II. Indications

  1. Symptoms suggesting Pneumonia

III. Imaging: Chest XRay Indications

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

IV. Management: Aspiration Pneumonia

  1. Option 1 Two drug combination
    1. Drug 1: Amoxicillin-Clavulanate (Augmentin) OR Ampicillin-Sulbactam (Unasyn) AND
    2. Drug 2: Azithromycin OR Doxycyline
  2. Option 2 Two drug combination
    1. Drug 1: Levofloxacin AND
    2. Drug 2: Clindamycin
  3. 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)
  4. 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

  1. Indications
    1. MDR Score 2 or more
  2. 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

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

VII. Management: Community Acquired Pneumonia Outpatient

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

VIII. References

  1. Orman and Berg in Herbert (2016) EM:Rap 16(12): 15-17
  2. Gilbert (2016) Sanford Guide, accessed on IOS app, 12/6/2016

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