The Harrison's Practice Preview allows you to view 5 FREE complete topics or conduct a search that delivers abstracts for more than 450 medical topics. For full access, please subscribe today!

Treatment Approach

• Site of care: 3-step process recommended in IDSA guidelines (2003)
  • Assessment of preexisting conditions that compromise safety of home care (e.g., baseline cognitive function, coexisting conditions, hemodynamic instability, ability to take oral medications)
  • Calculation of the pneumonia PORT (Pneumonia Outcomes Research Team) Severity Index (PSI)
    • Risk classes are based on age, gender, place of residence (nursing home or not), coexisting illness, physical examination findings, and laboratory/radiographic data.
    • Algorithm to calculate score: http://www.chestx-ray.com/Practice/PORT/PORT.html
    • Home care is recommended for patients in risk classes I, II, and III.
    • Patients in risk class IV or V generally should be admitted to the hospital.
  • Clinical judgment: other factors suggesting the need for inpatient treatment
    
    • Older age (especially when patients are nursing home residents)
    • Social issues (e.g., homelessness, substance abuse) that may compromise outpatient recovery
    • Respiratory rate of > 28/min
    • Systolic blood pressure of < 90 mmHg or 30 mmHg below baseline
    • Altered mental status
    • Hypoxemia: P_O2 of < 60 mmHg while patient is breathing room air or oxygen saturation of < 90%
    • Unstable comorbid illness (e.g., decompensated congestive heart failure, uncontrolled diabetes mellitus, alcoholism, immunosuppression)
    • Multilobar pneumonia, if hypoxemia is present
    • Pleural effusion that is > 1 cm on lateral decubitus chest x-ray and has the characteristics of a complicated parapneumonic effusion on pleural fluid analysis
• Antibiotic therapy
  
  • Factors that lower the mortality rate include:
    • Antibiotic administration within 8 h of arrival in the emergency room
    • Use of ≥ 2 agents in bacteremic pneumococcal pneumonia
  • Guidelines recommend empirical treatment based on:
    • Likely pathogens
    • Clinical trials showing efficacy of agents
    • Risk factors for antimicrobial resistance (e.g., age > 65 years, β-lactam therapy within the past 3 months, alcoholism, immunosuppressive illness, multiple medical comorbidities, exposure to a child in a day-care center)
    • Medical comorbidities (may influence the likelihood of a specific pathogen’s involvement and contribute to clinical failure)
    • Severity of illness (inpatient vs. outpatient treatment, medical ward vs. ICU care)
  • IV antibiotics can be switched to oral agents when:
    • The WBC count is returning toward normal.
    • Two temperature readings taken 16 h apart are normal.
    • The patient’s clinical condition has improved and the patient can take oral medications with adequate absorption.
• Other issues
  • Assess risk of aspiration.
  • Counsel about smoking cessation.
  • Assess vaccination status (influenza, pneumococcus).
  • Consider end-of-life decision making.
  • Optimize immune function if the patient is immunosuppressed.
    

Specific Treatments

Outpatient (dosing for adults with normal renal function)

• Patients with no comorbidities and no risk factors for drug-resistant S. pneumoniae (DSRP) infection
  • Clarithromycin XL (1000 mg PO qd for 7 days) or
  • Azithromycin (500 mg PO once, then 250 mg/d PO for 4 days or 500 mg/d PO for 3 days or 2 g PO once) or
  • Doxycycline (100 mg PO bid for 7–10 days)
• Patients with comorbidities (COPD, diabetes, renal or congestive heart failure, malignancy) and/or risk factors for DRSP infection or a high DRSP prevalence in the community
  • One of the following
    • Quinolone with enhanced activity against S. pneumoniae
      • Levofloxacin (500–750 mg PO qd) or
      • Moxifloxacin (400 mg PO qd) or
      • Gatifloxacin (400 mg PO qd)
    • β-lactam (cefpodoxime, 200 mg PO bid; or cefprozil, 500 mg PO bid; or amoxicillin, 1000 mg PO tid; or amoxicillin/clavulanic acid, 875/175 mg PO tid or 1000/62.5 mg PO tid) plus
      
      • Macrolide (clarithromycin or azithromycin dosed as above) or
      • Doxycycline dosed as above
    • Telithromycin (800 mg q24h for 7–10 days)

Hospital ward (dosing for adults with normal renal function)

• Quinolone with enhanced activity against S. pneumoniae (see above) or
• Azithromycin (1 g IV; then, 24 h later, start 500 mg IV q24h) plus
  • β-lactam
    • Cefuroxime (750 mg IV q8h) or
    • Ceftriaxone (1–2 g IV qd) or
    • Cefotaxime (1–2 g IV q6–8h) or
    • Ampicillin/sulbactam (1.5–3 g IV q6h)
      

ICU (dosing for adults with normal renal function)

• Patients with no risk factors for P. aeruginosa infection
  • β-lactam (ceftriaxone, 1–2 g IV q24h; or cefotaxime, 1–2 g IV q6–8h) plus
    • Quinolone IV (dosed as above) or
    • Azithromycin (1 g IV; then, 24 h later, start 500 mg IV q24h)
• Patients with risk factors for P. aeruginosa (e.g., bronchiectasis, malnutrition, treatment with > 10 mg of prednisone qd, HIV infection, broad-spectrum antibiotic therapy for > 7 days in the past month, prior P. aeruginosa infection)
  
  • Carbapenem or antipseudomonal cephalosporin or piperacillin/tazobactam (doses below) plus
    
    • Quinolone dosed as above or
    • Azithromycin (1 g IV; then, 24 h later, start 500 mg IV q24h)
  • Dosing
    • Carbapenem: imipenem, 500 mg IV q6h; or meropenem, 1g IV q8h
    • Antipseudomonal cephalosporin: cefepime, 2 g IV q8h; or ceftazidime, 2 g IV q8h
    • Piperacillin/tazobactam: 4.5 g IV q6h
• Severely ill patients
  • Consider coverage for methicillin-resistant S. aureus (MRSA) as well (vancomycin, 1 g IV q12h) until microbiology data become available.
• Monotherapy with a quinolone is not recommended for severely ill patients with CAP.
• Note: Quinolone treatment is not recommended for patients with pneumococcal meningitis.
  

Nursing home treatment (dosing for adults with normal renal function)

• As for outpatients with comorbidities or risk factors for DRSP (see above)
• May use ceftriaxone (500–1000 mg/d IM) or cefotaxime (500 mg IM q12h) in place of PO β-lactam
• Patients from a nursing home who are admitted to the hospital with pneumonia should be treated the same as other hospitalized/ICU patients.
  

Aspiration pneumonitis (dosing for adults with normal renal function)

• Aspiration pneumonitis (presumed to be due to effects of gastric acid or other irritants)
  • Wait 24 h.
  • If symptoms persist, give antibiotic therapy delineated below for aspiration pneumonia.
• Aspiration pneumonia; poor dental hygiene or putrid sputum, alcoholism (anaerobic infection suspected)
  • Quinolone, ceftriaxone, or cefotaxime (doses as above) plus anaerobic coverage
    • Clindamycin (450 mg PO qid or 300–900 mg IV q6–12h) or
    • Metronidazole (500 mg q12h PO) or
    • β-lactam (piperacillin/tazobactam, 4.5 g IV q6h; or ampicillin/sulbactam, 1.5–3 g IV q6h) or
    • Imipenem (500 mg IV q6h)
• Aspiration pneumonia, community-acquired
  • Levofloxacin, moxifloxacin, gatifloxacin, ceftriaxone, or cefotaxime
• Concomitant meningitis (suspected pneumococcal)
  • Vancomycin (1 g IV q12h) plus
  • Ceftriaxone (2 g IV q12h)
    

The Harrison's Practice Preview allows you to view 5 FREE complete topics or conduct a search that delivers abstracts for more than 450 medical topics. For full access, please subscribe today!