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. 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. Indications for outpatient, inpatient or ICU admission
    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
  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)
    2. Consider Corticosteroids (may reduce risk of ARDS, prolonged ICU stays, and overall morbidity)
      1. Wan (2016) Chest 149(1): 209-19 [PubMed]

V. Management: Antibiotics

  1. See Pneumonia Accelerated Diagnostic Protocol
  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 [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. 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]
    3. 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]

VI. Management: Outpatient in adults

  1. Low risk for Antibiotic Resistance
    1. Indications
      1. Community Acquired Pneumonia in previously healthy patients
      2. No daycare exposure
      3. No antibiotics in last 3 months
    2. Options (select one)
      1. Macrolide antibiotics (Azithromycin, Clarithromycin)
        1. Caution: High pneumococcus resistance rate in U.S.
      2. Doxycyline
        1. Dose: 100 mg orally twice daily for 7 days
        2. Activity against streptococcal Pneumonia, Mycoplasma, h. Influenzae and atypicals
  2. 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. Fluoroquinolones (review risk of Fluoroquinolone adverse effects with patient)
      1. Levofloxacin
      2. Gatifloxacin
      3. Grepafloxacin
      4. Moxifloxacin
      5. Sparfloxacin
    3. Combination (in lobar Pneumonia, reasonable to start beta-lactam alone)
      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 (Ceftin)
        6. Cefdinir (Omnicef)

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: Single agent using broad spectrum Fluoroquinolone (see adverse effects)
    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 [PubMed]
    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. See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)
    2. Add Vancomycin, Linezolid (Zyvox) or Ceftaroline
  8. Modification if risk for Aspiration Pneumonia (Anaerobic Bacteria)
    1. Consider following loss of consciousness, Alcoholism or stroke with bulbar symptoms
    2. See Aspiration Pneumonia
    3. 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. Combination protocol - use antibiotic 1 and antibiotic 2 in combination
  3. Antibiotic 1
    1. Ticarcillin-clavulanate (Timentin)
    2. Piperacillin-Tazobactam (Zosyn)
    3. Cefepime
    4. Imipenem-Cilastin (Primaxin)
    5. Meropenem (Merrem)
    6. Doripenem (Doribax)
  4. 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. Niederman (1993) Am Rev Respir Dis 148:1418-26 [PubMed]
  9. Thibodeau (2004) Am Fam Physician 69:1699-706 [PubMed]
  10. Watkins (2011) Am Fam Physician 83(11): 1299-306 [PubMed]
  11. Wunderink (2014) N Engl J Med 370:543-51 [PubMed]

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