Pneumonia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.D. [2]

Overview

The treatment of pneumonia involves three critical decisions: firstly whether the patient truly has pneumonia, secondly what is the severity of the pneumonia, and lastly whether hospitalization is required for adequate management. Most cases of pneumonia can be treated without hospitalization. Typically, oral antibiotics, rest, fluids, and home care are sufficient for complete resolution. However, people with pneumonia who are having trouble breathing, comorbidities, and the elderly may need more advanced treatment. If the symptoms get worse, the pneumonia does not improve with home treatment, or complications occur, the person will often have to be hospitalized.

Medical Therapy

General Considerations

• The treatment of pneumonia involves three critical decisions: firstly whether the patient truly has pneumonia, secondly what is the severity of the pneumonia, and lastly whether hospitalization is required for adequate management.
• Treatment for pneumonia should ideally be based on the causative microorganism and its known antibiotic sensitivity. However, a specific cause for pneumonia is identified in only 50% of people, even after extensive evaluation.
• Since treatment should generally not be delayed in any person with a serious pneumonia, empiric treatment is usually started well before laboratory reports are available. In both cases, a person's risk factors for different organisms must be remembered when choosing the initial antibiotics (called empiric therapy).
• In general, all therapies in older children and adults will include treatment for atypical bacteria. Typically this is a macrolide antibiotic such as azithromycin or clarithromycin although a fluoroquinolone such as levofloxacin can substitute.
• Multiple antibiotics may be administered in combination in an attempt to treat all of the possible causative microorganisms. Antibiotic choices vary from hospital to hospital because of regional differences in the most likely microorganisms and because of differences in the microorganisms' abilities to resist various antibiotic treatments.
• Treatment of viral pneumonia caused by influenza is beneficial only if they are started within 48 hours of the onset of symptoms.
• Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine.
• There are no known effective treatments for viral pneumonias caused by the SARS coronavirus, adenovirus, hantavirus, or parainfluenza virus.
• Most newborn infants with CAP are hospitalized and given intravenous ampicillin and gentamicin for at least ten days. This treats the common bacteria streptococcus agalactiae, listeria monocytogenes, and escherichia coli. If herpes simplex virus is the cause, intravenous acyclovir is administered for 21 days.
• Treatment of CAP in children depends on both the age of the child and the severity of his/her illness. Children less than five do not typically receive treatment to cover atypical bacteria. If a child does not need to be hospitalized, amoxicillin for seven days is a common treatment. However, with increasing prevalence of DRSP, other agents such as cefpodoxime will most likely become more popular in the future. Hospitalized children should receive intravenous ampicillin, ceftriaxone, or cefotaxime.
• Fungal pneumonia can be treated with antifungal drugs and sometimes by surgical debridement.
• Antibiotics are used to treat bacterial pneumonia. In contrast, antibiotics are not useful for viral pneumonia, although they sometimes are used to treat or prevent bacterial infections that can occur in the lungs that are damaged by a viral pneumonia. The antibiotic choice depends on:
  • Nature of the pneumonia
  • Microorganisms endemic to a local geographic area
  • Immune status
  • Underlying health of the individual

Infectious Diseases Society of America/American Thoracic Society consensus recommendation criteria for severe community acquired pneumonia in adults. (DO NOT EDIT)

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Minor Criteria Respiratory rate >30 breaths/min PaO2/FiO2 ratio <250 Multilobar infiltrates Confusion/disorientation Uremia (BUN level, >20 mg/dL) Leukopenia (WBC count, <4000 cells/mm3) Thrombocytopenia (platelet count, < 100,000 cells/mm3) Hypothermia (core temperature, <36 degrees C) Hypotension requiring aggressive fluid resuscitation Major criteria Invasive mechanical ventilation Septic shock with the need for vasopressors

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Infectious Diseases Society of America/American Thoracic Society consensus recommendation on site of care for community-acquired pneumonia in adults. (DO NOT EDIT)

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Hospital Admission Decision Severity-of-illness scores, such as the CURB-65 criteria (confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater), or prognostic models, such as the Pneumonia Severity Index (PSI), can be used to identify patients with CAP who may be candidates for outpatient treatment. (Strong recommendation; level I evidence) Objective criteria or scores should always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. (Strong recommendation; level II evidence) For patients with CURB-65 scores >2, more-intensive treatment—that is, hospitalization or, where appropriate and available, intensive in-home health care services—is usually warranted. (Moderate recommendation; level III evidence) Intensive Care Unit (ICU) Admission Decision Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation. (Strong recommendation; level II evidence) Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed in the Table below. (Moderate recommendation; level II evidence)

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For Level of evidence classification click here.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Empiric Antibiotic Treatment of community-acquired pneumonia in adults. (DO NOT EDIT)

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Previously Healthy and No Risk Factors for Drug-resistant Streptococcus Pneumoniae A macrolide (azithromycin, clarithromycin, or erythromycin (Strong recommendation; level I evidence) Doxycycline (Weak recommendation; level III evidence) Presence of Comorbidities or Other Risks for Drug-resistant Streptococcus Pneumoniae Presence of comorbidities, such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected); or other risks for DRSP infection: A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) (Strong recommendation; level I evidence) A beta-lactam plus a macrolide (Strong recommendation; level I evidence) (High-dose amoxicillin [e.g., 1 g 3 times daily] or amoxicillin-clavulanate [2 g 2 times daily] is preferred; alternatives include ceftriaxone, cefpodoxime, and cefuroxime [500 mg 2 times daily]; doxycycline (level II evidence) is an alternative to the macrolide.) In Regions with a High Rate (>25%) of Infection In regions with a high rate (>25%) of infection with high-level (minimal inhibitory concentration [MIC], >16 micrograms/mL) macrolide-resistant S. pneumoniae, consider the use of alternative agents for any patient, including those without comorbidities. (Moderate recommendation; level III evidence) Inpatient, Non-ICU Treatment The following regimens are recommended for hospital ward treatment. A respiratory fluoroquinolone (Strong recommendation; level I evidence) A beta-lactam plus a macrolide (Strong recommendation; level I evidence) (Preferred beta-lactam agents include cefotaxime, ceftriaxone, and ampicillin; ertapenem for selected patients; with doxycycline (level III evidence) as an alternative to the macrolide. A respiratory fluoroquinolone should be used for penicillin-allergic patients.) Inpatient, ICU Treatment The following regimen is the minimal recommended treatment for patients admitted to the ICU. A beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin (level II evidence) or a fluoroquinolone (Strong recommendation; level I evidence) (For penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended.) For Pseudomonas infection, use an antipneumococcal, antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750-mg dose) or the above beta-lactam plus an aminoglycoside and azithromycin or the above beta-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for the above beta-lactam). (Moderate recommendation; level III evidence) For community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) infection, add vancomycin or linezolid. (Moderate recommendation; level III evidence)

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For Level of evidence classification click here.

Infectious Diseases Society of America/American Thoracic Society consensus recommendation on pandemic Influenza community-acquired pneumonia in adults. (DO NOT EDIT)

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Pathogen-Directed Therapy Once the etiology of CAP has been identified on the basis of reliable microbiological methods, antimicrobial therapy should be directed at that pathogen (Moderate recommendation; level III evidence) Early treatment (within 48 h of the onset of symptoms) with oseltamivir or zanamivir is recommended for influenza A. (Strong recommendation; level I evidence) Use of oseltamivir and zanamivir is not recommended for patients with uncomplicated influenza with symptoms for >48 h (level I evidence), but these drugs may be used to reduce viral shedding in hospitalized patients or for influenza pneumonia. (Moderate recommendation; level III evidence) Pandemic Influenza Patients with an illness compatible with influenza and with known exposure to poultry in areas with previous H5N1 infection should be tested for H5N1 infection. (Moderate recommendation; level III evidence) In patients with suspected H5N1 infection, droplet precautions and careful routine infection control measures should be used until an H5N1 infection is ruled out. (Moderate recommendation; level III evidence) Patients with suspected H5N1 infection should be treated with oseltamivir (level II evidence) and antibacterial agents targeting S. pneumoniae and S. aureus, the most common causes of secondary bacterial pneumonia in patients with influenza. (Moderate recommendation; level III evidence)

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For Level of evidence classification click here.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Time, Route, and Duration of Community-acquired Pneumonia in Adults. (DO NOT EDIT)

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Time to First Antibiotic Dose For patients admitted through the emergency department (ED), the first antibiotic dose should be administered while still in the ED. (Moderate recommendation; level III evidence) Switch from Intravenous to Oral Therapy Patients should be switched from intravenous to oral therapy when they are hemodynamically stable and improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. (Strong recommendation; level II evidence). Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care. Inpatient observation while receiving oral therapy is not necessary. (Moderate recommendation; level II evidence) Duration of Antibiotic Therapy Patients with CAP should be treated for a minimum of 5 days (level I evidence), should be afebrile for 48 to 72 h, and should have no more than 1 CAP-associated sign of clinical instability before discontinuation of therapy. (level II evidence) (Moderate recommendation) A longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis. (Weak recommendation; level III evidence)

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For Level of evidence and classes click here.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on other Treatments Considerations for Acquired Pneumonia in adults. (DO NOT EDIT)

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This recommendation has been removed due to the market withdrawal of drotrecogin alfa. Hypotensive, fluid-resuscitated patients with severe CAP should be screened for occult adrenal insufficiency. (Moderate recommendation; level II evidence) Patients with hypoxemia or respiratory distress should receive a cautious trial of noninvasive ventilation (NIV) unless they require immediate intubation because of severe hypoxemia (arterial oxygen pressure/fraction of inspired oxygen [PaO2/FiO2] ratio <150) and bilateral alveolar infiltrates. (Moderate recommendation; level I evidence) Low-tidal-volume ventilation (6 cm3/kg of ideal body weight) should be used for patients undergoing ventilation who have diffuse bilateral pneumonia or acute respiratory distress syndrome. (Strong recommendation; level I evidence)

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For Level of evidence and classes click here.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Non Responding Acquired Pneumonia in Adults. (DO NOT EDIT)

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Because of the limitations of diagnostic testing, the majority of CAP is still treated empirically. Critical to empirical therapy is an understanding of the management of patients who do not follow the normal response pattern.

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For Level of evidence and classes click here.