Pneumonia Management

Aka: Pneumonia Management, Community Acquired Pneumonia Management

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II. Management: Children

  1. See Pneumonia Management in Children

III. Management: Disposition (outpatient versus hospitalization versus ICU admission)

  1. Severe Community Acquired Pneumonia Criteria
    1. Indications for ICU admission
  2. Mortality Prediction Tool for Patients with Community Acquired Pneumonia (CURB-65)
    1. Indications for outpatient, inpatient or ICU admission
    2. Consider as disposition triage tool used by both outpatient and emergency providers
      1. Clinic providers should consider transfer to ED, patient with Hypoxia or CURB-65 >=2
      2. Requires no laboratory data, allowing for easier clinic use
    3. Caveats
      1. Add Hypoxia as admission criteria (not included in CURB-65)
      2. Poor Test Sensitivity (use other prediction tools for low scores)
      3. High Test Specificity (strongly consider ICU admission for higher scores)
  3. Pneumonia Severity Index
    1. Indications for outpatient, observation or admission
    2. Based on 20 parameters including laboratory tests typically not be available during clinic evaluation
  4. Pneumonia IRVS Prediction Tool (SMART-COP)
    1. Indications for ICU admission (predicts Mechanical Ventilation and pressor support)
  5. Pneumonia in the Elderly
    1. See Pneumonia Hospitalization Criteria in the Elderly
    2. Pneumonia SOAR Score
      1. Disposition of Nursing Home resident with Pneumonia (outpatient, inpatient or ICU admission)

IV. Management: General Measures

  1. Early mobilization
    1. Sitting up for >20 minutes on first hospital day
    2. Mundy (2003) Chest 124:883-9 [PubMed]
  2. Additional management
    1. Consider Influenza management (e.g. Tamiflu)
      1. IDSA recommends adding to regimen when Influenza testing is also positive
      2. Recommended for both inpatient and outpatient and regardless of duration prior to CAP diagnosis
      3. In addition, continue initial Community Acquired Pneumonia Management
    2. Consider Corticosteroids (may reduce risk of ARDS, prolonged ICU stays, and overall morbidity)
      1. IDSA recommends only for use in CAP with Asthma or COPD exacerbation, or in refractory Septic Shock
        1. Otherwise not recommended by IDSA regardless of Pneumonia severity
      2. References
        1. Wan (2016) Chest 149(1): 209-19 [PubMed]

V. Management: Antibiotics

  1. See Pneumonia Accelerated Diagnostic Protocol
  2. Start Antibiotics within 4 hours of hospitalization
    1. Decreases mortality
    2. Decreases length of stay
    3. Houck (2004) Arch Intern Med 164:637-44 [PubMed]
  3. Be aware of Antibiotic Resistance
    1. See Streptococcus Pneumoniae resistance
    2. Reserve use of Fluoroquinolones to prevent resistance
  4. Course of Antibiotics
    1. Five day course is now recommended as default duration
      1. This is the minimum duration
      2. After at least 5 days, anibiotics may be discontinued when patient has improved and clinically stable
    2. Course of 5 days (and 2-3 days afebrile) is sufficient in low severity Community Acquired Pneumonia
      1. Greenberg (2014) Pediatr Infect Dis J 33(2):136-42 [PubMed]
      2. Uranga (2016) JAMA Intern Med 176(9):1257-65 [PubMed]
    3. Prior Pneumonia treatment durations
      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 [PubMed]

VI. Management: Outpatient in Adults

  1. See treatment duration as above
  2. Low risk for Antibiotic Resistance
    1. Indications
      1. Community Acquired Pneumonia in previously healthy patients (without significant comorbidity)
      2. No daycare exposure
      3. No Antibiotics in last 3 months
    2. First-line Options (select one)
      1. Doxycyline
        1. Dose: 100 mg orally twice daily for 5 days
        2. Activity against Streptococcal Pneumonia, Mycoplasma pneumonia, H. Influenzae Pneumonia, atypicals
      2. High-Dose Amoxicillin
        1. Dose: 1000 mg orally three times daily for 5 days
        2. Augmentin is not needed as Streptococcus Pneumoniae is not a Beta-Lactamase producer
    3. Alternative Options
      1. Macrolide Antibiotics (Azithromycin, Clarithromycin)
        1. Caution: High pneumococcus resistance rate in U.S. (>25%)
        2. No longer recommended as first-line Antibiotic in Community Acquired Pneumonia
    4. References
      1. (2019) Presc Lett 26(12):67
  3. Higher risk for Antibiotic Resistance (or higher risk patients)
    1. Indications
      1. See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)
      2. Comorbidities (COPD, CAD, Cirrhosis, DM, Chemical Dependency, Asplenia, cancer)
      3. Antibiotics in the last 3 months
      4. Daycare exposure
    2. Combination Macrolide and Beta-Lactam (in lobar Pneumonia, reasonable to start beta-lactam alone)
      1. Drug 1: Macrolide (Azithromycin, Clarithromycin) or Doxycyline (choose one)
        1. Azithromycin 500 mg day 1, then 250 mg orally on days 2-5
        2. Clarithromycin 500 mg orally twice daily for 5 days
        3. Doxycycline 100 mg orally every 12 hours for 5 days
      2. Drug 2: Beta-lactam (choose one)
        1. Amoxicillin-clavulanate (Augmentin) 875/125 mg (or 2000/125) orally twice daily for 5 days
        2. Cefpodoxime (Vantin) 200 mg orally every 12 hours for 5 days
        3. Cefuroxime (Ceftin) 500 mg orally every 12 hours for 5 days
        4. Cefprozil (Cefzil) 500 mg orally every 12 hours for 5 days
        5. Cefdinir (Omnicef) 300 mg every 12 hours or 600 mg daily for 5 days
    3. Monotherapy: Fluoroquinolones (review risk of Fluoroquinolone adverse effects with patient)
      1. Levofloxacin 750 mg orally daily for 5 days
      2. Gatifloxacin 320 mg orally daily for 5 days
      3. Moxifloxacin 400 mg orally daily for 5 days
      4. Gemifloxacin (Factive) 320 mg orally daily for 5 days
      5. Grepafloxacin
      6. Sparfloxacin

VII. 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 <100.9 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%
    6. Baseline cognitive status
    7. Tolerating oral agents
  4. Base option: Combination protocol using beta-lactam (esp. Ceftriaxone) with a Macrolide
    1. General
      1. Use one option from Antibiotic 1 and one from Antibiotic 2
      2. Cephalosporin (esp. Ceftriaxone) with Macrolide offers best outcomes
      3. Brown (2003) Chest 123:1503-11 [PubMed]
    2. Antibiotic 1 (choose one)
      1. Ceftriaxone (Rocephin)
      2. Cefotaxime (Claforan)
      3. Ampicillin-Sulbactam (Unasyn)
    3. Antibiotic 2: Macrolide
      1. Azithromycin 500 mg IV (especially ICU patient)
  5. Base option: Single agent using broad spectrum Fluoroquinolone (see adverse effects)
    1. Levofloxacin
    2. Gatifloxacin
    3. Grepafloxacin
    4. Moxifloxacin
    5. Sparfloxacin
  6. Modification for Severe Pneumonia (ICU patients)
    1. Antibiotics
      1. Choose one of the 2 base options
      2. If a Fluoroquinolone is used, add Aztreonam
    2. Hydrocortisone IV
      1. Indications
        1. Mechanical Ventilation or NIPPV (e.g. Bipap, HHFNC)
        2. Pneumonia Severity Index >130
      2. Dosing
        1. Hydrocortisone 50 mg IV every 6 hours (or 200 mg/day by IV continuous infusion)
        2. Median duration 5 days
      3. Precautions
        1. Avoid in Influenza (associated with worse outcomes)
      4. Efficacy
        1. Associated with reduced mortality in high risk patients (NNT 18)
        2. Best efficacy if started early (may have little impact if started after 48 to 72 hours)
        3. Higher efficacy in patients with elevated inflammatory markers (cRP >15 mg/dl)
      5. References
        1. (2023) Presc Lett 30(8): 45
        2. Dequin (2023) N Engl J Med 388(21):1931-41 +PMID: 36942789 [PubMed]
  7. Modification if risk of MRSA
    1. See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)
    2. MRSA cultured from respiratory tract in last year or admitted in last 90 days and has severe Pneumonia
    3. Add Vancomycin, Linezolid (Zyvox) or Ceftaroline
  8. Modification if risk for Aspiration Pneumonia (Anaerobic Bacteria)
    1. Additional coverage from suspected aspiration is NOT recommended at outset of management
      1. Consider adding anaerobic coverage if lack of response to initial regimen
    2. Consider following loss of consciousness, Alcoholism or stroke with bulbar symptoms
    3. See Aspiration Pneumonia
    4. Antibiotic coverage includes Carbapenems, Clindamycin, Flagyl, zosyn, Unasyn (or Augmentin)
  9. Modification in uncomplicated Community Acquired Pneumonia
    1. Beta-Lactam monotherapy has similar mortality to combination therapy
      1. Postma (2015) N Engl J Med 372:1312-23 [PubMed]
    2. Beta-Lactam monotherapy was not inferior to combination therapy in moderately severe CAP
      1. However combination therapy with Macrolide had better clinical response in atypical cases
      2. Garin (2014) JAMA Intern Med 174:1894-901 +PMID:25286173 [PubMed]
    3. Recommend combination therapy until further data
      1. If monotherapy used, consider Legionella urine Antigen testing
        1. Atypical cases
        2. Risk for Legionella pneumonia (e.g. returning from cruise)
      2. (2015) Presc Lett 22(6): 32-3

VIII. Management: Inpatient Management if risk of Pseudomonas infection

  1. See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)
  2. Pseudomonas cultured from respiratory tract in last year or admitted in last 90 days and has severe Pneumonia
  3. Combination protocol - use Antibiotic 1 and Antibiotic 2 in combination
  4. Antibiotic 1
    1. Ticarcillin-clavulanate (Timentin)
    2. Piperacillin-Tazobactam (Zosyn)
    3. Cefepime
    4. Imipenem-Cilastin (Primaxin)
    5. Meropenem (Merrem)
    6. Doripenem (Doribax)
  5. 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

IX. Management: Refractory Cases

  1. See Community Acquired Pneumonia Refractory to Standard Management
  2. Other Antibiotic options for Community Acquired Pneumonia
    1. Lefamulin (Xenleta)
    2. Omadacycline (Nuzyra)

X. Prevention

  1. See Pneumonia Prevention in the Elderly
  2. See Influenza Vaccine
  3. See Pneumococcal Vaccine (Pneumovax 23)
  4. See Pneumococcal Conjugate Vaccine (Prevnar 13)

XI. References

  1. Bartlett (1998) Clin Infect Dis 26:811-38 [PubMed]
  2. Bartlett (2000) Clin Infect Dis 31:347-82 [PubMed]
  3. Kaysin (2016) Am Fam Physician 94(9); 698-706 [PubMed]
  4. King (1997) Am Fam Physician 56:544-50 [PubMed]
  5. Lim (2009) Thorax 64(suppl 3):1-55 [PubMed]
  6. Lutfiyya (2006) Am Fam Physician 73:442-50 [PubMed]
  7. Mandell (2007) Clin Infect Dis 44(suppl 2): S27-72 [PubMed]
  8. Metlay (2019) Am J Respir Crit Care Med 200(7):e45-67 +PMID:P 31573350 [PubMed]
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812437/
  9. Niederman (1993) Am Rev Respir Dis 148:1418-26 [PubMed]
  10. Thibodeau (2004) Am Fam Physician 69:1699-706 [PubMed]
  11. Watkins (2011) Am Fam Physician 83(11): 1299-306 [PubMed]
  12. Womack (2022) Am Fam Physician 105(6): 625-30 [PubMed]
  13. Wunderink (2014) N Engl J Med 370:543-51 [PubMed]

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