What is the management of pneumonia in a hospital setting, including tests, consultations, labs, and medications?

Management of Pneumonia in Hospital Setting

For hospitalized patients with pneumonia, management should include prompt empiric antibiotic therapy based on pneumonia severity, risk factors for multidrug-resistant pathogens, and local antibiogram data, along with appropriate diagnostic testing, supportive care, and monitoring for clinical response. 1, 2

Initial Assessment and Diagnostics

Required Investigations

• Chest radiograph - mandatory for all hospitalized patients 1, 2
• Laboratory tests:
  • Complete blood count
  • Serum electrolytes, urea, and liver function tests
  • C-reactive protein (when available)
  • Oxygenation assessment (pulse oximetry or arterial blood gases) 1, 2

Microbiological Investigations

• Blood cultures - collect before antibiotic administration 1, 2
• Sputum cultures - for patients who can produce purulent samples and haven't received prior antibiotics 1, 2
• Legionella testing - for all patients with severe pneumonia or specific risk factors 2
• Additional testing based on clinical suspicion for specific pathogens 1, 2

Antibiotic Therapy

Hospital-Acquired Pneumonia (Non-Ventilator Associated)

For patients not at high risk of mortality and no MRSA risk factors:

• One of the following:
  • Piperacillin-tazobactam 4.5g IV q6h
  • Cefepime 2g IV q8h
  • Levofloxacin 750mg IV daily
  • Imipenem 500mg IV q6h
  • Meropenem 1g IV q8h 1

For patients not at high risk of mortality but with MRSA risk factors:

• One of the above antibiotics PLUS:
  • Vancomycin 15mg/kg IV q8-12h (target trough 15-20mg/mL) OR
  • Linezolid 600mg IV q12h 1

For patients at high risk of mortality:

• Two of the following (avoid using two β-lactams):
  • Antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, ceftazidime, imipenem, or meropenem)
  • Fluoroquinolone (levofloxacin or ciprofloxacin)
  • Aminoglycoside (amikacin, gentamicin, or tobramycin)
  • Aztreonam (for penicillin-allergic patients)
• PLUS MRSA coverage:
  • Vancomycin or linezolid 1, 2

Community-Acquired Pneumonia

For non-severe CAP:

• Combination therapy:
  • Non-antipseudomonal cephalosporin (ceftriaxone) plus macrolide OR
  • Respiratory fluoroquinolone monotherapy (moxifloxacin or levofloxacin 750mg daily) 2

For severe CAP:

• Combination therapy:
  • β-lactam plus macrolide OR
  • β-lactam plus respiratory fluoroquinolone 2

Supportive Care

• Oxygen therapy - maintain SpO2 ≥90% (or PaO2 ≥60 mmHg) 2
• Fluid management - ensure adequate hydration while avoiding fluid overload 2
• Early mobilization - for all patients when clinically stable 2
• Thromboprophylaxis - low molecular weight heparin for patients with acute respiratory failure 2
• Consider non-invasive ventilation - particularly for patients with COPD and ARDS 2

Monitoring and Follow-up

• Clinical assessment - evaluate response within 48-72 hours of starting treatment 2
• Serial vital signs - temperature, respiratory rate, blood pressure, heart rate, and oxygen saturation 1
• De-escalation of therapy - narrow antibiotic spectrum based on culture results 1, 2
• Duration of therapy:
  • Minimum 5 days
  • Patient should be afebrile for 48-72 hours
  • No more than one sign of clinical instability before discontinuing antibiotics 2
  • Longer duration may be needed if initial response is delayed or complications develop 2

Antibiotic Stewardship Considerations

• Use narrowest spectrum antibiotics appropriate for the clinical situation 2
• Limit treatment duration to 5-7 days for most cases 2
• Switch from IV to oral therapy when patient is clinically stable:
  • Hemodynamically stable
  • Improving respiratory status
  • Able to take oral medications
  • Normal gastrointestinal function 1, 2

Special Considerations

For Pseudomonas aeruginosa Risk

• Use antipseudomonal agents (ceftazidime, cefepime, piperacillin-tazobactam, or carbapenem) plus either ciprofloxacin or aminoglycoside 2

For Aspiration Pneumonia

• β-lactam/β-lactamase inhibitor, clindamycin, or cephalosporin plus metronidazole 2

For Atypical Pathogens

• Ensure coverage with doxycycline, macrolide, or respiratory fluoroquinolone 2

Common Pitfalls to Avoid

1. Delayed antibiotic administration - initiate therapy immediately after diagnosis, especially in patients with septic shock 2
2. Inappropriate empiric coverage - consider local resistance patterns and patient risk factors 1, 2
3. Failure to de-escalate - narrow therapy based on culture results 1
4. Unnecessarily prolonged treatment - most patients respond to 5-8 days of therapy 2
5. Overlooking complications - evaluate non-responding patients for complications, resistant organisms, or alternative diagnoses 1

By following this structured approach to pneumonia management in hospitalized patients, clinicians can optimize outcomes while practicing good antibiotic stewardship.