Management and Antibiotics of Choice For Pneumonia

1. Management And Antibiotics
Of Choice For Pneumonia

2. Severity assessment in primary care
• When a clinical diagnosis of
community-acquired pneumonia is
made in primary care,
determine whether patients are
at low, intermediate or high risk
of death using the CRB65 score

3. Investigations
Theaimsof investigation are
Confirmthe diagnosis
Excludeotherconditions
Assesstheseverity
Identifythedevelopmentof complications

4. Investigations..
Full blood count
 Very high (> 20 × 109/L) or low (< 4 × 109/L) whitecell
count:markerof severity
 Neutrophil leucocytosis > 15 × 109/L: suggestsbacterial
aetiology
 Haemolyticanaemia:occasional complicationof Mycoplasma
Erythrocyte sedimentation rate/C-reactive protein: Non-
specifically elevated
Blood culture: Bacteraemia:markerofseverity

5. Investigations..
Urea and electrolytes:
Urea > 7 mmol/L (~20 mg/dL): markerof severity
Hyponatraemia:markerof severity
Liver function tests:
Abnormalif basalpneumoniainflamesliver
Hypoalbuminaemia:markerof severity
Serology: Acuteand convalescenttitresfor Mycoplasma,
Chlamydia, Legionella and viral infections
Cold agglutinins: Positivein50% of patientswithMycoplasma
Arterial blood gases: Measure whenSaO2 < 93% or when
severe clinical features to assessventilatoryfailureor acidosis

6. Investigations..
Sputum
Sputum samples
Gramstain,cultureand antimicrobialsensitivity
testing. Gramstainof sputumshowingGram-
positivediplococcicharacteristicof Strep.
pneumoniae.
Oropharynx swab
PCRfor Mycoplasma pneumoniae and other
atypical pathogens

7. Investigations..
Urine
Pneumococcaland/or Legionellaantigen
Pleural fluid
Alwaysaspirateand culturewhenpresentinmore
thantrivialamounts,preferablywithultrasound
guidance

8. Investigations..
Other markersof severityofPneumonia
CXR :> One lobe involved
Pao2 <8kPa
Lowalbumin(<35gm/L)
WBC(<4000/cmm or >20000/cmm)
Blood culture positive

9. Investigations..
Chest X-ray
Lobar pneumonia
Patchyopacificationevolvesinto homogeneousconsolidation
of affected lobe
Airbronchogram(air-filled bronchiappearlucentagainst
consolidated lungtissue)maybe present.
Bronchopneumonia: Typicallypatchyand segmentalshadowing
Complications: Para-pneumoniceffusion,intrapulmonary
abscessorempyema
Staph. aureus: Suggestedbymultilobarshadowing,cavitation,
pneumatocoelesandabscesses

10. Investigations..
For evaluation of PSI
CBC
HCT,TC,DC
RBS
Blood Urea
Serum electrolytes
CXR
ABGAnalysis
Pulse oximetry

11. Management
Theprinciplesof managementfocusingon
Adequate oxygenation
Appropriatefluidbalance
Antibiotics
Insevereor prolongedillness,
Nutritional supportmaybe required
Evaluatetheeffectivenessof administeredmedications
Explainall proceduresto thepatientand family

12. Management…
Oxygen
Oxygen shouldbeadministeredto all patients
with
tachypnoea,
hypoxaemia,
hypotension or
acidosis
The aim of maintaining the PaO2 at or above 8
kPa (60 mmHg) or the SaO2 at or above 92%.

13. Management….
Oxygen
High concentrations (35% or more), preferably
humidified, should be used in all patients who do not
havehypercapniaassociatedwith COPD.
Continuous positive airway pressure (CPAP) should be
considered in those who remain hypoxic despite this and
these patients should be managed in a high-
dependency or intensive care environment, where
mechanicalventilationcanberapidlyemployed.

14. Management…
Intravenous fluids
Theseshouldbeconsideredinpatientswithsevere
illness,older patientsand thosewhoare vomiting.
Otherwise,anadequateoralintakeof fluid should be
encouraged.
Inotropicsupportmayberequiredinpatientswith
shock

15. Management…
Antibiotics
Prompt administration of antibiotics improves the outcome.
Th
e initialchoiceof antibioticisguidedby
clinical context,
severity assessment,
localknowledgeof antibioticresistancepatterns
anyavailableepidemiological information.
The choice of empirical antibiotic therapy is considerably
more challenging,dueto
Diversityofpathogens
Drug resistance.

16. Management…
Antibiotics :Uncomplicated CAP:
Amoxicillin500 mg3 timesdaily orally
If patient is allergic to penicillin: Clarithromycin500 mgtwicedailyorally
or Erythromycin 500 mg4 timesdaily orally
If Staphylococcus is cultured or suspected: Flucloxacillin1–2 g4 times
daily IVplus Clarithromycin500 mgtwicedaily IV
If Mycoplasma or Legionella is suspected: Clarithromycin500 mgtwice
daily orallyor IVor Erythromycin500 mg4 timesdaily orallyIVplus
Rifampicin600 mgtwicedaily IVinseverecases

17. Management…
Antibiotics :Severe CAP: Clarithromycin
500 mgtwicedaily IVor Erythromycin
500 mg4 timesdaily IV plus
Co-amoxiclav1.2g3 timesdaily IVor
Ceftriaxone1–2 gdaily IVor
Cefuroxime1.5g3 timesdaily IVor
Amoxicilin1g4timesdailyIVplusflucloxacilin2g4timesdailyIV

18. Management…
Antibiotics:Oral antibiotics are usuallyadequateunlessthe
patienthasa
severe illness,
impaired consciousness,
lossof swallowingreflex,or
functionalor anatomicalreasonsformalabsorption.
Inmostpatientswithuncomplicatedpneumonia,a7-day courseis
adequate,althoughtreatmentisusuallyrequiredfor longerin
thosewithLegionella, staphylococcal or Klebsiellapneumonia.

19. Management…Antibiotics:
Durationoftherapy
5 -7 days- outpatients
10-14 days – Mycoplasma,Chlamydia,Legionella
14+days- chronicsteroid users
14-21days – Staph. aureas,Legionellaspp
[AmJRespirCritCareMed163:1730-54, 2001]

20. Management…
Pain
Itisimportantto relievepleuralpain,asitmaypreventthe
patientfrombreathingnormallyand coughingefficiently.
Forthemajority,simpleanalgesiawithparacetamol,co-codamol
or NSAIDsis sufficient.
Insomepatients,opiatesmayberequiredbutthesemustbe
usedwithextremecautioninpatientswithpoor respiratory
function,astheymaysuppress ventilation.
Physiotherapy
Mayhelpexpectorationinthosewhosuppresscoughbecauseof
pleural pain.

21. Management…
Maintainapatentairwayand adequate oxygenation
Usesuctionif thepatientcan’tproducea specimen
Provideahighcalorie,highproteindiet&soft foods
Provide a quiet, calm environment, with frequent rest periods
Monitorthepatient’sABGlevels,especiallyif he’s hypoxic
Assessthepatient’srespiratorystatus
Auscultatebreathsoundsatleastevery4 hours

22. Management…
Delayed resolution means
Physicalsignspersistfor morethan2 weeksand
Radiologicalfeaturespersistfor morethan4 weeksafter
antibiotic therapy.
Non-resolution means
Ifradiological opacitypersistsafter8 weeks(with
treatment/after antibiotic therapy).

23. Management…Delayed resolution suggests
I. thediagnosis isincorrect
II. Incorrectmicrobiologicaldiagnosis
III. Fungal,tubercularor atypical pneumonia
IV. recurrent aspiration
V. Improperantibioticor insufficientdose
VI. pneumoniamaybesecondaryto aproximalbronchial obstruction
VII.complicationhasoccurred(Empyemaor atelectasis)
VIII.Bronchialobstruction(bronchial carcinoma,adenoma, foreignbody)
IX. Immunocompromisedpatient(HIV,DM,lymphoma,leukemia,multiple
myeloma).