What is the recommended management for pneumonia?

Management of Pneumonia

For pneumonia management, a combination of a β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin or a fluoroquinolone is strongly recommended for hospitalized patients requiring ICU care. 1

Initial Assessment and Treatment Selection

• Determine pneumonia severity using tools like CURB-65 to guide treatment setting and antibiotic choice 2
• Obtain chest radiography for all patients with suspected pneumonia 1
• Collect appropriate laboratory tests for hospitalized patients including complete blood count, renal and liver function tests, and oxygen saturation 1
• Obtain blood cultures and sputum samples for Gram stain and culture before starting antibiotics in hospitalized patients 1
• Administer the first antibiotic dose while still in the emergency department for patients being admitted 1

Antibiotic Recommendations by Setting

Outpatient Treatment

• For previously healthy patients: macrolide (e.g., azithromycin), doxycycline, or respiratory fluoroquinolone 1
• For patients with comorbidities: combination therapy with a β-lactam and a macrolide or monotherapy with a respiratory fluoroquinolone 3
• For penicillin-allergic patients: respiratory fluoroquinolone 1

Non-ICU Hospitalized Patients

• First-line therapy: β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus a macrolide (azithromycin or clarithromycin) 1, 2
• Alternative for penicillin-allergic patients: respiratory fluoroquinolone (e.g., levofloxacin) 1, 4

ICU Patients

• First-line therapy: β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin or a fluoroquinolone 1
• For suspected Pseudomonas infection: antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin/levofloxacin or an aminoglycoside plus azithromycin 1
• For suspected community-acquired MRSA: add vancomycin or linezolid 1

Route of Administration and Duration

• Use oral antibiotics for non-severe pneumonia when there are no contraindications 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
• Treat for a minimum of 5 days, ensure patient is afebrile for 48-72 hours, and has no more than one CAP-associated sign of clinical instability before stopping antibiotics 1, 2
• Standard duration for uncomplicated pneumonia is 7 days 1, 2
• Consider longer treatment duration if initial therapy was not active against the identified pathogen or if complicated by extrapulmonary infection 1

Monitoring Response to Treatment

• Review clinical response daily, including temperature, respiratory and hemodynamic parameters 2
• For patients not responding as expected:
  • Consider further investigations including repeat chest radiograph, CRP, white cell count, and additional microbiological testing 1
  • For non-severe pneumonia with inadequate response to amoxicillin monotherapy, add or substitute a macrolide 1
  • For non-severe pneumonia on combination therapy with inadequate response, consider changing to a fluoroquinolone with effective pneumococcal coverage 1
  • For severe pneumonia not responding to combination therapy, consider adding rifampicin 1

Special Considerations

• For influenza-associated pneumonia: treat with oseltamivir plus antibacterial agents targeting S. pneumoniae and S. aureus 1
• For patients with persistent septic shock despite fluid resuscitation: consider drotrecogin alfa activated within 24 hours of admission 1
• Screen hypotensive, fluid-resuscitated patients with severe CAP for occult adrenal insufficiency 1
• For patients with hypoxemia or respiratory distress: consider a trial of non-invasive ventilation unless immediate intubation is required 1
• Use low-tidal-volume ventilation (6 cm³/kg of ideal body weight) for patients with diffuse bilateral pneumonia or ARDS 1

Prevention

• Recommend influenza vaccination for high-risk groups including those with chronic lung, heart, renal and liver disease, diabetes mellitus, immunosuppression, and adults over 65 years 1, 2
• Consider pneumococcal vaccination for those at increased risk of pneumococcal infection 1, 2

Common Pitfalls to Avoid

• Delaying antibiotic administration - ensure prompt initiation of appropriate antibiotics 1
• Failing to narrow therapy when a specific pathogen is identified - direct therapy at the identified pathogen once available 1
• Prolonged intravenous therapy - switch to oral therapy as soon as clinically appropriate 1
• Inadequate follow-up - arrange clinical review for all patients at around 6 weeks, with chest radiograph for those with persistent symptoms or at higher risk of underlying malignancy 2
• Not monitoring for treatment complications - watch for C. difficile-associated diarrhea, particularly with broad-spectrum antibiotics 2