Volume I:
First Thirty Minutes
- Section 1
  Acute Care Algorithm/ Treatment Plans/ Acronyms
- Section 2
  Universal Approach
  - CALS Universal Approach To Emergency Advanced Life Support
- Section 3
  Steps 1-6
- Section 4
  Preliminary Impression/Focused Clinical Pathways
Volume II:
Resuscitation Procedures
Volume III:
Definitive Care

Infection 1: Adult Pneumonia

Pneumonia is a parenchymal infection of the lungs caused by inhalation, micro-aspiration, macro-aspiration, or hematogenous spread of microorganisms. Clinically, pneumonia is usually expressed by various symptoms of acute infection (such as productive cough, fever, dyspnea, chest pain). An infiltrate is usually present on the chest x-ray. Many other conditions present with a similar set of findings, including:

adult respiratory distress syndrome
aspiration
acute bronchitis
chemical pneumonitis
CHF
COPD
chronic interstitial lung disease
drug reactions and overdoses (aspirin, heroin)
hantavirus syndrome
hemorrhage
high altitude pulmonary edema
pulmonary embolism
pulmonary neoplasm
sarcoidosis
others

Pulmonary embolism mistaken as pneumonia can be fatal. Assess your patient for risk factors associated with pulmonary embolism and proceed accordingly. (Vol I—PATHWAY 6 Adult Respiratory, #10) Note that a rectal temperature greater than 102°F (38.8°C) is unlikely to be associated with pulmonary embolism.¹

Community-acquired microorganisms causing pneumonia include:

Bacteria: Streptococcal pneumoniae, Mycoplasma, Haemophilus influenza, Staphylococcus aureus, Legionella, Chlamydia, Moraxella, gram-negative bacilli, and anaerobes (in aspiration)
Viruses: adeno, influenza, parainfluenza, and respiratory syncytial viruses
Other: pneumocystis carinii, mycobacterium tuberculosis

Target high-risk findings with your initial investigation to help guide effective hospitalization and treatment issues. Note that many of the historical findings assume that you ask a significant number of detailed questions. The PORT study² reported the following risk factors:

demographics: age over 50, nursing home resident
comorbid diseases: cancer, liver, CHF, renal, cerebrovascular
physical exam findings: altered mental status; respiratory rate > 30, pulse >125; temperature < 35°C (95°F) or > 40°C (104°F); systolic BP < 90 mm Hg
lab findings: pleural effusion on chest x-ray; hematocrit < 30%; pH < 7.35; BUN > 10.7 mmol/L; sodium < 130 mEq/L; glucose > 250 mg/dL; PO2 < 60 mm Hg

Other high risk factors include²:

O₂ saturation < 90%.
situational factors such as no money, lack of support system, homelessness, compliance issues
alcoholism
vomiting
immunosuppression: asplenia, diabetes mellitus, steroid use, immunosuppressive drugs, HIV/AIDS, sickle cell disease, organ transplant, connective tissue diseases
neuromuscular disease
extrapulmonary infection
preexisting lung disease

All patients suspected of having pneumonia should have diagnostic testing, including pulse oximetry and chest x-ray. This may be the only diagnostic testing needed for many patients. The white blood count is rarely important, except in patients on chemotherapy. Seriously ill pneumonia patients need a minimum of sodium, glucose, hematocrit, and pH. For those patients with saturations < 90% to 92% by pulse oximetry, with ventilation problems, or with acidosis, ABGs are useful in evaluating the severity of hypoxia. Generally speaking, gram stains and cultures of sputum should neither be used in outpatient treatment nor in hospitalized patients.¹ Blood cultures in pneumonia have limited utility¹ but nonetheless are currently recommended in hospitalized patients by guidelines from the American Thoracic Society and the Infectious Disease Society of America.^1,2All pleural effusions seen on chest x-ray should be tapped, tested (pH, glucose, LDH), and drained if the pH of the fluid is < 7.2 or purulent. This procedure does not have to be done in the ED or before antibiotics are given. Do not delay antibiotic treatment of the acutely ill patient with pneumonia for diagnostic testing.

Clinical Management of Pneumonia
See Vol I—PATHWAY 6 Adult Respiratory, #9 for clinical management considerations. Antibiotic considerations follow.

Antibiotic Management of Pneumonia
No constellation of symptoms, findings, or initial tests can reliably distinguish the agent that causes pneumonia, with the rare exception of a chest x-ray diagnostic for a lung abscess or classic tuberculosis.7 This forms the rationale for administering antibiotics on an empirical basis. Treatment regimens differ based on the severity of illness and the opinions of various collective experts. Empirical treatment with antibiotics is a starting point; therapy may need to be modified depending on the patient’s response and subsequent testing results. Take into account your community’s microorganism-resistant patterns before making choice(s). Make several patient distinctions to guide antibiotic selection:

Patients who are immunocompromised versus those who are not. Patients who are immunocompromised may have a wider variety of infectious pathogens and a blunted inflammatory reaction of the host (which could lead to either an absence of sputum, fever, or infiltrate on chest x-ray or a changed pattern on the chest film)
Patients who acquired their symptoms in a community setting versus those who acquired them in a hospital/nursing home setting within the previous 7 to 14 days may have issues of resistant pathogens and gram-negative bacteria.
Patients who have recently received antibiotics versus those who have not may have issues of resistant pathogens.
Patients who have HIV/AIDS versus those who do not may have issues of opportunistic pathogens, especially PCP and tuberculosis.

Be aware of the interactions and contraindications of each of the agents you choose. Empiric antibiotic therapy should comprehensively cover all likely pathogens in the given clinical setting. Do not delay therapy as delays increase mortality. The following can help to guide the choice of antibiotics.

Acute Community-Acquired Pneumonia: Non-Immunocompromised Patient⁷

Outpatient Therapy Options

Macrolides, fluroquinolones, or doxycycline are effective; the fluroquinolones (levofloxacin, gatifloxacin, moxifloxacin) are perhaps a better choice in an older patient or those with underlying disease. Duration of treatment is unproven; 10 to 14 days seems to be standard in numerous communities. Provide explicit follow-up instructions.

Inpatient General Ward Therapy Options

A macrolide (erythromycin, azithromycin, clarithromycin) and certain third-generation cephalosporins (ceftriaxone, cefotaxime). Example: erythromycin 15 to 20 mg/kg IV every 6 h and cefotaxime (Claforan) 1 to 2 g IV every 8 h.
A macrolide and a beta-lactam/beta-lactamase inhibitor (ampicillin/sulbactam, ticarcillin/clavulanate, piperacillin/tazobactam). Example: erythromycin as described in #1, and ampicillin-sulbactam (Unasyn) 1.5 to 3 g IV every 6 h.
A fluroquinolone with good activity against Strep pneumococcus (levofloxacin, gatifloxacin, moxifloxacin). Example: levofloxacin 250 to 500 mg PO/IV once daily.

Inpatient Intensive Care Therapy Options

A macrolide (erythromycin, azithromycin, clarithromycin) and a select third-generation cephalosporin (ceftriaxone, cefotaxime).
A macrolide (erythromycin, azithromycin, clarithromycin) and a beta-lactam/beta-lactamase inhibitor (ampicillin/sulbactam, piperacillin/tazobactam).
A fluroquinolone (levofloxacin, gatifloxacin, moxifloxacin) and a select third-generation cephalosporin (ceftriaxone, cefotaxime).
A fluroquinolone (levofloxacin, gatifloxacin, moxifloxacin) and a beta-lactam/beta-lactamase inhibitor (ampicillin/sulbactam, piperacillin/tazobactam).
If the patient has underlying structural disease (such as COPD): a fluroquinolone (levofloxacin, gatifloxacin, moxifloxacin, or high-dose Cipro) and one of the following antipseudomonal agents: piperacillin, piperacillin/tazobactam, carbapenem, or cefepime.

Acute Community-Acquired Aspiration Pneumonia^7,8

A fluroquinolone (levofloxacin, gatifloxacin, moxifloxacin) with either:

Clindamycin: 600 to 900 mg IV every 8 h.
Metronidazole: load 15 mg/kg IV, then 7.5 mg/kg IV every 6 h; each dose over 1 h and not to exceed 4 g/d.
Beta-lactam/beta-lactamase inhibitor (ampicillin/sulbactam, piperacillin/tazobactam): Example: Ampicillin/sulbactam (Unasyn) 1.5 to 3 g IV every 6 h.

Hospital-Acquired Aspiration Pneumonia

Recommendations range from single drug coverage with clindamycin (Cleocin), ticarcillin/clavulanic acid (Timentin), or piperacillin/tazobactam (Zosyn), to dual coverage or triple coverage.
It seems reasonable to start with dual coverage with clindamycin and either a fluroquinolone (levofloxacin, gatifloxacin, moxifloxacin) or one of the beta-lactam/beta-lactamase inhibitors (ampicillin/sulbactam, piperacillin/tazobactam, ticarcillin/clavulanic acid).

Hospital/Nursing Home Acquired Pneumonia⁷

Antibiotic options: an aminoglycoside (tobramycin 5 to 7 mg/kg IV every 24 hours or gentamycin 5 to 7 mg/kg IV every 24 hours or amikacin 15 mg/kg IV every 24 hours)

PLUS one of the following:

cefotaxime (Claforan): 1 to 2 g IM/IV every 6 to 8 h.
ceftriaxone (Rocephin) 2 g IV every 24 hours.
cefepime (Maxipime): 0.5 to 2 g IM/IV every 12 h.
imipenem (Primaxin): 0.5 g IV every 6 h.
meropenem (Merrem): 1 g IV every 8 h.
piperacillin/tazobactam (Tazocin, Zosyn): 3.375 g IV every 4 to 6 h.
ticarcillin/clavulanic acid (Timentin): 3.1 g IV every 4 to 6 h.

Add vancomycin (Vancocin) 1 g IV every 12 h when methicillin-resistant Stapholococcus aureus (MRSA) is prevalent.

The Immunocompromised Patient with Pneumonia

Pneumonia is one of the leading causes of death in these patients. Besides bacteria, viruses such as the cytomegalovirus and fungi such as Candida and Aspergillus often become serious pathogens. Patients with renal failure or organ transplants are at risk for infection with Legionella.¹ Pneumocystis carinii is a pathogenic consideration for patients on chronic steroid use, those receiving cytotoxic drugs, and HIV/AIDS patients.

Options for the neutropenic patient¹ (< 500 neutrophils) and other immunocompromised patients:

An aminoglycoside (tobramycin 5 to 7 mg/kg IV every 24 hours or gentamycin 5 to 7 mg/kg IV every 24 hours or amikacin 15 mg/kg IV every 24 hours

PLUS one of the following:

ceftazidime (Fortaz): 2.0 g IV every 8 to 12 h.
cefepime (Maxipime): 0.5 to 2 g IM/IV every 12 h.
imipenem (Primaxin): 250 mg to 1 g IV every 6 to 8 h.
meropenem (Merrem): 1 g IV every 8 h.
piperacillin/tazobactam (Tazocin): 3.375 g IV every 4 to 6 h.
ticarcillin/clavulanic acid (Timentin): 3.1 g IV every 4 to 6 h.
Add vancomycin (Vancocin) 1 g IV every 12 h if methicillin-resistant Stapholococcus aureus (MRSA) or penicillin-resistant viridans Streptococci is suspected.
Add clindamycin (Cleocin) 600 to 900 mg IV every 8 h if anaerobes are suspected.
Add amphotericin B if you suspect fungal involvement.
Add azithromycin (500 mg IV once daily) or levofloxacin (250 to 500 mg PO/IV once daily) if Legionella is suspected.
Add trimethoprim/sulfamethoxazole 15 to 20 mg/kg/day IV (based on trimethoprim content) divided every 6 to 8 h if pneumocystis carinii is suspected. Also see below.

HIV/AIDS Patients with Pneumonia

Of primary importance is to recognize the presence of HIV/AIDS. Even knowing the patient’s status, AIDS-related illnesses often present atypically or with subtle findings. Furthermore, the sicker the HIV/AIDS patient is, the more likely they have any number of opportunistic infections secondary to immunosuppression, especially with a CD4 count < 200 cells/cc. Treatment of these patients can become complex, including elements of primary therapy for HIV/AIDS, primary therapy for the acute condition(s) they present with, and secondary therapy for prophylaxis against other threats. Multiple medications are involved which often interact with each other and/or are poorly tolerated. This section does not attempt to deal with the whole patient, but to mention some salient points about pneumonia in these patients and then focus on a common cause of death, pneumocystis carinii pneumonia.

Pneumonia is common in patients with HIV/AIDS, and HIV/AIDS is common among patients with pneumonia. One should alert you to the other. Besides being at risk for the pathogens that generate the treatment categories, patients with HIV/AIDS are at risk for tuberculosis, including multi-drug resistant strains. Immediately upon recognizing the possibility of tuberculosis (at triage), initiate control measures to prevent high mortality nosocomial outbreaks of multi-drug resistant tuberculosis strains. HIV/AIDS patients sick enough to be admitted for pneumonia should be placed in respiratory isolation until tuberculosis is ruled out. Empiric therapy for tuberculosis does not need to begin in the emergency setting.

Besides being at risk for the common pathogens (of which Streptococcus pneumoniae is predominant) and tuberculosis, HIV/AIDS patients are at risk for opportunistic pulmonary infections such as fungal infections from cryptococcus, histoplasma, and coccidioides. Furthermore, Kaposi’s sarcoma or lymphoma can be mistaken for pneumonia.⁹ However, the most common and serious opportunistic respiratory pathogen is pneumocystis carinii. Several physical findings are classic for pneumocystis carinii: oral thrush, exercise desaturation (a drop in oxygen sats on pulse oximetry with exercise), and LDH levels > 220 units/L.⁹ Obtain an ABG to guide treatment of pneumocystis carinii. A patient with a PaO₂ < 70 mm Hg or an A-a gradient > 35 not only needs O₂ but also corticosteroids added to their treatment regimen.⁹

In addition to one of these treatment categories, empiric antimicrobial treatment options for Pneumocystis carinii include:

Oral therapy options in mild to moderate disease (choose one):⁹
1. Trimethoprim/sulfamethoxazole 15 to 20 mg/kg/day X 21 days (approximately 2 double-strength tablets PO three times daily for smaller adults or four times daily for larger adults). or
2. Trimethoprim/sulfamethoxazole 15 to 20 mg/kg/d PO in 3 or 4 divided doses and Dapsone 100 mg PO once daily¹¹ or
3. Clindamycin (300 to 450 mg PO every 6 h) and Primaquine 26.3 mg=15 mg PO once daily.¹²
IV therapy options for moderate to severe cases (choose one):
1. Trimethoprim/sulfamethoxazole 15 to 20 mg /kg/day IV in 3 to 4 divided doses.
2. Pentamidine isethionate 4 mg/kg IV over 1 hour once daily.

Tuberculosis

Treatment of tuberculosis is complex and evolving, with issues of microbial resistance, drug interactions and complications, and long-term management. Triple therapy with isoniazid, rifampin, and pyrazinamide is common, with addition of ethambutol or streptomycin in certain cases.⁹ Place the patient in respiratory isolation, and obtain a consult for the latest recommendations while ruling tuberculosis in or out.

References

Stein PD, Saltzman HA, Weg JG. Clinical characteristics of patients with acute pulmonary embolism. Am J Cardiol. 1991;68:1723-1724.
Fine, MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336(4):243-250.
Bartlett JG, Breiman RF, Mandell LA, File TM Jr. Community-acquired pneumonia in adults: guidelines for management. The Infectious Diseases Society of America. Clin Infect Dis. 1998;26:811-838.
Woodhead MA, Arrowsmith J, Chamberlain-Webber R, Wooding S, Williams I. The value of routine microbial investigation in community-acquired pneumonia. Respir Med. 1991;85:313-317.
Chalasani NP, Valdecanas MA, Gopal AK, McGowan JE Jr, Jurado RL. Clinical utility of blood cultures in adult patients with community-acquired pneumonia without defined underlying risks. Chest. 1995;108:932-936.
Bartlett et al.
Niederman MS, Bass JB Jr, Campbell GD, et al. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. American Thoracic Society. Medical Section of the American Lung Association. Am Rev Respir Dis. 1993;148:1418-1426.
Fine et al.
Marrie TJ, Durant H, Yates L. Community-acquired pneumonia requiring hospitalization: 5-year prospective study. Rev Infect Dis. 1989;11:586-599.
Bartlett JG, Dowell SF, Mandell LA, File TM Jr, Musher DM, Fine MJ. Practice guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis. 2000;31:347-382.
Ibid.
The Medical Letter on Drugs and Therapeutics. The Choice of Antibacterial Drugs. 2001: Vol 43 (Issue 1111-1112); 69-70.
The Medical Letter on Drugs and Therapeutics. The Choice of Antibacterial Drugs. 2001: Vol 43. (Issue 1111-1112); 69-70.
Marston BJ, Lipman HB, Breiman RF. Surveillance for Legionnaires’ disease. Risk factors for morbidity and mortality. Arch Intern Med. 1994;154:2417-2422.
Medical Letter Vol 43.
Walker PA, White DA. Pulmonary disease. Med Clin North Am. 1996;80:1337-1362.
Lentino JR, Lucks DA. Nonvalue of sputum culture in the management of lower respiratory tract infections. J Clin Microbiol. 1987;25:758-762.
The National Institutes of Health University of California Expert Panel for Corticosteroids as Adjunctive Therapy for Pneumocystis Pneumonia. Consensus statement on the use of corticosteroids as adjunctive therapy for pneumocystis pneumonia in the acquired immunodeficiency syndrome. N Engl J Med. 1990;323:1500-1504.
Safrin S, Finkelstein DM, Feinberg J, et al. Comparison of three regimens for treatment of mild to moderate Pneumocystis carinii pneumonia in patients with AIDS. A double-blind, randomized, trial of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and clindamycin-primaquine. ACTG 108 Study Group. Ann Intern Med. 1996;124:792-802.
The Medical Letter on Drugs and Therapeutics. The Choice of Antibacterial Drugs. 2001: Vol 43 (Issue 1111-1112); 69-70.
Gilbert DN, Moelering RC, Sande MA, editors. The Sanford Guide to Antimicrobial Therapy, 31st ed. Hyde Park, VT: Antimicrobial Therapy Inc., 2000.

Infection 1: Adult Pneumonia

References

Edition 13-October 2011