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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.
    

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!