Rosen & Barkin's 5-Minute Emergency Medicine Consult (555 page)

• 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 days
      
  • Comorbidities:
    
    • Levofloxacin 750 mg PO daily for 5 days
      
• Inpatient:
  
  • 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
      

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

FOLLOW-UP

• 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 >19
      
    • Respiratory rate ≥30/min
      
    • BP with SBP <90 mm Hg, DBP <60 mm Hg
      
    • Age ≥65 yr
      
  • Interpretation:
    
    • 0–1: Outpatient treatment
      
    • 2: Close outpatient vs. brief inpatient
      
    • 3–5: Inpatient with ICU consideration
      
• Pneumonia Severity Index:
  
  • Demographics:
    
    • If Male: + age (yr)
      
    • If Female: + age (yr) – 10
      
    • If nursing home resident: +10
      
  • Comorbid illness:
    
    • Neoplastic disease: +30
      
    • Liver disease: +20
      
    • Congestive heart failure: +10
      
    • Cerebrovascular disease: +10
      
    • Renal disease: +10
      
  • Physical exam findings:
    
    • 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
      
  • Lab and radiographic findings:
    
    • Arterial pH < 7.35: +30
      
    • BUN ≥30 mg/dL: +20
      
    • Sodium <130 mmol/L: +20
      
    • Glucose ≥250 mg/dL: +10
      
    • Hematocrit <30%: +10
      
    • PaO
      ₂
      <60 mm Hg: +10
      
    • Pleural 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)
      
• Additional considerations:
  
  • 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
  

Follow-up with primary care within 72 hr

Primary care follow-up within 72 hr

• 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.
  

• 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.
  Rosen’s 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

• 481 Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]
  
• 486 Pneumonia, organism unspecified
  
• 507.0 Pneumonitis due to inhalation of food or vomitus
  

BASICS

• Mechanism is often unknown.
  
• Source is oropharyngeal aspiration (most common) or hematogenous.
  
• Distribution depends on the organism: Interstitial (
  Mycoplasma pneumoniae
  , virus), lobar (
  Streptococcus pneumoniae
  ), abscesses (
  Staphylococcus aureus
  ), or diffuse (
  Pneumocystis carinii
  )
  

• <2 wk:
  
  • Group B
    Streptococcus
    species
    
  • Enteric gram-negative organisms
    
  • Respiratory syncytial virus (RSV)
    
  • Herpes simplex virus
    
  • S. aureus
    
• 2 wk–3 mo:
  
  • Chlamydia trachomatis
    
  • Parainfluenza virus
    
  • RSV
    
  • S. pneumoniae
    
  • S. aureus
    
  • H. influenza
    
  • Bordetella pertussis
    
• 3 mo–8 yr:
  
  • Viral (predominate):
    
    • RSV
      
    • Parainfluenza virus
      
    • Influenza virus
      
    • Adenovirus
      
  • S. pneumoniae
    
  • H. influenza
    in unimmunized children
    
  • Group A streptococcus
    
  • S. aureus
    
  • B. pertussis
    
• >8 yr:
  
  • M. pneumoniae
    most common
    
  • Viral
    
  • S. pneumoniae
    
• Recent immigrants from developing countries:
  
  • Mycoplasma tuberculosis
    
  • H. influenza
    
  • B. pertussis
    
• Immunocompromised (e.g., HIV, cancer):
  
  • P. carinii
    
  • Mycoplasma avium
    complex
    
  • M. tuberculosis
    
  • Klebsiella pneumoniae
    
  • Pseudomonas aeruginosa
    
• Less common:
  
  • Fungal (coccidioidomycosis, histoplasmosis)
    
  • Rickettsia
    (Q fever)
    

DIAGNOSIS