Pneumonia
Posted by dkwinter

See also: 
     Cough/shortness of breath Ddx
     Pneumococcal pneumonia
     Staphylococcus aureus pneumonia
     Staphylococcus epidermis pneumonia
     Atypical pneumonia
          Hemophilus influenzae
          Legionella pneumonia
     Age-appropriate Pediatric Fever Without a Source workup
Hx
     Smoker
Sx
     Purulent cough
     Feverddd
     Chills
     Pleuritic chest pain
     Tachypnea     

     Dyspnea
PE
     Nasal flaringdkj
     Grunting
     Dullness on percussion
     Rales
Workup
     CBC
     Sputum Gram stain and culture
     CXR
     CT-chest
     ECG
     PPD
CXR
     Unilateral pleural effusion due to an empyema or parapneumonic effusion
Dx
     Absolute requirement is infiltrate on CXR plus clinical findings suggestive of pneumonia
Etiologies
     In neonates (<4 wk)
          Group B steptococci
          E. coli
     In children (4wk-18yr)
          Viruses (RSV)
          Mycoplasma
          Chlamydia pneumoniae
          Streptococcus pneumoniae
     Adults (18-40yr)
          Mycoplasma
          C. pneumoniae
          S. pneumoniae
     Adults (40-65yr)
          S. pneumoniae
          H. influenzae
          Anaerobes
          Viruses
          Mycoplasma
     Elderly
          S. pneumoniae
          Influenza virus
          Anaerobes     
          H. influenzae
          Legionella (classically associated with GI symptoms and relative bradycardia)
          Gram-negative rods
     Co-infection with multiple bacteria, such as Chlamydia and S. pneumoniae, is a well-recognized occurrence and should be sought out to ensure appropriate antibiotic coverage
     S. pneumoniae
          Risk factors for developing S. pneumoniae pneumonia include:
               Elderly (>65)
               Hx of alcoholism
               Hx of diabetes
               Hx of cardiovascular disease
               Hx of splenectomy
               Hx of sickle cell disease
               Hx of malignancy
               Hx of immunosuppressive disorders
          Vaccination is recommended for all people at increased risk
Tx
     A gram stain of a good sputum sample can suggest additional coverage needs in a particular patient, such as:
          Adding an anti-pseudomonal penicillin
          Adding coverage for G+ cocci in clusters
          Adding coverage for G- rods
Tx, CA-PNA, outpatient
     Macrolide (e.g. azithromycin)
     OR
     Doxycycline
     OR
     Fluoroquinolone (generally not necessary--avoid sending it home)
Tx, CA-PNA, admitted
     Levoquin standalone
     OR
     Ceftriaxone + a macrolide
          In this combination, the ceftriaxone does most of the work clearing G+ like Strep and H. influenza, the macrolide covers atypicals
Tx, HA-PNA
     Combo 1:
          Vancomycin (for MRSA) + 
          Zosyn (Piperacillin + Tazobactam [Strep, G-, Pseudomonas])
          Levaquin (Strep, G-, Pseudomonas, Atypicals, H. influenza)
     OR
     Combo 2:
          Vancomycin + Zosyn + Gentamycin
     OR
     Combo 3:
          Vancomycin + Zosyn + Tobramycin
Disposition
     Admission
          The decision whether to admit or discharge patients diagnosed with pneumonia in the ED is not straightforward. Despite numerous guidelines including those recommending admission for patients with co-morbid disease such as HIV, CHF, malignancy, renal disease, liver disease and others, the decision ultimately resides in the clinical judgement of the emergency department physician.
          Most patients with normal vital signs are typically well enough to be treated as outpatients, but circumstances may exist in which this choice is not optimal, such as an elderly patient who lives alone and has poor follow-up.