While community acquired pneumonia (CAP) is ‘bread and butter’ emergency medicine, and the diagnosis is often a ‘slam dunk’, it turns out that up one third of the time, we are wrong about the diagnosis; that x-rays are not perfect; that blood work is seldom helpful; that not all antibiotics are created equal and that deciding who can go home and who needs to go to the ICU isn’t always so clear cut
When using initial empiric therapy for sCAP, should a macrolide or fluoroquinolone be used as part of combination therapy, to reduce mortality and adverse clinical outcomes?
Recommendation: We SUGGEST the addition of macrolides, not fluoroquinolones, to beta-lactams as empirical antibiotic therapy in hospitalized patients with sCAP. These are the first published guidelines for patients with sCAP. There are other published guidelines in the literature; however, the present document aims to focus on the most severe spectrum of the patients with CAP.
Piperacillin-tazobactam 4.5g IV every 6 hours or Cefepime 2g IV every 8 hours or Levofloxacin 750mg IV daily or Imipenem 500mg IV every 6 hours -OR- Meropenem 1g IV every 8 hours.
Healthy patients can receive either amoxicillin 1g TID, doxycycline 100mg BID, or azithromycin 500mg followed by 250mg daily x 4 doses. Patients with comorbidities such as chronic heart, lung, liver, or renal disease, diabetes, alcoholism, malignancy, or asplenia should receive combination therapy with a beta-lactam (amoxicillin/clavulanate, cefdinir, or cefpodoxime) + azithromycin or doxycycline. If allergies preclude the use of a beta-lactam, a fluoroquinolone (levofloxacin or moxifloxacin) can be used. Patient admitted for non-severe CAP can receive combination beta-lactam (ampicillin/sulbactam, or ceftriaxone) and azithromycin therapy. Patients with severe beta-lactam allergies can receive either levofloxacin or moxifloxacin).
Penicillin works well! Most children, even ones who require hospitalization, will benefit from a narrow spectrum penicillin.
Atypical presentations - Patients can present with a host of “non-classic”
Symptoms including; myalgia, abdominal pain, back pain, headache or dizziness. Elderly patients are more likely to present atypically and often possess fewer of the cardinal symptoms. Confusion may be the only presenting complaint.
In all pediatric age groups excluding neonates, viral pathogens are the most common etiology of pneumonia, with S. pneumoniae as the most common typical bacterial pathogen. M. pneumoniae detection increases with increasing age, particularly in children 5 years and older. Treatment for presumed bacterial pneumonia should begin with narrow-spectrum beta-lactams but broadening to third-generation cephalosporins may be appropriate in certain situation...
As recommendations for the diagnosis, treatment, and disposition of patients with community-acquired pneumonia continue to evolve, this issue reviews the current evidence and guidelines for managing these patients in the emergency department.
Community acquired pneumonia is common, as it is responsible for 60,000 hospitalizations per year. Causes of pneumonia include bacteria (most common), viruses, and fungi. However, a microbial agent is never identified in over 50% of patients with pneumonia. Typical agents include S. pneumoniae and H. influenza, with S. pneumo being the most common. “Atypical” pathogens include Legionella, Mycoplasma, and Chlamydia. Viral causes include influenza, parainfluenza, coronavirus, and many others.
The most commonly used antibiotics for CAP are azithromycin, beta-lactams, and respiratory fluoroquinolones (levofloxacin and moxifloxacin). These drugs have different effects on inflammation...
The most commonly used antibiotics for CAP are azithromycin, beta-lactams, and respiratory fluoroquinolones (levofloxacin and moxifloxacin). These drugs have different effects on inflammation.
The challenge for the emergency clinician is identifying the children who are more likely to have bacterial CAP and will benefit from antibiotic therapy while avoiding unnecessary testing and treatment in the majority of children who will have viral etiologies.
Let’s not muck around — here are 8 Q-and-As to test whether you’re a (wo)man or an amoeba when it comes to childhood pneumonia…
Viral pneumonias classically show perihilar bronchial thickening, interstitial opacities and hyperinflation. Bacterial pneumonias classically cause lobar consolidation.
Usually azithromycin ???? 500 mg IV daily x3 days. (Azithromycin is safe regardless of QTc and can be used in nearly all patients.).
Prescribe 3–5 days of antibiotic therapy In children ≥6 months of age with CAP from high-income countries who are stable for outpatient management.
Ironically, the advantages of fluoroquinolones have also been their Achilles' heel (no pun intended). Fluoroquinolones are the #1 most commonly used antibiotics among outpatient prescribers, administered broadly for anything from diverticulitis to the common cold.
I typically prescribe a beta-lactam (amoxicillin 500 mg Q6 X 7 days) + a macrolide (azithromycin 500 mg X 1 followed by 250 mg Q24 X 4 days). This combination is likely to cover both S. pneumoniae and the atypicals.
Rick Pescatore (Southern New Jersey) and Jenny Beck-Esmay (NYC) suggested that we can replace the amoxicillin with cefdinir 300 mg BID X 7 days.
Let's be honest, our decisions to cover MRSA among patients admitted to the hospital with pneumonia are haphazard. It's not our fault. The guidelines are contradictory.
To aid diagnostic accuracy and avoid over prescribing antibiotics, force yourself to consider the diagnosic criteria for CAP: fever, respiratory symptoms and imaging evidence of an infiltrate. Pay close attention to respiratory rate and oxygen saturation – the vast majority of patients with CAP will have an elevated respiratory rate.
Inpatient, non-ICU Treatment - Respiratory fluoroquinolone OR Anti-pneumococcal beta-lactam PLUS a macrolide.