood cultures (if severe)
• Urinary antigen tests (Legionella, S. pneumoniae)
• PCR/nasal swabs (viral detection, e.g., influenza, COVID-19)
4. Biomarkers:

• Procalcitonin (PCT): Helps distinguish bacterial vs. viral infection.

• C-reactive protein (CRP): Elevated in bacterial pneumonia.

5. Severity Scoring:

• CURB-65 (Confusion, Uremia, Respiratory rate, Blood pressure, Age ≥65)

• Pneumonia Severity Index (PSI): Predicts mortality risk.

Guidelines for Management

1. Outpatient Treatment (Mild CAP):

• First-line:

o Amoxicillin (or doxycycline/macrolide if atypical pathogens suspected).

• Second-line:

o Respiratory fluoroquinolone (levofloxacin/moxifloxacin) if penicillin allergy.

2. Hospitalized Patients (Moderate-Severe CAP):

• First-line:

o Beta-lactam (ceftriaxone/ampicillin) + macrolide (azithromycin).

o OR respiratory fluoroquinolone (levofloxacin/moxifloxacin).

• MRSA/Pseudomonas risk: Add vancomycin/linezolid or anti-pseudomonal

coverage.

3. ICU Patients (Severe CAP/HAP/VAP):

• Broad-spectrum antibiotics:

o Piperacillin-tazobactam/meropenem + vancomycin/linezolid (if MRSA risk).

o Add macrolide/fluoroquinolone for atypical coverage.

4. Adjuvant Therapies:

• Corticosteroids (e.g., dexamethasone) in severe CAP with high inflammation.

• Oxygen therapy/mechanical ventilation if hypoxemic.

5. Duration of Treatment:

• 5–7 days for uncomplicated CAP.

• 7–14 days for severe cases or Legionella.

 Treatment Protocols
1. Empirical Therapy (Before Pathogen Identification):

Setting First-Line Alternatives

Outpatient CAP Amoxicillin or Respiratory fluoroquinolone
macrolide/doxycycline
Hospitalized CAP Ceftriaxone + azithromycin Levofloxacin/moxifloxacin

HAP/VAP Piperacillin-tazobactam + Meropenem + linezolid

vancomycin

2. Pathogen-Directed Therapy:

Pathogen Preferred Treatment

S. pneumoniae Penicillin/ceftriaxone
Legionella Levofloxacin/azithromycin
Pseudomonas Piperacillin-tazobactam + ciprofloxacin
MRSA Vancomycin/linezolid

3. Supportive Care:

• Oxygen therapy (target SpO₂ ≥92%).

• Fluid resuscitation if septic.

• Vaccination (pneumococcal, influenza) for prevention.

Reference
Lim, W. S. (2021). Pneumonia—overview. Encyclopedia of Respiratory Medicine, 185.
 MEFENAMIC ACID DRUG PROFILE
i) Brand Names

• Ponstan • Mefnac • Meflog

• Dolor DS • Mefast • Mefryl
• Mefacid • Mefnix • Mefprex
• Mefspan • Mefit

ii) Generic Name

• Mefenamic Acid

iii) Drug Classification

• Pharmacologic Class: Nonsteroidal Anti-Inflammatory Drug (NSAID)

• Chemical Class: Fenamate (anthranilic acid derivative)

iv) Dosage Form

• Oral Capsules: 250 mg, 500 mg

• Tablets: 250 mg, 500 mg

v) Other Dosage Forms and Strengths Available

• Suspension (Paediatric): 50 mg/5 mL (limited availability)

vi) Mechanism of Action

• Primary Action:

• COX-1 & COX-2 Inhibition: Reversible, competitive inhibition of

cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis (anti-
inflammatory, analgesic, antipyretic effects).
• PGE₂ Receptor Antagonism: Blocks prostaglandin E₂ binding to receptors,
particularly in the uterus (useful for dysmenorrhea).

• Secondary Effects:

• Modulates ion channels (e.g., Ca²⁺, GABA receptors).

• Inhibits platelet aggregation (mild effect).
• May have neuroprotective properties (experimental).
vii) Indications

1. Pain Management:

• Primary Dysmenorrhea (menstrual pain).

• Mild-to-Moderate Pain (e.g., headache, dental pain, musculoskeletal pain).
2. Menorrhagia: Reduces excessive menstrual bleeding (via prostaglandin inhibition).
 3. Off-Label Uses:

• Migraine prophylaxis.
• Postoperative pain.
• Pediatric antipyretic (limited use).
viii) Pharmacokinetics

Parameter Details
Absorption Rapid but incomplete (~80% oral bioavailability). Peak plasma levels: 2–
4 hours.
Distribution Highly protein-bound (>90%), primarily to albumin. Crosses placenta
and enters breast milk (minimal amounts).
Metabolism Hepatic via CYP2C9 oxidation to 3-hydroxymethyl and 3-carboxyl
metabolites. Glucuronidation follows.
Excretion Urine (major route, as glucuronides); feces (unchanged drug). Half-life:
2–4 hours.
Food Interaction Food does not significantly affect absorption, but water reduces it.

ix) Contraindications

• Hypersensitivity: To mefenamic acid, other NSAIDs, or aspirin (risk of cross-

reactivity).
• Asthma/NSAID-Induced Bronchospasm: Especially in aspirin-sensitive asthma.
• Renal Impairment: Severe CKD or active renal disease (risk of nephrotoxicity).
• Peptic Ulcer Disease/GI Bleeding: Active or history of ulcers.
• Pregnancy (3rd Trimester): Risk of premature ductus arteriosus closure.
• Heart Failure: Due to fluid retention risk.

x) Adverse Effects

Common (>10%):

• GI: Nausea, diarrhea, abdominal pain, dyspepsia.

• CNS: Dizziness, headache.

Less Common (1–10%):

• GI: Gastric ulcers, bleeding (risk increases with prolonged use).

• Skin: Rash, pruritus.
• Renal: Elevated creatinine, interstitial nephritis (rare).

Rare (<1%):

• Hematologic: Hemolytic anemia, neutropenia.

• Hepatic: Elevated LFTs, hepatitis.
• Hypersensitivity: Stevens-Johnson syndrome (SJS), anaphylaxis.
xi) Drug Interactions

Interacting Drug Effect

Warfarin ↑ Bleeding risk (displaces warfarin from protein
binding).
Lithium/Cyclosporine ↑ Toxicity (reduced renal clearance).
Diuretics/ACE Inhibitors ↓ Antihypertensive effect; ↑ nephrotoxicity.
Aspirin/Other NSAIDs ↑ GI toxicity (additive COX inhibition).

Methotrexate ↑ Methotrexate toxicity (competes for renal

excretion).

Reference

Cimolai, N. (2013). The potential and promise of mefenamic acid. Expert review of clinical
pharmacology, 6(3), 289-305.
 CEFTRIAXONE DRUG PROFILE
i) Brand Name:

• inocef • Neotrixone • Triax

• Rocephin • Xone • Cefmax
• Triaxon • Vialon • Ceftron

ii) Generic Name:

Ceftriaxone

iii) Drug Classification:

Third-generation cephalosporin antibiotic (β-lactam class)

iv) Dosage Form:

Inj: 1g, 2g, 250mg, 500mg

Inj-IV: 1g, 250mg, 500mg
Inj-IM: 1g, 2g, 250mg, 500mg
Inj IM/IV: 1g, 250mg, 500mg
Inj CS: 250mg
Inf: 1g
Gel: 500mg

v) Other Dosage Forms and Strengths Available:

• Vials containing 250 mg, 500 mg, 1 g, or 2 g of ceftriaxone equivalent

• Solutions prepared from sterile powder: IM (250 mg/mL or 350 mg/mL), IV (10–40
mg/mL)

vi) Mechanism of Action:

Ceftriaxone is bactericidal and acts by inhibiting bacterial cell wall synthesis. It is stable
against many β-lactamases (penicillinases and cephalosporinases)

vii) Pharmacokinetics:

Parameter Details
Absorption Complete after IM administration
Peak Plasma Time 2–3 hours (IM)
Half-life 5.8–8.7 hours in healthy adults
Excretion 33–67% in urine as unchanged drug; rest via bile and feces
Protein Binding ~85–95%, concentration-dependent
Volume of Distribution 5.78 to 13.5 L
Crosses Blood-Brain Yes (especially in inflamed meninges)
Barrier
viii) Indications:

• Respiratory tract infections • Septicemia

• Otitis media • Bone and joint infections
• Skin and soft tissue infections • Intra-abdominal infections
• Urinary tract infections • Meningitis
• Gonorrhea • Surgical prophylaxis
• Pelvic inflammatory disease
ix) Contraindications:

• Known allergy to cephalosporins

• Neonates with hyperbilirubinemia or needing calcium-containing IV fluids
• Concurrent use with calcium-containing IV solutions in neonates

x) Adverse Effects:

• Common: Diarrhea, nausea, rash, pain at injection site

• Less Common: Hematologic issues (eosinophilia, leukopenia), liver enzyme elevation,
nephrotoxicity
• Rare: Anaphylaxis, hemolytic anemia, gallbladder sludge, biliary pseudolithiasis,
severe cutaneous reactions

xi) Drug Interactions:

• Calcium-containing solutions: Risk of precipitation (esp. in neonates)

• Probenecid: No significant effect on elimination
• Incompatibilities: Do not mix with vancomycin, aminoglycosides, fluconazole in the
same line; ensure line flushing between sequential infusions

Reference
Khan, M. Y., Roy, M., Rawal, R. K., & Bansal, U. K. (2017). A review-ceftriaxone for
life. Asian Journal of Pharmaceutical Research, 7(1), 35-48.