What are the latest guidelines for managing pneumonia in the Philippines?

Management of Pneumonia in the Philippines Based on Latest Guidelines

The management of pneumonia in the Philippines should follow a structured approach with amoxicillin as the preferred first-line antibiotic for community-acquired pneumonia (CAP) treated in outpatient settings, while hospitalized patients should receive combination therapy with a β-lactam plus a macrolide. 1

Assessment and Classification

• Assess severity using clinical features to determine appropriate management setting (community vs. hospital) 1
• Core adverse prognostic features to evaluate include:
  • Respiratory rate ≥30/min
  • Diastolic BP ≤60 mmHg
  • Urea >7 mmol/l
  • Confusion 1
• Additional adverse features include hypoxemia (SaO2 <92% or PaO2 <8 kPa) and bilateral/multilobar involvement on chest radiograph 1

Diagnostic Approach

• For patients managed in the community, general investigations including chest radiograph are not necessary for most cases 1
• For hospitalized patients, the following investigations should be performed on admission:
  • Chest radiograph
  • Full blood count
  • Urea, electrolytes and liver function tests
  • C-reactive protein (CRP) when available
  • Oxygenation assessment 1
• Blood cultures are recommended for all hospitalized patients, preferably before antibiotic treatment 1
• Sputum samples should be sent for culture from patients able to expectorate purulent samples who have not received prior antibiotics 1

Antibiotic Management

For Community-Managed Patients:

• Amoxicillin remains the preferred agent but at a higher dose than previously recommended 1
• A macrolide (erythromycin or clarithromycin) is an alternative for patients hypersensitive to penicillins 1
• For patients referred to hospital with suspected CAP, general practitioners may consider administering antibiotics immediately where the illness is considered life-threatening or where admission delays are likely 1

For Hospitalized Patients with Non-Severe CAP:

• Most patients can be adequately treated with oral antibiotics 1
• Combined oral therapy with amoxicillin and a macrolide (erythromycin or clarithromycin) is preferred 1
• Oral monotherapy with amoxicillin can be considered for previously untreated patients or those admitted for non-clinical reasons 1

For Severe CAP:

• Combination therapy with a β-lactam plus either a macrolide or a respiratory fluoroquinolone is recommended for ICU patients 1
• For suspected Pseudomonas infection, an anti-pseudomonas beta-lactam (piperacillin/tazobactam, carbapenems, cefepime) should be used with either an anti-pseudomonas fluoroquinolone or an aminoglycoside 2

General Management

• Provide appropriate oxygen therapy with monitoring of oxygen saturations, aiming to maintain SaO2 >92% 1
• Assess for volume depletion and provide intravenous fluids if needed 1
• Provide nutritional support in prolonged illness 1
• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation at least twice daily, more frequently in severe cases 1
• For patients with dyspnea and increased respiratory secretions, consider selective (M1, M3) receptor anticholinergic drugs to reduce secretion and improve pulmonary ventilation 1

Monitoring and Follow-up

• Review patients in the community after 48 hours or earlier if clinically indicated 1
• For hospitalized patients not progressing satisfactorily:
  • Remeasure CRP level 1
  • Repeat chest radiograph 1
  • Consider further investigations including bronchoscopy for patients with persisting symptoms and radiological abnormalities after 6 weeks 1, 3
• Arrange clinical review for all patients at around 6 weeks, either with their general practitioner or in a hospital clinic 1
• A follow-up chest radiograph should be arranged for patients with persistent symptoms or physical signs, or who are at higher risk of underlying malignancy (especially smokers and those over 50 years) 1

Duration of Treatment

• For patients with non-severe and uncomplicated pneumonia, 7 days of appropriate antibiotics is typically sufficient 3
• For severe pneumonia or where Legionella, staphylococcal, or Gram-negative enteric bacilli are suspected or confirmed, extend treatment to 14-21 days 3

Common Pitfalls to Avoid

• Assuming radiological improvement will match clinical recovery; radiological changes often lag behind clinical improvement 1, 3
• Failing to consider resistant organisms or atypical pathogens not covered by initial therapy 3
• Delaying antibiotic administration in severe cases; antibiotics should be initiated within 4 hours after registration for hospitalized patients 1