What is the management of pneumonia in the Philippines based on the latest guidelines?

Management of Pneumonia in the Philippines Based on Latest Guidelines

The management of pneumonia in the Philippines should follow a structured approach including empiric antibiotic therapy with amoxicillin as the preferred agent for community-acquired pneumonia (CAP) in outpatient settings, and combination therapy with amoxicillin and a macrolide for hospitalized patients. 1

Assessment and Diagnosis

• All patients should undergo assessment of severity to determine appropriate management setting (community vs. hospital) 1
• Pulse oximetry should be used to assess oxygenation, with a target to maintain SaO₂ >92% 1
• Chest radiograph is not necessary for patients managed in the community but is recommended for all hospitalized patients 1
• Blood tests including full blood count, urea, electrolytes, liver function tests, and C-reactive protein should be performed for hospitalized patients 1
• Blood cultures should be obtained from all hospitalized patients, preferably before antibiotic administration 1

Management in Community Settings

• Patients with mild pneumonia can be managed as outpatients with oral antibiotics 1
• Amoxicillin remains the preferred antibiotic at a higher dose than previously recommended 1
• A macrolide (erythromycin or clarithromycin) is an alternative for patients with penicillin hypersensitivity 1
• Patients should be advised to rest, maintain hydration, and avoid smoking 1
• Simple analgesia such as paracetamol should be used for pleuritic pain 1
• Clinical review is recommended after 48 hours or earlier if clinically indicated 1

Management in Hospital Settings

• Combined oral therapy with amoxicillin and a macrolide (erythromycin or clarithromycin) is preferred for hospitalized patients with non-severe CAP 1
• For severe pneumonia requiring ICU admission, a combination of a β-lactam plus either a macrolide or a respiratory fluoroquinolone is recommended 1, 2
• Appropriate oxygen therapy should be provided with monitoring of oxygen saturations to maintain SaO₂ >92% 1
• Patients should be assessed for volume depletion and may require intravenous fluids 1
• Nutritional support should be provided in cases of prolonged illness 1
• Regular monitoring of vital signs (temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation) should be performed at least twice daily 1

Antibiotic Duration

• For patients with non-severe and uncomplicated pneumonia, 7 days of appropriate antibiotics is typically sufficient 3
• For severe pneumonia or cases involving Legionella, staphylococcal, or Gram-negative enteric bacilli, treatment should be extended to 14-21 days 3
• Levofloxacin 750 mg daily for 5 days has shown similar efficacy to 500 mg daily for 10 days in community-acquired pneumonia 4

Monitoring Response to Treatment

• The CRP level should be remeasured and chest radiograph repeated in patients who are not progressing satisfactorily 1
• For patients improving clinically, radiological improvement may lag behind clinical recovery and does not necessarily require further investigation 1
• If there is failure to improve, consider complications or resistant organisms and adjust antibiotics accordingly 3

Follow-up Planning

• Clinical review should be arranged 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 those at higher risk of underlying malignancy (especially smokers and those over 50 years) 1
• Further investigations including bronchoscopy should be considered in patients with persisting signs, symptoms, and radiological abnormalities about 6 weeks after completing treatment 1

Special Considerations

• For patients with severe pneumonia requiring ICU care, management should be 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 in ICU patients 1
• For pneumonia caused by specific pathogens like Legionella, treatment with azithromycin or a fluoroquinolone is preferred 1
• In cases where Pseudomonas aeruginosa is suspected, an anti-pseudomonal beta-lactam combined with either an anti-pseudomonal fluoroquinolone or an aminoglycoside is recommended 5

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, 5
• Inadequate assessment of severity leading to inappropriate treatment setting 1
• Insufficient oxygen monitoring and support in hospitalized patients 1