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Pneumonia, Adult, Emergency Medicine

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Pneumonia, Adult, Emergency Medicine

Basics

Description

Aztreonam may be substituted for Ž ˛-lactams in confirmed penicillin-allergic patients for the above ICU regimens. ‚

  • Epidemiology:7th leading cause of death and leading cause from infectious disease in US
  • Highest mortality in elderly and patients with the following coexisting conditions:Chronic heart, lung, liver, and kidney diseaseDiabetes mellitusAlcoholismMalignancyAspleniaImmunosuppressionUse of antimicrobials within last 3 mo
  • Classifications:Source based:Community acquired (CAP)Health care associated (HCAP)Hospital acquired (HAP)Ventilator associated (VAP)Symptom based:TypicalAtypical
  • Complications:BacteremiaSepsisAbscessEmpyemaRespiratory failure
  • 7th leading cause of death and leading cause from infectious disease in US
  • Chronic heart, lung, liver, and kidney disease
  • Diabetes mellitus
  • Alcoholism
  • Malignancy
  • Asplenia
  • Immunosuppression
  • Use of antimicrobials within last 3 mo
  • Source based:Community acquired (CAP)Health care associated (HCAP)Hospital acquired (HAP)Ventilator associated (VAP)
  • Symptom based:TypicalAtypical
  • Community acquired (CAP)
  • Health care associated (HCAP)
  • Hospital acquired (HAP)
  • Ventilator associated (VAP)
  • Typical
  • Atypical
  • Bacteremia
  • Sepsis
  • Abscess
  • Empyema
  • Respiratory failure

Etiology

  • CAP (typicals):Streptococcus pneumoniaeHaemophilus influenzaeKlebsiella pneumoniaeMoraxella catarrhalisStreptococcus pyogenesStaphylococcus aureus
  • CAP (atypicals):Mycoplasma pneumoniaeChlamydophila pneumoniaeLegionella pneumophilaViral
  • HCAP/HAP/VAP:Gram negatives (Pseudomonas, Stenotrophomonas)Methicillin-resistant S. aureus (MRSA)
  • Immunosuppressed:Mycobacterium tuberculosisPneumocystis jirovecii
  • Aspiration:Chemical pneumonitis ‚ ± oral and gastric anaerobes
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Klebsiella pneumoniae
  • Moraxella catarrhalis
  • Streptococcus pyogenes
  • Staphylococcus aureus
  • Mycoplasma pneumoniae
  • Chlamydophila pneumoniae
  • Legionella pneumophila
  • Viral
  • Gram negatives (Pseudomonas, Stenotrophomonas)
  • Methicillin-resistant S. aureus (MRSA)
  • Mycobacterium tuberculosis
  • Pneumocystis jirovecii
  • Chemical pneumonitis ‚ ± oral and gastric anaerobes

Diagnosis

Signs and Symptoms

  • Typical:Acute onsetFeverChillsRigorsCoughPurulent sputumShortness of breathPleuritic chest pain
  • Atypical:Subacute onsetViral prodromeNonproductive coughLow-grade feverHeadacheMyalgiasMalaiseAbsence of pleurisy and rigors
  • Acute onset
  • Fever
  • Chills
  • Rigors
  • Cough
  • Purulent sputum
  • Shortness of breath
  • Pleuritic chest pain
  • Subacute onset
  • Viral prodrome
  • Nonproductive cough
  • Low-grade fever
  • Headache
  • Myalgias
  • Malaise
  • Absence of pleurisy and rigors
  • Vital signs:TachypneaTachycardiaHypoxiaFever
  • Pulmonary exam:Dullness to percussionTactile fremitusEgophonyRalesRhonchiDecreased breath sounds
  • Note that pneumonia may be present in the absence of the above signs of consolidation.
  • Tachypnea
  • Tachycardia
  • Hypoxia
  • Fever
  • Dullness to percussion
  • Tactile fremitus
  • Egophony
  • Rales
  • Rhonchi
  • Decreased breath sounds
  • Elderly patients have higher morbidity and mortality from pneumonia.
  • Atypical presentations are more common.

Essential Workup

Diagnosis Tests & Interpretation

  • General:CBC with differentialSerum chemistry
  • Others:Blood cultures (ICU only)Sputum cultures and Gram stain (ICU only)Urine antigen tests for S. pneumoniae & LegionellaC-reactive protein possibly helpfulLactate may be helpfulInfluenza viral test
  • CBC with differential
  • Serum chemistry
  • Blood cultures (ICU only)
  • Sputum cultures and Gram stain (ICU only)
  • Urine antigen tests for S. pneumoniae & Legionella
  • C-reactive protein possibly helpful
  • Lactate may be helpful
  • Influenza viral test
  • General:Findings are nonspecific for particular infectious etiologies.May be deferred in young, healthy patients receiving empiric outpatient management.Negative imaging should not preclude antimicrobial therapy in patients with clinical diagnosis.
  • Suggestive findings:Silhouette sign (R. heart border = RML, L. heart border = lingula, R. hemidiaphragm = RLL, L. hemidiaphragm = LLL)Air bronchogramsSegmental or subsegmental consolidationDiffuse interstitial opacitiesPleural effusionEmpyemaAbscessCavitation
  • Findings are nonspecific for particular infectious etiologies.
  • May be deferred in young, healthy patients receiving empiric outpatient management.
  • Negative imaging should not preclude antimicrobial therapy in patients with clinical diagnosis.
  • Silhouette sign (R. heart border = RML, L. heart border = lingula, R. hemidiaphragm = RLL, L. hemidiaphragm = LLL)
  • Air bronchograms
  • Segmental or subsegmental consolidation
  • Diffuse interstitial opacities
  • Pleural effusion
  • Empyema
  • Abscess
  • Cavitation
  • For large effusions, enigmatic pneumonia, and patients who fail to respond to standard therapy

Differential Diagnosis

  • Asthma
  • Bronchitis
  • CHF
  • COPD
  • Foreign-body aspiration
  • Occupational or environmental exposure
  • Pneumothorax
  • Pulmonary embolism
  • Tumor

Treatment

Pre-Hospital

  • IV access
  • Supplemental oxygen
  • Cardiac monitor
  • Consider inhaled bronchodilators.
  • Consider endotracheal intubation in cases of severe respiratory distress.

Initial Stabilization/Therapy

  • IV access and fluid resuscitation as needed
  • Supplemental oxygen
  • Cardiac monitor
  • Inhaled bronchodilators
  • Endotracheal intubation in cases of severe respiratory distress as indicated

Ed Treatment/Procedures

  • American Thoracic Society guidelines for empiric therapy:
  • Outpatient:Previously healthy, no coexisting conditions:Macrolide (azithromycin) OR doxycyclineSignificant coexisting conditions (see above):Combination Ž ˛-lactam (ceftriaxone, cefuroxime, cefpodoxime, high-dose amoxicillin, Augmentin) PLUS macrolide (azithromycin) ORRespiratory floroquinolone (levofloxacin, moxifloxacin) alone
  • Inpatient:Noncritical care:Combination Ž ˛-lactam PLUS macrolide ORRespiratory floroquinolone aloneCritical care:Combination Ž ˛-lactam PLUS macrolide OR respiratory floroquinoloneFor Pseudomonas, consider adding antipseudomonal agent (piperacillin/tazobactam, imipenem, meropenem, cefepime) PLUS antipseudomonal fluoroquinolone (high-dose levofloxacin) OR antipseudomonal agent (see above) PLUS aminoglycoside (gentamicin) PLUS macrolide (azithromycin).For MRSA, consider adding vancomycin OR linezolid.For aspiration, consider adding clindamycin OR metronidazole.For drug-resistant S. pneumoniae, consider adding vancomycin.
  • Previously healthy, no coexisting conditions:Macrolide (azithromycin) OR doxycycline
  • Significant coexisting conditions (see above):Combination Ž ˛-lactam (ceftriaxone, cefuroxime, cefpodoxime, high-dose amoxicillin, Augmentin) PLUS macrolide (azithromycin) ORRespiratory floroquinolone (levofloxacin, moxifloxacin) alone
  • Macrolide (azithromycin) OR doxycycline
  • Combination Ž ˛-lactam (ceftriaxone, cefuroxime, cefpodoxime, high-dose amoxicillin, Augmentin) PLUS macrolide (azithromycin) OR
  • Respiratory floroquinolone (levofloxacin, moxifloxacin) alone
  • Noncritical care:Combination Ž ˛-lactam PLUS macrolide ORRespiratory floroquinolone alone
  • Critical care:Combination Ž ˛-lactam PLUS macrolide OR respiratory floroquinoloneFor Pseudomonas, consider adding antipseudomonal agent (piperacillin/tazobactam, imipenem, meropenem, cefepime) PLUS antipseudomonal fluoroquinolone (high-dose levofloxacin) OR antipseudomonal agent (see above) PLUS aminoglycoside (gentamicin) PLUS macrolide (azithromycin).For MRSA, consider adding vancomycin OR linezolid.For aspiration, consider adding clindamycin OR metronidazole.For drug-resistant S. pneumoniae, consider adding vancomycin.
  • Combination Ž ˛-lactam PLUS macrolide OR
  • Respiratory floroquinolone alone
  • Combination Ž ˛-lactam PLUS macrolide OR respiratory floroquinolone
  • For Pseudomonas, consider adding antipseudomonal agent (piperacillin/tazobactam, imipenem, meropenem, cefepime) PLUS antipseudomonal fluoroquinolone (high-dose levofloxacin) OR antipseudomonal agent (see above) PLUS aminoglycoside (gentamicin) PLUS macrolide (azithromycin).
  • For MRSA, consider adding vancomycin OR linezolid.
  • For aspiration, consider adding clindamycin OR metronidazole.
  • For drug-resistant S. pneumoniae, consider adding vancomycin.

Medication

  • Amoxicillin " “clavulanate (Augmentin): 500 mg PO q12h
  • Ampicillin " “sulbactam (Unasyn): 1.5 " “3 g IV q6h
  • Azithromycin: 500 mg PO on day 1 and 250 mg PO on days 2 " “5 OR 500 mg PO daily for 3 days OR 500 mg IV daily
  • Aztreonam: 1 " “2 g IV q12h
  • Cefepime: 2 g IV q12h
  • Cefotaxime: 1 " “2 g IV q8h
  • Cefpodoxime: 200 mg PO q12h
  • Ceftazidime: 2 g IV q12h
  • Ceftriaxone: 1 " “2 g IV daily
  • Cefuroxime: 0.75 and 1.5 g IV q8h
  • Doxycycline: 100 mg PO/IV q12h
  • Ertapenem: 1 g IV daily
  • Levofloxacin: 500 " “750 mg PO/IV daily
  • Linezolid: 600 mg PO/IV daily
  • Imipenem: 500 mg IV q6h
  • Meropenem: 1 g IV q8h
  • Moxifloxacin: 400 mg IV daily
  • Piperacillin " “tazobactam (Zosyn): 3.375 " “4.5 g IV q6h
  • Vancomycin: 1 g IV q12h
  • Outpatient:Healthy:Azithromycin 500 mg PO day 1, 250 mg PO days 2 " “5 OR 500 mg PO daily for 3 daysComorbidities:Levofloxacin 750 mg PO daily for 5 days
  • Inpatient:Non-ICU:Levofloxacin 750 mg IV dailyICU:Ceftriaxone 1 g IV daily AND levofloxacin 750 mg IV daily ‚ ± piperacillin " “tazobactam 4.5 g IV q6h ‚ ± vancomycin 1g IV q12h
  • Healthy:Azithromycin 500 mg PO day 1, 250 mg PO days 2 " “5 OR 500 mg PO daily for 3 days
  • Comorbidities:Levofloxacin 750 mg PO daily for 5 days
  • Azithromycin 500 mg PO day 1, 250 mg PO days 2 " “5 OR 500 mg PO daily for 3 days
  • Levofloxacin 750 mg PO daily for 5 days
  • Non-ICU:Levofloxacin 750 mg IV daily
  • ICU:Ceftriaxone 1 g IV daily AND levofloxacin 750 mg IV daily ‚ ± piperacillin " “tazobactam 4.5 g IV q6h ‚ ± vancomycin 1g IV q12h
  • Levofloxacin 750 mg IV daily
  • Ceftriaxone 1 g IV daily AND levofloxacin 750 mg IV daily ‚ ± piperacillin " “tazobactam 4.5 g IV q6h ‚ ± vancomycin 1g IV q12h

Follow-Up

Disposition

  • Based on severity of illness, coexisting conditions, ability of home care, and follow-up
  • Clinical decision-making rules may aid in stratifying patients but should not supersede clinical judgment.
  • CURB-65 rule:Criteria:Confusion (Abbreviated Mental Test ≤8)Urea >7 mmol/L OR BUN >19Respiratory rate ≥30/minBP with SBP <90 mm Hg, DBP <60 mm HgAge ≥65 yrInterpretation:0 " “1: Outpatient treatment2: Close outpatient vs. brief inpatient3 " “5: Inpatient with ICU consideration
  • Pneumonia Severity Index:Demographics:If Male: + age (yr)If Female: + age (yr) " “ 10If nursing home resident: +10Comorbid illness:Neoplastic disease: +30Liver disease: +20Congestive heart failure: +10Cerebrovascular disease: +10Renal disease: +10Physical exam findings:Altered mental status: +20Pulse ≥125/min: +20Respiratory rate >30/min: +20SBP <90 mm Hg: +15Temperature <35 ‚ °C or ≥40 ‚ °C: +10Lab and radiographic findings:Arterial pH < 7.35: +30BUN ≥30 mg/dL: +20Sodium <130 mmol/L: +20Glucose ≥250 mg/dL: +10Hematocrit <30%: +10PaO2 <60 mm Hg: +10Pleural effusion: +10Interpretation:0: Class I (outpatient)<70: Class II (outpatient vs. short observation)71 " “90: Class III (home with IV antibiotics vs. short observation)91 " “130: Class IV (inpatient)>130: Class V (inpatient)
  • Additional considerations:Previous hospitalization within last year for pneumoniaFailed outpatient therapySocial conditions preventing safe outpatient disposition
  • Criteria:Confusion (Abbreviated Mental Test ≤8)Urea >7 mmol/L OR BUN >19Respiratory rate ≥30/minBP with SBP <90 mm Hg, DBP <60 mm HgAge ≥65 yr
  • Interpretation:0 " “1: Outpatient treatment2: Close outpatient vs. brief inpatient3 " “5: Inpatient with ICU consideration
  • Confusion (Abbreviated Mental Test ≤8)
  • Urea >7 mmol/L OR BUN >19
  • Respiratory rate ≥30/min
  • BP with SBP <90 mm Hg, DBP <60 mm Hg
  • Age ≥65 yr
  • 0 " “1: Outpatient treatment
  • 2: Close outpatient vs. brief inpatient
  • 3 " “5: Inpatient with ICU consideration
  • Demographics:If Male: + age (yr)If Female: + age (yr) " “ 10If nursing home resident: +10
  • Comorbid illness:Neoplastic disease: +30Liver disease: +20Congestive heart failure: +10Cerebrovascular disease: +10Renal disease: +10
  • Physical exam findings:Altered mental status: +20Pulse ≥125/min: +20Respiratory rate >30/min: +20SBP <90 mm Hg: +15Temperature <35 ‚ °C or ≥40 ‚ °C: +10
  • Lab and radiographic findings:Arterial pH < 7.35: +30BUN ≥30 mg/dL: +20Sodium <130 mmol/L: +20Glucose ≥250 mg/dL: +10Hematocrit <30%: +10PaO2 <60 mm Hg: +10Pleural effusion: +10
  • Interpretation:0: Class I (outpatient)<70: Class II (outpatient vs. short observation)71 " “90: Class III (home with IV antibiotics vs. short observation)91 " “130: Class IV (inpatient)>130: Class V (inpatient)
  • If Male: + age (yr)
  • If Female: + age (yr) " “ 10
  • If nursing home resident: +10
  • Neoplastic disease: +30
  • Liver disease: +20
  • Congestive heart failure: +10
  • Cerebrovascular disease: +10
  • Renal disease: +10
  • Altered mental status: +20
  • Pulse ≥125/min: +20
  • Respiratory rate >30/min: +20
  • SBP <90 mm Hg: +15
  • Temperature <35 ‚ °C or ≥40 ‚ °C: +10
  • Arterial pH < 7.35: +30
  • BUN ≥30 mg/dL: +20
  • Sodium <130 mmol/L: +20
  • Glucose ≥250 mg/dL: +10
  • Hematocrit <30%: +10
  • PaO2 <60 mm Hg: +10
  • Pleural effusion: +10
  • 0: Class I (outpatient)
  • <70: Class II (outpatient vs. short observation)
  • 71 " “90: Class III (home with IV antibiotics vs. short observation)
  • 91 " “130: Class IV (inpatient)
  • >130: Class V (inpatient)
  • Previous hospitalization within last year for pneumonia
  • Failed outpatient therapy
  • Social conditions preventing safe outpatient disposition
  • Age <65 yr
  • No comorbid illnesses
  • Nontoxic appearance
  • Normal vital signs
  • Normal lab studies
  • Primary care follow-up within 72 hr

Followup Recommendations

Pearls and Pitfalls

  • Delayed initiation of antibiotics in ill-appearing patients
  • Failure to recognize pneumonia in patients assumed to have exacerbations of underlying lung conditions
  • Failure to question patients regarding TB and HIV risk factors
  • Elderly and immunocompromised patients may not exhibit any classic symptoms of pneumonia when ill.

Additional Reading

  • Mandell ‚ LA, Wunderink ‚ RG, Anzueto ‚ A, et al. Infectious Disease Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S27 " “S72.
  • Moran ‚ GJ, Talan ‚ DA. Pneumonia. In: Marx ‚ JA, Hockberger ‚ RS, Walls ‚ RM, et al., eds. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009: 927 " “938.
  • Moran ‚ GJ, Talan ‚ DA, Abrahamian ‚ FM. Diagnosis and management of pneumonia in the emergency department. Infect Dis Clin North Am. 2008;22(1):53 " “72.
  • Nazarian ‚ DJ, Eddy ‚ OL, Lukens ‚ TW, et al. Clinical policy: Critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2009;54:704 " “731.

See Also (Topic, Algorithm, Electronic Media Element)

  • Pneumonia, Pediatric
  • Pneumocystis carinii Pneumonia

Codes

ICD9

  • 481 Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]
  • 486 Pneumonia, organism unspecified
  • 507.0 Pneumonitis due to inhalation of food or vomitus
  • 997.31 Ventilator associated pneumonia
  • 482.0 Pneumonia due to Klebsiella pneumoniae
  • 482.2 Pneumonia due to Hemophilus influenzae [H. influenzae]
  • 482.40 Pneumonia due to Staphylococcus, unspecified
  • 483.0 Pneumonia due to mycoplasma pneumoniae

ICD10

  • J13 Pneumonia due to Streptococcus pneumoniae
  • J18.9 Pneumonia, unspecified organism
  • J69.0 Pneumonitis due to inhalation of food and vomit
  • J95.851 Ventilator associated pneumonia
  • J14 Pneumonia due to Hemophilus influenzae
  • J15.0 Pneumonia due to Klebsiella pneumoniae
  • J15.211 Pneumonia due to methicillin suscep staph
  • J15.7 Pneumonia due to Mycoplasma pneumoniae

SNOMED

  • 233604007 Pneumonia (disorder)
  • 422588002 aspiration pneumonia (disorder)
  • 34020007 pneumonia due to Streptococcus (disorder)
  • 429271009 ventilator-acquired pneumonia (disorder)
  • 385093006 Community acquired pneumonia (disorder)
  • 408679000 healthcare associated pneumonia (disorder)
  • 441658007 pneumonia due to Staphylococcus aureus (disorder)
  • 46970008 Pneumonia due to Mycoplasma pneumoniae (disorder)
  • 64479007 Pneumonia due to Klebsiella pneumoniae
  • 70036007 Haemophilus influenzae pneumonia