Pneumonia

Outpatient

Question 8: In the Outpatient Setting, Which Antibiotics Are Recommended for Empiric Treatment of CAP in Adults? (no comorbidities)

- amoxicillin 1 g TID (strong recommendation, moderate quality of evidence)

- doxycycline 100 mg BID (conditional recommendation, low quality of evidence)

- macrolide (azithromycin 500 mg on first day then 250 mg daily or clarithromycin 500 mg BIDor clarithromycin extended release 1,000 mg daily) if local pneumococcal resistance < 25% (conditional recommendation, moderate quality of evidence).

For outpatient adults with comorbidities such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia we recommend (in no particular order of

preference) (Table 3):

Combination therapy:

- amoxicillin/clavulanate 500 mg/125 mg TID

- amoxicillin/ clavulanate 875 mg/125 mg BID

- amoxicillin/ clavulanate 2,000 mg/125 mg BID

- cephalosporin (cefpodoxime 200 mg BID or cefuroxime 500 mg BID)

 AND 

- macrolide (azithromycin 500 mg on first day then 250 mg daily, clarithromycin [500 mg twice daily or extended release 1,000 mg once daily]) (strong recommendation, moderate quality of evidence for combination therapy), or doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence for combination therapy); 

OR

Monotherapy:

respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily, or gemifloxacin 320 mg daily) (strong recommendation, moderate quality of evidence).

Inpatient

Question 9: In the Inpatient Setting, Which Antibiotic Regimens Are Recommended for Empiric Treatment of CAP in Adults without Risk Factors for MRSA and P. aeruginosa?

combination therapy with a 

b-lactam

- ampicillin 1 sulbactam 1.5–3 g every 6 h

- cefotaxime 1–2 g every 8 h, ceftriaxone 1–2 g daily, or ceftaroline 600 mg every 12 h)

AND

macrolide

- azithromycin 500 mg daily

- clarithromycin 500 mg twice daily) (strong recommendation, high quality of evidence)

OR

monotherapy with a respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily) (strong recommendation, high quality of evidence)

Third Option if CI to macrolide and fluoroquinolone

combination therapy with a b-lactam (ampicillin 1 sulbactam, cefotaxime, ceftaroline, or ceftriaxone, doses as above) and doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence).

Question 10: In the Inpatient Setting, Should Patients with Suspected Aspiration Pneumonia Receive Additional Anaerobic Coverage beyond Standard Empiric Treatment for CAP?

Recommendation. We suggest not routinely adding anaerobic coverage for suspected aspiration pneumonia unless lung abscess or empyema is suspected (conditional

recommendation, very low quality of evidence).

Question 11: In the Inpatient Setting, Should Adults with CAP and Risk Factors for MRSA or P. aeruginosa Be Treated with Extended-Spectrum Antibiotic Therapy Instead of Standard CAP Regimens?

Empiric treatment options for P. aeruginosa include piperacillin-tazobactam (4.5 g every 6 h),

cefepime (2 g every 8 h), ceftazidime (2 g every 8 h), aztreonam (2 g every 8 h), meropenem (1 g every 8 h), or imipenem (500 mg every 6 h).

ertapenem no coverage against pseudomonas

Aztreonam monobactam no coverage against gram positives

How to distinguish breath sounds/percussion/fremitus from physical exam findings in lung pathology:

{{c1::BreC PA FreC - breath sounds decreased in everything except consolidation (lobar pneumonia, pulmonary edema), percussion hyperresonant when air increases (pneumothorax, asthma, COPD), fremitus decreased in everything except consolidation}}

BreC FreC PA

breath sounds - consolidation has bronchial breath sounds, late inspiratory crackles, egophony, whispered pectoriloquy
percussion - dull when air decreases (atelectasis, everything else like pleural effusion, consolidations)
fremitus - sound travels better in solids than in air (so hears better in consolidation than normal lung air)

Community-acquired pneumonia (CAP) UpToDate risk factors:

{{c1::COVID MISSESS Home - Chronic (COPD/CHF/CF/bronchiectasis), Old age (65+), Viral URI, Immunosuppression (DM/HIV), Drugs (smoke/alcohol/opioid), Meds (Immunomodulators, Sedatives, acid Suppressants - histamine/cholinergic inhibitors HIGH YIELD bc inc dryness/microaspirations), Esophageal dysmotility, Seizures/Stroke, Home (prisons/homeless/low income)}}

{{c1::Active smoking}} increases the risk of postoperative pulmonary complications (eg, pneumonia, respiratory failure requiring mechanical ventilation), especially in patients with underlying lung disease (eg, chronic obstructive pulmonary disease)

Recurrent pneumonia occurring in the same anatomic location of the lung raises suspicion for {{c1::localized airway obstruction}}

V/Q mismatch increased vs decreased etiologies:

{{c1::Dead PECS vs ShuntAAA - dead space/PE/CS (also emphysema and interstitial lung disease) vs shunt/pneumoniA/pulmonary edemA/Aspiration}}

Pneumocystis pneumonia diagnosis and treatment:

{{c1::induced sputum/bronchoalveolar lavage -> TMP-SMX and corticosteroids (IF pulse ox<92%, PaO₂ 70- mmHg, or A-a gradient 35+ mmHg) vs clinda/primaquine (sulfa allergy)}}

ATS Pneumonia Guideliens

https://drive.google.com/file/d/1QS1j-6rEPVYtSq5xQtk1ekzQvQxHc8py/view?usp=sharing MRSA Procal Aspiration Pneumonia URI HAP CAP PNA