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Pulmonary infection is common in patients receiving immunosuppressive drugs and in those with diseases causing defects of cellular or humoral immune mechanisms. For example, patients with AIDS are susceptible to many types of pneumonia, in particular Pneumocystis carinii (see p. 120). It is important to recognise, however, that the common pathogenic bacteria are responsible for the majority of lung infections in immunocompromised patients (see Box 13.48). Despite this, the Gram-negative bacteria, especially Pseudomonas aeruginosa, are more of a problem than Gram-positive organisms, and unusual organisms or those normally considered to be of low virulence or non-pathogenic may become 'opportunistic' pathogens. Likewise, infection is often due to more than one organism. Pneumocystis carinii and other fungi such as Aspergillus fumigatus, viral infections, cytomegalovirus, herpesviruses, and infections with M. tuberculosis and other types of mycobacteria are all common causes of infection in patients who are immunocompromised.
Clinical features
The patient usually presents with fever, cough, breathlessness and infiltrates on the chest radiograph. Patients may develop non-specific symptoms, and a high index of suspicion is required to determine the site and nature of the infection. In general, the onset of symptoms tends to be less rapid in patients with opportunistic organisms such as Pneumocystis carinii and mycobacterial infections. In Pneumocystis carinii pneumonia symptoms of cough and breathlessness can be present several days or weeks before the onset of systemic symptoms or even a chest radiograph abnormality.
Management
Whenever possible, treatment should be based on an established aetiological diagnosis. In practice, however, the cause of the pneumonia is frequently not known when treatment has to be started. Hence, broad-spectrum antibiotic therapy is required (e.g. a third-generation cephalosporin, or a quinolone, plus an antistaphylococcal antibiotic, or an antipseudomonal penicillin plus an aminoglycoside) and this treatment is thereafter tailored according to the results of investigations and the clinical response.
| Agent | Drugs |
| Virus | Acyclovir, guncyclovir |
| Pneumocysta carinii | Trimethoprim-sulfamethoxazole |
| Fungi | Cetoconazol, fluconazol, voriconazol, itraconazol |
· Streptococcus pneumoniae (pneumococcus)
o Penicillin
o Amoxicillin
o Cephalosporins
o Erythromycin
o Azithromycin
o Clarithromycin
o Fluoroquinolones
· Haemophilus influenzae
o Cephalosporins (2nd and 3rd generation)
o Amoxicillin-clavulanate
o Azithromycin
o Fluoroquinolones
o Trimethoprim-sulfamethoxazole
· Legionella pneumophila
o Erythromycin (with or without rifampin)
o Azithromycin
o Fluoroquinolones
· Mycoplasma pneumoniae
o Erythromycin
o Doxycycline
o Azithromycin
o Clarithromycin
o Fluoroquinolones
· Chlamydia pneumoniae
o Erythromycin
o Doxycycline
o Azithromycin
o Clarithromycin
o Fluoroquinolones
· Staphylococcus aureus
o Cephalosporins (1st generation)
o Nafcillin
o Oxacillin
o Vancomycin
· Anaerobic bacteria
o Clindamycin
o Metronidazole
· Gram-negative bacteria
o Imipenem
o Cephalosporins (3rd and 4th generation)
o Aminoglycosides
o Fluoroquinolones
o Newer fluoroquinolones
o levofloxacin, monifloxacin, gatifloxacin
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