J13/J14/J15.0-9/J16.0/8/J18.0-2/J18.8-9
Pneumonia is an acute infection of the lung parenchyma. Early appropriate antibiotic therapy decreases mortality. The decision to hospitalise a patient and choice of initial antibiotic therapy is guided by age, comorbid diseases (such as HIV infection, diabetes or chronic respiratory disease), and severity.
Socio-economic circumstances should form part of the clinical assessment when deciding if a patient is suitable for outpatient treatment.
GENERAL MEASURES
Diagnosis:
Clinical features include cough, fever, tachypnoea, and signs of consolidation on chest examination.
CXR almost invariably shows a focal area of opacification or consolidation. However, empiric antibiotic therapy can be considered for severely ill hospitalised patients with suspected pneumonia and a negative CXR – pneumonia is excluded if repeat CXR after 24-48 hours still shows no opacification. Diffuse bilateral interstitial infiltrates in a patient with HIV infection and hypoxaemia is suggestive of Pneumocystis jirovecii pneumonia.
All patients should be offered HIV testing as HIV infection is associated with a markedly increased risk of bacterial pneumonia.
Even in typical cases of pneumonia, exclude tuberculosis by sending sputum for Xpert MTB/RIF Ultra®.
A follow-up CXR 4–6 weeks after completion of therapy should be done in patients >50 years of age, or if symptoms persist.
Follow-up CXRs are indicated earlier only when complications are suspected, e.g. empyema, abscess, or pneumothorax.
MEDICINE TREATMENT
- Oxygen, if saturation <94%.
Adequate analgesia for pleuritic chest pain, if present. See section 26.2.1: Medical conditions associated with severe pain.
Antimicrobial therapy
Duration of antibiotic therapy is guided by clinical response, but should be 5–7 days, with a minimum of 7 days for MRSA or Pseudomonas.
Longer duration of antibiotic therapy recommended for:
- pathogen identified that was not susceptible to initial empiric therapy
- extrapulmonary infection (e.g. meningitis or endocarditis)
- empyema, lung abscess or necrotizing pneumonia
- unusual organism present
Prolonged fever and clinical signs may be due to unrecognised TB, or of complications (such as empyema), or the incorrect choice of antibiotic (e.g. atypical bacteria), or to an underlying bronchus obstruction (foreign body or carcinoma). These patients should be further investigated.
Community-acquired pneumonia without features of severe pneumonia (see below for definition) and without co-morbidity and in patients <65 years of age J18.0-2/J18.8-9
- Ampicillin, IV, 1 g 6 hourly.
In haemodynamically stable patients with respiratory rate <25 breaths/min and the temperature is <37.8C switch to:
- Amoxicillin, oral, 1 g 8 hourly.
Severe penicillin allergy: (Z88.0)
- Moxifloxacin, oral, 400 mg daily for 5 days.
If poor response after 48 hours, exclude TB and consider atypical bacterial pneumonia, which requires treatment with a macrolide.
Community-acquired pneumonia without features of severe pneumonia (see below for definition) in patients >65 years of age or co-morbidity (e.g. COPD, HIV, cardiac failure, diabetes) J13/J14/J15.0-9/J16.0/J16.8/J18.0-2/J18.8-9
- Ceftriaxone, IV, 2 g daily.
In haemodynamically stable patients with respiratory rate <25 breaths/min and the temperature is <37.8C switch to:
- Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 days.
Severe penicillin allergy: (Z88.0)
- Moxifloxacin, oral, 400 mg daily for 5 days.
If poor response after 48 hours, exclude TB and consider atypical bacterial pneumonia, which requires treatment with a macrolide.
Severe pneumonia (cyanosis, confusion, hypotension or respiratory rate >30 breaths/min): J13/J14/J15.0-9/J16.0/J16.8/J18.0-2/J18.8-9
- Mechanical ventilation may be required (refer to a centre, if needed).
- Ceftriaxone, IV, 2 g daily:
In haemodynamically stable patients with respiratory rate <25 breaths/min and the temperature is <37.8C switch to:
- Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 days.
AND
- Azithromycin, 500 mg, slow IV (over not less than 60 minutes) daily for 3 days.
Severe penicillin allergy: (Z88.0)
- Moxifloxacin, IV, 400 mg daily.
In haemodynamically stable patients with respiratory rate <25 breaths/min and the temperature is <37.8C switch to:
- Moxifloxacin, oral, 400 mg daily for 5 days.
Note: There is no need to add a macrolide, as moxifloxacin has adequate cover for the atypical bacteria.
HIV infected with bilateral diffuse interstitial infiltrates on CXR
Clinically may present with a dry cough of <12 weeks’ duration and significant tachypnoea.
Treat as Pneumocystis jirovecii pneumonia (exclude TB) - see Pneumocystis pneumonia.