Management Of Community Acquired Pneumonia

Diagnostic Tests

• CBCD, electrolytes, glucose, BUN, Cr
• ABG on RA
• blood cultures (draw 2 before treatment, at least 10 min. apart)
• sputum gram stain and culture
• CXR (PA and lateral)
• acid fast stain of sputum if cough > 1 month or suspicious CXR for TB
• thoracocentesis if pleural effusions present
  • stain, culture, pH, leukocyte count, differential

General Management

• analgesics/antipyretics
• ensure adequate hydration
• oxygen therapy to O2 sat ≥ 90%
• consult RT, PT, OT, speech language pathologist, dietician as needed

Hospitalization

• When to admit
  • Age >65 yrs
  • Decreased immunity (cancer, diabetes, AIDS, splenectomy)
  • Mental status changes
  • Increased A-a gradient
  • Two or more lobes involved
  • No home
  • Organ failure (↑Cr, bone marrow suppression, severe hypotension, liver failure)
  • WBC > 30,000/mm3 or < 4000/mm3 (sepsis)

Treatment

• if no pathogen identified, empirically treat
  • NO COMORBIDITIES: po macrolide or doxycycline
  • WITH COMORBIDITIES: po beta-lactam plus macrolide, or fluoroquinolone, quinolones (levofloxacin)
  • if suspect ASPIRATION: amoxicillin-clavulanate or levofloxacin and metronidazole
• treat empirically until pathogen identified by sputum or blood culture, then use specific therapy

• OUTPATIENT: treat for 10 - 14 days
  • Followup with GP, CXR in 8-12 weeks

• INPATIENT: treatment length based on response to therapy, comorbid illnesses, complications
  • usually treat bacterial infections until patient is afebrile for >72 hours
    • resolution of respiratory symptoms, fever, PaO2 level, WBC, and findings on serial CXR

• give influenza and pneumococcal vaccine on day of discharge
• smoke cessation

Poor prognostic factors

• age, men, nursing home
• comorbidities: cancer, liver, CHF, CVD, renal
• O/E: LOC, RR, BP, pulse, temperature
• labs: pH, pO2, ↓hematocrit, ↑BUN, ↓Na, ↑glucose, pleural effusion

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