What is the recommended management for pneumonia?

Management of Pneumonia

The recommended management for pneumonia depends on the classification (community-acquired, hospital-acquired, or ventilator-associated) and severity of illness, with empiric antibiotic therapy tailored to likely pathogens and local resistance patterns.

Classification and Initial Assessment

Community-Acquired Pneumonia (CAP)

• Determine severity using clinical parameters:
  • Need for ventilatory support
  • Presence of septic shock
  • Risk factors for mortality

Hospital-Acquired Pneumonia (HAP)/Ventilator-Associated Pneumonia (VAP)

• Assess risk factors for multidrug-resistant (MDR) pathogens:
  • Prior intravenous antibiotic use within 90 days
  • Hospitalization in a unit where >20% of S. aureus isolates are methicillin-resistant
  • Unknown MRSA prevalence
  • High risk for mortality

Empiric Antibiotic Therapy

For Community-Acquired Pneumonia

Outpatient Management:

• First-line therapy: Amoxicillin at higher doses 1
• Alternative for penicillin-allergic patients: Macrolide (erythromycin or clarithromycin) 1

Non-Severe CAP Requiring Hospitalization:

• Preferred: Combined oral therapy with amoxicillin and a macrolide (erythromycin or clarithromycin) 1
• If oral treatment contraindicated: IV ampicillin or benzylpenicillin plus erythromycin or clarithromycin 1
• Duration: Minimum 5 days, should be afebrile for 48-72 hours, and have no more than 1 CAP-associated sign of clinical instability before discontinuation 1

Severe CAP Requiring Hospitalization:

• Immediate parenteral antibiotics: IV combination of broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone) plus a macrolide (clarithromycin or erythromycin) 1
• Alternative for β-lactam/macrolide intolerant patients: Fluoroquinolone with enhanced pneumococcal activity (levofloxacin) plus IV benzylpenicillin 1
• Duration: 10 days for microbiologically undefined pneumonia; 14-21 days for Legionella, staphylococcal, or Gram-negative enteric bacilli pneumonia 1

ICU Admission:

• A β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin or a fluoroquinolone 1
• For Pseudomonas risk: Antipneumococcal, antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin/levofloxacin OR the β-lactam plus an aminoglycoside and azithromycin 1
• For community-acquired MRSA: Add vancomycin or linezolid 1

For Hospital-Acquired Pneumonia

Not at High Risk of Mortality and No MRSA Risk Factors:

• One of the following: Piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem 1

Not at High Risk of Mortality but with MRSA Risk Factors:

• Piperacillin-tazobactam, cefepime/ceftazidime, levofloxacin, ciprofloxacin, imipenem, meropenem, or aztreonam 1
• Plus MRSA coverage with vancomycin or linezolid 1

High Risk of Mortality or Recent IV Antibiotics:

• Two antibiotics from different classes (avoid two β-lactams) plus MRSA coverage with vancomycin or linezolid 1

Route of Administration and Duration

• Switch from IV to oral therapy when:

  • Hemodynamically stable
  • Clinically improving
  • Afebrile for 24 hours
  • Able to ingest medications
  • Normally functioning GI tract 1

• Duration of therapy:

  • Community-acquired pneumonia: Minimum 5 days 1
  • Hospital-acquired pneumonia: 7-14 days based on clinical response 1

Monitoring Response to Treatment

Assessment at 48-72 Hours:

• Evaluate clinical response: Temperature, WBC, chest X-ray, oxygenation, purulent sputum, hemodynamic changes 1
• If improving: Consider de-escalation of antibiotics based on culture results 1
• If not improving:
  1. Review clinical history, examination, and investigation results
  2. Consider further investigations (repeat chest radiograph, CRP, WBC)
  3. Collect additional microbiological samples 1

Antibiotic Adjustment for Non-Responders:

• For non-severe CAP on amoxicillin monotherapy: Add or substitute a macrolide 1
• For non-severe CAP on combination therapy: Consider changing to a fluoroquinolone with pneumococcal coverage 1
• For severe CAP not responding to combination therapy: Consider adding rifampicin 1

Prevention

• Influenza vaccination for high-risk groups: Chronic lung/heart/renal/liver disease, diabetes mellitus, immunosuppression, and adults >65 years 1
• Pneumococcal vaccination for those aged ≥2 years at high risk for pneumococcal infection 1

Follow-up

• Clinical review at approximately 6 weeks post-treatment 1
• Repeat chest radiograph for patients with:
  • Persistent symptoms or physical signs
  • Higher risk of underlying malignancy (smokers, those >50 years) 1

Common Pitfalls to Avoid

1. Delaying antibiotic administration in severe pneumonia (should be given immediately after diagnosis) 1
2. Using fluoroquinolones as first-line agents in the community setting 1
3. Failing to adjust therapy based on culture results
4. Inadequate duration of therapy for specific pathogens
5. Not considering MRSA coverage when risk factors are present 1
6. Overlooking the possibility of influenza or COVID-19 when these viruses are circulating in the community 2