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?

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

Coverage targeted at S. pneumoniae, H. influenzae. M. pneumoniae, C. pneumoniae, and Legionella

Healthy

No comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) and no or risk factors for MRSA or Pseudomonas aeruginosa (include prior respiratory isolation of MRSA or P. aeruginosa or recent hospitalization AND receipt of parenteral antibiotics (in the last 90 d))

• Amoxicillin 1 g three times daily (strong recommendation, moderate quality of evidence), OR
• Doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence), OR
• Macrolide in areas with pneumococcal resistance to macrolides <25% (conditional recommendation, moderate quality of evidence).
  • Azithromycin 500 mg on first day then 250 mg daily OR
  • Clarithromycin 500 mg BID or clarithromycin ER 1,000 mg daily
• Duration of therapy 5 days minimum

Unhealthy

If patient has comorbidities or risk factors for MRSA or Pseudomonas aeruginosa

• Combination therapy:
  • Amoxicillin/Clavulanate
    • 500 mg/125 mg TID OR amox/clav 875 mg/125 mg BID OR 2,000 mg/125 mg BID. Duration is for a minimum of 5 days and varies based on disease severity and response to therapy; patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued
  • OR cephalosporin
    • Cefpodoxime 200 mg BID OR cefuroxime 500 mg BID
  • AND macrolide
    • Azithromycin 500 mg on first day then 250 mg daily
    • OR clarithromycin 500 mg BID OR clarithromycin ER 1,000 mg daily]) (strong recommendation, moderate quality of evidence for combination therapy)
  • OR doxycycline 100 mg BID (conditional recommendation, low quality of evidence for combination therapy)
• Monotherapy: respiratory fluoroquinolone (strong recommendation, moderate quality of evidence):
  • Levofloxacin 750 mg daily OR
  • Moxifloxacin 400 mg daily OR
  • Gemifloxacin 320 mg daily

Inpatient

• Monotherapy or combination therapy is acceptable
• Combination therapy includes a cephalosporin and macrolide targeting atypicals and Strep Pneumonia
• The use of adjunctive corticosteroids (methylprednisolone 0.5 mg/kg IV BID x 5d) in CAP of moderate-high severity (PSI Score IV or V; CURB-65 ≥ 2) is associated with:
  • ↓ mortality (3%)
  • ↓ need for mechanical ventilation (5%)
  • ↓ length of hospital stay (1d)

Community Acquired (Non-ICU)

Coverage against community acquired organisms plus M. catarrhalis, Klebsiella, S. aureus

• β-lactam (e.g. ceftriaxone 1–2g daily OR ampicillin-sulbactam 1.5–3g q6h OR cefotaxime 1–2g q8h OR ceftaroline 600mg q12h) PLUS
  • Macrolide (e.g. azithromycin 500 mg daily or clarithromycin 500 mg BID)OR
  • Doxycycline 100mg IV/PO BID (if contraindications to both macrolides and fluoroquinolones ) OR
• Levofloxacin 750mg IV/PO once daily OR
• Moxifloxacin 400mg IV/PO once daily

Hospital Acquired or Ventilator Associated Pneumonia

• 3-drug regimen recommended options:
  • Cefepime 1-2gm q8-12h OR ceftazidime 2gm q8h + Levofloxacin 750 mg PO/IV every 24 hours + Vancomycin 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
• Consider tobramycin in place of fluoroquinolones given FDA 2016 warnings
• Of note, the combination of vanco+ piperacillin-tazobactam carries higher risk of AKI when compared to cefepime + vanco’’’

Ventilator Associated Pneumnoia

• High Risk of MRSA: Use 3-Drug Regimen. Several options are available, but recommendation is to include an antibiotic from each of these categories:
  • 1. MRSA Antibiotic: Vancomycin 15mg/kg q12h OR Linezolid 600 mg IV q12h PLUS
  • 2. Antipseudomonal Antibiotic: Piperacillin-Tazobactam 4.5gm q6h OR Cefepime 2 g IV q8h OR Imipenem 500 mg IV q6h OR Aztreonam 2 g IV q8h PLUS
  • 3. GN Antibiotic With Antipseudomonal Activity: Cipro 400 mg IV q8h

ICU, low risk of pseudomonas

• Ceftriaxone 1gm IV + Azithromycin 500mg IV OR
• Ceftriaxone 1gm IV + (moxifloxacin 400mg IV or levofloxacin 750mg IV)
• Penicillin allergy
  • (Moxifloxacin or levofloxacin) + (aztreonam 1-2gm IV or clindamycin 600mg IV)

ICU, risk of pseudomonas

• Cefepime, Imipenem, OR Piperacillin/Tazobactam + IV cipro/levo
• Cefepime, imipenem, OR piperacillin-tazobactam + gent + azithromycin
• Cefepime, imipenem, OR piperacillin-tazobactam + gent + cipro/levo

Disposition

See Pneumonia (Port Score)

See Also

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

Source

• UpToDate, Dr. Spellberg HUMC 8/13