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