Pneumonia


Score: CURB-65
1 point for each of the following clinical features:
C: Confusion
U: BUN > 20 mg/dL (7 mmol/L)
R: Respiratory rate > 30 breaths/min
B: SBP < 90 or DBP < 60
65: Age >65
Score Mortality Suggested Management
0 0.6% Outpatient
1 2.7% Outpatient
2 6.8% Short inpatient or supervised outpatient
3 14% Inpatient
4 or 5 27.8% Inpatient/ICU

Summary

FEVER, COUGH & SPUTUM

MCC:
Strep Pneumonia

CURB-65 Score
0-1 > 2
 ↓
Out Pt

Admit
Tx:
- Amoxil
- Azithro
- Levaquin
- Avelox
CAP HAP VAP HCAP Aspiration
Pneumonia in pt who has not been hospitalized or has not resided in a long-term care facility (eg NH) within the past 14 days. Occurs 48 hrs after admission. Type of HAP that develops > 48 - 72h after intubation. Occurs in a non-hospitalized patient with extensive healthcare contact, as defined by one or more of the following:

- Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days
- Residence in a nursing home or other long-term care facility
- Hospitalization in an acute care hospital for two or more days within the prior 90 days
- Attendance at a hospital or hemodialysis clinic within the prior 30 days

Bronchopneumonia that develops due to the entrance of foreign materials into the bronchial tree, usually oral or gastric contents (including food, saliva, or nasal secretions).

Think: in pt w/ altered level of consciousness

 
Inpatient, non-ICU
Levofloxacin 750 mg po/iv qd x 7d
Moxifloxacin 400 mg po/iv qd x 7d

OR

Ampicillin 1000 mg IV qid  or
Ceftriaxone 1g IV qd   or
Cefotaxime 1g IV q8h or
Ertapenem 1g IV qd
AND
Azithromycin 500 mg PO/IV qd
  or
Clarithromycin 500mg po BID x 5 days or
Doxycycline 100mg po bid
+/-
Vancomycin 500-1000mg IV q12h or
Linezolid 600mg PO/IV q12htr>

Inpatient, ICU
Unasyn 1-2g IV q6h
Cefotaxime 1g IV q6-8h
Ceftriaxone 1g IV qd
PLUS
Azithromycin 500mg IV qd

Levaquin 750mg IV qd
Moxifloxacin 400mg IV qd
+/-
Vancomycin 500-1000mg IV q12h

Linezolid 600mg PO/IV q12h

OR

For PCN allergy:

  • Levaquin 750mg IV qd
  • Moxifloxacin 400mg IV qd
    PLUS
  • Aztreonam 1-2g q8h

 
Choose one from List 1 AND List 2 AND List 3: USE THREE DRUGS
List 1
Cefepime 2g IV q8h
Ceftazidime 2g IV q8h
Zosyn 4.5g IV Q6h
Primaxin 500mg IV q6h
List 2
Ciprofloxacin 400mg IV q8h
Levofloxacin 750mg IV q24h
Azithromycin 500mg IV q24h PLUS 
Gentamicin 5-7 mg/kg IV q24h OR
Tobramycin 5-7 mg/kg IV q24h
List 3
Vancomycin 15-20 mg/kg IV q12h (per pharmacy protocol)
Linezolid 600mg IV q12h

 
Community-acquired:
Clindamycin : 300 mg PO q6h; or 600 mg IV q8h
Levofloxacin : 750 mg PO or IV qd
Moxifloxacin : 400 mg PO or IV qd
Zosyn : 3.375 g IV q6h
Unasyn : 1-2 g IV q6h
Primaxin : 250-500 mg IV q6h
 
Hospital- or long-term care-acquired
With risk factors for MRSA or multidrug-resistant pathogens:
cefepime : 1-2 g q12h or
Unasyn : 1-2 g IV q6h  or
Zosyn : 4.5 g IV q6h  or
Timentin : 3.1 g IV q4-6h 
-- AND --
Primaxin : 250-500 mg IV q6h or
meropenem : 1 g IV q8h
-- AND --
tobramycin : per pharmacy  or
gentamicin : per pharmacy
-- AND --
linezolid : 600 mg IV q12h or
vancomycin : 15 mg/kg IV q12h initially, adjust based on vancomycin levels
 

Without risk factors for MRSA or multidrug-resistant pathogens:
Clindamycin : 600 mg IV q8h
Unasyn : 1-2 g IV q6h 
Moxifloxacin : 400 mg IV qd

Confirmed Staphylococcus aureus infection or nasopharyngeal colonization
Vancomycin : 15 mg/kg IV q12h
Linezolid : 600 mg PO/IV q12h
 
 

MIMICS NOT TO MISS

  • Cancer
  • Pulmonary Embolism
  • Tuberculosis
  • Diffuse Alveolar Hemorrhage
  • ARDS
  • Right-sided Endocarditis
  • Septic emboli
  • Atelectasis
  • Environmental or Toxicologic

Specific Organisms

ORGANISM FEATURES & KEYWORDS
Typical
Streptococcus pneumoniae
  • Lobar with rust colored sputum; single rigor; Gram + diplococci
  • Most common overall
Haemophilus influenzae
  • Lobar or patchy; small Gram - rods
  • Smokers, COPD
Klebsiella pneumonia
  • RUL, bulging minor fissure, currant jelly sputum; short wide Gram - paired rods
  • COPD, diabetics, ETOH
Pseudomonas, Enterobacter
  • Patchy, multilobar, fulminant, necrotizing; sickly sweet odor; Gram - rods
  • Cystic fibrosis, hospital acquired, ventilator related, immuno-compromised
Staphylococcus
  • Abscess, cavitation, empyema, effusion, necrotizing; Gram + cocci in clusters
  • IVDA, post-influenza
Anaerobes
  • Patchy, foul-smelling sputum
  • Poor dentition, ETOH, Aspiration
Atypical (No organisms on standard gram stain)
Legionella
  • Unilateral lobar infiltrates; GI symptoms, elevated LFTs, hyponatremia; AMS with relative bradycardia; No person to person spread; Large PMNs
  • Toxic appearing elderly males in nursing homes; Associated with air conditioning and water sources
Mycoplasma pneumoniae
  • Patchy perihilar infiltrate; “walking pneumonia”; Associated with encephalitis, Guillain-Barre, hemolysis, bullous myringitis, erythema multiforme, cold agglutinins; Mononuclear cells
  • Young, healthy adults
Chlamydia pneumoniae
  • Patchy interstitial; Staccato cough, conjunctivitis; Gram - intracellular
  • Non-toxic appearing infants 3-20 weeks and young adults
Fungi
  • Bilateral adenopathy with patchy infiltrates; associated with erythema nodosum and chest pain
  • Coccidiodomycosis (Valley Fever): Southwest US
  • Histoplasmosis: Mississippi, Ohio River Valley
  • Blastomycosis: Southeast US
Chlamydia psittaci (psittacosis)
  • Variable CXR; Associated with relative bradycardia, epistaxis, leucopenia, epistaxis, sepsis and shock
  • Bird handlers
Coxiella burnetii (Q fever)
  • Hepatitis, endocarditis
  • Vets and farmers with goats, sheep, cattle
Others
Bacillus anthracis (Anthrax)
  • Wide mediastinum; No person to person spread; Gram + rods
  • Woolsorter’s, bioterrorism
Hantavirus
  • Pulmonary edema with cardiac and renal failure
  • Aerosolized rodent feces in southwest US
Yersinia pestis (Plague)
  • Multilobar, bilateral; Very contagious
  • Bubonic: rodent fleas
  • Pulmonary: bioterrorism


 
Special Groups:
Hospital Aquired Staph, enteric G(-) rods
Immunocompromised Staph, enteric G(-) rods, fungi, viruses, pneumocystis jirovicii-with HIV
Aspiration Anaerobes
Alcoholic/IV drugs S. pneumoniae, Klebsiella, Staph
Cystic Fibrosis Pseudomonas, S. aureus, S. pneumoniae
Postviral Staph, H. influenzae, S. pneumoniae
Atypical Mycoplasma, Legionella, Chlamydia

Common Causes

By Age
< 4 wk
(Neonate)
4wk-18yr
(children)
18-40 yr
(Adults)
40-65yr
(Adults)
Elderly
- GBS
- E.coli
- RSV
- Mycoplasma
- Chlamydia trichomatis
       (inf-3yr)
- C. pneumoniae
  (School-age child) 
- Strep Pneumoniae
- Mycoplasma
- C. Pneumoniae
- S. Pneumoniae
- S. Pneumoniae
- H. infulenzae
- Anaerobes
- Viruses
- Mycoplasma
- S. Pneumoniae
- Influenza virus
- Anaerobes
- H. Influenzae
- G(-) Rods
  4wk-3Mo:
- Erythromycin, Azithromycin,

Add cefotaxime if febrile, ill-appearing.

Consider adding Clindamycin or Vanc in severe infection


3Mo-5yr:
- Outpt:
 Amoxil (HD) +/- Azithromycin

- Inpt:
 Rocephin OR cefotaxime + azithromycin

 Clindamycin OR vancomycin + azithromycin.

>5yr:
Outpt:
 Azithromycin +/- amoxil

 Azithromycin+/- clindamycin

Inpt:
 Rocephin OR cefotaxime + azithromycin
     


 
Special Groups:
Hospital Aquired Staph, enteric G(-) rods
Immunocompromised Staph, enteric G(-) rods, fungi, viruses, pneumocystis jirovicii-with HIV
Aspiration Anaerobes
Alcoholic/IV drugs S. pneumoniae, Klebsiella, Staph
Cystic Fibrosis Pseudomonas, S. aureus, S. pneumoniae
Postviral Staph, H. influenzae, S. pneumoniae
Atypical Mycoplasma, Legionella, Chlamydia

 

Treatment

COMMUNITY ACQUIRED TREATMENT

Outpatient
  • Previously healthy, no antibiotics in last 3 months
    • Macrolide
      • Azithromycin 500mg PO on day 1, then 250mg PO qd x 4 days
      • Clarithromycin 500mg po BID x 5 days
         OR
    • Doxycycline 100mg po bid x 7d
  • Presence of comorbidities, such as heart, liver, renal, DM, ETOH, CA, immunospression or use of antibiotics within 3 months
    • Respiratory fluoroquinolone
      • Levofloxacin 750 mg po qd x 7d
      • Moxifloxacin 400 mg po qd x 7d
        OR
    • Beta-lactam
      • Amoxicillin 1000 mg po tid  or
      • Amoxicillin-clavulanate (Augmntin) 875 mg po bid
      • Azithromycin 500 mg po on day one, then 250 mg po qd x 4 days orr
      • Clarithromycin 500mg po BID x 5 days
 
Inpatient, non-ICU
  • Levofloxacin 750 mg po/iv qd x 7d
  • Moxifloxacin 400 mg po/iv qd x 7d

    OR
  • Ampicillin 1000 mg IV qid  or
  • Ceftriaxone 1g IV qd   or
  • Cefotaxime 1g IV q8h or
  • Ertapenem 1g IV qd
    and
  • Azithromycin 500 mg PO/IV qd   or
  • Clarithromycin 500mg po BID x 5 days or
  • Doxycycline 100mg po bid
    +/-
  • Vancomycin 500-1000mg IV q12h
  • Linezolid 600mg PO/IV q12h
Inpatient, ICU
  • Unasyn (ampicillin-sulbactam) 1-2g IV q6h
  • Cefotaxime 1g IV q6-8h
  • Ceftriaxone 1g IV qd
    PLUS
  • Azithromycin 500mg IV qd
  • Levaquin 750mg IV qd
  • Moxifloxacin 400mg IV qd
    +/-
  • Vancomycin 500-1000mg IV q12h
  • Linezolid 600mg PO/IV q12h

    OR
     
  • For PCN allergy:
    • Levaquin 750mg IV qd
    • Moxifloxacin 400mg IV qd
      PLUS
    • Aztreonam 1-2g q8h
Pseudomonas Coverage: 
  • Zosyn (Piperacillin-tazobactam) 4.5g IV q6h  or
  • Cefepime 1-2g IV q12h or
  • Meropenem 1g IV q8h
    PLUS
  • Ciprofloxacin 400mg IV q12h   or
  • Levofloxacin 750mg PO/IV qd

    OR
     
  • Zosyn (Piperacillin-tazobactam) 4.5g IV q6h or
  • Cefepime 1-2g IV q12h or
  • Meropenem 1g IV q8h
    PLUS
  • Gentamycin 5-7 mg/kg/day IV q8h
    PLUS
  • Ciprofloxacin 400mg IV q12h or
  • Levofloxacin 750mg PO/IV qd  or
  • Azithromycin 500mg IV qd
MRSA Coverage: 
  • Vancomycin 500-1000mg IV q12h
  • Linezolid 600mg PO/IV q12h

 

HCAP, HAP, and VAP

Choose one from List 1 AND List 2 AND List 3: USE THREE DRUGS
List 1
Cefepime 2g IV q8h
Ceftazidime 2g IV q8h
Piperacillin-Tazobactam 4.5g IV Q6h
Imipenem-Cilastatin 500mg IV q6h
List 2
Ciprofloxacin 400mg IV q8h
Levofloxacin 750mg IV q24h
Azithromycin 500mg IV q24h PLUS 
Gentamicin 5-7 mg/kg IV q24h OR
Tobramycin 5-7 mg/kg IV q24h
List 3
Vancomycin 15-20 mg/kg IV q12h (per pharmacy protocol)
Linezolid 600mg IV q12h

 

Aspiration Pneumonia

Community-acquired:
  • Clindamycin : 300 mg orally every 6 hour; or 600 mg IV q8h
  • Levofloxacin : 750 mg orally or IV qd
  • Moxifloxacin : 400 mg orally or IV qd
  • Piperacillin/tazobactam (Zosyn) : 3.375 g IV q 6 h
  • Ampicillin/sulbactam (Unasyn) : 1-2 g IV q 6 h
  • Imipenem/cilastatin (Primaxin) : 250-500 mg IV q 6 h
Hospital- or long-term care-acquired

cefepime : 1-2 g q12h or
ampicillin/sulbactam : 1-2 g IV q6h  or
piperacillin/tazobactam : 4.5 g IV q6h  or
ticarcillin/clavulanate : 3.1 g IV q 4-6 h 
-- AND --
imipenem/cilastatin : 250-500 mg IV q 6 h or
meropenem : 1 g IV q8h
-- AND --
tobramycin : per pharmacy  or
gentamicin : per pharmacy
-- AND --
linezolid : 600 mg IV q12h or
vancomycin : 15 mg/kg IV q12h initially, adjust based on vancomycin levels
 

Without risk factors for MRSA or multidrug-resistant pathogens:

Clindamycin : 600 mg IV q8h
Ampicillin/sulbactam (Unasyn) : 1-2 g IV q6h 
Moxifloxacin : 400 mg IV qd

Confirmed Staphylococcus aureus infection or nasopharyngeal colonization
  • Vancomycin : 15 mg/kg intravenously every 12 hours
  • Linezolid : 600 mg orally/intravenously every 12 hours
     

 

When to Stop Treatment?

  • CAP pts should be treated
    • For a minimum of 5 days (SOR A)
    • Until afebrile for 48-72 hrs
    • Until no more than 1 CAP associated sign of clinical instability (SOR B)
      • Temp < 37.8 C
      • HR < 100 BPM
      • RR < 24 BrPM
      • SBP > 90 mm hg
      • O2 Sats > 90% pO2 > 60 mm Hg on Rm air
      • Ability to maintain oral intake
      • Normal mental status

Admit Orders: Pneumonia

1. Admit to:

2. Diagnosis: Pneumonia

3. Condition:

4. Vital Signs: q4-8h. Call physician if BP >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C or O2 saturation <90%.

5. Activity: Up ad lib, bathroom privileges.

6. Nursing: Pulse oximeter, inputs and outputs, nasotracheal suctioning prn, incentive spirometry.

7. Diet: Regular.

8. IV Fluids: IV D5 ½ NS at 125 cc/hr.

9. Special Medications:

-Oxygen by NC at 2-4 L/min, or 24-50% by Ventimask, or 100% by non-rebreather (reservoir) to maintain O2saturation >90%.

Not in the ICU:

Ceftriaxone (1 to 2 g IV daily), OR
Cefotaxime (1 to 2 g IV every eight hours),
OR
Ceftaroline (600 mg IV every 12 hours),
OR
Ertapenem (1 g IV daily), OR
Ampicillin-sulbactam (1.5 to 3 g IV every six hours)
PLUS
a macrolide (azithromycin [500 mg IV or orally daily] or clarithromycin XL [two 500 mg tablets once daily]).
 

-Monotherapy with a respiratory fluoroquinolone given either IV or orally (levofloxacin 750 mg daily or moxifloxacin 400 mg daily or gemifloxacin 320 mg daily).

 

Admitted to an ICU:

Ceftriaxone 1 to 2 g daily, OR
Cefotaxime 1 to 2 g q8h,
OR

Ampicillin-sulbactam 1.5 to 3 g q6h)
 PLUS
either an advanced macrolide (azithromycin 500 mg daily)
 OR
a respiratory fluoroquinolone (levofloxacin 750 mg daily or moxifloxacin 400 mg daily).
+/-
Vancomycin per pharmacy protocol.

 

COPD and frequent antimicrobial or glucocorticoid use:
Piperacillin-tazobactam (4.5 g q6h)
OR
Imipenem (500 mg IV q6h) OR
Meropenem (1 g q8h) OR
Cefepime (2 g every eight hours) OR
Ceftazidime (2 g q8h)
PLUS

Ciprofloxacin (400 mg q8h) OR
Levofloxacin (750 mg daily)
+/-
Vancomycin per pharmacy protocol.
 

Penicillin-allergic:
Aztreonam 2 g IV q6-8h
plus
Levofloxacin (750 mg daily); OR

aztreonam plus moxifloxacin plus an aminoglycoside.
 

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 650 mg 2 tab PO/PR q4-6h prn temp >38°C or pain.

Acetaminophen (Ofirmev) IV 1000 mg every 6 hours or 650 mg every 4 hours, with a maximum single dose of of 1000 mg, a minimum dosing interval of 4 hours, and a maximum daily dose of acetaminophen of 4000 mg per day.

-Docusate sodium (Colace) 100 mg PO qhs.

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Heparin 5000 U SQ q12h or pneumatic compression stockings.
 

11. Extras: CXR PA and LAT, ECG, PPD.

12. Labs: CBC with differential, CMP, ABG. Blood C&S x 2. Induced Sputum Gram stain, C&S. Methenamine silver sputum stain (PCP); AFB smear/culture. UA, urine culture, Urine Legionella Antigen, Urine Strep Antigen, high sesitivity CRP

 
 

 

 

 










ITE 2013, Q66
A previously healthy 74-year-old male presents to the emergency department with a fever and altered mental status. His illness began 2 days ago with symptoms of fever, malaise, body aches, reduced appetite, nausea, and diarrhea. His temperature is 39.6°C (103.3°F) in the emergency department and his examination is nonfocal. Initial laboratory studies include a sodium level of 131 mEq/L (N 135–145) and a WBC count of 14,200/mm3 (N 4500–11,000) with a neutrophilic predominance. Blood and urine cultures are obtained and he is admitted to the hospital for observation.
The next morning he develops a productive cough and shortness of breath. You order a chest radiograph, which shows patchy consolidation of the bilateral bases. Which one of the following is the most likely cause of this patient’s condition?

A) Chlamydophila pneumoniae
B) Legionella pneumophila
C) Mycoplasma pneumoniae
D) Streptococcus pneumoniae