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
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
Treatment
Outpatient, community-acquired PNA
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. Add
- 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 Doxy
- 3rd generation cephalosporin AND Azithromycin or Doxy
Inpatient
Community-acquired PNA
- Levofloxacin 750mg QD x5d OR
- Moxifloxacin 400mg QD x7-14d OR
- 3rd generation cephalosporin AND azithromycin
Health Care-associated PNA
- 3-drug regimen recommended
- (Cefepime 1-2gm q8-12h OR ceftazidime 2gm q8h) + cipro 400mg q8h + vanco 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
ICU, low risk of pseudomonas
- Ceftriaxone 1gm IV and Azithromycin 500mg IV OR
- Ceftriaxone 1gm IV and (moxifloxacin 400mg IV or levofloxacin 750mg IV)
- Penicillin allergy
- Moxi/levofloxacin and (aztreonam 1-2gm IV or clindamycin 600mg IV)
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
Disposition
See Also
Source
- UpToDate