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 (required if pt may require ICU during their course)
2. Sputum staining
   1. If concern for particular organism

Treatment

• Must cover at least pneumococcus and legionella (most virulent causes in healthy adults)

Outpatient

1. 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)
2. Unhealthy (chronic heart, lung, liver, or renal disease; DM, alcholism, malignancy)
   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
   4. 3rd generation cephalosporin AND azithromycin

Inpatient

1. Ward
   1. Levofloxacin 750mg QD x5d OR
   2. Moxifloxacin 400mg QD x7-14d OR
   3. 3rd generation cephalosporin AND azithromycin
2. ICU, low risk of pseudomonas
   1. Beta-lactam + (macrolide OR respiratory fluoroquinolone)
3. 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

Pseudomonas risk factors

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

Disposition

See Pneumonia (Port Score)

See Also

Pneumonia (Pathogens)

Pneumonia (Peds)

Pneumonia (Port Score)

Source

UpToDate