Pneumonia (main)

Background

3 questions:

1. Does this pt have pneumonia?
2. If yes, does this pt need to be admitted?
3. If yes, admit to the ward or ICU?

Clinical Presentation

• Fever, chills, pleuritic CP, productive cough
  • Fever is seen in 80%
• Tachypnea
  • Most sensitive sign in elderly
• Abdominal pain, N/V/diarrhea may be seen with Legionella infection

Work-Up

1. CXR
2. CBC
3. Chemistry

If pt will be admitted:

1. Blood Cx are ONLY indicated for CAP pts with:
   1. ICU pts (required), multi-lobar, or pleural effusion
   2. Consider for higher-risk patients admitted with CAP
      1. Liver disease, immunocompromised, significant comorbidities, or other risk factors
         
2. Sputum staining
   1. If concern for particular organism

Health care–associated PNA risk factors

1. Pts hospitalized for 2 or more days w/in past 90d
2. Nursing home/long-term care residents
3. Pts receiving home IV abx
4. Dialysis pts
5. Pts receiving chronic wound care
6. Pts receiving chemotherapy
7. Immunocompromised pts

Pseudomonas risk factors

1. Alcoholism
2. Immunosuppression (incl. steroids)
3. Structural lung disease
4. Malnutrition
5. Recent abx
6. Recent hospital stay

Treatment

Outpatient, community-acquired PNA

Healthy

1. Clarithromycin XL 1000mg PO QD x7d OR
2. Azithromycin 500mg PO day 1, 250mg on days 2-5 OR
3. Doxycycline 100mg BID x 10-14d (2nd line choice)

Unhealthy

1. Chronic heart, lung, liver, or renal disease; DM, alcholism, malignancy.  Add
   1. Levofloxacin 750mg QD x5d OR
   2. Moxifloxacin 400mg QD x7-14d OR
   3. Amoxicillin-clavulanate 2g BID AND Azithromycin 500mg day 1, 250mg days 2-5 OR Doxy
   4. 3rd generation cephalosporin AND Azithromycin or Doxy

Inpatient

Community-acquired PNA

1. Levofloxacin 750mg QD x5d OR
2. Moxifloxacin 400mg QD x7-14d OR
3. 3rd generation cephalosporin AND azithromycin

Health Care-associated PNA

1. 3-drug regimen recommended
   1. (Cefepime 1-2gm q8-12h OR ceftazidime 2gm q8h) + cipro 400mg q8h + vanco 15mg/kg q12 OR
   2. Imipenem 500mg q6hr + cipro 400mg q8hr + vanco 15mg/kg q12 OR
   3. Piperacillin-tazobactam 4.5gm q6h + cipro 400mg q8h + vanco 15mg/kg q12

ICU, low risk of pseudomonas

1. Ceftriaxone 1gm IV and Azithromycin 500mg IV OR
2. Ceftriaxone 1gm IV and (moxifloxacin 400mg IV or levofloxacin 750mg IV)
3. Penicillin allergy
   1. Moxi/levofloxacin and (aztreonam 1-2gm IV or clindamycin 600mg IV)

ICU, risk of pseudomonas

1. Cefipime, imipenem, OR piperacillin-tazobactam + IV cipro/levo
2. Cefipime, imipenem, OR piperacillin-tazobactam + gent + azithromycin
3. Cefipime, imipenem, OR piperacillin-tazobactam + gent + cipro/levo

Disposition

See Pneumonia (Port Score)

See Also

• Pneumonia (Pathogens)
• Pneumonia (Peds)
• Pneumonia (Port Score)

Source

• UpToDate