DEFINITIONS:
Infection of the lower respiratory airway/lung parenchyma by a bacteria acquired in a hospital or healthcare facility. It can be classified as:
Hospital-acquired Pneumonia (HAP or Nosocomial Pneumonia): Pneumonia that develops after at least 48 hours from hospital admission.
Ventilator-associated Pneumonia (VAP): Pneumonia after 48 or more hours of intubation.
Healthcare-associated Pneumonia: Pneumonia that develops in patients that have been recently hospitalized (within 90 days), resided in a nursing home or long-term care facility or received parenteral antimicrobial therapy, chemotherapy or wound care within 30 days of presentation.
Most common agents:
Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumanii, Klebsiella pneumoniae, Escherichia coli.
SYMPTOMS:
New onset of:
- Cough
- Fever
- Malaise
- Shortness of breath
- Chest pain on inspiration
- In atypical pneumonias the patient may have: headache, ear pain, diarrhea, rash
SIGNS:
- Increased RR and HR
- Cough
- Crackles/Rales on Auscultation
- Bronchial breathing
- Egophony
- Increased tactile fremitus
- Dullness to percussion
- Reduced breath sounds or Muffled sound (Pleural effusion)
- Changes in blood work
- In severe cases: hypotension, altered mental status, signs of imminent respiratory failure
TESTS TO CONSIDER ORDERING:
- Chest X-Ray (usually consolidation in bacterial infections and diffuse infiltrates in viral infections)
- CBC, CMP, C-Reactive protein, Procalcitonin
- Arterial Blood Gases
- Blood cultures
- Sputum cultures
- Urine Antigen for Legionella and Streptococcus
- Bronchoalveolar Lavage
- If pleural effusion: Diagnostic thoracentesis (pH, GRAM stain, LDH, protein, ADA)
DIAGNOSTIC CRITERIA:
Suggestive clinical features + Infiltrate on the X-Ray.
MANAGEMENT & TREATMENT:
Assess severity and decide for inpatient or ICU care.
Check if there is risk for multidrug-resistant (MDR) organisms: Patients who have stayed in a hospital more than 5 days at the time of diagnosis; have history of prior antibiotic use; have recent hospitalization within 90 days; are admitted from health care–associated facility (nursing home, long-term care facility, dialysis center, etc) should be classified as being at risk for MDR organisms
Treatment:
MDR risk: Beta-lactam with beta-lactamase inhibitor (Piperacilin+Tazobactam 4.5g q6) OR Antipseudomonal cephalosporins (Ceftazidime 2g q8 or Cefepime 2g q8) OR Carabapenems (Meropenem 1g q8 or Imipenem 500mg q8) PLUS Fluoroquinolone (Levofloxacin 750mg daily, Ciprofloxacin 400mg daily or Moxifloxacin 400mg daily) OR Aminoglycoside (Gentamicin 7mg/kg/daily, Amikacin 20mg/kg/daily, Tobramycin 7mg/kg/daily) PLUS Vancomycin 15-20mg/kg q12 OR Linezolid 600mg q12.
No MDR risk: Cephalosporin OR Fluoroquinolone OR Ampicilin+Sulbactam OR Ertapenem
Manage septic patients according to the sepsis protocol.
DISEASES THAT MAY PRESENT WITH SIMILAR SIGNS AND SYMPTOMS:
- Viral pneumonia
- Fungal pneumonia
- Tuberculosis
- Lung vasculitis
SOURCES & REFERENCES, RESOURCES AND FURTHER READING: