Pneumonia Management in Children

Aka: Pneumonia Management in Children

Pulmonology
Pediatrics Chapter

 Sleep Apnea Disorders

 Obstructive Sleep Apnea in Children

 Bronchial Disorders
 Respiratory Syncytial Virus

 CF
 Cystic Fibrosis

 Infectious Disease
 Pneumonia in Children
 Pneumonia Management in Children

 Symptoms
 Pediatric Acute Cough
 Acute Cough Triage in Children
 Chronic Cough in Children
 Chronic Cough Causes in Children
 Habit Cough in Children

 Tuberculosis
 Tuberculosis Screening in Children

From Related Chapters

 Airway Disorders
 Pediatric Obstructed Airway Causes

 Examination
 Clinical Severity Scoring System Tool
 Respiratory Distress in Children with Pneumonia

 Pathology and Laboratory Medicine

 Delta F508
 Sweat Chloride

 Obstetrics
 Cystic Fibrosis in Pregnancy

 See Also
 Page Contents

 Pneumonia
 Pneumonia in Children
 Pneumonia Causes in Children
 Pneumonia Management
 Pneumonia
 Respiratory Distress in Children with Pneumonia
 Pediatric Early Warning Score
 PEWS Score

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II. Management: General

A. See Pneumonia Management

B. See age directed management below

III. Indications: Hospitalization

A. Respiratory distress (Apnea, grunting, nasal flaring)

1. See Respiratory Distress in Children with Pneumonia
2. See Pediatric Early Warning Score (PEWS Score)
B. Hypoxemia (<90% Oxygen Saturation) or Cyanosis
C. Virulent pathogen suspected (e.g. MRSA)
D. All infants under age 4 months (consider in children under 6 months)
E. Toxic appearance
F. Dehydration with Vomiting or poor oral intake
G. Immunocompromised patient
H. Pneumonia refractory to oral antibiotics
I. Unreliable home environment
J. (2002) Thorax 57:i1-24 [PubMed]

IV. Indications: PICU admission

A. Mechanical Ventilation or CPAP

B. Impending respiratory failure
C. Shock state
D. Pulse Oximetry <92% despite Supplemental Oxygen with FIO2 50% or higher
E. Altered Mental Status

V. Management: Newborn (under 3 weeks old)

A. Admit all newborns with Pneumonia

B. Antibiotic regimen (Use 2-3 antibiotics combined)
1. Antibiotic 1: Ampicillin
a. Age <7 days
i. Weight <2 kg: 50-100 mg/kg divided q12 hours
ii. Weight >2 kg: 75-150 mg/kg divided q8 hours
b. Age >7 days
i. Weight <1.2 kg: 50-100 mg/kg divided q12 hours
ii. Weight 1.2-2 kg: 75-150 mg/kg divided q8 hours
iii. Weight >2 kg: 100-200 mg/kg divided q6 hours
2. Antibiotic 2: Gentamicin (dosing below if >37 weeks)
a. Age <7 days
i. Weight <2 kg: 2.5 mg/kg IV every 18 to 24 hours
ii. Weight >2 kg: 2.5 mg/kg IV every 12 hours
 b. Age >7 days
i. Dose: 2.5 mg/kg IV every 12 hours
3. Antibiotic 3: Cefotaxime (optional)
a. Age <7 days: 50 mg/kg IV every 12 hours
b. Age >7 days: 50 mg/kg IV every 8 hours
C. Organisms requiring additional antibiotic coverage
1. Methicillin Resistant Staphylococcus Aureus (MRSA): Choose 1
a. Vancomycin
i. Age <7 days
1. Weight <2 kg: 12.5 mg/kg IV every 12 hours
2. Weight >2 kg: 15 mg/kg IV every 12 hours
ii. Age >7 days
1. Weight <2 kg: 18 mg/kg IV every 12 hours
2. Weight >2 kg: 22 mg/kg IV every 12 hours
b. Linezolid
i. Dose: 10 mg/kg every 8 hours
2. Chlamydia trachomatis
a. Erythromycin 12.5 mg/kg orally or IV every 6 hours for 14 days

VI. Management: Age 3 weeks to 3 months

A. Precautions
1. Erythromycin is associated with increased risk of Hypertrophic Pyloric Stenosis in infants under
6 weeks of age
2. No empiric therapy is needed for Staphylococcus aureus coverage as this rarely occurs in this
age group
B. Outpatient (if affebrile without respiratory distress)
1. Azithromycin 10 mg/kg (max 500 mg) orally on day 1 then 5 mg/kg (max 250 mg) orally on days
2 to 5 or
2. Erythromycin 12.5 mg/kg orally every 6 hours for 14 days
C. Inpatient (if febrile or hypoxic)
1. Macrolide
a. Azithromycin 10 mg/kg (max 500 mg) IV on day 1 then 5 mg/kg (max 250 mg) IV on
days 2 to 5 or
b. Erythromycin 10 mg/kg IV every 6 hours
2. Febrile
a. Add Cefotaxime 50 mg/kg IV every 8 hours
3. Lobar Pneumonia (presumed Streptococcus Pneumoniae)
a. Add Ampicillin 50-75 mg/kg IV every 6 hours

VII. Management: Age 3 months to 5 years (outpatient)

A. See inpatient antibiotic selection below

B. Precautions
1. Viral Pneumonia (esp. Influenza, RSV) predominates in preschool children
a. Most common in under age 2 years old
b. Viral PneumoniaIncidence decreases with age
2. Empiric antibiotic therapy is not recommended unless Bacterial Pneumonia is suspected
a. Coverage below first addresses Streptococcus Pneumoniae coverage
b. Streptococcus Pneumoniae has increasing resistance to Macrolide antibiotics
(e.g. Azithromycin)
3. May treat as outpatient if patient affebrile without respiratory distress
C. First-line oral agent for presumed Bacterial cause (choose one)
1. Amoxicillin (preferred)
a. Dose: 45 mg/kg/day orally divided every 12 hours for 5 days
b. Hazir (2008) Lancet 371(9606): 49-56 [PubMed]
2. Augmentin (alternative)
 a. Dose: 45 mg/kg every 12 hours
D. Presumed Atypical Pneumonia (choose one)
1. Azithromycin
a. Dose: 10 mg/kg (max 500 mg) orally on day 1 then 5 mg/kg (max 250 mg) orally on
days 2 to 5
2. Clarithromycin
a. Dose: 7.5 mg/kg twice daily for 7 to 14 days
3. Erythromycin
a. Dose: 10 mg/kg orally four times daily
E. Consider initial parenteral antibiotic at diagnosis
1. See inpatient antibiotic regimen below
2. Start oral antibiotics concurrently as below
F. Influenza suspected
1. Oseltamavir (Tamiflu)

VIII. Management: Age 5 to 18 years (outpatient)

A. See inpatient antibiotic selection below

B. Approach
1. Choose an agent based on typical versus atypical Bacterial cause suspected
2. In more severe cases, or in which typical can not be distinguished from each other
a. Choose an antibiotic from each category (one from typical, one from atypical)
C. Typical Bacterial Pneumonia (i.e. Streptococcus Pneumoniae): Choose one
1. Amoxicillin (preferred)
a. Dose: 45 mg/kg/day orally divided every 12 hours for 5 days
b. Hazir (2008) Lancet 371(9606): 49-56 [PubMed]
2. Augmentin (alternative)
a. Dose: 45 mg/kg every 12 hours
D. Presumed Atypical Bacterial Pneumonia: Choose one
1. Azithromycin
a. Dose: 10 mg/kg (max 500 mg) orally on day 1 then 5 mg/kg (max 250 mg) orally on
days 2 to 5
2. Clarithromycin
a. Dose: 7.5 mg/kg twice daily for 7 to 14 days
3. Erythromycin
a. Dose: 10 mg/kg orally four times daily
4. Doxycycline (use only if over age 8 years)
a. Dose: 100 mg orally every 12 hours
E. Consider initial parenteral antibiotic at diagnosis
1. See inpatient antibiotic regimen below
2. Start oral antibiotics concurrently as below
F. Influenza suspected
1. Oseltamavir (Tamiflu) or
2. Zanamavir
a. Indicated only for children 7 years or older

IX. Management: Age 3 months to 18 years (inpatient, parenteral)

A. See outpatient antibiotics above

B. Primary Antibiotic (choose one)
1. Fully immunized and not life-threatening infection
a. Ampicillin 12.5 mg/kg IV every 6 hours (preferred)
2. Not fully immunized against S. Pneumoniae and H. Influenzae or life-threatening infection
a. Cefotaxime 50 mg/kg IV every 8 hours or
b. Ceftriaxone 50 to 100 mg/kg/day up to 1-2 g/day divided every 12 to 24 hours
C. Atypical Pneumonia suspected (choose one)
 1.
Add Azithromycin 10 mg/kg (max 500 mg) IV on day 1 then 5 mg/kg (max 250 mg) IV on days 2
to 5 or
2. Add Erythromycin 40 mg/kg/day IV divided q6 hours or
3. Add Clarithromycin 7.5 mg/kg twice daily for 7 to 14 days
D. MRSA suspected (choose one)
1. Add Vancomycin 14 to 20 mg/kg IV every 8 hours or
2. Add Linezolid (Zyvox) 10 mg/kg IV/PO every 8h or if >12 yo, 600 mg PO/IV twice daily
3. Add Clindamycin 14 mg/kg IV every 8 hours or
a. If patient stable without bacteremia and Clindamycin resistance <10%

X. Management: Adjunctive measures

A. Zinc supplementation in critically ill children with Pneumonia

1. Zinc supplementation associated with decreased mortality, shorter hospitalizations and fewer
treatment failures
2. Greatest benefit appears to be in developing countries where Zinc Deficiency occurs frequently
(30% of world population)
3. Basnet (2012) Pediatrics 129(4): 701-8 [PubMed]
4. Srinivasan (2012) BMC Med 10: 14 [PubMed]

XI. References

A. Gilbert (2011) Sanford Guide to Antimicrobial Therapy

B. Bradley (2011) Clin Infect Dis 53(7): e1-52 [PubMed]
C. McIntosh (2002) N Engl J Med 346:429-37 [PubMed]
D. Nelson (2000) Pediatr Infect Dis 19:251-3 [PubMed]
E. Ostapchuk (2004) Am Fam Physician 70(5):899-908 [PubMed]
F. Stuckey-Schrock (2012) Am Fam Physician 86(7): 661-7 [PubMed]

II. Epidemiology

A. Adults: 346 Israeli patients admitted for Pneumonia

1. Pneumococcal Pneumonia (43%)
2. Mycoplasma pneumonia (29%)
3. Chlamydia pneumoniae (18%)
4. Legionella pneumonia (16%)
B. References
1. Lieberman (1996) Chest 109:1243-9 [PubMed]

III. Causes: Viral Pneumonia

A. Common viral causes

1. Influenza A
2. Influenza B
3. Parainfluenza Virus
4. Respiratory Syncytial Virus
5. Adenovirus
B. Other viral causes
1. Rubeola
2. Herpes Simplex Virus
3. Varicella Zoster Virus
4. Cytomegalovirus

IV. Causes: Bacterial Pneumonia

 A. Typical Bacterial Pneumonia causees
1. Pneumococcal Pneumonia
2. Haemophilus Influenzae Pneumonia
3. Moraxella pneumonia
4. Staphylococcal Pneumonia
B. Atypical Bacterial Pneumonia Causes
1. Mycoplasma pneumonia
2. Legionella pneumonia
3. Chlamydia Pneumonia
4. Q Fever
5. Psittacosis

V. Causes: Fungal Pneumonia

A. Blastomycosis
B. Coccidioidomycosis
C. Histoplasmosis

VI. Causes: Newborn (birth to 3 weeks)

A. General
1. Vertical transmission from mother at birth
B. Virus (See Viral Pneumonia)
1. Cytomegalovirus (CMV)
2. Rubella
3. Herpes Simplex Virus (HSV)
C. Bacteria (See Bacterial Pneumonia)
1. Group B Streptococcus (common)
2. Listeria monocytogenes (common)
3. Escherichia coli (common)
4. Group D Streptococcus
5. HaemophilusInfluenzae
6. Streptococcus Pneumoniae
7. Ureaplasma urealyticum

VII. Causes: Age 3 weeks to 3 months

A. Virus (See Viral Pneumonia)

1. Respiratory Syncytial Virus (common)
2. Parainfluenza Virus 1-3 (common)
3. Influenza Virus (common)
4. Adenovirus (common)
5. Cytomegalovirus
B. Bacteria (See Bacterial Pneumonia)
1. Streptococcus Pneumoniae (most common Bacteria)
2. Chlamydia trachomatis (common)
3. Bordetella pertussis
4. HaemophilusInfluenzae type B
5. Moraxella catarrhalis
6. Staphylococcus aureus
7. Ureaplasma urealyticum

VIII. Causes: Age 4 months to 5 years

 A. Mixed viral and Bacterial community acquired Pneumonia may account for 30-50% of cases in children
B. Virus (See Viral Pneumonia)
1. Respiratory Syncytial Virus (common)
2. Parainfluenza Virus Types 1-3 (common)
3. Adenovirus
a. Most common cause of Conjunctivitis
4. Human Metapneumovirus (common)
a. Similar presentation to RSV
5. Influenza Virus Type A (common) and Type B
6. Rhinovirus
7. Varicella Zoster Virus
C. Bacteria (See Bacterial Pneumonia)
1. Streptococcus Pneumoniae (common)
2. Chlamydia pneumoniae (common)
3. Mycoplasma pneumoniae (common)
4. HaemophilusInfluenzae Type B
5. Moraxella catarrhalis
6. Staphylococcus aureus
7. Mycobacterium tuberculosis
8. Neisseria Meningitis

IX. Causes: Ages 5 to 18 years

A. Virus
1. Adenovirus
2. Epstein-Barr Virus
3. Parainfluenza Virus
4. Adenovirus
a. Most common cause of Conjunctivitis
5. Influenza Virus
6. Rhinovirus
7. Respiratory Syncytial Virus
8. Varicella Zoster Virus
B. Bacteria (See Bacterial Pneumonia)
1. Streptococcus Pneumoniae (common)
a. Invasive disease is less common with Prevnar (but still increased risk in day care
attendance)
b. Penicillin Resistant Pneumococcus is more common with antibiotics in the prior 60
days
2. Staphylococcus aureus
a. MRSA Pneumonia is increasing in Incidence with higher morbidity and mortality
3. Atypical Pneumonia
a. Mycoplasma pneumonia (common)
b. Chlamydia pneumoniae (common)

X. Causes: Age 18 to 65 years (no comorbidity)

A. Virus (See Viral Pneumonia)

1. Parainfluenza Virus
2. Adenovirus (Most common cause of Conjunctivitis)
3. Influenza Virus
B. Bacteria (See Bacterial Pneumonia)
1. Streptococcus Pneumoniae
a. Middle aged patients
b. Super-infection of post-viral Bronchitis
2. Atypical Pneumonia
a. Mycoplasma pneumonia (young patients)
 b. Chlamydia pneumoniae

XI. Causes: Age over 65 years (no comorbidity)

A. Virus: See Viral Pneumonia

B. Bacteria: Most common (See Bacterial Pneumonia)
1. Streptococcus Pneumoniae
2. Respiratory viruses
3. HaemophilusInfluenzae
4. Gram Negative Bacilli
5. Staphylococcus aureus
C. Bacteria: Less common (See Bacterial Pneumonia)
1. Moraxella catarrhalis
2. Legionella pneumonia (Atypical Pneumonia)

XII. Causes: Patients with chemical addiction

A. Tobacco abuse
1. Streptococcus Pneumoniae
2. HaemophilusInfluenzae
3. Moraxella catarrhalis
4. Legionella pneumonia (Atypical Pneumonia)
B. Alcohol Abuse (See also Aspiration Pneumonia)
1. Streptococcus Pneumoniae
2. Anaerobic Bacteria
3. Coliform Bacteria (e.g. KlebsiellaPneumonia)
4. Mycobacterium tuberculosis
C. Intravenous Drug Abuse
1. Staphylococcus aureus
2. Streptococcus Pneumoniae
3. Mycobacterium tuberculosis
4. Anaerobic Bacteria

XIII. Causes: Patients with chronic disease

A. Chronic Obstructive Pulmonary Disease

1. Streptococcus Pneumoniae
2. Haemophilus Influenzae
3. Moraxella catarrhalis
4. Legionella pneumonia
5. Chlamydophila pneumoniae
6. Pseudomonas aeruginosa
7. Gram-negative rods
B. Cystic Fibrosis
1. Early disease: Staphylococcus aureus
2. Later disease: Pseudomonas aeruginosa
C. HIV
1. See Pulmonary manifestations of HIV
2. Early HIV
a. Mycobacterium tuberculosis
b. Haemophilus Influenzae Pneumonia
c. Pneumococcal Pneumonia
3. Late HIV or AIDS
a. Aspergillus
b. Cryptococcal Pneumonia
 c. Histoplasma capsulatum
d. Haemophilus Influenzae Pneumonia
e. Nocardia
f. Nontuberculous Mycobacteria
g. Pneumocystis jiroveci

XIV. Causes: Animal Exposure

A. Bat exposure: Histoplasma capsulatum

B. Bird Exposure: Psittacosis, Histoplasma capsulatum
C. Rabbit Exposure: Tularemia
D. Livestock or cats: Coxiella burnetii (Q Fever)

XV. Causes: Bioterrorism

A. Bacillus anthracis (Anthrax)

B. Francisella tularensis (Tularemia)
C. Yersinia pestis (Plague)

XVI. Causes: Chronic or refractory Pneumonia

A. Mycobacterium tuberculosis
B. Coccidioidomycosis
C. Histoplasmosis

XVII. Causes: Travel

A. Hotel or cruise ship

1. Legionella
B. Middle East:
1. Middle East Respiratory Syndrome
C. Southeast or East Asia
1. Avian Influenza
2. Severe Acute Respiratory Syndrome
D. Southeast or southcentral U.S.
1. Blastomyces dermatidis
E. Southwestern U.S.
1. Coccidioidomycosis
2. Hantavirus

XVIII. References

A. Gilbert (2001) Sanford Antimicrobial, p. 28

B. Bartlett (2000) Clin Infect Dis 31:347-82 [PubMed]
C. Kaysin (2016) Am Fam Physician 94(9); 698-706 [PubMed]
D. Mandell (2007) Clin Infect Dis 44(suppl 2): S27-72 [PubMed]
E. Niederman (1993) Am Rev Respir Dis 148:1418-26 [PubMed]

II. Causes

A. See Pneumonia Causes

III. Signs: Factors that differentiate from Bacterial cause

A. Non-productive cough
B. Gradual Onset with prodrome (malaise and Headache)
C. Chest XRay more impressive than exam
D. Onset in fall or winter
E. Wheezing more common in viral causes
F. Low grade Temperature (<101.3 F)
G. Conjunctivitis
1. Adenovirus most commonly causes Conjunctivitis

IV. Labs

A. Sputum Gram Stain

1. Negative

V. Radiology: Chest XRay

A. Air trapping
B. Bilateral fine, fluffy infiltrates
C. Atelectasis

VI. Management

A. Influenza A
1. Symmetrel
B. Respiratory Syncytial Virus
1. Manage comorbidity
2. Ribavirin for infants with severe comorbidity
C. Herpes Simplex Virus or Varicella Zoster Virus
1. Acyclovir
D. Cytomegalovirus
1. Ganciclovir or Foscarnet

VII. Complications

A. Risk of secondary infection

II. Management: Children

A. See Pneumonia Management in Children

III. Management: Disposition (outpatient versus hospitalization versus ICU admission)

A. Severe Community Acquired Pneumonia Criteria

1. Indications for ICU admission
B. Mortality Prediction Tool for Patients with Community Acquired Pneumonia (CURB-65)
1. Consider as disposition triage tool used by both outpatient and emergency providers
a. Clinic providers should consider transfer to ED, patient with Hypoxia or CURB-65 >=2
2. Indications for outpatient, inpatient or ICU admission
3. Caveats
 a. Add Hypoxia as admission criteria (not included in CURB-65)
b. Poor Test Sensitivity (use other prediction tools for low scores)
c. High Test Specificity (strongly consider ICU admission for higher scores)
C. Pneumonia Severity Index
1. Indications for outpatient, observation or admission
D. Pneumonia IRVS Prediction Tool (SMART-COP)
1. Indications for ICU admission (predicts Mechanical Ventilation and pressor support)
E. Pneumonia in the Elderly
1. See Pneumonia Hospitalization Criteria in the Elderly
2. Pneumonia SOAR Score
a. Disposition of Nursing Home resident with Pneumonia (outpatient, inpatient or ICU
admission)

IV. Management: General Measures

A. Early mobilization
1. Sitting up for >20 minutes on first hospital day
2. Mundy (2003) Chest 124:883-9 [PubMed]
B. Additional management
1. Consider Influenza management (e.g. Tamiflu)
2. Consider Corticosteroids (may reduce risk of ARDS, prolonged ICU stays, and overall
morbidity)
a. Wan (2016) Chest 149(1): 209-19 [PubMed]

V. Management: Antibiotics

A. See Pneumonia Accelerated Diagnostic Protocol

B. Start antibiotic within 4 hours of hospitalization
1. Decreases mortality
2. Decreases length of stay
3. Houck (2004) Arch Intern Med 164:637-44 [PubMed]
C. Be aware of Antibiotic Resistance
1. See Streptococcus Pneumoniae resistance
2. Reserve use of Fluoroquinolones to prevent resistance
D. Course of antibiotics
1. Course of 10-14 days has been used historically
2. Course of 7 days appears to be equally effective
a. Dunbar (2003) Clin Infect Dis 37(6): 752-60 [PubMed]
3. Course of 5 days (and 2-3 days afebrile) is sufficient in low severity community
acquired Pneumonia
a. Greenberg (2014) Pediatr Infect Dis J 33(2):136-42 [PubMed]
b. Uranga (2016) JAMA Intern Med 176(9):1257-65 [PubMed]

VI. Management: Outpatient in adults

A. Low risk for Antibiotic Resistance

1. Indications
a. Community acquired Pneumonia in previously healthy patients
b. No daycare exposure
c. No antibiotics in last 3 months
2. Options (select one)
a. Macrolide antibiotics (Azithromycin, Clarithromycin)
i. Caution: High pneumococcus resistance rate in U.S.
b. Doxycyline (high dose protocol)
i. Initial: 200 mg orally twice daily for 6 doses (3 days), then
 ii. Next: 100 mg orally twice daily for 4 doses (4 days)
B. Higher risk for Antibiotic Resistance (or higher risk patients)
1. Indications
a. See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)
b. Comorbidities (COPD, CAD, Cirrhosis, DM, Chemical Dependency, Asplenia, cancer)
c. Antibiotics in the last 3 months
d. Daycare exposure
2. Fluoroquinolones
a. Levofloxacin
b. Gatifloxacin
c. Grepafloxacin
d. Moxifloxacin
e. Sparfloxacin
3. Combination
a. Macrolide (Azithromycin, Clarithromycin) AND
b. Beta-lactam (choose one)
i. High dose Amoxicillin
ii. Amoxicillin-clavulanate (Augmentin)
iii. Cefpodoxime (Vantin)
iv. Cefprozil (Cefzil)
v. Cefuroxime (Ceftin)
vi. Cefdinir (Omnicef)

VII. Management: Inpatient Management in adults

A. See inpatient indications as above

B. Convert to oral antibiotic within 72 hours if possible
C. Criteria to switch to oral antibiotics
1. Temperature <100.9 F (37.8 C)
2. Heart Rate <100 beats per minute
3. Respiratory Rate <24 breaths per minute
4. Systolic Blood Pressure >90 mmHg
5. Oxygen Saturation >90%
6. Baseline cognitive status
7. Tolerating oral agents
D. Base option: Single agent using broad spectrum Fluoroquinolone
1. Levofloxacin
2. Gatifloxacin
3. Grepafloxacin
4. Moxifloxacin
5. Sparfloxacin
E. Base option: Combination protocol using beta-lactam with a Macrolide
1. General
a. Use one option from antibiotic 1 and one from antibiotic 2
b. Cephalosporin with Macrolide offers best outcomes
c. Brown (2003) Chest 123:1503-11 [PubMed]
2. Antibiotic 1 (choose one)
a. Cefotaxime (Claforan)
b. Ceftriaxone (Rocephin)
c. Ampicillin-Sulbactam (Unasyn)
3. Antibiotic 2: Macrolide
a. Azithromycin 500 mg IV (especially ICU patient)
F. Modification for ICU patients
1. Choose one of the 2 base options
2. If a Fluoroquinolone is used, add Aztreonam
G. Modification if risk of MRSA
1. See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)
2. Add Vancomycin, Linezolid (Zyvox) or Ceftaroline
 H. Modification if risk for Aspiration Pneumonia (Anaerobic Bacteria)
1. Consider following loss of consciousness, Alcoholism or stroke with bulbar symptoms
2. See Aspiration Pneumonia
3. Antibiotic coverage includes carbapenems, Clindamycin, Flagyl,
zosyn, Unasyn (or Augmentin)
I. Modification in uncomplicated community acquired Pneumonia
1. Beta-Lactam monotherapy has similar mortality to combination therapy
a. Postma (2015) N Engl J Med 372:1312-23 [PubMed]
2. Beta-Lactam monotherapy was not inferior to combination therapy in moderately severe CAP
a. However combination therapy with Macrolide had better clinical response in atypical
cases
b. Garin (2014) JAMA Intern Med 174:1894-901 +PMID:25286173 [PubMed]
3. Recommend combination therapy until further data
a. If monotherapy used, consider Legionella urine antigen testing
i. Atypical cases
ii. Risk for Legionella pneumonia (e.g. returning from cruise)
b. (2015) Presc Lett 22(6): 32-3

VIII. Management: Inpatient Management if risk of Pseudomonas infection

A. See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)

B. Combination protocol - use antibiotic 1 and antibiotic 2 in combination
C. Antibiotic 1
1. Ticarcillin-clavulanate (Timentin)
2. Piperacillin-Tazobactam (Zosyn)
3. Cefepime
4. Imipenem-Cilastin (Primaxin)
5. Meropenem (Merrem)
6. Doripenem (Doribax)
D. Antibiotic 2
1. Option: Fluoroquinolone (choose one)
a. Ciprofloxacin
b. Levofloxacin
2. Option: Macrolide AND Aminoglycoside (use both)
a. Azithromycin and
b. Aminoglycoside
3. Option: Fluoroquinolone AND Aminoglycoside (use both)
a. Fluoroquinolone and
b. Aminoglycoside

IX. Management: Refractory Cases

A. See Community Acquired Pneumonia Refractory to Standard Management

X. Prevention

A. See Pneumonia Prevention in the Elderly

B. See Influenza Vaccine
C. See Pneumococcal Vaccine (Pneumovax 23)
D. See Pneumococcal Conjugate Vaccine (Prevnar 13)

XI. References

A. Bartlett (1998) Clin Infect Dis 26:811-38 [PubMed]

 B. Bartlett (2000) Clin Infect Dis 31:347-82 [PubMed]
C. Kaysin (2016) Am Fam Physician 94(9); 698-706 [PubMed]
D. King (1997) Am Fam Physician 56:544-50 [PubMed]
E. Lim (2009) Thorax 64(suppl 3):1-55 [PubMed]
F. Lutfiyya (2006) Am Fam Physician 73:442-50 [PubMed]
G. Mandell (2007) Clin Infect Dis 44(suppl 2): S27-72 [PubMed]
H. Niederman (1993) Am Rev Respir Dis 148:1418-26 [PubMed]
I. Thibodeau (2004) Am Fam Physician 69:1699-706 [PubMed]
J. Watkins (2011) Am Fam Physician 83(11): 1299-306 [PubMed]

II. Indications

A. Symptoms suggesting Pneumonia

III. Imaging: Chest XRay Indications

A. History
1. Known structural lung disease
2. Age > 60 years old
B. Symptoms
1. Pleuritic Chest Pain
C. Abnormal Vital Signs
1. Heart Rate > 100/min
2. Respiratory Rate >24
3. Temperature >38 C
D. Signs
1. Rales, asymmetric breath sounds or other signs of lung consolidation
2. Hypoxemia
3. Confusion
4. Systemic illness signs

IV. Management: Aspiration Pneumonia

A. Option 1 Two drug combination

1. Drug 1: Amoxicillin-Clavulanate (Augmentin) OR Ampicillin-Sulbactam (Unasyn) AND
2. Drug 2: Azithromycin OR Doxycyline
B. Option 2 Two drug combination
1. Drug 1: Levofloxacin AND
2. Drug 2: Clindamycin
C. Option 3 Two drug combination
1. Drug 1: Ceftriaxone 1 g IV every 24 hours AND
2. Drug 2: Metronidazole 500 mg IV every 6 hours (or 1 g IV every 12 hours)
3. If atypical coverage needed, add Azithromycin (or Doxycycline or Fluoroquinolone)
D. Option 4 Single drug options
1. Piperacillin-Tazobactam (Zosyn) 3.375 g IV every 6 hours OR
2. Ertapenem 1 g IV every 24 hours
3. If atypical coverage needed, add Azithromycin (or Doxycycline or Fluoroquinolone)

V. Management: Multi-Drug Resistance Risk

A. Indications
1. MDR Score 2 or more
B. Parenteral antibiotic regimen (managed inpatient or ICU)
1. Vancomycin (or Linezolid) AND
 2. Cefepime OR Meropenem OR Zosyn AND
3. Azithromycin OR Doxycycline (or Fluoroquinolone)

VI. Management: Community Acquired Pneumonia Inpatient

A. Indications
1. CURB-65 >=2 or Hypoxia
B. Inpatient, Non-ICU oral regimen (may be preferred for non-ICU patients)
1. Levofloxacin OR
2. Two drug option
a. Drug 1: Azithromycin (or Doxycycline) AND
b. Drug 2: Amoxicillin-clavulanate or Cefprozil or Cefuroxime or Cefdinir
C. Inpatient, Non-ICU parenteral regimen (for patients unable to take oral medications)
1. Ceftriaxone AND Azithromycin (or Doxycycline) OR
2. Levofloxacin
D. Intensive care unit
1. Ceftriaxone AND Azithromycin (or Doxycycline) OR
2. Levofloxacin AND Aztreonam

VII. Management: Community Acquired Pneumonia Outpatient

A. Levofloxacin OR
B. Azithromycin AND high dose Amoxicillin OR
C. High Dose Doxycycline (3 days at 200 mg bid, then 4 days at 100 mg twice daily)

VIII. References

A. Orman and Berg in Herbert (2016) EM:Rap 16(12): 15-17

B. Gilbert (2016) Sanford Guide, accessed on IOS app, 12/6/2016