Management Of Community Acquired Pneumonia

From Wikiversity
Jump to: navigation, search

Diagnostic Tests[edit]

  • CBCD, electrolytes, glucose, BUN, Cr
  • ABG on RA
  • blood cultures (draw 2 before treatment, at least 10 min. apart)
  • sputum gram stain and culture
  • CXR (PA and lateral)
  • acid fast stain of sputum if cough > 1 month or suspicious CXR for TB
  • thoracocentesis if pleural effusions present
    • stain, culture, pH, leukocyte count, differential

General Management[edit]

  • analgesics/antipyretics
  • ensure adequate hydration
  • oxygen therapy to O2 sat ≥ 90%
  • consult RT, PT, OT, speech language pathologist, dietician as needed

Hospitalization[edit]

  • When to admit
    • Age >65 yrs
    • Decreased immunity (cancer, diabetes, AIDS, splenectomy)
    • Mental status changes
    • Increased A-a gradient
    • Two or more lobes involved
    • No home
    • Organ failure (↑Cr, bone marrow suppression, severe hypotension, liver failure)
    • WBC > 30,000/mm3 or < 4000/mm3 (sepsis)

Treatment[edit]

  • if no pathogen identified, empirically treat
    • NO COMORBIDITIES: po macrolide or doxycycline
    • WITH COMORBIDITIES: po beta-lactam plus macrolide, or fluoroquinolone, quinolones (levofloxacin)
    • if suspect ASPIRATION: amoxicillin-clavulanate or levofloxacin and metronidazole
  • treat empirically until pathogen identified by sputum or blood culture, then use specific therapy
  • OUTPATIENT: treat for 10 - 14 days
    • Followup with GP, CXR in 8-12 weeks
  • INPATIENT: treatment length based on response to therapy, comorbid illnesses, complications
    • usually treat bacterial infections until patient is afebrile for >72 hours
      • resolution of respiratory symptoms, fever, PaO2 level, WBC, and findings on serial CXR
  • give influenza and pneumococcal vaccine on day of discharge
  • smoke cessation

Poor prognostic factors[edit]

  • age, men, nursing home
  • comorbidities: cancer, liver, CHF, CVD, renal
  • O/E: LOC, RR, BP, pulse, temperature
  • labs: pH, pO2, ↓hematocrit, ↑BUN, ↓Na, ↑glucose, pleural effusion

Other OSCE modules[edit]