What are the symptoms and treatment options for pneumonia?

Pneumonia Symptoms and Treatment

Pneumonia should be suspected in patients with acute cough and one of the following signs/symptoms: new focal chest signs, dyspnea, tachypnea, or fever lasting >4 days. A chest radiograph should be performed to confirm the diagnosis. 1

Symptoms of Pneumonia

Common Symptoms

• Cough (new or with change in sputum production/color) 1
• Fever or hypothermia 1
• Dyspnea (shortness of breath) 1
• Chest discomfort or pleuritic pain 1
• Rigors and sweats 1
• Fatigue and myalgias 1, 2
• Tachypnea (rapid breathing) 1

Special Populations

• Elderly patients may present with:

  • Confusion or altered mental status 1
  • Failure to thrive 1
  • Worsening of underlying chronic illness 1
  • Falls 1
  • Absence of fever (though tachypnea usually present) 1

• Children may present with:

  • Headache 2
  • Nausea 2
  • Abdominal pain 2
  • Absence of typical pneumonia symptoms 2

Physical Examination Findings

• Abnormal breath sounds 1
• Crackles (rales) on auscultation 1
• Tachycardia 1
• Hypotension (in severe cases) 1
• Localized dullness to percussion 3

Diagnostic Approach

• Standard posteroanterior (PA) and lateral chest radiographs are valuable for confirming pneumonia diagnosis 1
• Radiographs can help differentiate pneumonia from other conditions and identify complications like pleural effusion 1
• Pulse oximetry should be used to assess oxygen saturation 1
• Consider blood cultures in hospitalized patients 1
• Test for COVID-19 and influenza when these viruses are common in the community 4

Treatment Options

Outpatient Management

• Rest, adequate hydration, and simple analgesia (e.g., paracetamol) for pleuritic pain 1
• Empiric antibiotic therapy:
  • Amoxicillin at higher doses is the preferred agent 1
  • Macrolides (erythromycin or clarithromycin) are alternatives, especially for those with penicillin hypersensitivity 1
  • Doxycycline is another alternative 1
  • Respiratory fluoroquinolones may be considered in areas with high pneumococcal resistance 1

Hospitalized Patients (Non-ICU)

• Oxygen therapy with monitoring of oxygen saturations (aim for PaO2 >8 kPa and SaO2 >92%) 1
• Intravenous fluids for volume depletion 1
• Empiric antibiotic therapy:
  • β-lactam (cefotaxime, ceftriaxone) plus a macrolide (azithromycin) 1, 4
  • Alternatively, a respiratory fluoroquinolone 1
  • Minimum treatment duration of 3 days, with continuation until clinically stable 4

ICU-Admitted Patients

• For patients without risk for Pseudomonas aeruginosa:

  • Intravenous β-lactam (cefotaxime, ceftriaxone) plus either intravenous macrolide (azithromycin) or intravenous fluoroquinolone 1

• For patients with risk for Pseudomonas aeruginosa:

  • Antipseudomonal β-lactam (cefepime, imipenem, meropenem, piperacillin/tazobactam) plus either an antipseudomonal quinolone or an aminoglycoside plus a macrolide 1

Special Considerations

• Corticosteroids may reduce 28-day mortality when administered within 24 hours of severe CAP development 4
• Nutritional support should be considered in prolonged illness 1
• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, and oxygen saturation at least twice daily in hospitalized patients 1

Follow-up and Complications

Follow-up

• Review outpatients after 48 hours or earlier if clinically indicated 1
• Clinical review should be arranged for all patients at around 6 weeks 1
• Repeat chest radiograph for patients with persistent symptoms or physical signs, or those at higher risk of underlying malignancy 1

Potential Complications

• Metastatic infections (meningitis, arthritis, endocarditis, pericarditis, peritonitis, empyema) 1
• Pleural effusion or empyema 1
• Lung abscess 1
• Acute respiratory distress syndrome (ARDS) 1
• Multiple system organ failure 1
• Sepsis 4, 5

Common Pitfalls

• Failure to obtain chest radiograph to confirm diagnosis 1, 3
• Inadequate assessment of disease severity leading to inappropriate site-of-care decisions 1
• Delayed antibiotic administration in severe cases 1
• Failure to consider atypical pathogens in empiric therapy 6
• Overlooking pneumonia in elderly patients who may present with atypical symptoms 1
• Not testing for viral causes like influenza and COVID-19 when prevalent 4