Pneumonia (main): Difference between revisions
No edit summary
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# If yes, does this pt need to be admitted?
# If yes, does this pt need to be admitted?
# If yes, admit to the ward or ICU?  
# If yes, admit to the ward or ICU?  
===Health care–associated PNA risk factors===
#Pts hospitalized for 2 or more days w/in past 90d
#Nursing home/long-term care residents
#Pts receiving home IV abx
#Dialysis pts
#Pts receiving chronic wound care
#Pts receiving chemotherapy
#Immunocompromised pts
===Pseudomonas risk factors===
# Alcoholism
# Immunosuppression (incl. steroids)
# Structural lung disease
# Malnutrition
# Recent abx
# Recent hospital stay


==Clinical Presentation==
==Clinical Presentation==
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*Tachypnea
*Tachypnea
**Most sensitive sign in elderly  
**Most sensitive sign in elderly  
*Abdominal pain, N/V/diarrhea may be seen with Legionella infection
*Abdominal pain, N/V/diarrhea may be seen with [[Legionella]] infection


== Work-Up  ==
== Work-Up  ==
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If pt will be admitted:  
If pt will be admitted:  


#Blood Cx are '''ONLY''' indicated for CAP pts with:
#[[Blood Cultures]] are '''ONLY''' indicated for CAP pts with:
##ICU pts (required)
##ICU pts (required)
##Multi-lobar
##Multi-lobar
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#Sputum staining  
#Sputum staining  
##If concern for particular organism
##If concern for particular organism
==Health care–associated PNA risk factors==
#Pts hospitalized for 2 or more days w/in past 90d
#Nursing home/long-term care residents
#Pts receiving home IV abx
#Dialysis pts
#Pts receiving chronic wound care
#Pts receiving chemotherapy
#Immunocompromised pts
==Pseudomonas risk factors==
# Alcoholism
# Immunosuppression (incl. steroids)
# Structural lung disease
# Malnutrition
# Recent abx
# Recent hospital stay


==Treatment==
==Treatment==
===Outpatient, community-acquired PNA===
===Outpatient, community-acquired PNA===
====Healthy====
====Healthy====
#Clarithromycin XL 1000mg PO QD x7d OR
#[[Clarithromycin]] XL 1000mg PO QD x7d OR
#Azithromycin 500mg PO day 1, 250mg on days 2-5 OR
#[[Azithromycin]] 500mg PO day 1, 250mg on days 2-5 OR
#Doxycycline 100mg BID x 10-14d (2nd line choice)
#[[Doxycycline]] 100mg BID x 10-14d (2nd line choice)
 
==== Unhealthy ====
==== Unhealthy ====
#Chronic heart, lung, liver, or renal disease; DM, alcholism, malignancy.  Add
#Chronic heart, lung, liver, or renal disease; DM, alcholism, malignancy.  Add
##Levofloxacin 750mg QD x5d OR  
##[[Levofloxacin]] 750mg QD x5d OR  
##Moxifloxacin 400mg QD x7-14d OR  
##[[Moxifloxacin]] 400mg QD x7-14d OR  
##Amoxicillin-clavulanate 2g BID AND Azithromycin 500mg day 1, 250mg days 2-5 OR Doxy
##[[Amoxicillin/Clavulanate]] 2g BID AND [[Azithromycin]] 500mg day 1, 250mg days 2-5 OR [[Doxy]]
##3rd generation cephalosporin AND Azithromycin or Doxy
##3rd generation [[cephalosporin]] AND [[Azithromycin]] or [[Doxycycline]]


===Inpatient===
===Inpatient===
====Community-acquired PNA====
====Community-acquired PNA====
#Levofloxacin 750mg QD x5d OR
#[[Levofloxacin]] 750mg QD x5d OR
#Moxifloxacin 400mg QD x7-14d OR
#[[Moxifloxacin]] 400mg QD x7-14d OR
#3rd generation cephalosporin AND azithromycin
#3rd generation [[cephalosporin]] AND [[azithromycin]]
 
====Health Care-associated PNA====
====Health Care-associated PNA====
#3-drug regimen recommended
#3-drug regimen recommended
##(Cefepime 1-2gm q8-12h OR ceftazidime 2gm q8h) + cipro 400mg q8h + vanco 15mg/kg q12 OR
##([[Cefepime]] 1-2gm q8-12h OR [[ceftazidime]] 2gm q8h) + [[cipro]] 400mg q8h + [[vanco]] 15mg/kg q12 OR
##Imipenem 500mg q6hr + cipro 400mg q8hr + vanco 15mg/kg q12 OR
##[[Imipenem]] 500mg q6hr + [[cipro]] 400mg q8hr + [[vanco]] 15mg/kg q12 OR
##Piperacillin-tazobactam 4.5gm q6h + cipro 400mg q8h + vanco 15mg/kg q12  
##[[Piperacillin-Tazobactam]] 4.5gm q6h + [[cipro]] 400mg q8h + [[vanco]] 15mg/kg q12  


====ICU, low risk of pseudomonas====
====ICU, low risk of pseudomonas====
#[[Ceftriaxone]] 1gm IV and Azithromycin 500mg IV OR
#[[Ceftriaxone]] 1gm IV and [[Azithromycin]] 500mg IV OR
#[[Ceftriaxone]] 1gm IV and (moxifloxacin 400mg IV or levofloxacin 750mg IV)
#[[Ceftriaxone]] 1gm IV and ([[moxifloxacin]] 400mg IV or [[levofloxacin]] 750mg IV)
#Penicillin allergy
#Penicillin allergy
##Moxi/levofloxacin and ([[aztreonam]] 1-2gm IV or clindamycin 600mg IV)
##[[Moxi]]/[[levofloxacin]] and ([[aztreonam]] 1-2gm IV or [[clindamycin]] 600mg IV)


====ICU, risk of pseudomonas====
====ICU, risk of pseudomonas====
# Cefipime, imipenem, OR piperacillin-tazobactam + IV cipro/levo
# [[Cefipime]], [[Imipenem]], OR [[Piperacillin/Tazobactam]] + IV [[cipro]]/[[levo]]
# Cefipime, imipenem, OR piperacillin-tazobactam + gent + azithromycin
# [[Cefipime]], [[imipenem]], OR [[piperacillin-tazobactam]] + [[gent]] + [[azithromycin]]
# Cefipime, imipenem, OR piperacillin-tazobactam + gent + cipro/levo
# [[Cefipime]], [[imipenem]], OR [[piperacillin-tazobactam]] + [[gent]] + [[cipro]]/[[levo]]


==Disposition==
==Disposition==

Revision as of 20:09, 8 March 2014

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?

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

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 Cultures are ONLY indicated for CAP pts with:
    1. ICU pts (required)
    2. Multi-lobar
    3. Pleural effusion
    4. Consider for higher-risk patients admitted with CAP
      1. Liver disease
      2. Immunocompromised
      3. Significant comorbidities
      4. Other risk factors
  2. Sputum staining
    1. If concern for particular organism

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 Doxycycline

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

Source

  • UpToDate, Dr. Spellberg HUMC 8/13
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