What are the recommendations for prehospital treatment of pneumonia?

Prehospital Treatment of Pneumonia

Empirical antibiotics targeting suspected potential infections should be used as soon as possible in the prehospital setting, with careful attention to avoid blind or improper combination of broad-spectrum antibiotics. 1

Initial Assessment and Oxygen Therapy

Assessment

• Evaluate severity using clinical features:
  • Respiratory rate
  • Oxygen saturation
  • Mental status changes
  • Blood pressure
  • Heart rate

Oxygen Management

• Provide oxygen therapy only when SpO₂ is <92% 2, 3
• Titrate oxygen to maintain SpO₂ >92% 1, 2
• Monitor oxygen saturation continuously with pulse oximetry when available 1
• If flow rates >5 L/min are required, urgent evacuation and critical care support should be requested 2

Antibiotic Therapy

For Non-Severe Community-Acquired Pneumonia

• First choice: Amoxicillin at higher doses than traditionally used 1
• Alternative (for penicillin-allergic patients): Macrolide (erythromycin or clarithromycin) 1
• If referring to hospital with life-threatening illness or expected delays >2 hours in admission, consider immediate antibiotic administration 1

For Moderate to Severe Pneumonia

• Consider combination therapy with a β-lactam and a macrolide if available 1
• Fluoroquinolones can be used as an alternative 1

Supportive Care

• Advise patients to:
  • Rest
  • Maintain adequate hydration
  • Avoid smoking 1
• Provide analgesia (e.g., paracetamol) for pleuritic pain 1
• Consider nutritional supplements for prolonged illness 1

Special Considerations

Septic Shock Management (if present)

1. Recognize septic shock: Hypotension despite fluid resuscitation, lactate ≥2 mmol/L, or signs of hypoperfusion (mental status changes, oliguria, poor peripheral perfusion) 1
2. Initial fluid resuscitation:
   • Adults: At least 30 ml/kg of isotonic crystalloid in first 3 hours 1
   • Children: 20 ml/kg as rapid bolus, up to 40-60 ml/kg in first aid 1
3. Use isosmotic crystal solutions; avoid hypotonic crystalloids, starches, or gelatins 1
4. If shock persists after fluid resuscitation, administer vasopressors (noradrenaline as first choice) 1

Monitoring and Reassessment

• Review patients after 48 hours or earlier if clinically indicated 1
• Assess for:
  • Temperature response
  • Respiratory rate
  • Oxygen requirements
  • Mental status
  • Hemodynamic stability 1

Pitfalls to Avoid

1. Overuse of oxygen: Providing oxygen to all patients regardless of saturation levels can be harmful; only administer when SpO₂ <92% 2, 3

2. Inappropriate antibiotic selection: Pre-hospital antibiotic use may affect the causative organism profile, with Legionella pneumophila being nearly three times more common in pre-treated patients 4

3. Delayed treatment: For severe cases, early antibiotic administration improves outcomes; don't delay if hospital transport will take >2 hours 1

4. Improper fluid management: In septic shock, inadequate fluid resuscitation worsens outcomes; follow proper fluid administration protocols 1

5. Routine corticosteroid use: Unless specifically indicated, avoid routine use of corticosteroids in the prehospital setting 1