Pneumonia

Background

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• 1-3 wks productive cough, often preceded by URI, may have wheezing/rhonchi
• Distinct from chronic bronchitis (>3 mos of consecutive cough x 2 consecutive yrs)
• Distinct from PNA (parenchymal consolidation, fever >100.4F, hypoxia, tachypnea)
• DDx: COVID19, post-nasal drip, GERD, undertreated/new asthma, ACE-i induced bradykinin cough, undertreated CHF, acute PE, or new lung cancer
• Typically clinical dx; CXR/labs not necessary unless PNA suspected

Management

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• Supportive: lozenges, cough suppressants (guaifenesin or dextromethorphan), smoking cessation. Consider albuterol inhaler for wheezing
• No indication for antibiotics

Background

• • • • •  
• Dx often clinical w/cough, sore throat, #sputum/nasal discharge, HA, fever, myalgias, and malaise; ± N/V/D. Exam with increased flushing, rarely with lower respiratory symptoms

Evaluation

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• During flu season: Obtain RPP or dedicated Influenza PCR in pts w/immunocompromise, acute hypoxic respiratory failure, respiratory distress, worsening of COPD, asthma, CAD/CHF; testing more accurate if obtained within 96 hour of symptom onset
• CXR if concerned for bacterial superinfection

Management

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• Antivirals most effective when given <48 hours from symptom onset; however, recommended to be given if symptomatic despite duration
• Oseltamivir 75mg BID x 5 days or peramivir 600mg IV x 1 (needs renal adjustment)
• Pain and fever: high-dose acetaminophen 1g TID are most effective; avoid aspirin, especially in children due to risk of Reye syndrome
• There is emerging resistance to amantadine and rimantadine, and are no longer employed

Background

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• All PNA that does not otherwise meet criteria for Hospital Acquired Pneumonia (PNA that develops ≥48 hours after hospital admission), Ventilator Associated Pneumonia (PNA that develops ≥48-72 hours after endotracheal intubation), or aspiration PNA
• Healthcare-associated pneumonia is no longer a clinical entity per 2016 IDSA guidelines
• MRSA Risk Factors: recent history, cavitary lesion, post-influenza bacterial PNA, pts with IDU, severe hypoxemia requiring intubation
• Pseudomonas: Double coverage is not indicated in general population; LQ has 82% sensitivity so not recommended unless isolate proven susceptible

Evaluation

• Resting pulse oximetry, ± ambulatory pulse oximetry
• Sputum cultures prior to abx, BCx prior to abx in select groups (severe pneumonia, ICU admission, cavitary disease, immunosuppression).
• Rule out flu if the right season, COVID-19, consider RVP if it will change management
• CURB-65 or PSI can aid in decision between outpatient vs inpatient therapy
  • CURB65: Confusion, Uremia (BUN >=19 mg/dL), RR (>30/min), BP(<90/60 mmHg), Age ≥ 65 If ≥ 2, hospitalization is recommended.
    • • Consider urine pneumococcal Ag, urine Legionella Ag in severe CAP and in certain pts (e.g., neutropenia, asplenia, obstructive lung disease, hyponatremia, diarrhea, or heavy alcohol use); these are performed at reference labs and will take several days to return.
      • CRP, ESR, and pro-calcitonin have not been shown to reliably improve outcomes; however, pro-calcitonin < 0.25 suggests against bacterial respiratory infection and antibiotic discontinuation is encouraged     
      • PA/ lateral CXR to evaluate for and localize infiltrate. If immunocompromised, consider CT chest w/o contrast (does not improve outcomes)
  • Lobar Consolidation - likely bacterial
  • Interstitial Infiltrate - likely atypical vs. viral vs. non-infectious
  • Cavitation - concerning for fungal vs. necrotizing vs. mycobacterial

Management

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• Duration: 5-7 days (at least 5 days and improvement with clinical stability)

*No chronic heart, lung, liver, renal disease, DM, alcoholism, immunocompromise

Additional Information

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• CTX is generally adequate coverage for aspiration PNA without evidence of abscess, empyema, or cavitary lesion on imaging
• There is low sensitivity of S. pneumoniae to azithromycin (42%) and doxycycline (72%), so these should not be used as monotherapy
• Check for DDI with Linezolid (e.g., SSRI)