What diagnostic tests and treatments to order for pneumonia?

From the Guidelines

For pneumonia treatment, I recommend empiric antibiotic therapy based on the likely pathogens and severity of illness, as suggested by the most recent guidelines 1.

Key Considerations

• For community-acquired pneumonia in outpatients without comorbidities, amoxicillin 1g three times daily for 5 days is appropriate.
• For patients with comorbidities or risk factors for drug-resistant pathogens, consider amoxicillin-clavulanate 875/125mg twice daily or doxycycline 100mg twice daily for 5 days.
• For hospitalized non-ICU patients, ceftriaxone 1-2g daily plus azithromycin 500mg daily is recommended, as per the guidelines 1.
• Severely ill patients requiring ICU admission should receive broader coverage with ceftriaxone 2g daily plus either azithromycin 500mg daily or levofloxacin 750mg daily.

Diagnostic Approach

• The diagnosis of pneumonia should be based on clinical symptoms and signs, such as cough, dyspnea, pleural pain, sweating/fevers/shivers, aches and pains, temperature 38C or greater, tachypnea, and new and localizing chest examination signs 1.
• Measuring C-reactive protein (CRP) can help strengthen the diagnosis and exclusion of pneumonia, with a CRP of 30 mg/L or higher increasing the likelihood of pneumonia 1.
• Chest radiography should be ordered to improve diagnostic accuracy in patients with abnormal vital signs secondary to suspected pneumonia 1.

Treatment Duration and Adjustments

• Treatment duration typically ranges from 5-7 days for most patients, extending to 10-14 days for complicated cases.
• Supportive care, including oxygen therapy, adequate hydration, and antipyretics, is also essential.
• Antibiotics target the causative bacteria while the body's immune system works to clear the infection.
• Treatment should be adjusted based on culture results when available, and clinical improvement should be evident within 48-72 hours of starting appropriate therapy.

Additional Considerations

• The choice of antibiotic therapy should be guided by the severity of illness, the presence of comorbidities, and the risk of drug-resistant pathogens, as outlined in the guidelines 1.

From the FDA Drug Label

Adult Patients with Nosocomial Pneumonia: Initial presumptive treatment of patients with nosocomial pneumonia should start with piperacillin and tazobactam for injection at a dosage of 4.5 grams every six hours plus an aminoglycoside, totaling 18.0 grams (16.0 grams piperacillin and 2.0 grams tazobactam). Adult patients with clinically and radiologically documented nosocomial pneumonia were enrolled in a multicenter, randomized, open-label study comparing intravenous levofloxacin (750 mg once daily) followed by oral levofloxacin (750 mg once daily) for a total of 7 to 15 days to intravenous imipenem/cilastatin (500 to 1000 mg every 6 to 8 hours daily) followed by oral ciprofloxacin (750 mg every 12 hours daily) for a total of 7 to 15 days.

Treatment Options for Pneumonia:

• Levofloxacin: 750 mg once daily intravenously or orally for 7 to 15 days 2
• Piperacillin-Tazobactam: 4.5 grams every six hours plus an aminoglycoside, totaling 18.0 grams (16.0 grams piperacillin and 2.0 grams tazobactam) for nosocomial pneumonia 3 3 Key Considerations:
• The choice of antibiotic should be based on the severity of the pneumonia, the suspected or confirmed causative pathogen, and the patient's renal function and other comorbidities.
• Combination therapy with an aminoglycoside may be necessary for nosocomial pneumonia.
• The duration of treatment should be individualized based on the patient's response to therapy.

From the Research

Treatment Options for Pneumonia

• Azithromycin 1g once daily for 3 days is at least as effective as amoxicillin-clavulanate 875/125 mg twice daily for 7 days in the treatment of adult patients with community-acquired pneumonia 4.
• Amoxicillin/clavulanate (Augmentin) is a broad-spectrum antibacterial that has been available for clinical use in a wide range of indications for over 20 years and is now used primarily in the treatment of community-acquired respiratory tract infections, including pneumonia 5.
• Ceftriaxone could be a useful option in the treatment of aspiration pneumonia, instead of piperacillin-tazobactam or carbapenems, as it could generally cover oral streptococcus and anaerobes implicated in aspiration pneumonia 6.

Antibiotic Regimens

• Azithromycin 1g once daily for 3 days: clinical success rates were 126/136 (92.6%) 4.
• Amoxicillin-clavulanate 875/125 mg twice daily for 7 days: clinical success rates were 122/131 (93.1%) 4.
• Ceftriaxone: no differences in 30-day mortality, duration of hospital stay or antibiotic treatments compared to piperacillin-tazobactam or carbapenems 6.

Considerations

• The choice of antibiotic regimen should be based on the severity of the pneumonia, the patient's medical history, and the presence of any underlying conditions 4, 5, 6.
• The medical costs of ceftriaxone are significantly lower than those of piperacillin-tazobactam or carbapenems 6.