What are the supportive care and treatment options for pneumonia?

Supportive Care and Treatment for Pneumonia

The most effective supportive care and treatment for pneumonia includes rest, adequate hydration, oxygen therapy when needed, appropriate antibiotics based on severity, and nutritional support, with regular reassessment of the patient's condition to adjust management appropriately. 1

General Supportive Care

For Patients in the Community

• Advise patients to rest and avoid smoking 1
• Encourage adequate fluid intake to maintain hydration 1
• Provide simple analgesia such as paracetamol for pleuritic pain 1
• Consider nutritional supplements for prolonged illness 1
• Regular reassessment after 48 hours or earlier if clinically indicated 1
• Pulse oximetry should be used when available to assess severity and oxygen requirements 1

For Hospitalized Patients

• Provide appropriate oxygen therapy with monitoring of oxygen saturations and FiO2, aiming to maintain PaO2 >8 kPa and SaO2 >92% 1
• For patients with pre-existing COPD and ventilatory failure, guide oxygen therapy with repeated arterial blood gas measurements 1
• Assess for volume depletion and provide intravenous fluids as needed 1
• Provide nutritional support, especially in prolonged illness 1
• Monitor vital signs (temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation) at least twice daily, more frequently in severe cases 1
• Repeat CRP measurement and chest radiograph in patients not progressing satisfactorily 1

Antibiotic Therapy

For Community-Managed Pneumonia

• Amoxicillin is the preferred agent (at higher doses than previously recommended) 1
• A macrolide (erythromycin or clarithromycin) is an alternative choice, especially for patients with penicillin hypersensitivity 1
• For patients referred to hospital with suspected severe pneumonia, consider immediate antibiotic administration if the illness is life-threatening or if hospital admission may be delayed 1

For Hospitalized Patients with Non-Severe Pneumonia

• Oral route is recommended if no contraindications exist 1
• Switch from parenteral to oral antibiotics as soon as clinical improvement occurs and temperature has been normal for 24 hours 1
• Treatment duration of 7 days is recommended for uncomplicated cases 1

For Hospitalized Patients with Severe Pneumonia

• Immediate treatment with parenteral antibiotics after diagnosis 1
• Combination therapy with a broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone) plus a macrolide (clarithromycin or erythromycin) 1
• For β-lactam or macrolide intolerant patients, a fluoroquinolone with enhanced pneumococcal activity plus intravenous benzyl-penicillin is an alternative 1
• Treatment duration of 10 days for microbiologically undefined severe pneumonia, extended to 14-21 days for legionella, staphylococcal, or Gram-negative enteric bacilli pneumonia 1

For Specific Pathogens

• For community-acquired pneumonia due to Streptococcus pneumoniae, β-lactams (amoxicillin, cefotaxime, and ceftriaxone) are generally the drugs of choice 1
• For patients with COVID-19 pneumonia, empirical antibiotics should target suspected potential infections, avoiding blind or improper combinations of broad-spectrum antibiotics 1

Advanced Respiratory Support for Severe Pneumonia

Oxygen Therapy and Ventilation

• High-flow nasal oxygen (HFNO) should be considered when standard oxygen therapy fails to maintain SpO2 above 93% with rapidly increasing breathing rate 1
• Non-invasive ventilation (NIV) may be useful to reduce respiratory power consumption and improve oxygenation 1, 2
• Invasive mechanical ventilation should be implemented if ARDS persists or acutely deteriorates despite HFNO or NIV 1
• Protective lung ventilation strategy should be used: lower tidal volume (4-6 ml/kg), lower plateau pressure (<30 cmH2O), and appropriate PEEP 1
• For moderate-severe ARDS, consider higher PEEP, prone ventilation for >12 hours per day, and deep sedation and analgesia muscle relaxation within the first 48 hours of mechanical ventilation 1

For Critically Ill Patients

• Management by specialists with appropriate training in intensive care and respiratory medicine 1
• Bronchoscopy can be valuable to remove retained secretions, obtain samples for culture, and exclude endobronchial abnormality 1
• Consider Extracorporeal Life Support (ECLS) for patients with severe refractory hypoxemia 1
• Conservative fluid management for ARDS patients without tissue hypoperfusion 1
• Use vasoactive drugs to improve microcirculation when needed 1

Management of Complications

Septic Shock

• Recognize septic shock early (infection with need for vasoconstrictors to maintain MAP ≥65 mmHg with lactate ≥2 mmol/L despite fluid resuscitation) 1
• Provide at least 30 ml/kg of isotonic crystalloid for adults in the first 3 hours 1
• Administer vasoconstrictors when shock persists after fluid resuscitation, with noradrenaline as first choice 1

Failure to Improve

• Conduct careful review by an experienced clinician of clinical history, examination, prescription chart, and all available investigation results 1
• Consider further investigations including repeat chest radiograph, CRP, white cell count, and additional microbiological testing 1
• For non-severe pneumonia with failure to improve on amoxicillin monotherapy, add or substitute a macrolide 1
• For non-severe pneumonia on combination therapy with failure to improve, consider changing to a fluoroquinolone with effective pneumococcal coverage 1
• For severe pneumonia not responding to combination therapy, consider adding rifampicin 1

Prevention

• Influenza vaccination is recommended for high-risk groups including those with chronic lung, heart, renal and liver disease, diabetes mellitus, immunosuppression, and those aged over 65 years 1
• Pneumococcal vaccination is recommended for those aged 2 years or older in whom pneumococcal infection is likely to be more common or serious 1

Special Considerations

Early Assessment Impact

• Early oxygenation assessment (within 3 hours) is associated with more rapid antibiotic delivery and better ICU survival 3
• Delayed oxygenation assessment (>3 hours) is an independent risk factor for death 3

Duration of Therapy

• For patients with normal oxygenation (≥95% on ambient air), shorter courses of antibiotics (1-2 days) may be as effective as longer courses (5-8 days) 4
• This approach can reduce antibiotic exposure without compromising outcomes 4