Pneumonia (main)
For Pediatric pneumonia see Pneumonia (peds)
Background
General Approach
3 questions:
- Does this pt have pneumonia?
- If yes, does this pt need to be admitted?
- 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
Commonly Encountered Pathogens by Risk Factor
Alcoholism
COPD and/or Smoking
Nursing Home
- S. pneumoniae
- Gram-negative bacilli
- H. influenzae
- Staphylococcus aureus
- Anaerobes
- Chlamydophilia pneumoniae
Exposure to bird droppings
Exposure to birds
Exposure to rabbits
Exposure to farm animals
Exposure to southwestern US
- Coccidiomycosis (Valley fever)
HIV
- Early
- Late (as above, plus:)
- Pneumocystis jiroveci (formerly Pneumocystis carinii)
- Cryptococcus
- Histoplasma species
Aspiration
- Anaerobes
Structural Lung Disease (CF, bronchiectasis)
- Pseudomonas aeruginosa
- Burkholderia (Pseudomonas) cepacia
- S. aureus
Injection Drug Use
Influenza
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
Differential Diagnosis
Acute dyspnea
Emergent
- Pulmonary
- Airway obstruction
- Anaphylaxis
- Angioedema
- Aspiration
- Asthma
- Cor pulmonale
- Inhalation exposure
- Noncardiogenic pulmonary edema
- Pneumonia
- Pneumocystis Pneumonia (PCP)
- Pulmonary embolism
- Pulmonary hypertension
- Tension pneumothorax
- Idiopathic pulmonary fibrosis acute exacerbation
- Cystic fibrosis exacerbation
- Cardiac
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
Non-Emergent
- ALS
- Ascites
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Fever
- Hyperventilation
- Interstitial lung disease
- Neoplasm
- Obesity
- Panic attack
- Pleural effusion
- Polymyositis
- Porphyria
- Pregnancy
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- URI
Diagnosis
- CXR
- CBC
- Chemistry
If pt will be admitted:
- Blood Cultures are ONLY indicated for CAP pts with:
- ICU pts (required)
- Multi-lobar
- Pleural effusion
- Consider for higher-risk patients admitted with CAP
- Liver disease
- Immunocompromised
- Significant comorbidities
- Other risk factors
- Sputum staining
- If concern for particular organism
Treatment
Outpatient
Coverage targeted at S. pneumoniae, H. influenzae. M. pneumoniae, C. pneumoniae, and Legionella
Healthy[1]
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[2]
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[3]
- 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)
- Amoxicillin/Clavulanate
- 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 [4]
- 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:[5]
- ↓ 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’’’[6]
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:[7]
- 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
Pneumonia severity index (Port Score)
Risk Factors |
Points |
Demographic Factors | |
Age for men |
Age |
Age for women |
Age -10 |
Nursing home resident |
+10 |
Coexisting Illnesses |
|
Neoplastic disease (active) |
+30 |
Chronic liver disease |
+20 |
Heart Failure |
+10 |
Cerebrovascular disease |
+10 |
Chronic renal disease |
+10 |
Physical Exam |
|
AMS |
+20 |
RR > 30/min |
+20 |
Sys BP < 90 |
+20 |
Temp <35 or >40 |
+15 |
Pulse > 125 |
+10 |
Lab and xray findings |
|
Arterial pH < 7.35 |
+30 |
BUN > 30 |
+20 |
Na <130 |
+20 |
Glucose > 250 |
+10 |
Hematocrit <30% |
+10 |
PaO2 < 60 or SpO2 < 90% |
+10 |
Pleural effusion |
+10 |
Classification
Class |
Points |
Mortality |
I |
<51 | 0.1% |
II |
51-70 | 0.6% |
III |
71-90 |
0.9% |
IV |
91-130 |
9.3% |
V |
>130 |
27% |
Disposition Pathway
- Classes I and II: consider discharge
- Class III: discharge verus admit based on clinical judgment
- Classes IV and V: consider admission
CURB-65
- Confusion
- bUn > 19 mg/dl
- RR > 30
- BP < 90 SBP, or < 60 DBP
- Age > 65
- Approximate 30-day mortalities and Tx considerations
- +1 --> 3%, outpt tx
- +2 -->7%, inpt, possible outpt
- +3 --> 14% inpt, possible ICU
- +4-5 --> 30% ICU
Prognosis
- Half of patients are still symptomatic at 30 days, with a significant minority of patients experiencing chest pain, malaise or mild dyspnea even 2 to 3 months after treatment
- In adults with CAP whose symptoms have resolved within 5-7 days, it is not recommended to routinely obtain follow-up chest imaging
External Links
See Also
Source
- UpToDate, Dr. Spellberg HUMC 8/13
- ↑ Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67
- ↑ Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67
- ↑ IDSA. Mandell 2007
- ↑ Chokshi R, Restrepo MI, Weeratunge N, Frei CR, Anzueto A, Mortensen EM. Monotherapy versus combination antibiotic therapy for patients with bacteremic Streptococcus pneumoniae community-acquired pneumonia. Eur J Clin Microbiol Infect Dis. Jul 2007;26(7):447-51
- ↑ Siemieniuk RA, Meade MO, Alonso-Coello P, Briel M, Evaniew N, Prasad M, Alexander PE, Fei Y, Vandvik PO, Loeb M, Guyatt GH. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Ann Intern Med. Aug 11, 2015
- ↑ Luther MK, Timbrook TT, Caffrey AR, Dosa D, Lodise TP, LaPlante KL. Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis. Crit Care Med. 2018;46(1):12-20.
- ↑ Kalil AC, Metersky ML, Klompas M et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63(5):e61-e111.