By the time Hillary Clinton almost collapsed in front of the cameras at the 9/11 memorial service in September 2016, she had been coughing for a couple of weeks and the “allergic symptoms” she complained of turned out to be pneumonia. This disclosure initiated questions from reporters and voters, alike: How serious was the condition? Why was she allowed to continue her incredibly challenging schedule if she knew she had pneumonia? Was she infectious to others?
Pneumonia is one of the most common infectious diseases. It can range from a mild case to a level so severe as to be life threatening. An infection of the lungs, pneumonia can be caused by a virus or it can be bacterial.
The lungs are composed of breathing tubes called bronchi that end in breathing sacs called alveoli. When there is inflammation of the bronchi we call it bronchitis. The air sacs or alveoli contain cells that that are the defenses against outside particles that enter the lungs on a daily basis — including bacteria. When the inflammatory reaction to invading germs is overwhelming, excess secretions are created, and they can fill up the alveoli. This results in pneumonia.
How serious is pneumonia?
Pneumonia can present itself like a bad cold, or, the person can deteriorate rapidly with a severe, life threatening disease, in which case an X-ray likely shows disease involving all lung fields. It’s important to seek treatment if you suspect that you have pneumonia. (Jim Henson, the creator of the Muppets and Sesame Street, was sick at home with undiagnosed pneumonia for a few days when his health quickly deteriorated and he died.)
The Infectious Disease Society of America (IDSA) and the American Thoracic Society (ATS) came to a consensus with guidelines for evaluation and treatment of pneumonia. Two scales were developed to assess the illness: The CURB-65 scale which takes into account the patient’s age, vital signs, and level of confusion (usually from a high fever) and the Pneumonia Severity Index (PSI). These two evaluation tools are particularly useful for emergency room doctors so they can decide how aggressively to treat the infectious process and also decide if the patient needs to be hospitalized.
What causes the infections and to what degree is pneumonia contagious?
In the case of pneumonia acquired in the community — community acquired pneumonia or CAP — only a minority of cases is spread from person-to-person. These are significant pneumonias because of their severity. The most common pneumonia infections that spread person-to-person are caused by mycoplasma ("atypical" pneumonia), influenza (pneumonia that results from complications from the yearly flu), and tuberculosis.
The majority of cases of pneumonia are due to aspiration of bacteria from one’s mouth or teeth into the lungs. In individuals who are in a weakened condition and unable to clear the excess secretions on a regular basis (the very elderly for example), this daily occurrence allows secretions to accumulate and solidify in the lung, and the risk of pneumonia is quite high.
Germs can grow on humidifiers and in air conditioners and can also spread through infected water. Legionella, the cause of Legionnaire’s disease, was named after attendees at a Legionnaire’s convention who were infected by contaminated air conditioners. There are also some infections that are transmitted through contact with animals (chlamydia and trachoma).
What should be done if one suspects pneumonia?
The guidelines are very clear about treatment. If the illness meets the criteria for bacterial pneumonia (rather than a viral infection) antibiotics must be started immediately. This will help to arrest the inflammatory process. The choice of antibiotics is addressed in the guidelines and sometimes involves starting two medications and then "de-escalating” to a single drug, two to three days later, after the condition has stabilized.
Do all the pneumonias behave similarly?
The guidelines help to delineate the difference between pneumonias, by analyzing where and how the infection was contracted. Pneumonia acquired in the community is different from one acquired while you are a patient in the hospital being treated for another disease (hospital-acquired pneumonia or HAP). The infecting bacteria are different, so choices of antibiotics need to be matched to the particular bacteria in question.
Now that many elderly are treated at home by home health agencies, there is a new category called healthcare-associated pneumonia (HCAP). Each of these pneumonias has different characteristics that mandate different treatment approaches.
Who is most at risk for pneumonia?
Generally speaking, individuals with poor defenses are more vulnerable. Other risk factors include:
Recent viral infections such as influenza
Living in a nursing facility
Recent surgery or trauma
Chronic pulmonary conditions such as COPD, Bronchiectasis
Children have other risk factors that may make them more prone to pneumonia.
What are the biggest mistakes people make regarding pneumonia?
An abnormal X-ray does not necessarily suggest pneumonia. Individuals need to assess their symptoms and seek medical attention if they suspect that they or a family member has pneumonia. In some cases, there can be rapid deterioration and even death. On the other hand, too many patients are unnecessarily treated with antibiotics, a situation which contributes to the growing problem of antibiotic resistance. It’s best to get a doctor’s opinion if you’re in doubt.
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Eli Hendel, M.D. is a board-certified Internist and pulmonary specialist with board certification in Sleep Medicine. He is an Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations. His areas of expertise in private practice include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases.