Pneumonia Symptoms and Treatment
Clinical Presentation
Pneumonia should be suspected in patients presenting with acute cough plus at least one of the following: new focal chest signs, dyspnea, tachypnea, or fever lasting more than 4 days 1.
Common Symptoms
Respiratory symptoms include new or increased cough (often productive), dyspnea, and pleuritic chest pain that worsens with breathing 1, 2.
Constitutional symptoms include fever (>38°C) or hypothermia (≤36°C), rigors and sweats, fatigue, myalgias, headache, and general malaise 1, 2, 3.
Elderly patients may present atypically with confusion or altered mental status, failure to thrive, worsening of underlying chronic illness, falls, or absence of fever 1.
Physical Examination Findings
Vital sign abnormalities include tachypnea (respiratory rate >30), tachycardia (pulse >100), fever (>38°C), and hypotension (blood pressure <90/60 mmHg) 4, 1.
Pulmonary findings include abnormal breath sounds, crackles on auscultation, and signs of consolidation 1, 5.
Severe illness indicators requiring immediate attention include confusion/diminished consciousness, marked tachypnea, and hemodynamic instability 4, 1.
Diagnostic Confirmation
Chest radiography (posteroanterior and lateral views) should be performed to confirm the diagnosis and identify complications like pleural effusion 1.
Laboratory testing should include pulse oximetry for oxygen saturation assessment, and blood cultures should be considered in hospitalized patients 1.
COVID-19 and influenza testing should be performed when these viruses are circulating in the community, as results may affect treatment decisions 2.
Treatment Approach
Outpatient Management (Mild Cases)
First-line antibiotics include amoxicillin or tetracycline based on safety profile and clinical experience 4.
Alternative agents for penicillin-allergic patients include macrolides (azithromycin, clarithromycin, erythromycin) or doxycycline in areas with low pneumococcal macrolide resistance 4, 1.
Supportive care includes rest, adequate hydration, and simple analgesia for pleuritic pain 1.
Hospitalized Patients (Moderate to Severe)
Empiric antibiotic therapy for hospitalized patients without risk factors for resistant bacteria should be β-lactam/macrolide combination therapy, such as ceftriaxone combined with azithromycin, for a minimum of 3 days 1, 2.
Fluoroquinolone monotherapy (levofloxacin or moxifloxacin) is an alternative when first-choice agents are contraindicated 4, 6.
Supportive measures include oxygen therapy to maintain adequate saturation and intravenous fluids as needed 1.
ICU-Level Care (Severe Pneumonia)
Intensive antibiotic regimens require antipseudomonal β-lactam combined with either an antipseudomonal quinolone or an aminoglycoside plus a macrolide 1.
Adjunctive therapy with systemic corticosteroids administered within 24 hours of severe CAP development may reduce 28-day mortality 2.
Pseudomonas coverage requires combination therapy with an anti-pseudomonal β-lactam when this pathogen is documented or presumed 6.
Clinical Response and Monitoring
Expected Response Timeline
Clinical improvement should be evident within 3 days of initiating antibiotics; patients should contact their physician if no improvement occurs 4.
Symptom resolution varies considerably: fever typically resolves within 3 days, while cough and fatigue may persist for 14 days or longer 7.
Complete recovery takes more than 28 days for approximately 35% of patients, with some symptoms persisting throughout this period 7.
Follow-Up Requirements
Outpatients should be reviewed after 48 hours or earlier if clinically indicated 1.
Seriously ill patients (those with suspected pneumonia and elderly with relevant comorbidity) should be followed up 2 days after the first visit 4.
Clinical review at approximately 6 weeks is recommended, with repeat chest radiograph for patients with persistent symptoms, physical signs, or higher risk of underlying malignancy 1.
Warning Signs Requiring Immediate Re-evaluation
Red flags include fever exceeding 4 days, worsening dyspnea, decreased oral intake, or decreasing consciousness 4.
Radiographic progression in severe pneumonia with clinical deterioration may necessitate aggressive evaluation and antibiotic change even before 72 hours of therapy 4.
Important Caveats
Antibiotic changes should not occur within the first 72 hours unless there is marked clinical deterioration or bacteriologic data necessitate modification 4.
Cough suppressants, expectorants, mucolytics, antihistamines, inhaled corticosteroids, and bronchodilators should not be prescribed for acute lower respiratory tract infections in primary care 4.
Only 38% of hospitalized CAP patients have a pathogen identified, with viruses accounting for up to 40% of identified cases and Streptococcus pneumoniae in approximately 15% 2.