Pneumonia (main)
Background
3 questions:
- Does this pt have pneumonia?
- If yes, does this pt need to be admitted?
- 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
- CXR
- CBC
- Chemistry
If pt will be admitted:
- Blood cx (required if pt may require ICU during their course)
- Sputum staining
- If concern for particular organism
Treatment
- Must cover at least pneumococcus and legionella (most virulent causes in healthy adults)
Outpatient
- Healthy
- Clarithromycin XL 1000mg PO QD x7d OR
- Azithromycin 500mg PO day 1, 250mg on days 2-5 OR
- Doxycycline 100mg BID x 10-14d (2nd line choice)
- Unhealthy (chronic heart, lung, liver, or renal disease; DM, alcholism, malignancy)
- Levofloxacin 750mg QD x5d OR
- Moxifloxacin 400mg QD x7-14d OR
- Amoxicillin-clavulanate 2g BID AND Azithromycin 500mg day 1, 250mg days 2-5 OR
- 3rd generation cephalosporin AND azithromycin
Inpatient
- Ward
- Levofloxacin 750mg QD x5d OR
- Moxifloxacin 400mg QD x7-14d OR
- 3rd generation cephalosporin AND azithromycin
- ICU, low risk of pseudomonas
- Beta-lactam + (macrolide OR respiratory fluoroquinolone)
- ICU, risk of pseudomonas
- Cefipime, imipenem, OR piperacillin-tazobactam + IV cipro/levo
- Cefipime, imipenem, OR piperacillin-tazobactam + gent + azithromycin
- Cefipime, imipenem, OR piperacillin-tazobactam + gent + cipro/levo
Pseudomonas risk factors
- Alcoholism
- Immunosuppression (incl. steroids)
- Structural lung disease
- Malnutrition
- Recent abx
- Recent hospital stay
Disposition
See Also
Source
UpToDate