This document outlines protocols for treating various types of pneumonia, including community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and aspiration pneumonia. It details definitions, clinical features, common pathogens, investigations and workup, severity assessments, empirical antibiotic treatment options and durations, and monitoring considerations for each type. Empirical treatment regimens are tailored based on severity and risk factors. Duration of treatment typically ranges from 7-10 days but may be longer for complicated cases.

1. PNEUMONIA TREATMENT
PROTOCOL
BY SEHAM MOUSTAFA
FETOUH
BCPS , MSc of clinical pharmacy , Pharm D

2. CONTENTS OF PROTOCOL
protocol By Clinical pharmacist
CAP Seham Moustafa Fetouh
HAP Eman Mohamed Elfakhrany
Aspiration
pneumonia
Seham Moustafa Fetouh

3. COMMUNITY ACQUIRED
PNEUMONIA

4. DEFINITION
•Acute infection of the pulmonary parenchyma in a
patient who has acquired the infection in the
community

5. INVESTIGATIONS WORKUP
• Signs and symptoms
• Chest examination
• plain chest radiograph
• CT scan
• lung ultrasound
• CBC
• C-reactive protein test
• blood cultures and sputum Gram stain and culture

6. • C-reactive protein test if clinical diagnosis is unclear. it can
reveal that you have inflammation somewhere in your body.
< 20 mg/litre no AB
20-100 delayed AB if symptoms worsen
>100 immediate AB

7. CLINICAL FEATURES OF CAP
• Chest manifestation
● cough, fever, rigors, chills , pleuritic chest pain, dyspnea, sputum
production
● Mucopurulent sputum with bacterial pneumonia, scant or watery sputum
with atypical
pathogen and on Chest examination audible crackles
● respiratory rate > 24 breaths/minute
● nausea, vomiting, diarrhea
● mental status changes, tachycardia

8. SEVERITY ASSESSMENT IN PRIMARY CARE
confusion Mental Test score ≤ 8 , or new disorientation in person, place or time
blood urea nitrogen > 7 mmol/litre
respiratory rate ≥30 breaths per minute
low blood pressure diastolic ≤ 60 mmHg , or systolic <90 mmHg
age ≥ 65 years
1 point for each of the following prognostic features:
CURB65 score

9. M.O SUSPECTED
Atypical pneumonia
(uncommon)
Typical organisms (Common)
Legionella spp
M. pneumonia
C. pneumonia
Chlamydia psittaci
S. pneumonia
Haemophilus influenza
Staphylococcus aureus
group A streptococci
Moraxella catarrhalis
anaerobes, and aerobic gram-negative bacteria
respiratory viruses

10. EMPERIC TREATMENT WITHIN 4 HOURS OF PRESENTATION TO
HOSPITAL
severity duration TTT
Outpatient
treatment
Low severity
CURB65 0-1
-Previously
healthy
- no use of
antimicrobials
within the
previous three
months
3-5 days
if symptoms do
not improve as
expected after 3
days.
course of the
antibiotic > 5
days
amoxicillin 500/8hr
-patients who are allergic to penicillin
Macrolide (azithromycin 500/24hr, clarithromycin
500/12hr
OR
Doxycycline 100/12hr
Low severity
CURB65 0-1
-Presence of
comorbidities
or
-use of
antimicrobials
within the
previous three
months
7-10 days respiratory fluoroquinolone (levofloxacin 750
/24hr or moxifloxacin 400mg /24hr)
(high-dose amoxicillin 1g /8hr , or amoxicillin-
clavulanate 2g /12hr or ceftriaxone1-2/12-24 hr
, or cefpodoxime200/12hr)
plus
macrolide (azithromycin500/24hr , or
clarithromycin 500/12 hr or doxycycline 100/12 hr

11. Inpatient,
non-ICU
treatment
-Moderate severity
CURB65 2
-Presence of
comorbidities
7-10 days respiratory fluoroquinolone (levofloxacin 750 /24hr
or moxifloxacin 400 /24hr)
cefotaxime1-2g/8hr or ceftriaxone1-2g /12-24hr
plus
macrolide OR doxycycline
Inpatient, ICU
treatment
-high severity
CURB65 3-5
7-10 days fluoroquinolone OR azithromycin
plus
cefotaxime1-2g/8hr or ceftriaxone 1-2g /12-24hr
or ampicillin-sulbactam 1.5-3g/ 6hr
if
Pseudomonas
risk
10 days (Piperacillin-tazobactam3.375/6hr,
cefepime2g/8hr,imipenem500/6hr,or
meropenem1g/8hr)
plus
ciprofloxacin400/8hr or levofloxacin 750 mg/24hr
(Piperacillin-tazobactam ,cefepime, imipenem, or
meropenem)
plus
aminoglycoside and azithromycin
(Piperacillin-tazobactam,cefepime, imipenem, or
meropenem)
plus
aminoglycoside and fluoroquinolone
CA-MRSA risk 7-21days Add vancomycin15-20mg/kg/day/8-12hr or linezolid

12. * comorbidities such as chronic heart, lung, liver, or renal disease;
diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing
conditions or use of immunosuppressing drugs.
* Do not routinely offer a glucocorticosteroid unless they have other
conditions for which glucocorticosteroid treatment is indicated.
* the preferable use of antibiotic is ordered in descending order
* the use of antipseudomonal and anti MRSA medications according to
microbiological data and with consultation of microbiologists
• Switching from intravenous to oral
when patients are hemodynamically stable and improving clinically, are
able to ingest medications, and have a normally functioning
gastrointestinal tract.

13. Monitoring in hospital
C-reactive protein baseline on admission and repeat the test if clinical progress is
uncertain after 48 to 72 hours.
Do not routinely discharge patients if in the past 24 hours they have had 2 or more of
the following :
Temp
RR
HR
SBP
PaO2
> 37.5°C
≥24 breaths per minute
> 100 beats per minute
≤ 90 mmHg
90%
abnormal mental status
inability to eat without assistance.

14. HOSPITAL ACQUIRED PNEUMONIA

15. DEFINITION
HAP is pneumonia that occur 48 hr or more
after admission and did not appear at the
time of admission and not associated with
mechanical ventilation during that time .

16. PATHOGENS
Gm – ve
bacilli
E-coli , klebsiella pneumoniae ,Enterobacter spp, Pseudomonas
aeruginosa , Acinobacter spp .
Gm +ve cocci Staphylococcus aureus including MRSA , streptococcus spp.

17. Emperic Treatment
IF Not of high risk of mortality* Using one of the following:
Levofloxacin 750 mg /24hr
Cefepim 2 g /8hr
piperacillin –tazobactam 4.5 g/6hr
if suspected MRSA: add
vancomycin 15mg /kg / 8-12 hr.
(consider loading dose 25-30 mg
/kg x 1 for severe illness )
IF high risk of mortality* Using one of the following:
Levofloxacin 750 mg /24hr
Ciprofloxacin 400 mg /8hr
Amikacin 15-20 mg/kg /24hr
Gentamycin 5-7 mg /kg /24hr
PLUS
Using one of the following:
Cefepim 2 g /8hr
Ceftazidim 2g /8hr
Imipenem 500mg /6hr
Meropenem 1g /8hr
piperacillin –tazobactam 4.5 g/6hr
if suspected MRSA: add
vancomycin 15mg /kg / 8-12 hrs.
(consider loading dose 25-30 mg
/kg x 1 for severe illness )

18. * high risk of mortality
-Ventilator support due to HAP and septic shock
-Prior intravenous antibiotic use within 90 days
-the patient has structure lung disease (cystic fibrosis, bronchiectasis)
 Duration : 7-10 days consider using procalcitonine levels plus clinical criteria
to define the treatment course .

19. ASPIRATION PNEUMONIA

20. DEFINITION
• refers to the pulmonary consequences resulting from the abnormal entry of
fluid, particulate exogenous substances, or endogenous secretions into the
lower airways.
Aspiration of gastric acidchemical pneumonitis (
Mendelson syndrome)
Aspiration of bacteria from oral and
pharyngeal areas
aspiration pneumonia
Types of spiration

21. Risk factors of aspiration

22. INVESTIGATIONS WORKUP
• Signs and symptoms
• CBC With Differential
• Arterial blood gas (ABG)
• mixed venous gas measurement
• sputum culture
• chest radiograph
• Bronchoscopy

23. CHEMICAL PNEUMONITIS
Clinical features
●Abrupt onset of symptoms within a few minutes to two hours of the
aspiration event
● dyspnea , respiratory distress, Tachypnea , audible wheezing, rales, and
cough with pink or frothy sputum.
● Cyanosis and diffuse crackles on lung auscultation
●Severe hypoxemia
●low grade Fever
●tachycardia
● infiltrates ( on Chest imaging ) on involving dependent pulmonary segments
.The dependent lobes in the upright position are the lower lobes. aspiration
that occurs while patients are in the recumbent position may result in infection

24. ANTIBIOTIC TTT
•In patients who are severely ill, the empiric use of antibiotics is appropriate.
However, if no infiltrates develop after 48 to 72 hours, it is appropriate to
stop antibiotics
•repeat a chest radiograph and discontinue antibiotics if the infiltrates and
signs and symptoms of pneumonia have resolved

25. BACTERIAL INFECTION
Chest manifestation
● Cough with purulent sputum ,Shortness of breath, dyspnea on exertion
● Pleuritic chest pain
● Putrid expectoration (a clue to anaerobic bacterial pneumonia)
● Fever or chills
● Malaise, myalgias
● Rigors may be present of absent
●complication untreated aspiration pneumonia  bronchopleural fistula 
Lung abscess, necrotizing pneumonia, or empyema.

26. M.O suspected
Community aspiration
pneumonia
mixed bacterial infection  anaerobes and facultative anaerobes
such as oral streptococci
lung abscess streptococci
Hospital-acquired or
healthcare-associated
aspiration pneumonia
aerobic bacteria, especially gram-negative bacilli and S. aureus,
are more important than the anaerobes

27. Emperic Treatment
IV drugs Oral drugs dose considerations
ampicillin-sulbactam 1.5 to 3 g IV /6hr first-line therapy
ceftriaxone
or cefotaxime
+
metronidazole
1 or 2 g IV daily
1 or 2 g IV /8hr
500 mg orally or IV /8hr
1st Alternative agents
Carbapenem
imipenem/cilastatin 500 mg IV /6hr 1st Alternative agents
Pipracillin/tazobactam 3.375g iv/ 6hr 1st Alternative agents
amoxicillin-
clavulanate
875 mg /125 orally /12hr 1st Alternative agents
clindamycin clindamycin 600 mg IV /8hr followed by
300 mg orally /6hr or 450
mg orally /8hr
-for penicillin-allergic
patients added to regimens
not containing
Piperacillin/tazobactam
-has high rate of C. difficile
moxifloxacin 400mg oral once Has high rate of resistance
and higher risk of
•Community acquired aspiration pneumonia
-oral antibiotics used in patients who are hemodynamically stable, able to take oral medications, and have a
normally functioning gastrointestinal tract

28. Hospital-acquired or healthcare-
associated aspiration pneumonia
aerobic bacteria, especially gram-
negative bacilli and S. aureus
Cefepim 2 g /8hr
Levofloxacin 750 mg /24hr
Ciprofloxacin 400 mg /8hr
Gentamycin 5-7 mg /kg /24 hr
-patients with poor dentition
-patients known to be colonized with
resistant gram-negative bacilli
-patients who have received IV
antibiotics within the past 90 days
regimen against both aerobes and
anaerobes
Imipenem 500mg /6 hr
Meropenem 1g /8 hr
piperacillin –tazobactam 4.5 g/6 hr
patients with risk factors for MRSA Add vancomycin 15mg /kg / 8-12 h
or linezolid
•Hospital-acquired or healthcare-associated aspiration pneumonia
Prophylactic antibiotic are not recommended for patients who are at increased risk for
aspiration.

29. Duration
• If not complicated by cavitation or empyema is 7 days
• Patients with lung abscess need a longer course of antibiotics, usually until
there is radiographic clearance or significant improvement
• Switch to oral antibiotics
when they are improving clinically, hemodynamically stable, able to take oral
medications, and have a normally functioning gastrointestinal tract
amoxicillin-clavulanate (875 mg orally twice daily).
or
clindamycin (450 mg orally three times daily) For patients who have a serious
allergy to penicillin.

30. Risk factors
-previous antibiotic therapy
-recent hospitalization
-immunosuppression
-pulmonary comorbidity (cystic fibrosis, bronchiectasis, or repeated exacerbations of COPD)
-probable aspiration, and multiple medical comorbidities
Pseudomonas or
drug-resistant
pathogens
-colonization with MRSA (ESKD, contact sport participants, injection drug users, those living
in crowded conditions, prisoners)
-recent influenza-like illness
-antimicrobial therapy (particularly fluoroquinolone) in the prior 3 months
-necrotizing or cavitary pneumonia, and presence of empyema
MRSA
-Age >65 years
-Beta-lactam, macrolide, fluoroquinolone therapy within the past 3-6 months
-Alcoholism
-Medical comorbidities
-Immunosuppressive illness or therapy
-Exposure to a child in a daycare center
-prior hospitalization or residence in a long-term care facility
drug-resistant
S. pneumonia

31. REFERANCES CAP
• Uptodate
1-Epidemiology, pathogenesis, and microbiology of community-acquired pneumonia in adults
Authors:Thomas J Marrie, MDThomas M File, Jr, MDSection Editor:John G Bartlett, MDDeputy Editor:Sheila Bond, MD
2-Diagnostic approach to community-acquired pneumonia in adults
Author:John G Bartlett, MDSection Editor:Stephen B Calderwood, MDDeputy Editor:Sheila Bond, MD
3- Treatment of community-acquired pneumonia in adults who require hospitalization
Author:Thomas M File, Jr, MDSection Editor:John G Bartlett, MDDeputy Editor:Sheila Bond, MD
Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of
Community-Acquired Pneumonia in Adults
Lionel A. Mandell Richard G. Wunderink Antonio Anzueto John G. Bartlett G. Douglas Campbell Nathan C. Dean Scott
F. Dowell Thomas M. File, Jr. Daniel M. Musher Michael S. Niederman Antonio Torres Cynthia G. Whitney
clinical Infectious Diseases, Volume 44, Issue Supplement_2, 1 March 2007, Pages S27–S72
NICE clinical guideline 191
guidance.nice.org.uk/cg191
Diagnosis and management of community- and hospital-acquired pneumonia in adults

32. REFERANCES HAP
• Andre C. Kalil, Mark L. Metersky, Michael Klompas , et al .
Management of Adults With Hospital-acquired and Ventilator-
associated Pneumonia: 2016 Clinical Practice Guidelines by the
Infectious Diseases Society of America and the American
Thoracic Society.

33. REFERENCES ASPIRATION
-Uptodate
Aspiration pneumonia in adults
Author:John G Bartlett, MDSection Editor:Daniel J Sexton, MDDeputy Editor:Sheila Bond, M
-http://emedicine.medscape.com/article/296198-overview#a9
-Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the
Management of Community-Acquired Pneumonia in Adults
Lionel A. Mandell Richard G. Wunderink Antonio Anzueto John G. Bartlett G. Douglas Campbell Nathan
C. Dean Scott F. Dowell Thomas M. File, Jr. Daniel M. Musher Michael S. Niederman Antonio Torres
Cynthia G. Whitney
Clinical Infectious Diseases, Volume 44, Issue Supplement_2, 1 March 2007, Pages S27–S72
-Antibiotic Guidelines johns hopkins 2015-2016 Sara E. Cosgrove, M.D., M.S.
Director, Antimicrobial Stewardship Program, Edina Avdic, Pharm.D., M.B.A, ID Pharmacist
Associate Director, Antimicrobial Stewardship Program
-Sanford guide antimicrobial therapy electronic application