SIGNS AND SYMPTOMS 
History
- Typical:
- Atypical:
- Subacute onset
- Viral prodrome
- Nonproductive cough
- Low-grade fever
- Headache
- Myalgias
- Malaise
- Absence of pleurisy and rigors
Physical Exam
- Vital signs:
- Tachypnea
- Tachycardia
- Hypoxia
- Fever
- Pulmonary exam:
- Dullness to percussion
- Tactile fremitus
- Egophony
- Rales
- Rhonchi
- Decreased breath sounds
- Note that pneumonia may be present in the absence of the above signs of consolidation.
Geriatric Considerations
- Elderly patients have higher morbidity and mortality from pneumonia.
- Atypical presentations are more common.
ESSENTIAL WORKUP
Combination of clinical and radiographic diagnosis
DIAGNOSIS TESTS & INTERPRETATION
Lab
- General:
- CBC with differential
- Serum chemistry
- Others:
- 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
Imaging
Chest radiograph:
- 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 bronchograms
- Segmental or subsegmental consolidation
- Diffuse interstitial opacities
- Pleural effusion
- Empyema
- Abscess
- Cavitation
Diagnostic Procedures/Surgery
Thoracentesis:
- For large effusions, enigmatic pneumonia, and patients who fail to respond to standard therapy
DIFFERENTIAL DIAGNOSIS
[Outline]
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:
- Significant coexisting conditions (see above):
- Combination β-lactam (ceftriaxone, cefuroxime, cefpodoxime, high-dose amoxicillin, Augmentin) PLUS macrolide (azithromycin) OR
- Respiratory floroquinolone (levofloxacin, moxifloxacin) alone
- Inpatient:
- Noncritical care:
- Combination β-lactam PLUS macrolide OR
- Respiratory floroquinolone alone
- Critical care:
- Combination β-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
First Line
- 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
Second Line
Aztreonam may be substituted for β-lactams in confirmed penicillin-allergic patients for the above ICU regimens.
[Outline]
DISPOSITION
Admission Criteria
- 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:
- 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
- PaO2 < 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
Discharge Criteria
- Age < 65 yr
- No comorbid illnesses
- Nontoxic appearance
- Normal vital signs
- Normal lab studies
- Primary care follow-up within 72 hr
Issues for Referral
Follow-up with primary care within 72 hr
FOLLOW-UP RECOMMENDATIONS
Primary care follow-up within 72 hr
[Outline]
- 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.
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