We stressed the management which includes:
Stabilize the patient:
- IV fluids, pressors if required, oxygen, mechanical ventilation if required. Early goal directed therapy.
Obtain microbiological specimens:
- sputum, blood culture, legionella urinary antigen if appropriate, other special tests as appropriatge
- pathogens most likely: streptococcus pneumoniae, haemophilus influenza, moraxella catarrhalis, staphylococcus aureus (including MRSA if risk factors), legionella, mycoplasma pneumoniae, chlamydia pneumoniae
Empiric antibiotic therapy (within 4h)
- Cover the most likely pathogens
- IDSA/ATS joint guidelines (are being revised to make more use of beta-lactams -- my suggestions include these guidelines and some new evidence)
- Healthy young person: macrolide (like azithromycin 500mg po x1 then 250mg po OD x 4d), beta-lactam like amoxicillin (1g po TID)
- Older, more ill:
- respiratory fluoroquinolone (like levofloxacin -- 750mg po Q24h x 5days)
- beta-lactam (ceftriaxone 1g IV q24, amoxicillin - high dose) plus macrolide
- MRSA: vancomycin (1g IV q12, renal dosed)
- Pseudomonas or other hospital acquired: Piperacillin-Tazobactam (4.5g IV q8h infuse over 4 hours) or Meropenem (1g IV q8h infuse over 4 hours)
Decision re: admission
Decision re: sending home
- Eating, drinking, mobilizing
- Off oxygen
- Ideally afebrile
- tolerating PO antibiotics
- Reliable follow up
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