General Medical Officer (GMO) Manual: Clinical Section

Pneumonia
Department of the Navy Bureau of Medicine and Surgery Peer Review Status: Internally Peer Reviewed ( ) !ntroduction Pneumonia is the 5th most common cause of death and is a common infectious disease of lung parenchyma. Pneumonia is loosely divided into community acquired and nosocomial groups. Pneumonia that develops either during the hospital stay or within 4 to 6 wee s after discharge from the hospital! in the nursing home or in long"term care facilities! is considered nosocomial pneumonia. Pneumonia that develops in other settings is called community acquired pneumonia. #ommunity acquired pneumonia is further divided into acute $acterial pneumonia and atypical pneumonia. (") #tiology %he common causes of community acquired pneumonia are Pneumococcus! &emophilus influen'ae! (egionella )$acterial*! +ycoplasma! and #hlamydia. ,ther uncommon causes of community acquired pneumonia are -roup . Streptococcus! Staph aureus! gram"negative rods! +ora/ella catarrhalis )smo ers*! and anaero$es )aspiration*. ,ther rare causes of pneumonia $ased on endemic areas are #occidiomycosis! histoplasmosis! 0lastomycosis! and Ric ettsia. 1inally consider Pneumocystis carinii pneumonia )P#P* and tu$erculosis )%0* in immunosuppressed patients. )2* Clue$ from the hi$tory and phy$ical e%am 3ith pleuritic type chest pain! suspect a pleural effusion4 rigors are more common with pneumococcal lung infection. #hec the respiratory rate and o$serve the patient closely if a$ove 55. #hec tilts to assess whether the patient is dehydrated. #hec the o/ygen saturation. &emoptysis )$lood tinged sputum* is rare with +ycoplasma pneumonia $ut is often seen with $acterial! %0! and fungal type lung infections. Severe coughing spells and whee'ing in a non"asthmatic is suggestive of chlamydia. .ssociated headache and -I symptoms suggest (egionella. (&) Diagno$i$ .fter gathering the history and performing the physical e/am! request a #0#! chemistry studies! #6R! and sputum smear. .lways chec a pulse o/imetry. If a pulse o/imetry is not availa$le! place the patient on o/ygen. Initiate I7 hydration. . 30# of 8 2!999:mm2 or ; 55!999 is an ominous sign. . respiratory rate ;29! a diastolic $lood pressure 8 69 mm&g! and a 0<= ; 59 are other poor prognostic signs. If you suspect tu$erculosis $ased upon clinical and:or radiographic features! IS,(.%> the patient immediately. ?o not hesitate when in dou$t. Perform a sputum gram stain. If the gram stain demonstrates gram positive organisms suggestive of Pneumococcus or Streptococci! $egin a third generation cephalosporin such as #eftria/one or #efuro/ime. If either anti$iotic is not availa$le! penicillin may $e given at a dosage schedule of 5 million units every 4 hours )I7*. If a sputum sample is not availa$le or the gram stain is not helpful! $egin empiric therapy with #eftria/one )or #efuro/ime* and .'ithromycin. If the gram stain demonstrates gram"negative cocco"$acillary forms! $egin #eftria/one! #efuro/ime or Septra.

)5* 'adiographic 'ed (lag$ )a* 7olume loss @ %his implies endo$ronchial o$struction )i.e. foreign $ody! anatomical a$normalities! or tumor*. %he patient needs $ronchoscopy and isolation. )$* Pleural effusion @ (oo at the costophrenic angle. If this is o$literated! request lateral decu$itus /"ray views. If the fluid layers out to more than A9mm! a thoracentesis should $e performed to determine the cause. If clinical deterioration occurs! tap the fluid even if it is 8A9mm. )c* .denopathy " &ilar and mediastinal adenopathy signify an atypical pneumonia. Suspicion for organisms such as tu$erculosis or fungi should $e high. Isolate the patient and do an aggressive wor up for diagnosis. )d* #avitation @ %he most common community acquired pneumonias rarely cavitate e/cept Staph aureus pneumonia. 3hen cavitation is seen! isolate the patient. Suspect tu$erculosis! aspiration pneumonia! and a fungal infection. )e* +ultilo$ar involvement @ 3hen more than two lo$es are involved! this signifies high mortality in pneumonia. )f* Progression of pneumonia while on anti$iotics @ Suspect %0! fungal! P#P! or (egionella as the etiology. R>? 1(.-S require aggressive diagnostic! therapeutic management! and early transfer or +>?>7.#. )6* )nti*iotic therapy %he following description outlines empiric therapy for outpatient #.P: )a* >rythromycin 599mg ! one P,! every 6 hours! or )$* .'ithromycin 559mg! two P, initially! followed $y one P, every day for the remaining 4 more days! or )c* #larithromycin 599mg! one P, 0I? for B to A4 days! or )d* ?o/ycycline A99mg! one P, 0I?. In patients with comor$idities such as smo ing! alcoholism or those older than 69! consider coverage for &. influen'ae with the addition of a second generation cephalosporin: )a* #efuro/ime )#eftin* 599mg! one P, 0I?! or )$* #efpodo/ime )7antin* 599mg! one P, 0I?! or )c* .ugmentin 599mg! one P, %I?! or CB5mg! one P, %I?! or )d* Septra ?S! one P, 0I?. If the patient requires hospitali'ation! use the same anti$iotic agents4 a macrolide with a second or third generation cephalosporin such as #eftria/one )Rocephin 5 gm I7 D?*! or #efuro/ime A.5 gm I7! every C hours. )B* Specific +herapy )a* #mpiric >rythromycin4 599mg every 6 hours )with or without #efuro/ime %I? or Septra twice a day*. .dd &. Influen'a coverage for smo ers and for patients older than 49. Strongly consider ?o/ycycline for whee'ing pneumonias )as #hlamydia pneumonias frequently are*.

)$* Pneumococcu$ Penicillin - I7 699!999"A.5 million units every 4 hours. If there are high rates of Penicillin resistance in the area or if the organismEs suscepti$ility )+I#* to P#= is ;9.A micrograms:ml! I7 Rocephin with 7ancomycin )A gm I7 D A5 hours* should $e used. %he newer quinilones such as levoflo/acin or trovoflo/acin have good activity against P#= resistant pneumococcus and can $e used. #iproflo/acin should not $e used. )c* ,- influen.ae #efuro/ime )#eftin 599 mg* orally or I7. Intravenous #eftria/one or Septra ?S one ta$ P, 0I? )if the organism is sensitive* or .ugmentin! orally or I7 599 mg %I? should $e considered. )d* Chlamydia pneumoniae %etracycline 599 P, DI? or ?o/ycycline A99 0I? P, or I7. +acrolides or fluroquinolones can also $e used. )e* Mora%ella catarrhali$ <sually causes acute $ronchitis $ut is covered $y macrolides such as >rythromycin! .'ithromycin! or #larithromycin. %etracycline! Septra! or .ugmentin can also $e used. )f* Staph aureu$ ,/acillin or =afcillin 5 gm I7 every 6 hours or 7ancomycin A gram every A5 hours I7 )for penicillin allergic patients*. )g* /egionella pneumophila: >rythromycin A gm I7 every 6 hours with or .'ithromycin 599 mg I7 D? with or without Rifampin 699mg P, 0I?. )h* Su$pected +u*erculo$i$ Rifampin 699mg P, D?! I=& 299mg P, D?! PF. 55mg: g:day P,! >tham$utol 55mg: g:day P,. .ssess the liver en'ymes $efore and during therapy. )i* Pneumocy$ti$ carinii pneumonia (PCP) Septra ?S 5 P, DI?! or #lindamycin )#leocin* 699 mg P, DI? plus Primaquine 56.2 mg P, D?! or ?apsone A99 mg P, D? plus %rimethoprim 59 mg: g P, daily! divided into a DI? dosage schedule. )C* )$piration pneumonia %his can occur after dental wor or drin ing alcohol. #lues can include $ad smelling or tasting sputum! night sweats! and mild anemia. %reatment choices include %imentin I7! <nisyn I7! .ugmentin P, or #lindamycin P,. (0) 'e1evaluation ,nce therapy is started! daily clinical reevaluation is necessary to ensure a good response to therapy. %he chest /"ray findings may lag $ehind the clinical response $ut should $e o$tained in 5"2 wee s to ensure complete resolution of the infiltrate. Reviewed by CAPT Angeline A. Lazararus, MC, USN, Pulmonary Spe ial!y Leader, "epar!men! o# $n!ernal Medi ine, Na!ional Naval Medi al Cen!er, %e!&esda, M" '()))*.