Management Approach for Pneumonia
The management of pneumonia requires a severity-based approach with appropriate antibiotic selection tailored to the setting of care, with empiric therapy covering the most likely pathogens while considering local resistance patterns. 1
Severity Assessment
- Severity assessment is the key to planning appropriate management both in the community and hospital settings 2
- Use validated severity assessment tools such as:
- Regular reassessment of severity during the course of illness is mandatory to adjust management appropriately 2
Outpatient Management
- Patients in PORT risk Classes I and II should be considered for outpatient treatment 2
- For healthy adults without comorbidities, amoxicillin 1g three times daily is the first-choice antibiotic 1
- For adults with comorbidities, combination therapy with amoxicillin/clavulanate or a cephalosporin plus a macrolide or doxycycline is recommended 1
- Patients should be advised to:
- Review patients after 48 hours or earlier if clinically indicated 2
Inpatient Management (Non-Severe CAP)
- Most patients can be adequately treated with oral antibiotics 2
- Combined therapy with amoxicillin and a macrolide (erythromycin or clarithromycin) is preferred for hospitalized patients 2
- Provide appropriate oxygen therapy with monitoring of oxygen saturations to maintain PaO2 >8 kPa and SaO2 >92% 2
- Monitor temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation, and inspired oxygen concentration at least twice daily 2
- Measure CRP levels and repeat chest radiographs in patients not progressing satisfactorily 2
Management of Severe CAP Requiring ICU Care
- For patients without risk factors for Pseudomonas aeruginosa, use a non-antipseudomonal β-lactam plus a macrolide or a respiratory fluoroquinolone 1
- For patients with risk factors for Pseudomonas aeruginosa, use an antipseudomonal β-lactam plus either ciprofloxacin or a macrolide plus an aminoglycoside 1
- Patients with severe CAP admitted to ICU should be managed by specialists with appropriate training in intensive care and respiratory medicine 2
- Consider bronchoscopy to remove retained secretions, obtain samples for culture, and exclude endobronchial abnormality 2
Duration of Therapy and Follow-up
- Treat patients for a minimum of 5 days and ensure they are afebrile for 48-72 hours with no more than 1 CAP-associated sign of clinical instability before discontinuing therapy 1
- Switch from intravenous to oral therapy when patients are hemodynamically stable, improving clinically, able to ingest medications, and have a normally functioning gastrointestinal tract 1
- The chest radiograph need not be repeated prior to hospital discharge in patients who have made a satisfactory clinical recovery 2
- Arrange clinical review for all patients at around 6 weeks, either with their general practitioner or in a hospital clinic 2
- A follow-up chest radiograph should be arranged for patients with persistent symptoms or physical signs, or those at higher risk of underlying malignancy 2
Special Considerations
- For suspected or confirmed influenza pneumonia, add oseltamivir to the treatment regimen 1
- For patients with pre-existing COPD complicated by ventilatory failure, guide oxygen therapy by repeated arterial blood gas measurements 2
- Consider further investigations, including bronchoscopy, in patients with persisting signs, symptoms, and radiological abnormalities about 6 weeks after completing treatment 2
Common Pitfalls to Avoid
- Delayed antibiotic administration can increase mortality 1
- Overuse of fluoroquinolones should be avoided to prevent development of resistance 1
- Inadequate coverage of causative pathogens is associated with worse outcomes 1
- Relying solely on clinical presentation without radiographic confirmation can lead to misdiagnosis 1
- When using azithromycin, be aware of potential QT prolongation, especially in elderly patients or those with cardiac risk factors 3