Pneumonia Management

Aka: Pneumonia Management, Community Acquired Pneumonia Management

1. See Also
   1. Pneumonia Management in the Nursing Home Resident
   2. Pneumonia Management in Children
   3. Viral Pneumonia
   4. Nosocomial Pneumonia
   5. Aspiration Pneumonia
   6. See Community Acquired Pneumonia Refractory to Standard Management
2. Management: Children
   1. See Pneumonia Management in Children
3. Management: General Measures
   1. Early mobilization
      1. Sitting up for >20 minutes on first hospital day
      2. Mundy (2003) Chest 124:883-9
   2. Start antibiotic within 4 hours of hospitalization
      1. Decreases mortality
      2. Decreases length of stay
      3. Houck (2004) Arch Intern Med 164:637-44
   3. Determine if hospitalization needed (and ICU placement)
      1. See Pneumonia Hospitalization Criteria
      2. See Pneumonia Hospitalization Criteria in the Elderly
      3. See Severe Community Acquired Pneumonia Criteria
      4. See Mortality Prediction Tool for Patients with Community Acquired Pneumonia (CURB-65)
      5. Pneumonia IRVS Prediction Tool (SMART-COP)
   4. Be aware of Antibiotic Resistance
      1. See Streptococcus Pneumoniae resistance
      2. Reserve use of Fluoroquinolones to prevent resistance
   5. Course of antibiotics
      1. Course of 10-14 days has been used historically
      2. Course of 7 days appears to be equally effective
         1. Dunbar (2003) Clin Infect Dis 37(6): 752-60
4. Management: Outpatient in adults
   1. First line agents for community acquired Pneumonia in previously healthy patients and no antibiotics in last 3 months
      1. Doxycycline
      2. Macrolide antibiotics (Azithromycin, Clarithromycin)
   2. Patients with comorbidities (COPD, CAD, Cirrhosis, DM, Chemical Dependency, Asplenia, cancer) or antibiotics in the last 3 months
      1. Fluoroquinolones
         1. Levofloxacin
         2. Gatifloxacin
         3. Grepafloxacin
         4. Moxifloxacin
         5. Sparfloxacin
      2. Combination
         1. Macrolide (Azithromycin, Clarithromycin) and
         2. Beta-lactam (choose one)
            1. High dose Amoxicillin
            2. Amoxicillin-clavulanate (Augmentin)
            3. Cefpodoxime (Vantin)
            4. Cefprozil (Cefzil)
            5. Cefuroxime (Cefzil)
            6. Cefdinir (Omnicef)
5. Management: Inpatient Management in adults
   1. See inpatient indications as above
   2. Convert to oral antibiotic within 72 hours if possible
   3. Criteria to switch to oral antibiotics
      1. Temperature <100.0 F (37.8 C)
      2. Heart Rate <100 beats per minute
      3. Respiratory Rate <24 breaths per minute
      4. Systolic Blood Pressure >90 mmHg
      5. Oxygen Saturation >90%
   4. Base option: Single agent using broad spectrum Fluoroquinolone
      1. Levofloxacin
      2. Gatifloxacin
      3. Grepafloxacin
      4. Moxifloxacin
      5. Sparfloxacin
   5. Base option: Combination protocol using beta-lactam with a Macrolide
      1. General
         1. Use one option from antibiotic 1 and one from antibiotic 2
         2. Cephalosporin with Macrolide offers best outcomes
         3. Brown (2003) Chest 123:1503-11
      2. Antibiotic 1 (choose one)
         1. Cefotaxime (Claforan)
         2. Ceftriaxone (Rocephin)
         3. Ampicillin-Sulbactam (Unasyn)
      3. Antibiotic 2: Macrolide
         1. Azithromycin 500 mg IV (especially ICU patient)
   6. Modification for ICU patients
      1. Choose one of the 2 base options
      2. If a Fluoroquinolone is used, add Aztreonam
   7. Modification if risk of MRSA
      1. Add Vancomycin or Linezolid (Zyvox)
6. Management: Inpatient Management if risk of Pseudomonas infection
   1. Combination protocol - use antibiotic 1 and antibiotic 2 in combination
   2. Antibiotic 1
      1. Ticarcillin-clavulanate (Timentin)
      2. Piperacillin-Tazobactam (Zosyn)
      3. Cefepime
      4. Imipenem-Cilastin (Primaxin)
      5. Meropenem (Merrem)
      6. Doripenem (Doribax)
   3. Antibiotic 2
      1. Option: Fluoroquinolone (choose one)
         1. Ciprofloxacin
         2. Levofloxacin
      2. Option: Macrolide AND Aminoglycoside (use both)
         1. Azithromycin and
         2. Aminoglycoside
      3. Option: Fluoroquinolone AND Aminoglycoside (use both)
         1. Fluoroquinolone and
         2. Aminoglycoside
7. Management: Refractory Cases
   1. See Community Acquired Pneumonia Refractory to Standard Management
8. References
   1. Gilbert (2001) Sanford Antimicrobial, p. 27
   2. Bartlett (1998) Clin Infect Dis 26:811-38
   3. Bartlett (2000) Clin Infect Dis 31:347-82
   4. King (1997) Am Fam Physician 56:544-50
   5. Lim (2009) Thorax 64(suppl 3):1-55
   6. Lutfiyya (2006) Am Fam Physician 73:442-50
   7. Mandell (2007) Clin Infect Dis 44(suppl 2): S27-72
   8. Niederman (1993) Am Rev Respir Dis 148:1418-26
   9. Thibodeau (2004) Am Fam Physician 69:1699-706
   10. Watkins (2011) Am Fam Physician 83(11): 1299-306