Pneumonia - Quick Reference
This is a Quick Reference article. See also the main article Pneumonia Pneumonia.
- Symptoms develop rapidly in pneumococcal pneumonia: fever (often > 38.0°C), purulent cough, dyspnoea, wheezing, chest wall pain, worsening general condition.
- Symptoms are similar to those in acute bronchitis, but usually more severe.
- The only symptoms in an elderly patient may be, for example, confusion, worsening of an underlying disease, abdominal symptoms, overall poor health; fever may be absent (in up to one third of cases).
- Based on a chest x-ray. Lack of infiltrates does not exclude pneumonia if clinical picture and laboratory findings are convincing.
- Auscultation usually reveals fine crackles or crepitation but may also be normal (in up to one third of cases).
- Laboratory tests
- The patient often has concurrent sinusitis (ultrasonography, sinus x-ray if needed).
- Aetiological studies are not necessary in primary health care. The most common causative agent in community-acquired pneumonia are pneumococci. It is not possible to identify the causative agent on the basis of clinical presentation.
Antimicrobials
- Treatment must always be effective against pneumococci. Consider other causative agents if their presence is possible according to clinical or epidemiological factors.
- First-line drugs in primary care for community-acquired pneumonia: amoxicillin 1 g every 8 hours or 750 mg every 6-8 hours. Give the first dose at the appointment. Amoxicillin is combined with roxithromycin (300 mg once daily) if the aim is to cover chlamydia and mycoplasma.
- Patients with penicillin allergy, or in mild pneumonia when activity against chlamydia and mycoplasma is required: doxycycline 100 mg twice daily
- Second-line drugs (consider if during the past 3 months antimicrobials have been used (not for cystitis) or foreign travel, or the patient has severe underlying disease): moxifloxacin 400 mg once daily or levofloxacin 500 mg once or twice daily or 750 mg once daily (also active against pneumococci)
- First-line drugs for pneumonia with severe symptoms in patients with penicillin allergy
- Do not use macrolides alone (30% of pneumococci are resistant).
- Intravenous antimicrobials when general condition has deteriorated or concomitant disease affects the immune system. The choice of initial intravenous antibiotic for community-acquired pneumonia in hospital care:
- Cefuroxime 1.5 g every 6-8 hours i.v. (particularly if the pneumonia diagnosis is not confirmed)
- Benzylpenicillin (penicillin G) 2 million IU every 4 hours, or 2.5-5 million IU every 6 hours i.v., when pneumococcal aetiology appears certain and particularly in a young fit patient with lobar pneumonia and no underlying diseases
- Second-line drugs in hospital care: moxifloxacin 400 mg once daily i.v. or by mouth; levofloxacin 500 mg twice daily or 750 mg once daily i.v. or by mouth
- Oral medication as soon as the patient is haemodynamically stable, there are clinical signs of recovery and the patient is able to swallow medication. The drugs used after intravenous treatment are the same as used for pneumonia in outpatient care.
- Antimicrobials can usually be discontinued after 10 days or at the latest when CRP has normalised. There is no need to routinely monitor CRP if the patient is recovering normally.
Other treatment
- If no response to therapy within 2-4 days, specify the aetiology, supplement the antimicrobial medication to cover chlamydia and mycoplasma, try to exclude complications in very ill patients (pleural effusion, empyema, pulmonary abscess) and don't hesitate to consult a specialist whenever necessary.
- Assess a hospitalised patient's need for oxygen therapy (pulse oximetry, blood gases).
- Manage dehydration.
- Avoid unnecessary antipyretic and antitussive medication.
- Treat other existing diseases (heart failure, diabetes).
- All patients must be followed up and offered additional investigations and treatment should recovery not progress as expected.
- A repeat x-ray is indicated in patients over 50 years and smokers, but not before 8 weeks have elapsed from the completion of treatment. However, repeat the x-ray within 2 weeks if the symptoms have not subsided.
- Recovery often takes a long time; extend sick leave accordingly.
Indications for hospital treatment
- If pneumonia has had a violent start (symptoms have developed within a few hours), suspect a pneumococcal infection and refer the patient to a hospital without delay.
- Hospital treatment is recommended, if the patient has
- at least one of the following signs suggesting severe pneumonia:
- a severe primary disease (severe pulmonary disease, cancer, hepatic, renal or cardiac failure, cerebrovascular disturbance) or immunosuppression
- extensive changes involving several pulmonary lobes or both lungs
- poor general condition without the above-mentioned findings.
- Respiratory rate ≥ 25/min and oxygen saturation≤ 93% in a patient less than 50 years of age suggest a severe disease. CRP concentration > 100 mg/l may also suggest a severe or rapidly progressing pneumonia.
- Hospitalisation may be indicated even if symptoms are mild, if any of the following is present:
- vomiting which prevents the intake of medication
- dyspnoea and other complications
- problems with differential diagnosis
- severe primary disease
- immunosuppression
- unsatisfactory home situation.