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.
