Community-Acquired PNEUMONIA

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Community-Acquired PNEUMONIA, The Persistent Global Threat

Subal Khanal, an MBBS student at Kathmandu Medical College, is passionate about public health and community service. With leadership experience in organizations such as the Rotaract Club of KMC, Nepal Health Corps, and various youth clubs, he has been actively involved in health camps, blood donation, mental health advocacy, and youth empowerment. Dedicated to research, writing, and continuous learning, he works toward improving healthcare access and supporting underprivileged communities.

Community-Acquired Pneumonia (CAP) is one of the most common infectious diseases and remains a major cause of morbidity and mortality worldwide, particularly among children under five years of age and elderly patients.

Epidemiology

The incidence of CAP varies widely between developing and developed countries. It continues to occur frequently in children younger than five years, accounting for approximately 28–34% of all deaths in this age group globally. According to the World Health Organization, one in three newborn deaths occurs due to pneumonia.

Situation in Nepal

In Nepal, the incidence of Acute Respiratory Infections (ARI) increased from 266 per 1,000 children under five in FY 2079/80 to 290 per 1,000, while the incidence of pneumonia remained constant at 34 per 1,000 under-five children.

Karnali Province reported the highest ARI incidence (433 per 1,000) as well as the highest pneumonia incidence (70 per 1,000).
Madhesh Province recorded the lowest ARI (242 per 1,000) and pneumonia incidence (19 per 1,000).

At the national level, the rate of antibiotic-treated pneumonia remained above 100% for three consecutive fiscal years.

Community-Acquired Pneumonia: Risk Factors, Causes, and Clinical Features

Risk Factors for Pneumonia

Malnutrition
Low birth weight
Non-exclusive breastfeeding (during the first 4 months of life)
Lack of measles immunization (within the first 12 months of life)
Indoor air pollution
Crowding
Parental smoking
Zinc deficiency
Mother’s experience as a caregiver
Concomitant diseases (e.g., diarrhea, heart disease, asthma, COPD)
Mother’s education level
Day-care attendance
Rainfall and high humidity
High altitude (cold air exposure)
Vitamin A deficiency
Birth order
Outdoor air pollution

Causes of Community-Acquired Pneumonia (CAP)

Pneumonia that develops outside a healthcare facility is called community-acquired pneumonia (CAP). The causes include:

Bacteria

Streptococcus pneumoniae – the most common cause (also responsible for ear infections, sinus infections, and meningitis).
Mycoplasma pneumoniae – causes “atypical pneumonia,” which is usually milder.
Haemophilus influenzae and Chlamydia pneumoniae – less common but important bacterial causes.

Viruses

Influenza, Respiratory Syncytial Virus (RSV), adenovirus, and COVID-19 are frequent viral causes.
These viruses typically cause colds or flu but may spread to the lungs.

Fungi & Protozoa

Rare causes, usually seen in people with weakened immune systems (e.g., HIV, cancer, transplant patients).

How Pneumonia Develops

The lungs are normally protected by mucociliary clearance and the cough reflex, which prevent germs from entering.
These defenses may be weakened by smoking, alcohol use, malnutrition, or chronic illnesses.
Pneumonia germs can reach the lungs through:
1. Inhalation – breathing in infected droplets (e.g., flu, “walking pneumonia”).
2. Aspiration – inhaling saliva or secretions from the mouth/throat carrying harmful bacteria.
Normally harmless mouth bacteria can become dangerous (e.g., Streptococcus pneumoniae, Staphylococcus aureus) in people with low immunity, leading to lung inflammation, cough, fever, and breathing difficulty.

Differentiating Pneumonia from Cold or Flu

It can be difficult to distinguish pneumonia from common viral illnesses. Medical evaluation is necessary. Seek urgent care if the following occur:

Chest congestion or pain
Difficulty breathing
Fever of 102°F (38.9°C) or higher
Cough producing yellow, green, or bloody mucus

Signs and Symptoms of Pneumonia

Bacterial Pneumonia

High fever (up to 105°F / 40.5°C) with rigors
Cough with yellow, green, or bloody mucus
Fatigue and weakness
Rapid breathing and shortness of breath
Rapid heart rate
Sweating or chills
Pleuritic chest or abdominal pain (worse with coughing or deep breathing)
Loss of appetite
Bluish skin, lips, or nails (cyanosis)
Confusion or altered mental state (common in elderly patients)

Viral Pneumonia

Symptoms similar to bacterial pneumonia, but usually milder
Dry cough
Headache
Muscle aches
Extreme tiredness or weakness

Pneumonia in Different Age Groups

In Young Children

Fever, chills, flushed skin, sweating, and general discomfort
Persistent cough
Rapid or difficult breathing (tachypnea)
Loss of appetite
Vomiting
Low energy, restlessness, or fussiness
Grunting or noisy breathing
Fewer wet diapers than usual
Pale skin
Limpness or excessive crying
Difficulty feeding

In Adults Over 65

Mild or less obvious symptoms (cough, shortness of breath)
Sudden confusion or mental status changes
Loss of appetite
Fatigue
Worsening of underlying chronic health conditions

Is Pneumonia Contagious?

Yes, pneumonia can be contagious depending on the cause.

Bacterial and viral pneumonia: Spread through coughing, sneezing, or contaminated surfaces. For example, the flu virus can spread easily and sometimes lead to pneumonia. Streptococcus pneumoniae also spreads person-to-person.
Fungal pneumonia: Not considered contagious. Instead, it comes from environmental exposure (e.g., moldy rooms during rainy seasons may increase risk).

Can You Have Pneumonia Without a Fever?

Yes. While about 80% of pneumonia patients develop fever, some may not. This is more common in:

Adults over 65 years
Infants under 2 years (especially newborns)
Individuals with weakened immune systems

Complications of Pneumonia

Pneumonia can lead to serious complications that often require hospitalization. These include:

Breathing difficulties such as respiratory failure or Acute Respiratory Distress Syndrome (ARDS)
Pleural effusion – fluid buildup around the lungs
Bacteremia (bacteria in the bloodstream), which may progress to sepsis or organ failure
Lung abscesses – pus-filled cavities in the lungs
Mortality risk: The average mortality rate is 12% among hospitalized patients, but it can rise to 30–40% in severe CAP (community-acquired pneumonia) cases requiring ICU admission

Prevention of Pneumonia

The most effective prevention is vaccination combined with healthy lifestyle habits and infection control measures.

Vaccines

Pneumococcal vaccines – recommended for high-risk individuals and certain age groups
Influenza (flu) and COVID-19 vaccines – reduce the risk of viral pneumonia
Routine childhood immunizations – prevent infections that may progress to pneumonia

Other Preventive Measures

Quit smoking and avoid exposure to secondhand smoke
Practice good hand hygiene (soap and water or alcohol-based sanitizers)
Limit close contact with sick individuals
Ask about infection-prevention protocols during hospital stays
Maintain a healthy lifestyle: balanced diet, regular exercise, and adequate sleep
Properly manage chronic illnesses (e.g., asthma, COPD, diabetes)
Avoid excessive alcohol use

Indications for Hospitalization

The decision to hospitalize a patient with community-acquired pneumonia (CAP) is often guided by clinical scoring systems such as the Pneumonia Severity Index (PSI) or the CURB-65 score.

CURB-65 Criteria:
- C: Confusion
- U: Urea > 40 mg/dL
- R: Respiratory rate ≥ 30/min
- B: Blood pressure (systolic < 90 mmHg or diastolic ≤ 60 mmHg)
- 65: Age > 65 years

Interpretation:

Score 0–1: Outpatient treatment is generally sufficient
Score 2: Hospital admission is recommended
Score ≥3: Consider ICU admission

Expert Insight

While drafting this article, I had the opportunity to meet Dr. Aabishkar Subedi, Consultant Physician at Kathmandu Medical College, and sought his views on community-acquired pneumonia. He emphasized the importance of timely recognition and proper medical care, stating:

“If you or someone you know develops signs and symptoms of pneumonia, please remain cautious and seek medical attention promptly. It is important to consult a qualified doctor at the earliest opportunity. In our society, many people first visit a pharmacy for self-medication or rely on advice from the person running the pharmacy, who may or may not be a qualified pharmacist. At times, antibiotics are dispensed without proper diagnosis, which can delay appropriate treatment and potentially worsen the patient’s condition.”

Key Reminders

Pneumonia can be caused by viruses, bacteria, or fungi.

Antibiotics only work against bacterial pneumonia. They are ineffective for viral or fungal pneumonia and may delay proper treatment, increasing the risk of complications.

Taking antibiotics without a doctor’s prescription is dangerous. Misuse can lead to antibiotic resistance, making the medicine ineffective when it is truly needed.

The safest step: If you have symptoms of pneumonia, seek medical care from a qualified doctor, not just a pharmacy. Early and correct treatment saves lives.