Treatment of Suspected Pneumonia in Long-Term Care Resident
Initiate empiric antibiotic therapy immediately for community-acquired pneumonia based on the clinical presentation of bilateral infiltrates, leukocytosis (WBC 14.3), and respiratory symptoms, even in the absence of fever, as this constellation strongly suggests bacterial pneumonia in a long-term care resident. 1, 2
Diagnostic Interpretation
The clinical picture warrants urgent treatment:
WBC count of 14.3 (≥14,000 cells/mm³) has a likelihood ratio of 3.7 for bacterial infection and warrants careful assessment even without fever 1, 2
Absence of fever does not rule out serious infection in long-term care residents, as basal body temperature decreases with age and frailty, making classic fever definitions unreliable in this population 1, 3
Bilateral infiltrates with cough and congestion constitute specific clinical manifestations of focal respiratory infection that, combined with leukocytosis, indicate the need for immediate intervention 2, 3
Essential Immediate Actions
Before initiating antibiotics, obtain:
Manual differential count to assess for left shift (band neutrophils ≥16% or absolute band count ≥1,500 cells/mm³), which has the highest likelihood ratio (14.5) for documented bacterial infection 2, 3
Pulse oximetry to document hypoxemia, as recommended for patients with respiratory symptoms 3
Blood cultures only if bacteremia is highly suspected clinically and the facility has quick laboratory access, adequate physician coverage, and capacity to administer parenteral antibiotics 3
Antibiotic Selection
Standard empiric therapy for community-acquired pneumonia in long-term care should cover Streptococcus pneumoniae, Haemophilus influenzae, and atypical pathogens including Mycoplasma pneumoniae and Chlamydia pneumoniae 4
Appropriate regimens include:
Respiratory fluoroquinolone (levofloxacin or moxifloxacin) as monotherapy, OR
Beta-lactam (amoxicillin-clavulanate or ceftriaxone) PLUS macrolide (azithromycin) for combination therapy 4
Azithromycin has demonstrated safety and efficacy specifically for community-acquired pneumonia due to C. pneumoniae, H. influenzae, M. pneumoniae, and S. pneumoniae in patients appropriate for oral therapy 4
Critical Caveats and Pitfalls
Do not delay antibiotics while awaiting diagnostic test results in a long-term care resident with bilateral infiltrates and leukocytosis, as this represents presumptive bacterial pneumonia requiring immediate treatment 1, 2
Consider alternative or contributing diagnoses:
Clostridium difficile infection should be considered, as it is present in 25% of patients with WBC >30,000 cells/mm³ without hematological malignancy and can occur even without diarrheal symptoms 5
Persistent inflammation-immunosuppression and catabolism syndrome (PICS) may develop in long-term care residents with prolonged leukocytosis, particularly if there is extensive tissue damage rather than active infection 6
Avoid azithromycin monotherapy if:
Patient has known QT prolongation, history of torsades de pointes, congenital long QT syndrome, bradyarrhythmias, or uncompensated heart failure 4
Patient is on drugs that prolong QT interval or has uncorrected hypokalemia/hypomagnesemia 4
Patient has moderate to severe illness, is elderly or debilitated, or has significant underlying health problems that may compromise ability to respond to illness 4
Monitoring and Follow-Up
Reassess clinical response within 48-72 hours:
If no improvement, consider chest imaging if not already obtained, broadening antibiotic coverage, or transfer to acute care facility 3
Monitor for development of Clostridium difficile-associated diarrhea (CDAD), which has been reported with azithromycin and nearly all antibacterial agents 4
Discontinue antibiotics immediately if signs of hepatotoxicity occur (abnormal liver function, hepatitis, cholestatic jaundice), as these have been reported with azithromycin 4
Document advance directives review prior to intervention, and if specific diagnostic measures are withheld, document reasons in the medical record 1