What is the recommended management for pneumonia?

Management of Pneumonia

The recommended management for pneumonia depends on the classification (community-acquired, hospital-acquired, ventilator-associated, or healthcare-associated) and severity of illness, with prompt initiation of appropriate antibiotic therapy being essential to reduce mortality. 1

Classification and Initial Assessment

• Pneumonia is classified as community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), or healthcare-associated pneumonia (HCAP) based on where it was acquired 1
• Severity assessment is the key to planning appropriate management both in community and hospital settings 1
• Adverse prognostic features associated with increased mortality risk include hypoxemia (SaO2 <92% or PaO2 <8 kPa), bilateral or multilobe involvement on chest radiograph 1

Diagnostic Approach

• Lower respiratory tract samples should be obtained from all patients with suspected pneumonia before antibiotic changes 1
• Blood cultures should be collected before antibiotic treatment 1
• A negative respiratory secretion culture in the absence of new antibiotics within the past 72 hours virtually rules out bacterial pneumonia 1

Empiric Antibiotic Therapy

Community-Acquired Pneumonia (CAP)

Outpatient Treatment:

• Amoxicillin at higher doses than previously recommended is the preferred agent 1
• Alternatives include a macrolide (erythromycin or clarithromycin) for patients with penicillin hypersensitivity 1
• Fluoroquinolones with enhanced activity against S. pneumoniae are another option 1

Non-ICU Hospitalized Patients:

• A fluoroquinolone alone or an extended-spectrum cephalosporin (cefotaxime or ceftriaxone) plus a macrolide 1

ICU Patients:

• A β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin or a fluoroquinolone 1
• For penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended 1

Hospital-Acquired, Ventilator-Associated, or Healthcare-Associated Pneumonia

• Initial empiric therapy should be broad-spectrum based on risk factors for multidrug-resistant pathogens 1
• For patients with risk factors for Pseudomonas infection, use an antipneumococcal, antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin/levofloxacin or an aminoglycoside plus azithromycin 1
• For suspected methicillin-resistant Staphylococcus aureus (MRSA), add vancomycin or linezolid 1

Special Considerations

Pregnant Women

• Combined therapy with a beta-lactam antibiotic and a macrolide antibiotic is recommended 2
• Treatment duration: 7-10 days for non-severe cases and 10-14 days for severe cases 2
• Fluoroquinolones should be avoided if possible during pregnancy 2

Treatment Duration and Monitoring

• Patients with CAP should be treated for a minimum of 5 days, should be afebrile for 48–72 hours, and should have no more than 1 CAP-associated sign of clinical instability before discontinuation of therapy 1
• For HAP/VAP, therapy should be adjusted on days 2 and 3 based on clinical response and culture results 1
• Intravenous antibiotics may be switched to oral agents when the patient is improving clinically, is hemodynamically stable, and is able to ingest medications 1

Management of Treatment Failure

• Failure to respond may indicate incorrect diagnosis, inappropriate antibiotic choice/dose/route, unusual pathogen, adverse drug reaction, or complications such as empyema 1
• For patients who fail to improve, conduct a careful clinical review and consider additional investigations 1

Prevention

• Pneumococcal vaccination is recommended for adults at high risk for pneumococcal pneumonia, including those with chronic diseases, immunocompromised persons, elderly persons, and residents of nursing homes 3
• Influenza vaccination is recommended to reduce the risk of pneumonia complications, particularly in pregnant women 2

Common Pitfalls and Caveats

• Delay in the initiation of appropriate antibiotic therapy is consistently associated with increased mortality 1
• Overuse of antibiotics contributes to increased frequency of antibiotic-resistant pathogens 1
• Reliance on non-quantitative cultures may lead to either more or broader spectrum antibiotic therapy than necessary 1
• S. pneumoniae remains the most common identifiable etiologic agent of CAP, with increasing concerns about drug resistance 3