Pneumonia

Types of pneumonia

  • CAP (community-acquired pneumonia)
  • HCAP (healthcare-associated pneumonia) - occurs in non-hospitalized pts with extensive healthcare contact
    • IV therapy/wound care in past 30 days
    • At hospital or dialysis in last 30 days
    • At acute care hospital for ≥ 2 days in last 90 days
    • Nursing home/long-term care facility residence
  • HAP (hospital-acquired pneumonia) - occurred ≥ 48 hrs after admission, did not appear to be incubating at admission
    • VAP (ventilator-associated) - type of HAP developing ≥ 48-72 hrs after endotracheal intubation

Pathogens

  • Common bugs: strep. pneumo, h. flu, staph aureus, flu/viruses
  • Less common: pseudomonas, Pneumocystis, moraxella; TB, legionella, mycoplasma, chlamydophila

Clinical features suggesting MRSA pneumonia:

  • Cavitations, necrosis
  • Rapidly increasing pleural effusion
  • Gross hemoptysis
  • Concurrent flu
  • Neutropenia
  • Erythematous rash, skin pustules

CXR

Prognostication of CAP

  • CURB-65 score correlates with mortality
  • Score ≥ 1 = should hospitalize
    • Confusion
    • BUN > 19
    • RR > 30
    • BP < 90/60
    • Age ≥ 65
Outpatient CAP (s. pneumo, atypicals)
Azithromycin 500 mg PO x 1d, then 250 mg PO qd x 4d

Macrolide; covers atypical pna, but high s. pneumo resistance (20-30%)
Moxi 400 mg PO qd, OR levo 750 mg PO qd

Respiratory FQ; recommended if local macrolide resistance > 25%, or co-morbidities (see below)
Augmentin XR (1000/62.5) 2 tabs PO BID + azithro x 7d

Recommended if co-morbidities (COPD, alcoholism, CHF)
Inpatient CAP (as above + GNR)
Ceftriaxone 1g IV qd + azithro 500 mg IV/PO qd x 5-7d Can substitute ceftriaxone with ertapenem
Moxi 400 mg IV/PO qd, OR levo 750 mg IV/PO qd Pseudomonal coverage
+ vanc 15-20 mg/kg IV q8-12h cover MRSA if IVDU or influenza
HCAP, HAP, VAP (as above + MDR gram-negative)
Cefepime 2g IV q12h Antipseudomonal cephalosporin
Meropenem 1g IV q8h Carbapenem if suspect ESBL (extended spectrum beta lactamase) organisms - resistant to penicillins, ceftriaxone, cefotaxime, ceftazidime
+ levo 750 mg IV/PO qd pseudomonas + legionella coverage
+ vanc 15-20 mg/kg IV q8-12h, or linezolid 600 mg IV/PO q12h MRSA coverage (linezolid is bacteriostatic, not -cidal)
author: admin | last edited: June 11, 2018, 6:14 p.m. | pk: 97 | unpublished