What are the guidelines for diagnosing and treating pneumonia?

From the Guidelines

Pneumonia diagnosis and treatment should be guided by a combination of clinical assessment, imaging, and laboratory tests, with antibiotics selected based on suspected pathogens and illness severity, as recommended by the most recent guidelines from the American College of Chest Physicians 1.

Diagnosis

Diagnosis typically begins with a physical examination, looking for symptoms like fever, cough, shortness of breath, and abnormal breath sounds.

• Chest X-rays are essential to confirm the diagnosis, showing infiltrates or consolidation in the lungs.
• Laboratory tests include complete blood count showing elevated white blood cells, blood cultures to identify pathogens, and sputum cultures when possible.
• Measuring C-reactive protein (CRP) can help strengthen the diagnosis and exclusion of pneumonia, especially when combined with clinical symptoms and signs 1.

Treatment

For treatment, antibiotics are the cornerstone therapy, with selection based on suspected pathogens and illness severity.

• For community-acquired pneumonia in outpatients, amoxicillin or doxycycline are first-line options, as suggested by various guidelines 1.
• For hospitalized patients, combination therapy with a beta-lactam plus a macrolide is often used, while severe cases may require broader coverage with piperacillin-tazobactam or meropenem plus vancomycin or linezolid for MRSA coverage 1.

Supportive Care

Supportive care includes oxygen therapy to maintain saturation above 90%, adequate hydration, and antipyretics for fever.

• Treatment duration typically ranges from 5-7 days for mild cases to 7-14 days for severe infections, with clinical improvement guiding duration.
• Patients should be reassessed within 48-72 hours of starting treatment to ensure appropriate response, with follow-up chest imaging recommended for certain high-risk patients or those with persistent symptoms 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of Piperacillin and Tazobactam for Injection and other antibacterial drugs, piperacillin and tazobactam should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. Piperacillin and Tazobactam for Injection is a combination of piperacillin, a penicillin-class antibacterial and tazobactam, a beta-lactamase inhibitor, indicated for the treatment of: Nosocomial pneumonia in adult and pediatric patients 2 months of age and older Community-acquired pneumonia in adults

The guidelines for diagnosing and treating pneumonia include:

• Diagnosis: Pneumonia should be diagnosed based on clinical and radiological documentation.
• Treatment: Piperacillin and Tazobactam for Injection is indicated for the treatment of nosocomial pneumonia in adult and pediatric patients 2 months of age and older, and community-acquired pneumonia in adults.
• Dosage: The usual daily dosage of piperacillin and tazobactam for injection for adults is 3.375 grams every six hours totaling 13.5 grams. For nosocomial pneumonia, the initial presumptive treatment should start with piperacillin and tazobactam for injection at a dosage of 4.5 grams every six hours plus an aminoglycoside.
• Administration: Administer piperacillin and tazobactam for injection by intravenous infusion over 30 minutes. 2

From the Research

Diagnosing Pneumonia

• Pneumonia is diagnosed by clinical features (e.g., cough, fever, pleuritic chest pain) and by lung imaging, usually an infiltrate seen on chest radiography 3
• Initial evaluation should determine the need for hospitalization versus outpatient management using validated mortality or severity prediction scores 3
• Selected diagnostic laboratory testing, such as sputum and blood cultures, is indicated for inpatients with severe illness but is rarely useful for outpatients 3
• Clinical gestalt demonstrates greater ability to diagnose pneumonia, and clinical scores including Pneumonia Severity Index (PSI) and Confusion, blood Urea nitrogen, Respiratory rate, Blood pressure, age 65 score (CURB-65) may be helpful for disposition 4

Treating Pneumonia

• Initial outpatient therapy should include a macrolide or doxycycline 3
• For outpatients with comorbidities or who have used antibiotics within the previous three months, a respiratory fluoroquinolone (levofloxacin, gemifloxacin, or moxifloxacin), or an oral beta-lactam antibiotic plus a macrolide should be used 3
• Inpatients not admitted to an intensive care unit should receive a respiratory fluoroquinolone, or a beta-lactam antibiotic plus a macrolide 3
• Patients with severe community-acquired pneumonia or who are admitted to the intensive care unit should be treated with a beta-lactam antibiotic, plus azithromycin or a respiratory fluoroquinolone 3
• Single-agent, high-dose levofloxacin treatment exhibited excellent clinical and microbiological efficacy with a safety profile comparable to that of ceftriaxone plus azithromycin therapy 5
• The combination of a third-generation cephalosporin and a macrolide is at least as efficacious as monotherapy with a fluoroquinolone with enhanced anti-pneumococcal activity, for hospitalized patients with moderate to severe CAP 6

Hospitalization and Treatment Duration

• Hospitalized patients may be switched from intravenous to oral antibiotics after they have clinical improvement and are able to tolerate oral medications, typically in the first three days 3
• The length of hospital stay (LOS) and length of intravenous antibiotic therapy (LOIV) for patients who received initial levofloxacin 750 mg daily versus ceftriaxone 1000 mg plus azithromycin 500 mg daily were compared, and results showed that LOS and LOIV were shorter with levofloxacin versus combination therapy 7