Pneumonia (main)

For pediatrics see pediatric pneumonia

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

  • Hospitalized for 2 or more days within past 90 days
  • Nursing home/long-term care residents
  • Receiving home IV antibiotics
  • Dialysis
  • Receiving chronic wound care
  • Receiving chemotherapy
  • Immunocompromised

Pseudomonas risk factors

  • Alcoholism
  • Immunosuppression (including steroids)
  • Structural lung disease
  • Malnutrition
  • Recent antibiotics
  • Recent hospital stay

Causes of Pneumonia

Bacteria

Viral

Fungal

Parasitic

Commonly Encountered Pathogens by Risk Factor

Alcoholism

COPD and/or Smoking

Nursing Home

Exposure to bird droppings

Exposure to birds

Exposure to rabbits

Exposure to farm animals

Exposure to southwestern US

HIV

Aspiration

  • Anaerobes

Structural Lung Disease (CF, bronchiectasis)

Injection Drug Use

Influenza

Ventilator Associated Pneumonia

Clinical Features

Differential Diagnosis

Acute dyspnea

Emergent

Non-Emergent

Diagnosis

CXR showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial pneumonia.
CT chest showing right sided pneumonia
  • CXR
  • CBC
  • Chemistry

If pt will be admitted:

  • Blood Cultures are ONLY indicated for CAP patients with:
    • ICU (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

Chest X-Ray Mimics

Management

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).
  • 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
    • 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):

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

Hospital Acquired or Ventilator Associated Pneumonia

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]

ICU, low risk of pseudomonas

ICU, risk of pseudomonas

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

  1. Confusion
  2. bUn > 19 mg/dl
  3. RR > 30
  4. BP < 90 SBP, or < 60 DBP
  5. 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

See Also

External Links

References

  1. 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
  2. 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
  3. IDSA. Mandell 2007
  4. 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
  5. 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
  6. 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.
  7. 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.