Pneumonia medical therapy: Difference between revisions

	Pneumonia Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Pneumonia from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Criteria
Diagnostic Algorithm
History and Symptoms
Physical Examination
Laboratory Findings
Chest X Ray
CT
Other Imaging Findings
Treatment
Medical Therapy
Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Pneumonia medical therapy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Pneumonia medical therapy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Pneumonia medical therapy
CDC onPneumonia medical therapy
Pneumonia medical therapy in the news
Blogs on Pneumonia medical therapy
Directions to Hospitals Treating Pneumonia
Risk calculators and risk factors for Pneumonia medical therapy

VisualWikitext

Latest revision as of 23:45, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2], Alejandro Lemor, M.D. [3]; Priyamvada Singh, M.D. [4]

Overview

The majority of pneumonia cases can be treated with outpatient therapy. However, patients with severe disease, comorbidities, and/or complications usually require hospitalization. Antimicrobial therapy is indicated in pneumonia and it depends on whether the patient is receiving inpatient or outpatient therapy and whether the infection was community or hospital-acquired. Supportive therapy includes adequate hydration, rest, and home care.

Medical Therapy

General Considerations

The treatment of pneumonia involves three critical decisions: first whether the patient truly has pneumonia, second what is the severity of the pneumonia, and last whether hospitalization is required for adequate management.
Treatment for pneumonia should ideally be based on the causative microorganism and its known antibiotic sensitivity. However, a specific cause for pneumonia is identified in only 50% of people, even after extensive evaluation.
Since treatment should generally not be delayed in any person with a serious pneumonia, empiric treatment is usually started well before laboratory reports are available. In both cases, a person's risk factors for different organisms must be remembered when choosing the initial antibiotics (empiric therapy).
In general, all therapies in older children and adults will include treatment for atypical bacteria. Typically this is a macrolide antibiotic such as azithromycin or clarithromycin although a fluoroquinolone such as levofloxacin can substitute.
Treatment of viral pneumonia caused by influenza is beneficial only if they are started within 48 hours of the onset of symptoms.
Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine.
There are no known effective treatments for viral pneumonias caused by the SARS coronavirus, adenovirus, hantavirus, or parainfluenza virus.
Fungal pneumonia can be treated with antifungal drugs and sometimes by surgical debridement.
Antibiotics are used to treat bacterial pneumonia. In contrast, antibiotics are not useful for viral pneumonia, although they sometimes are used to treat or prevent bacterial infections that can occur in the lungs that are damaged by a viral pneumonia. The antibiotic choice depends on:
- Nature of the pneumonia
- Microorganisms endemic to a local geographic area
- Immune status
- Underlying health of the individual

Initiation of treatment

Starting effective treatment within 4-8 hours may reduce mortality.^[1]

Duration of treatment

Randomized controlled trials have addressed short course of therapy:

For outpatients, less than 7 days^[2]^[3]
For inpatients, the role of individualizing duration of treatment is uncertain.^[4]

Serial measurement of procalcitonin levels can reduce length of exposure to antibiotics from 6.2 to 5.7 days (95% CI: -2.71 to -2.15; P < 0.001)^[5] or 10.5 to 8.0 (95% CI: -2.87 to -2.02; P < 0.001)^[6]

Pediatrics

Most newborn infants with CAP are hospitalized and given intravenous ampicillin and gentamicin for at least ten days. This treats the common bacteria streptococcus agalactiae, listeria monocytogenes, and escherichia coli. If herpes simplex virus is the cause, intravenous acyclovir is administered for 21 days.
Treatment of CAP in children depends on both the age of the child and the severity of his/her illness. Children less than five do not typically receive treatment to cover atypical bacteria. If a child does not need to be hospitalized, amoxicillin for seven days is a common treatment. However, with increasing prevalence of DRSP, other agents such as cefpodoxime will most likely become more popular in the future.
Hospitalized children should receive intravenous ampicillin, ceftriaxone, or cefotaxime.

Antimicrobial Regimens

1. Community-acquired pneumonia

1.1 Empiric therapy in adults ^[7]

1.1.1 Outpatient treatment

1.1.1.1 Previously healthy and no use of antimicrobials within the previous 3 months

Preferred regimen (1): (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days) OR Azithromycin 500 mg IV single dose
Preferred regimen (2): Clarithromycin 250 mg PO bid for 7-14 days OR Clarithromycin 1000 mg PO qd for 7 days
Preferred regimen (3): Erythromycin 250-500 mg PO bid or tid (maximum daily dose 4 g)
Alternative regimen: Doxycycline 100 mg PO/IV q12h

1.1.1.2 Presence of comorbidities, use of immunosuppressing drugs, or use of antimicrobials within the previous 3 months

Preferred regimen (1): Levofloxacin 500 mg PO qd for 7-14 days OR Levofloxacin 750 mg PO qd for 5 days OR Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR Gemifloxacin 320 mg PO qd for 5 or 7 days
Preferred regimen (2): (Amoxicillin 1 g PO q8h OR Amoxicillin-clavulanate 1-2 g PO bid OR Ceftriaxone 1-2 g IV q24h OR Cefpodoxime 200 mg PO bid for 14 days OR Cefuroxime 750 mg IM/IV q8h) AND either (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days) OR (Clarithromycin 250 mg PO bid for 7-14 days OR Clarithromycin 1000 mg PO qd for 7 days) OR Erythromycin 250-500 mg PO bid or tid (maximum daily dose 4 g)
Note: In the case of recent (past 3 months) antimicrobial therapy, an alternative from a different class should be selected.

1.1.2 Inpatient treatment

1.1.2.1 Non-ICU treatment

Preferred regimen (1): Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days OR Moxifloxacin 400 mg IV q24h for 7-14 days OR Gemifloxacin 320 mg PO qd for 5-7 days
Preferred regimen (2): (Amoxicillin 1 g PO q8h OR Amoxicillin-clavulanate 1-2 g PO bid OR Ceftriaxone 1-2 g IV q24h OR Cefpodoxime 200 mg PO bid for 14 days OR Cefuroxime 750 mg IM/IV q8h) AND either (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days) OR (Clarithromycin 250 mg PO bid for 7-14 days OR Clarithromycin 1000 mg PO qd for 7 days) OR Erythromycin 250-500 mg PO bid or tid (maximum daily dose 4 g)

1.1.2.2 ICU treatment

Preferred regimen (1): (Cefotaxime 1 g IM/IV q12h OR Ceftriaxone 1-2 g IV q24h OR Ampicillin-sulbactam 1.5-3 g IV q6h) AND (Levofloxacin 500 mg IV q24h for 7-14 days OR Levofloxacin 750 mg IV q24h for 5 days OR Moxifloxacin 400 mg IV q24h for 7-14 days OR Gemifloxacin 320 mg PO q24h for 5-7 days)
Alternative regimen (1): (Cefotaxime 1 g IM/IV q12h OR Ceftriaxone 1-2 g IV q24h OR Ampicillin-sulbactam 1.5-3 g IV q6h) AND (Azithromycin 500 mg IV qd for 2 days (PO for a total of 7-10 days)
Alternative regimen (2): Aztreonam 2 g IV q6-8h (maximum daily dose 8 g) AND (Levofloxacin 500 mg IV q24h for 7-14 days OR Levofloxacin 750 mg IV q24h for 5 days OR Moxifloxacin 400 mg IV q24h for 7-14 days OR Gemifloxacin 320 mg PO q24h for 5-7 days)

1.1.3 Special considerations

1.1.3.1 Suspected Pseudomonas

Preferred regimen (1): Piperacillin-Tazobactam 3.375-4.5 g IV q6h for 7-14 days AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days)
Preferred regimen (2): Cefepime 1-2 g IV q8-12h for 7-10 days AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days)
Preferred regimen (3): (Imipenem 500 mg IV q6h for ≤5 days OR Meropenem 500 mg IV q8hr for ≤5 days) AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days)
Preferred regimen (4): Piperacillin-Tazobactam 3.375-4.5 g IV q6h for 7-14 days AND (Amikacin 20 mg/kg/day IV q8-12h OR Gentamicin 3-5 mg/kg/day IV/IM q8h OR Tobramycin 3-6 mg/kg/day IV/IM q8h) AND (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days)
Preferred regimen (5): Cefepime AND (Amikacin 20 mg/kg/day IV q8-12h OR Gentamicin 3-5 mg/kg/day IV/IM q8h OR Tobramycin 3-6 mg/kg/day IV/IM q8h) AND (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days)
Preferred regimen (6): (Imipenem 500 mg IV q6h for ≤5 days OR Meropenem 500 mg IV q8hr for ≤5 days) AND (Amikacin 20 mg/kg/day IV q8-12h OR Gentamicin 3-5 mg/kg/day IV/IM q8h OR Tobramycin 3-6 mg/kg/day IV/IM q8h) AND (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days)
Preferred regimen (7): (Imipenem 500 mg IV q6h for ≤5 days OR Meropenem 500 mg IV q8hr for ≤5 days) AND (Amikacin 20 mg/kg/day IV q8-12h OR Gentamicin 3-5 mg/kg/day IV/IM q8h OR Tobramycin 3-6 mg/kg/day IV/IM q8h) AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg PO qd for 7-14 days OR Levofloxacin 750 mg PO qd for 5 days)
Preferred regimen (8): Piperacillin-Tazobactam 3.375-4.5 g IV q6h for 7-14 days AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days)
Preferred regimen (9): Cefepime 1-2 g IV q8-12h for 7-10 days AND (Amikacin 20 mg/kg/day IV q8-12h OR Gentamicin 3-5 mg/kg/day IV/IM q8h OR Tobramycin 3-6 mg/kg/day IV/IM q8h) AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days)
Preferred regimen (10): (Imipenem 500 mg IV q6h for ≤5 days OR Meropenem 500 mg IV q8hr for ≤5 days) AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg PO qd for 7-14 days OR Levofloxacin 750 mg PO qd for 5 days)
Note: For penicillin-allergic patients, substitute the beta-lactam for Aztreonam 1-2 g IV q6-8h.

1.1.3.2 Suspected methicillin resistant Staphylococcus aureus (add the following)

Preferred regimen: Vancomycin 45-60 mg/kg/day divided q8-12h OR Linezolid 600 mg PO/IV q12h for 10-14 days

1.1.3.3 Neutropenic patient ^[8]

1.1.3.3.1 No risk for multi-drug resistance

Preferred regimen: Ceftriaxone 1-2 g q24h IV or IM (max: 4 g/day) OR Levofloxacin 750 mg q24h for 7-14 days OR Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR Ciprofloxacin 400 mg PO q8h for 10-14 days OR Ampicillin sulbactam 1-2 g q6-8h IV/IM (maximum: 8 g/day) OR Ertapenem 1 g IM/IV q24h for 10-14 days.

1.1.3.3.2 Risk for multi drug resistance

Preferred Regimen: (Cefepime 1-2 g q8-12h OR Ceftazidime 2 g q8h OR Imipenem 500 mg q6h or 1g q8h OR Meropenem 1 g q8h OR Piperacillin-tazobactam 4.5 g q6h) AND (Ciprofloxacin 400 mg q8h OR Levofloxacin 750 mg q24h OR Amikacin 20 mg/kg per day OR Gentamycin 7 mg/kg per day OR Tobramycin 7 mg/kg per day) AND (Linezolid 600 mg q12h OR Vancomycin 15 mg/kg q12h).
Note (1) : Trough levels for Gentamycin and Tobramycin should be less than 1 g/ml, and for Amikacin they should be less than 4-5 g/ml.
Note (2) : Trough levels for Vancomycin should be 15-20 g/ml
Note (3) : Hospital or community acquired, neutropenic patient (<500 neutrophils per mm3) Vancomycin not included in initial therapy unless high suspicion of infected intravenous access or drug-resistant Streptococcus pneumonia. Amphotericin not used unless still febrile after 3 days or high clinical likelihood.

1.2 Pathogen-directed antimicrobial therapy

1.2.1 Bacterial pathogens

1.2.1.1 Streptococcus pneumoniae

1.2.1.1.1 Penicillin sensitive (minimum inhibitory concentration < 2 mg/mL)

Preferred regimen : Penicillin G 2-3 million units IV q4h OR Amoxicillin 875 mg PO q12h or 500 mg q8h
Alternative regimen : Azithromycin 500 mg PO on day 1 followed by 250 mg q24h OR Cefpodoxime 200 mg PO q12h for 14 days OR Cefprozil 500 mg PO q12h for 10 days OR Cefuroxime 750 mg PO/IV q8h OR Cefdinir 300 mg PO q12h for 10 days OR Cefditoren 400 mg PO q12h for 14 day OR Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR Cefotaxime 1 g IM/IV q12h OR Clindamycin 150-450 mg PO q6-8h (maximum: 1800 mg/day) OR Clindamycin 1.2-2.7 g/day IM/IV in 2-4 divided doses (maximum:4800 mg/day) OR Doxycycline 100 mg PI/IV q12h ORLevofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h

1.2.1.1.2 Penicillin resistant (minimum inhibitory concentration > 2 mg/mL)

Preferred regimen (Agents chosen on the basis of susceptibililty) : Cefotaxime 1 g IM/IV q12h OR Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h
Alternative regimen: Vancomycin 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity OR Linezolid 600 mg PO/IV q12h for 10-14 days OR Amoxicillin 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin, minimum inhibitory concentration 4 ≤ microgram / mL)

1.2.1.2 Haemophilus influenzae

1.2.1.2.1 Non-beta lactamase producing

Preferred regimen: Amoxicillin 875 mg PO q12h or 500 mg q8h
Alternative regimen : Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h OR Doxycycline 100 mg PO/IV q12h OR Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR Clarithromycin 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days

1.2.1.2.2 Beta lactamase producing

Preferred regimen: 2nd or 3rd Generation Cephalosporin OR Amoxicillin-clavulanate 2 g q12h
Alternative regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h OR Doxycycline 100 mg PO/IV q12h OR Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR Clarithromycin 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days

1.2.1.2 Bacillus anthracis (inhalational)

Preferred Regimen :Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR Doxycycline 100 mg PO/IV q12h
Alternate Regimen : Other Fluoroquinolones OR B-lactam (if susceptible) OR Rifampin 600 mg PO/IV q24h for 4 days OR Clindamycin 150-450 mg PO q6-8h OR Chloramphenicol 50-100 mg/kg/day IV in divided q6h

1.2.1.3 Enterobacteriaceae

Preferred Regimen: 3rd generation cephalosporin OR Carbapenem- (Imipenem-Cilastatin, OR Meropenem, OR Ertapenem) (drug of choice if extended-spectrum b-lactamase producer)
Alternate Regimen : b-Lactam / b-lactamase inhibitor- (Piperacillin-Tazobactam for gram-negative bacilli, OR Ticarcillin-Clavulanate OR Ampicillin-Sulbactam OR Amoxicillin-Clavulanate) OR (Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h)

1.2.1.4 Pseudomonas aeruginosa

Preferred Regimen: (Ticarcillin 200-300 mg/kg/day in divided doses q4-6h (maximum: 18 g/day) OR Piperacillin 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h OR Ceftazidime 500 mg to 1 g q8h OR Cefepime 1-2 g q12h for 10 days OR Aztreonam 2 g IV q6-8h (maximum: 8 g/day) OR Imipenem 500 mg IV q6h OR Meropenem 500 mg IV q8h) AND (Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 750 mg daily OR Aminoglycoside)
Alternative Regimen: Aminoglycoside AND (Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 750 mg daily)

1.2.1.5 Staphylococcus aureus

1.2.1.5.1 Methicillin sensitive

Preferred Regimen : Nafcillin 1000-2000 mg q4h OR Oxacillin 2 g IV q4h OR Flucloxacillin 250 mg IM/IV q6h
Alternative Regimen : Cefazolin 500 mg IV q12h OR Clindamycin 150-450 mg PO q6-8h

1.2.1.5.2 Methicillin resistant

Preferred Regimen : Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days OR Linezolid 600 mg PO/IV q12h for 10-14 days
Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h

1.2.1.6 Klebsiella pneumonia^[9]

1.2.1.6.1 Resistant to third generation cephalosporins and aztreonam

Preferred regimen (1): Imipenem 0.5 g IV q6h OR Meropenem 0.5–1 g IV q8h

1.2.1.6.2 Klebsiella pneumoniae Carbapenemase producers

Preferred regimen (1): Colistin (=Polymyxin E).In USA : Colymycin-M 2.5-5 mg/kg per day of base divided into 2-4 doses 6.7-13.3 mg/kg per day of colistimethate sodium (max 800 mg/day). Elsewhere: Colomycin and Promixin ≤60 kg, 50,000-75,000 IU/kg per day IV in 3 divided doses (=4-6 mg/kg per day of colistimethate sodium). >60 kg, 1-2 mill IU IV tid (= 80-160 mg IV tid) OR Polymyxin B (Poly-Rx) 15,000–25,000 units/kg/day divided q12h
Note (1): some strains which hyperproduce extended spectrum beta-lactamase are primarily resistant to Ticarcillin-Clavulanate, Piperacillin-Tazobactam
Note (2): Extended spectrum beta-lactamases inactivates all Cephalosporins, beta-lactam/beta-lactamase inhibitor drug activation not predictable; co-resistance to all Fluoroquinolones & often Aminoglycosides.
Note (3): Can give IM, but need to combine with “caine” anesthetic due to pain.

1.2.1.7 Moraxella catarrhalis

Preferred regimen: Amoxicillin-Clavulanate (Augmentin) 2 tablets po bid ( (or)500/125 mg 1 tablet po tid (or) 875/125 mg 1 tablet po bid) OR Cephalosporins- Cefdinir 300 mg po q12h (or) 600 mg q24h, OR (Cefditoren pivoxil 200–400 mg, 2 tabs po bid,OR Cefpodoxime proxetil 0.1–0.2 g po q12h, OR Cefprozil 500 mg po q12h), OR Cefoxitin 1 g q8h–2 g IV/IM q4h, OR (Cefuroxime 0.75–1.5 g IV/IM q8h,ORCefotaxime 1 g q8–12h to 2 g IV q4h, OR Ceftazidime 1–2 g IV/IM q8–12h) OR Trimethoprim-Sulfamethoxazole Single-strength (SS) is Trimethoprim 80 mg / Sulfamethoxazole 400 mg ,OR (double-strength (DS) Trimethoprim 160 mg /Sulfamethoxazole 800 mg)
Alternative regimen: Azithromycin 500 mg IV q24h ,OR Clarithromycin 0.5 g po q12h, OR Telithromycin 800 mg po q24h (two 400 mg tabs po q24h).

1.2.1.8 Stenotrophomonas maltophilia

Preferred regimen: Trimethoprim-Sulfamethoxazole Single-strength (SS) tablet is Trimethoprim 80 mg / Sulfamethoxazole 400 mg, double-strength (DS) tablet is Trimethoprim 160 mg / Sulfamethoxazole 800 mg OR IV treatment (base on TMP component): standard 8–10 mg per kg per day divided q6h, q8h, or q12h.
Alternative regimen: Ticarcillin-Clavulanate 3.1 g IV q4–6h (Ticarcillin 3 g, Clavulanate 0.1 g per vial) AND Aztreonam 1 g IV q6h (or) 2 g IV q8h
Note (1): Potential synergy with Trimethoprim-Sulfamethoxazole AND Ticarcillin-Clavulanate.
Note (2): Stenotrophomonas is one of the microorganisms causing hospital-acquired pneumonia usually with mechanical ventilation.

1.2.1.9 Bordetella pertussis

Preferred Regimen:Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h

1.2.1.10 Anaerobes (aspiration pneumonia)

Preferred Regimen: Piperacillin-Tazobactam 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) OR Ticarcillin Clavulanate 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) OR Ampicillin-Sulbactam 1500-3000 mg IV q6h OR Amoxicillin-Clavulanate 250-500 mg PO q8h or 875 mg q12h OR Clindamycin 150-450 mg PO q6-8h (max: 1800 mg/day)
Alternative Regimen: Carbapenem -(Imipenem-Cilastatin, OR Meropenem, OR Ertapenem)

1.2.1.11 Mycobacterium tuberculosis

1.2.1.11.1 Intensive phase

Preferred Regimen: Isoniazid 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) AND Ethambutol 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) AND Pyrazinamide 1000 - 2000 mg / day daily for 2 months.
Alternative regimen (1): Isoniazid 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) AND Ethambutol 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) AND Pyrazinamide 1000 - 2000 mg / day daily for 2 months.
Alternative regimen (2): Isoniazid 5 mg/kg/day q24h 3 times per week for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day 3 times per week for 2 months (maximum: 600 mg / day) s AND Ethambutol 5-25 mg/kg (maximum dose: 1.6 g) 3 times per week for 2 months AND Pyrazinamide 1000 - 2000 mg / day 3 times per week for 2 months.

1.2.1.11.2 Continuation phase

Preferred Regimen:Isoniazid 300 mg/day PO daily for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO daily for 4 months (10 mg/kg/day)
Alternative regimen (1): Isoniazid 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day)

1.2.1.12 Yersinisa pestis

Preferred Regimen: Streptomycin 15 mg/kg/day (max 1 g/day) OR Gentamicin 7 mg/kg/day
Alternate Regimen: Doxycycline 100 mg PO/IV q12h OR Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h

1.2.1.13 Atypical bacteria

1.2.1.13.1 Mycoplasma pneumoniae

Preferred Regimen:Azithromycin 500 mg PO on day 1 followed by 250 mg q24h OR Tetracycline Oral: 250-500 mg q6h
Alternate Regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h

1.2.1.13.2 Chlamydophila pneumoniae

Preferred Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h OR Tetracycline 250-500 mg PO q6h
Alternate Regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h

1.2.1.13.3 Legionella spp.

Preferred Regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h OR Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
Alternate Regimen: Doxycycline 100 mg PO/IV q12h

1.2.1.13.4 Chlamydophila psittaci

Preferred Regimen: Tetracycline 250-500 mg PO q6h
Alternate Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h

1.2.1.13.5 Coxiella burnetii

Preferred Regimen: Tetracycline 250-500 mg PO q6h
Alternate Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h

1.2.1.13.6 Francisella tularensis

Preferred Regimen: Doxycycline 100 mg PO/IV q12h
Alternate Regimen: Gentamicin 7 mg/kg/day OR Streptomycin 15 mg/kg/day (maximum: 1 g)

1.2.1.13.7 Burkholderia pseudomallei

Preferred Regimen : Carbapenem -(Imipenem-Cilastatin, OR Meropenem, OR Ertapenem) OR Ceftazidime 0.5-1 g q8h
Alternate Regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h OR Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h

1.2.1.13.8 Acinetobacter species

Preferred Regimen : Carbapenem-(Imipenem-Cilastatin, OR Meropenem, OR Ertapenem)
Alternate Regimen: Cephalosporin-Aminoglycoside OR Ampicillin-Sulbactam OR Colistin 2.5-5 mg/kg/day IM/IV divided q6-12h (maximum: 5 mg/kg/day)

1.2.1.14 Gram-positive filamentous bacteria

1.2.1.14.1 Actinomyces spp.^[10]^[11]

Preferred regimen: Penicillin V 1 g po qid 2-6 wk
Alternative regimen: Tetracycline 500 mg po q 6 h OR Doxycycline 100 mg q 12 h
Note: Minocycline, Clindamycin, and Erythromycin have also been successful.

1.2.1.14.2 Nocardia spp.^[12], ^[13], ^[14]

1.2.1.14.2.1 Initial intravenous therapy (induction therapy)

Preferred regimen: Trimethoprim-Sulfamethoxazole (15 mg/kg/day IV of the trimethoprim component in 2 to 4 divided doses) for at least three to six weeks AND Amikacin (7.5 mg/kg IV q12h) for at least three to six weeks
Alternative regimen: Imipenem (500 mg IV q6h) AND Amikacin (7.5 mg/kg IV q12h)
Note (1): If the patient is allergic to Sulfonamides, desensitization should be performed when possible.
Note (2): If the isolate is susceptible to the third-generation cephalosporins (Ceftriaxone, Cefotaxime), Imipenem can be switched to one of these agents.
Note (3): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.

1.2.1.14.2.2 Oral maintenence therapy

Preferred regimen: A sulfonamide (eg,Trimethoprim-Sulfamethoxazole 10 mg/kg/day of the trimethoprim component in 2 or 3 divided doses) AND / OR Minocycline (100 mg bd) AND / OR Amoxicillin-Clavulanate (875 mg bd)
Note (1): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.
Note (2): The duration of intravenous therapy varies with the patient's immune status. In immunocompromised patients, maximal tolerated doses should be given intravenously for at least six weeks and until clinical improvement has occurred; in contrast, immunocompetent patients may be successfully treated with a shorter duration of intravenous therapy. Following the intravenous induction phase, patients may be stepped down to oral antibiotics based upon susceptibility studies
Note (3): Serious pulmonary infection is treated for 6 to 12 months or longer.

1.2.2 Viral pathogens

1.2.2.1 Influenza virus

Preferred Regimen: Oseltamivir 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) OR Zanamivir Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)

1.2.2.2 Cytomegalovirus^[15]

Preferred regimen (1): Ganciclovir Induction therapy 5 mg/ kg IV every 12 h for normal GFR; maintenance therapy 5 mg/kg IV daily; 1 g orally every 8 h with food.
Preferred regimen (2): Valganciclovir Induction therapy 900 mg orally every 12 h; maintenance therapy 900 mg daily.
Alternative regimen (1): Foscarnet Induction therapy 60 mg/ kg every 8 h for 14–21 days or 90 mg/kg every 12 h for 14–21 days; maintenance therapy 90–120 mg/kg per day as a single infusion.
Alternative regimen (2): Cidofovir Induction therapy 5 mg/ kg per week for 2 weeks, followed by maintenance therapy every 2 weeks.

1.2.3 Fungal pathogens

1.2.3.1 Coccidioides species

Preferred Regimen: Itraconazole 200 mg q12h OR Fluconazole 200-400 mg daily for 3-6 month
Alternative Regimen: Amphotericin B 0.5-0.7 mg/kg/day
Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection

1.2.3.2 Histoplasmosis

Preferred Regimen: Itraconazole 200 mg q12h
Alternative Regimen: Amphotericin B 0.5-0.7 mg/kg/day

1.2.3.3 Blastomycosis

Preferred Regimen: Itraconazole 200 mg q12h
Alternate Regimen: Amphotericin B 0.5-0.7 mg/kg/day

2. Health care-associated pneumonia^[8]

2.1 Empiric antimicrobial therapy

2.1.1 No risk factors for multi drug resistance

Preferred Regimen : Ceftriaxone 1-2 g q24h IV or IM (max: 4 g/day) OR Levofloxacin 750 mg q24h for 7-14 days OR Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR Ciprofloxacin 400 mg PO q8h for 10-14 days OR Ampicillin sulbactam 1-2 g q6-8h IV/IM (maximum: 8 g/day) OR Ertapenem 1 g IM/IV q24h for 10-14 days.

2.1.2 Risk factors for multi drug resistance

Preferred Regimen: (Cefepime 1-2 g q8-12h OR Ceftazidime 2 g q8h OR Imipenem 500 mg q6h or 1g q8h OR Meropenem 1 g q8h OR Piperacillin-tazobactam 4.5 g q6h) AND (Ciprofloxacin 400 mg q8h OR Levofloxacin 750 mg q24h OR Amikacin 20 mg/kg per day OR Gentamycin 7 mg/kg per day OR Tobramycin 7 mg/kg per day) AND (Linezolid 600 mg q12h OR Vancomycin 15 mg/kg q12h).
Note (1): Health care-associated pneumonia used to designate large diverse population of patients with many co-morbidities who reside in nursing homes, other long-term care facilities, require home intravenous therapy (or) are dialysis patients. Pneumonia in these patients frequently resembles hospital-acquired pneumonia.
Note (2): Trough levels for Gentamycin and Tobramycin should be less than 1 g/ml, and for Amikacin they should be less than 4-5 g/ml.
Note (3): Trough levels for Vancomycin should be 15-20 g/ml.

Pneumonia Site of Care Decision

Infectious Diseases Society of America/American Thoracic Society consensus recommendation on site of care for community-acquired pneumonia in adults

“

Hospital Admission Decision

Severity-of-illness scores, such as the CURB-65 criteria (confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater), or prognostic models, such as the Pneumonia Severity Index (PSI), can be used to identify patients with CAP who may be candidates for outpatient treatment. (Strong recommendation; level I evidence)^[7]
Objective criteria or scores should always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. (Strong recommendation; level II evidence)
For patients with CURB-65 scores >2, more-intensive treatment—that is, hospitalization or, where appropriate and available, intensive in-home health care services—is usually warranted. (Moderate recommendation; level III evidence)

Intensive Care Unit (ICU) Admission Decision

Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation. (Strong recommendation; level II evidence)
Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed in the Table below. (Moderate recommendation; level II evidence)

”

For Level of evidence classification click here.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Empiric Antibiotic Treatment of community-acquired pneumonia in adults

“

Previously Healthy and No Risk Factors for Drug-resistant Streptococcus Pneumoniae

A macrolide (azithromycin, clarithromycin, or erythromycin (Strong recommendation; level I evidence)^[7]

Doxycycline (Weak recommendation; level III evidence)

Presence of Comorbidities or Other Risks for Drug-resistant Streptococcus Pneumoniae

Presence of comorbidities, such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected); or other risks for DRSP infection:

A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) (Strong recommendation; level I evidence)
A beta-lactam plus a macrolide (Strong recommendation; level I evidence) (High-dose amoxicillin [e.g., 1 g 3 times daily] or amoxicillin-clavulanate [2 g 2 times daily] is preferred; alternatives include ceftriaxone, cefpodoxime, and cefuroxime [500 mg 2 times daily]; doxycycline (level II evidence) is an alternative to the macrolide.)

In Regions with a High Rate (>25%) of Infection

In regions with a high rate (>25%) of infection with high-level (minimal inhibitory concentration [MIC], >16 micrograms/mL) macrolide-resistant S. pneumoniae, consider the use of alternative agents for any patient, including those without comorbidities. (Moderate recommendation; level III evidence)

Inpatient, Non-ICU Treatment

The following regimens are recommended for hospital ward treatment.

A respiratory fluoroquinolone (Strong recommendation; level I evidence)

A beta-lactam plus a macrolide (Strong recommendation; level I evidence) (Preferred beta-lactam agents include cefotaxime, ceftriaxone, and ampicillin; ertapenem for selected patients; with doxycycline (level III evidence) as an alternative to the macrolide. A respiratory fluoroquinolone should be used for penicillin-allergic patients.)

Inpatient, ICU Treatment

The following regimen is the minimal recommended treatment for patients admitted to the ICU.

A beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin (level II evidence) or a fluoroquinolone (Strong recommendation; level I evidence) (For penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended.)

For Pseudomonas infection, use an antipneumococcal, antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750-mg dose)

or the above beta-lactam plus an aminoglycoside and azithromycin or the above beta-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for the above beta-lactam). (Moderate recommendation; level III evidence)

For community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) infection, add vancomycin or linezolid. (Moderate recommendation; level III evidence)

”

For Level of evidence classification click here.

Infectious Diseases Society of America/American Thoracic Society consensus recommendation on pandemic Influenza community-acquired pneumonia in adults

“

Pathogen-Directed Therapy

Once the etiology of CAP has been identified on the basis of reliable microbiological methods, antimicrobial therapy should be directed at that pathogen (Moderate recommendation; level III evidence)^[7]
Early treatment (within 48 h of the onset of symptoms) with oseltamivir or zanamivir is recommended for influenza A. (Strong recommendation; level I evidence)
Use of oseltamivir and zanamivir is not recommended for patients with uncomplicated influenza with symptoms for >48 h (level I evidence), but these drugs may be used to reduce viral shedding in hospitalized patients or for influenza pneumonia. (Moderate recommendation; level III evidence)

Pandemic Influenza

Patients with an illness compatible with influenza and with known exposure to poultry in areas with previous H5N1 infection should be tested for H5N1 infection. (Moderate recommendation; level III evidence)
In patients with suspected H5N1 infection, droplet precautions and careful routine infection control measures should be used until an H5N1 infection is ruled out. (Moderate recommendation; level III evidence)
Patients with suspected H5N1 infection should be treated with oseltamivir (level II evidence) and antibacterial agents targeting S. pneumoniae and S. aureus, the most common causes of secondary bacterial pneumonia in patients with influenza. (Moderate recommendation; level III evidence)

”

For Level of evidence classification click here.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Time, Route, and Duration of Community-acquired Pneumonia in Adults

“

Insert the text of the quote here, without quotation marks.

”

For Level of evidence and classes click here.

Other Treatments Consideration

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on other Treatments Considerations for Acquired Pneumonia in adults

“

This recommendation has been removed due to the market withdrawal of drotrecogin alfa.^[7]
Hypotensive, fluid-resuscitated patients with severe CAP should be screened for occult adrenal insufficiency. (Moderate recommendation; level II evidence)
Patients with hypoxemia or respiratory distress should receive a cautious trial of noninvasive ventilation (NIV) unless they require immediate intubation because of severe hypoxemia (arterial oxygen pressure/fraction of inspired oxygen [PaO2/FiO2] ratio <150) and bilateral alveolar infiltrates. (Moderate recommendation; level I evidence)
Low-tidal-volume ventilation (6 cm3/kg of ideal body weight) should be used for patients undergoing ventilation who have diffuse bilateral pneumonia or acute respiratory distress syndrome. (Strong recommendation; level I evidence)

”

For Level of evidence and classes click here.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Non Responding Acquired Pneumonia in Adults

“

Because of the limitations of diagnostic testing, the majority of CAP is still treated empirically. Critical to empirical therapy is an understanding of the management of patients who do not follow the normal response pattern.^[7]

”

For Level of evidence and classes click here.

References

↑ Lee JS, Giesler DL, Gellad WF, Fine MJ (2016). "Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia: A Systematic Review". JAMA. 315 (6): 593–602. doi:10.1001/jama.2016.0115. PMID 26864413.
↑ Li JZ, Winston LG, Moore DH, Bent S (2007). "Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis". Am J Med. 120 (9): 783–90. doi:10.1016/j.amjmed.2007.04.023. PMID 17765048. Review in: J Fam Pract. 2007 Dec;56(12):1003
↑ Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, Grammatikos AP, Athanassa Z, Falagas ME (2008). "Short- versus long-course antibacterial therapy for community-acquired pneumonia : a meta-analysis". Drugs. 68 (13): 1841–54. PMID 18729535.
↑ Aliberti S, Ramirez J, Giuliani F, Wiemken T, Sotgiu G, Tedeschi S; et al. (2017). "Individualizing duration of antibiotic therapy in community-acquired pneumonia". Pulm Pharmacol Ther. 45: 191–201. doi:10.1016/j.pupt.2017.06.008. PMID 28666965.
↑ Schuetz et al. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. Lancet Infectious Disease. 2017 doi:10.1016/S1473-3099(17)30592-3
↑ Schuetz P, Wirz Y, Sager R, Christ-Crain M, Stolz D, Tamm M; et al. (2017). "Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections". Cochrane Database Syst Rev. 10: CD007498. doi:10.1002/14651858.CD007498.pub3. PMID 29025194.
↑ ^7.0 ^7.1 ^7.2 ^7.3 ^7.4 ^7.5 Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC; et al. (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin Infect Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
↑ ^8.0 ^8.1 American Thoracic Society. Infectious Diseases Society of America (2005). "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". Am J Respir Crit Care Med. 171 (4): 388–416. doi:10.1164/rccm.200405-644ST. PMID 15699079.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ (2010). "Treatment of thoracic actinomycosis: A retrospective analysis of 40 patients". Ann Thorac Med. 5 (2): 80–5. doi:10.4103/1817-1737.62470. PMC 2883202. PMID 20582172.
↑ Sudhakar SS, Ross JJ (2004). "Short-term treatment of actinomycosis: two cases and a review". Clin Infect Dis. 38 (3): 444–7. doi:10.1086/381099. PMID 14727221 PMID: 14727221 Check |pmid= value (help).
↑ Lerner PI (1996). "Nocardiosis". Clin Infect Dis. 22 (6): 891–903, quiz 904-5. PMID 8783685.
↑ Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ (2006). "Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy". Clin Microbiol Rev. 19 (2): 259–82. doi:10.1128/CMR.19.2.259-282.2006. PMC 1471991. PMID 16614249.
↑ Brown-Elliott BA, Biehle J, Conville PS, Cohen S, Saubolle M, Sussland D; et al. (2012). "Sulfonamide resistance in isolates of Nocardia spp. from a US multicenter survey". J Clin Microbiol. 50 (3): 670–2. doi:10.1128/JCM.06243-11. PMC 3295118. PMID 22170936.
↑ Torres-Madriz G, Boucher HW (2008). "Immunocompromised hosts: perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid-organ transplant recipients". Clin Infect Dis. 47 (5): 702–11. doi:10.1086/590934. PMID 18652557.

[pmid26864413-1] Lee JS, Giesler DL, Gellad WF, Fine MJ (2016). "Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia: A Systematic Review". JAMA. 315 (6): 593–602. doi:10.1001/jama.2016.0115. PMID 26864413.

[pmid17765048-2] Li JZ, Winston LG, Moore DH, Bent S (2007). "Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis". Am J Med. 120 (9): 783–90. doi:10.1016/j.amjmed.2007.04.023. PMID 17765048. Review in: J Fam Pract. 2007 Dec;56(12):1003

[pmid18729535-3] Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, Grammatikos AP, Athanassa Z, Falagas ME (2008). "Short- versus long-course antibacterial therapy for community-acquired pneumonia : a meta-analysis". Drugs. 68 (13): 1841–54. PMID 18729535.

[pmid28666965-4] Aliberti S, Ramirez J, Giuliani F, Wiemken T, Sotgiu G, Tedeschi S; et al. (2017). "Individualizing duration of antibiotic therapy in community-acquired pneumonia". Pulm Pharmacol Ther. 45: 191–201. doi:10.1016/j.pupt.2017.06.008. PMID 28666965.

[5] Schuetz et al. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. Lancet Infectious Disease. 2017 doi:10.1016/S1473-3099(17)30592-3

[pmid29025194-6] Schuetz P, Wirz Y, Sager R, Christ-Crain M, Stolz D, Tamm M; et al. (2017). "Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections". Cochrane Database Syst Rev. 10: CD007498. doi:10.1002/14651858.CD007498.pub3. PMID 29025194.

[pmid17278083-7] 7.0 ^7.1 ^7.2 ^7.3 ^7.4 ^7.5 Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC; et al. (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin Infect Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.

[pmid15699079-8] 8.0 ^8.1 American Thoracic Society. Infectious Diseases Society of America (2005). "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". Am J Respir Crit Care Med. 171 (4): 388–416. doi:10.1164/rccm.200405-644ST. PMID 15699079.

[9] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[pmid20582172-10] Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ (2010). "Treatment of thoracic actinomycosis: A retrospective analysis of 40 patients". Ann Thorac Med. 5 (2): 80–5. doi:10.4103/1817-1737.62470. PMC 2883202. PMID 20582172.

[pmidPMID:_14727221-11] Sudhakar SS, Ross JJ (2004). "Short-term treatment of actinomycosis: two cases and a review". Clin Infect Dis. 38 (3): 444–7. doi:10.1086/381099. PMID 14727221 PMID: 14727221 Check |pmid= value (help).

[pmid8783685-12] Lerner PI (1996). "Nocardiosis". Clin Infect Dis. 22 (6): 891–903, quiz 904-5. PMID 8783685.

[pmid16614249-13] Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ (2006). "Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy". Clin Microbiol Rev. 19 (2): 259–82. doi:10.1128/CMR.19.2.259-282.2006. PMC 1471991. PMID 16614249.

[pmid22170936-14] Brown-Elliott BA, Biehle J, Conville PS, Cohen S, Saubolle M, Sussland D; et al. (2012). "Sulfonamide resistance in isolates of Nocardia spp. from a US multicenter survey". J Clin Microbiol. 50 (3): 670–2. doi:10.1128/JCM.06243-11. PMC 3295118. PMID 22170936.

[pmid18652557-15] Torres-Madriz G, Boucher HW (2008). "Immunocompromised hosts: perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid-organ transplant recipients". Clin Infect Dis. 47 (5): 702–11. doi:10.1086/590934. PMID 18652557.

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14]

[15]

@@ Line 2: / Line 2: @@
 {{Pneumonia}}
-{{CMG}}; {{AE}} {{AL}}; [[Priyamvada Singh|Priyamvada Singh, M.D.]] [mailto:psingh13579@gmail.com]
+{{CMG}}; {{AE}} {{HQ}}, {{AL}}; [[Priyamvada Singh|Priyamvada Singh, M.D.]] [mailto:psingh13579@gmail.com]
 ==Overview==
-The majority of pneumonia cases can be treated with outpatient therapy.  However, patients with severe disease, comorbidities, and/or complications usually require hospitalization. Antimicrobial therapy is indicated in pneumonia and it depends on whether the patient is receiving inpatient or outpatient therapy and whether the infection was community or hospital-acquired.  Supportive therapy includes adequate hydration, rest, and home care.
+The majority of pneumonia cases can be treated with outpatient therapy.  However, patients with severe disease, comorbidities, and/or complications usually require hospitalization. [[Antimicrobial]] therapy is indicated in pneumonia and it depends on whether the patient is receiving inpatient or outpatient therapy and whether the [[infection]] was community or hospital-acquired.  Supportive therapy includes adequate hydration, rest, and home care.
 ==Medical Therapy==
@@ Line 12: / Line 12: @@
 * The treatment of pneumonia involves three critical decisions: first whether the patient truly has pneumonia, second what is the severity of the pneumonia, and last whether hospitalization is required for adequate management.
 * Treatment for pneumonia should ideally be based on the causative microorganism and its known [[antibiotic sensitivity]]. However, a specific cause for pneumonia is identified in only 50% of people, even after extensive evaluation.
-* Since treatment should generally not be delayed in any person with a serious pneumonia, [[Empiric therapy|empiric treatment]] is usually started well before laboratory reports are available. In both cases, a person's risk factors for different organisms must be remembered when choosing the initial antibiotics (empiric therapy).
+* Since treatment should generally not be delayed in any person with a serious pneumonia, [[Empiric therapy|empiric treatment]] is usually started well before laboratory reports are available. In both cases, a person's risk factors for different organisms must be remembered when choosing the initial [[Antibiotic|antibiotics]] (empiric therapy).
-* In general, all therapies in older children and adults will include treatment for atypical bacteria. Typically this is a macrolide antibiotic such as [[azithromycin]] or [[clarithromycin]] although a [[fluoroquinolone]] such as [[levofloxacin]] can substitute.
+* In general, all therapies in older children and adults will include treatment for atypical bacteria. Typically this is a [[macrolide]] antibiotic such as [[azithromycin]] or [[clarithromycin]] although a [[fluoroquinolone]] such as [[levofloxacin]] can substitute.
-* Treatment of [[viral pneumonia]] caused by influenza is beneficial only if they are started within 48 hours of the onset of symptoms.
+* Treatment of [[viral pneumonia]] caused by [[influenza]] is beneficial only if they are started within 48 hours of the onset of symptoms.
-* Many strains of [[H5N1]] influenza A, also known as [[avian influenza]] or "bird flu," have shown resistance to [[rimantadine]] and [[amantadine]].
+* Many strains of [[H5N1]] [[Influenza|influenza A]], also known as [[avian influenza]] or "bird flu," have shown resistance to [[rimantadine]] and [[amantadine]].
-* There are no known effective treatments for viral pneumonias caused by the [[SARS|SARS coronavirus]], [[adenovirus]], [[hantavirus]], or [[parainfluenza]] virus.
+* There are no known effective treatments for viral pneumonias caused by the [[SARS|SARS coronavirus]], [[adenovirus]], [[hantavirus]], or [[parainfluenza]] [[virus]].
-* Most newborn infants with CAP are hospitalized and given [[intravenous]] [[ampicillin]] and [[gentamicin]] for at least ten days. This treats the common bacteria [[streptococcus agalactiae]], [[listeria monocytogenes]], and [[escherichia coli]]. If [[herpes simplex virus]] is the cause, intravenous [[acyclovir]] is administered for 21 days.
+* [[Fungus|Fungal]] pneumonia can be treated with [[Antifungal drug|antifungal]] drugs and sometimes by surgical [[debridement]].
-* Treatment of CAP in children depends on both the age of the child and the severity of his/her illness. Children less than five do not typically receive treatment to cover atypical bacteria. If a child does not need to be hospitalized, [[amoxicillin]] for seven days is a common treatment. However, with increasing prevalence of DRSP, other agents such as [[cefpodoxime]] will most likely become more popular in the future.
+* [[Antibiotic]]s are used to treat bacterial pneumonia. In contrast, [[Antibiotic|antibiotics]] are not useful for [[viral pneumonia]], although they sometimes are used to treat or prevent [[Bacteria|bacterial]] [[Infection|infections]] that can occur in the [[Lung|lungs]] that are damaged by a [[Virus|viral]] pneumonia. The antibiotic choice depends on:
-*Hospitalized children should receive intravenous [[ampicillin]], [[ceftriaxone]], or [[cefotaxime]].
-* Fungal pneumonia can be treated with antifungal drugs and sometimes by surgical debridement.
-* [[Antibiotic]]s are used to treat bacterial pneumonia. In contrast, antibiotics are not useful for [[viral pneumonia]], although they sometimes are used to treat or prevent bacterial infections that can occur in the lungs that are damaged by a viral pneumonia. The antibiotic choice depends on:
 ** Nature of the pneumonia
-** Microorganisms endemic to a local geographic area
+** [[Microorganism|Microorganisms]] endemic to a local geographic area
 ** Immune status
 ** Underlying health of the individual
-==Pneumonia Site of Care Decision==
+===Initiation of treatment===
-==Infectious Diseases Society of America/American Thoracic Society consensus recommendation on site of care for community-acquired pneumonia in adults. <ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref> (DO NOT EDIT)==
+Starting effective treatment within 4-8 hours may reduce [[Mortality rate|mortality]].<ref name="pmid26864413">{{cite journal| author=Lee JS, Giesler DL, Gellad WF, Fine MJ| title=Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia: A Systematic Review. | journal=JAMA | year= 2016 | volume= 315 | issue= 6 | pages= 593-602 | pmid=26864413 | doi=10.1001/jama.2016.0115 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26864413  }} </ref>
-{{cquote|
+===Duration of treatment===
-===Hospital Admission Decision===
+Randomized controlled trials have addressed short course of therapy:
-* Severity-of-illness scores, such as the [[CURB-65]] criteria ([[confusion]], [[uremia]], [[respiratory rate]], low [[blood pressure]], age 65 years or greater), or prognostic models, such as the [[Pneumonia Severity Index]] ([[PSI]]), can be used to identify patients with CAP who may be candidates for outpatient treatment. '''(Strong recommendation; level I evidence)'''
+* For outpatients, less than 7 days<ref name="pmid17765048">{{cite journal| author=Li JZ, Winston LG, Moore DH, Bent S| title=Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis. | journal=Am J Med | year= 2007 | volume= 120 | issue= 9 | pages= 783-90 | pmid=17765048 | doi=10.1016/j.amjmed.2007.04.023 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17765048  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18069161 Review in: J Fam Pract. 2007 Dec;56(12):1003] </ref><ref name="pmid18729535">{{cite journal| author=Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, Grammatikos AP, Athanassa Z, Falagas ME| title=Short- versus long-course antibacterial therapy for community-acquired pneumonia : a meta-analysis. | journal=Drugs | year= 2008 | volume= 68 | issue= 13 | pages= 1841-54 | pmid=18729535 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18729535  }} </ref>
-* Objective criteria or scores should always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. '''(Strong recommendation; level II evidence)'''
+* For inpatients, the role of individualizing duration of treatment is uncertain.<ref name="pmid28666965">{{cite journal| author=Aliberti S, Ramirez J, Giuliani F, Wiemken T, Sotgiu G, Tedeschi S et al.| title=Individualizing duration of antibiotic therapy in community-acquired pneumonia. | journal=Pulm Pharmacol Ther | year= 2017 | volume= 45 | issue=  | pages= 191-201 | pmid=28666965 | doi=10.1016/j.pupt.2017.06.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28666965  }} </ref>
-* For patients with CURB-65 scores >2, more-intensive treatment—that is, hospitalization or, where appropriate and available, intensive in-home health care services—is usually warranted. (Moderate recommendation; level III evidence)
-===Intensive Care Unit (ICU) Admission Decision===
-* Direct admission to an ICU is required for patients with [[septic shock]] requiring [[vasopressors]] or with acute respiratory failure requiring [[intubation]] and [[mechanical ventilation]]. '''(Strong recommendation; level II evidence)'''
-* Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed in the Table below. (Moderate recommendation; level II evidence)
-}}
-'''For Level of evidence classification click [[ACC AHA Guidelines Classification Scheme|here]].'''
-==Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Empiric Antibiotic Treatment of community-acquired pneumonia in adults. <ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref> (DO NOT EDIT)==
+Serial measurement of [[procalcitonin]] levels can reduce length of exposure to [[antibiotic]]s from 6.2 to 5.7 days (95% CI: -2.71 to -2.15; P < 0.001)<ref>Schuetz
+ et al. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. Lancet Infectious Disease. 2017 {{doi|10.1016/S1473-3099(17)30592-3}}</ref> or 10.5 to 8.0 (95% CI: -2.87 to -2.02; P < 0.001)<ref name="pmid29025194">{{cite journal| author=Schuetz P, Wirz Y, Sager R, Christ-Crain M, Stolz D, Tamm M et al.| title=Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. | journal=Cochrane Database Syst Rev | year= 2017 | volume= 10 | issue=  | pages= CD007498 | pmid=29025194 | doi=10.1002/14651858.CD007498.pub3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29025194  }} </ref>
-{{cquote|
+===Pediatrics===
+* Most newborn infants with CAP are hospitalized and given [[intravenous]] [[ampicillin]] and [[gentamicin]] for at least ten days. This treats the common bacteria [[streptococcus agalactiae]], [[listeria monocytogenes]], and [[escherichia coli]]. If [[herpes simplex virus]] is the cause, intravenous [[acyclovir]] is administered for 21 days.
-===Previously Healthy and No Risk Factors for Drug-resistant Streptococcus Pneumoniae===
+* Treatment of CAP in children depends on both the age of the child and the severity of his/her illness. Children less than five do not typically receive treatment to cover atypical bacteria. If a child does not need to be hospitalized, [[amoxicillin]] for seven days is a common treatment. However, with increasing prevalence of DRSP, other agents such as [[cefpodoxime]] will most likely become more popular in the future.
-* A [[macrolide]] ([[azithromycin]], [[clarithromycin]], or [[erythromycin]] '''(Strong recommendation; level I evidence)'''
+*Hospitalized children should receive intravenous [[ampicillin]], [[ceftriaxone]], or [[cefotaxime]].
-* [[Doxycycline]] (Weak recommendation; level III evidence)
-===Presence of Comorbidities or Other Risks for Drug-resistant Streptococcus Pneumoniae===
-Presence of comorbidities, such as chronic heart, lung, liver, or renal disease; [[diabetes mellitus]]; [[alcoholism]]; malignancies; [[asplenia]]; immunosuppressing conditions or use of immunosuppressing drugs; use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected); or other risks for DRSP infection:
-* A respiratory [[fluoroquinolone]] ([[moxifloxacin]], [[gemifloxacin]], or [[levofloxacin]] [750 mg]) ('''Strong recommendation; level I evidence''')
-* A beta-lactam plus a [[macrolide]] (Strong recommendation; level I evidence) (High-dose [[amoxicillin]] [e.g., 1 g 3 times daily] or amoxicillin-clavulanate [2 g 2 times daily] is preferred; alternatives include [[ceftriaxone]], [[cefpodoxime]], and [[cefuroxime]] [500 mg 2 times daily]; [[doxycycline]] (level II evidence) is an  alternative to the macrolide.)
-===In Regions with a High Rate (>25%) of Infection===
+===Antimicrobial Regimens===
-In regions with a high rate (>25%) of infection with high-level (minimal inhibitory concentration [MIC], >16 micrograms/mL) macrolide-resistant S. pneumoniae, consider the use of alternative agents for any patient, including those without comorbidities. (Moderate recommendation; level III evidence)
-====Inpatient, Non-ICU Treatment====
-The following regimens are recommended for hospital ward treatment.
-* A respiratory fluoroquinolone (Strong recommendation; level I evidence)
-* A beta-lactam plus a macrolide (Strong recommendation; level I evidence) (Preferred beta-lactam agents include cefotaxime, ceftriaxone, and ampicillin; ertapenem for selected patients; with doxycycline (level III evidence) as an alternative to the macrolide. A respiratory fluoroquinolone should be used for penicillin-allergic patients.)
-====Inpatient, ICU Treatment====
-The following regimen is the minimal recommended treatment for patients admitted to the ICU.
-* A beta-lactam ([[cefotaxime]], [[ceftriaxone]], or [[ampicillin-sulbactam]]) plus either [[azithromycin]] (level II evidence) or a [[fluoroquinolone]] (Strong recommendation; level I evidence) (For penicillin-allergic patients, a respiratory fluoroquinolone and [[aztreonam]] are recommended.)
-* For [[Pseudomonas]] infection, use an antipneumococcal, antipseudomonal beta-lactam ([[piperacillin]]-[[tazobactam]], [[cefepime]], [[imipenem]], or [[meropenem]]) plus either [[ciprofloxacin]] or [[levofloxacin]] (750-mg dose)
-'''or'''
-the above beta-lactam plus an [[aminoglycoside]] and [[azithromycin]]
-'''or'''
-the above beta-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for the above beta-lactam). (Moderate recommendation; level III evidence)
-* For community-acquired [[methicillin resistant Staphylococcus aureus]] (CA-MRSA) infection, add [[vancomycin]] or [[linezolid]]. (Moderate recommendation; level III evidence)
-}}
-'''For Level of evidence classification click [[ACC AHA Guidelines Classification Scheme|here]].'''
-==Infectious Diseases Society of America/American Thoracic Society consensus recommendation on pandemic Influenza community-acquired pneumonia in adults. <ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref> (DO NOT EDIT)==
-{{cquote|
-===Pathogen-Directed Therapy===
-* Once the etiology of CAP has been identified on the basis of reliable microbiological methods, antimicrobial therapy should be directed at that pathogen (Moderate recommendation; level III evidence)
-* Early treatment (within 48 h of the onset of symptoms) with oseltamivir or zanamivir is recommended for influenza A. '''(Strong recommendation; level I evidence)'''
-* Use of oseltamivir and zanamivir is not recommended for patients with uncomplicated influenza with symptoms for >48 h (level I evidence), but these drugs may be used to reduce viral shedding in hospitalized patients or for influenza pneumonia. (Moderate recommendation; level III evidence)
-===Pandemic Influenza===
-* Patients with an illness compatible with influenza and with known exposure to poultry in areas with previous H5N1 infection should be tested for H5N1 infection. (Moderate recommendation; level III evidence)
-* In patients with suspected H5N1 infection, droplet precautions and careful routine infection control measures should be used until an H5N1 infection is ruled out. (Moderate recommendation; level III evidence)
-* Patients with suspected H5N1 infection should be treated with oseltamivir (level II evidence) and antibacterial agents targeting S. pneumoniae and S. aureus, the most common causes of secondary bacterial pneumonia in patients with influenza. (Moderate recommendation; level III evidence)
-}}
-'''For Level of evidence classification click [[ACC AHA Guidelines Classification Scheme|here]].'''
-==Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Time, Route, and Duration of Community-acquired Pneumonia in Adults. <ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref> (DO NOT EDIT)==
-{{cquote|
-===Time to First Antibiotic Dose===
-* For patients admitted through the emergency department (ED), the first antibiotic dose should be administered while still in the ED. (Moderate recommendation; level III evidence)
-===Switch from Intravenous to Oral Therapy===
-* Patients should be switched from intravenous to oral therapy when they are hemodynamically stable and improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. '''(Strong recommendation; level II evidence)'''.
-* Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care. Inpatient observation while receiving oral therapy is not necessary. (Moderate recommendation; level II evidence)
-===Duration of Antibiotic Therapy===
-* Patients with CAP should be treated for a minimum of 5 days (level I evidence), should be afebrile for 48 to 72 h, and should have no more than 1 CAP-associated sign of clinical instability before discontinuation of therapy. (level II evidence) (Moderate recommendation)
-* A longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis. (Weak recommendation; level III evidence)
-}}
-'''For Level of evidence and classes click [[ACC AHA Guidelines Classification Scheme|here]].'''
-==Other Treatments Consideration==
-==Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on other Treatments Considerations for Acquired Pneumonia in adults. <ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref> (DO NOT EDIT)==
-{{cquote|
-* This recommendation has been removed due to the market withdrawal of drotrecogin alfa.
-* Hypotensive, fluid-resuscitated patients with severe CAP should be screened for occult [[adrenal insufficiency]]. (Moderate recommendation; level II evidence)
-* Patients with hypoxemia or respiratory distress should receive a cautious trial of [[noninvasive ventilation]] (NIV) unless they require immediate intubation because of severe hypoxemia (arterial oxygen pressure/fraction of inspired oxygen [PaO2/FiO2] ratio <150) and bilateral alveolar infiltrates. (Moderate recommendation; level I evidence)
-* Low-tidal-volume ventilation (6 cm3/kg of ideal body weight) should be used for patients undergoing ventilation who have diffuse bilateral [[pneumonia]] or [[acute respiratory distress syndrome]]. (Strong recommendation; level I evidence)
-}}
-'''For Level of evidence and classes click [[ACC AHA Guidelines Classification Scheme|here]].'''
-==Management of Non-responding Pneumonia==
-==Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Non Responding Acquired Pneumonia in Adults. <ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref> (DO NOT EDIT)==
-{{cquote|
-* Because of the limitations of diagnostic testing, the majority of CAP is still treated empirically. Critical to empirical therapy is an understanding of the management of patients who do not follow the normal response pattern.
-}}
-'''For Level of evidence and classes click [[ACC AHA Guidelines Classification Scheme|here]].
-===Antimicrobial Regimen===
 :* 1. '''Community-acquired pneumonia'''
 ::* 1.1 '''Empiric therapy in adults''' <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
@@ Line 172: / Line 84: @@
 ::::::* Note (2) : Trough levels for [[Vancomycin]] should be 15-20 g/ml
 ::::::* Note (3) : Hospital or community acquired, neutropenic patient (<500 neutrophils per mm3) [[Vancomycin]] not included in initial therapy unless high suspicion of infected intravenous access or drug-resistant Streptococcus pneumonia. Amphotericin not used unless still febrile after 3 days or high clinical likelihood.
 ::* 1.2 '''Pathogen-directed antimicrobial therapy'''
 :::* 1.2.1 '''Bacterial pathogens'''
@@ Line 181: / Line 92: @@
 :::::* 1.2.1.1.2 '''Penicillin resistant (minimum inhibitory concentration > 2 mg/mL)'''
 ::::::* Preferred regimen (Agents chosen on the basis of susceptibililty) : [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
-::::::* Alternative regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)
+::::::* Alternative regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin, minimum inhibitory concentration 4 ≤ microgram / mL)
 ::::* 1.2.1.2 '''Haemophilus influenzae'''
 :::::* 1.2.1.2.1 '''Non-beta lactamase producing'''
@@ Line 190: / Line 100: @@
 ::::::* Preferred regimen: 2nd or 3rd Generation [[Cephalosporin]] {{or}} [[Amoxicillin-clavulanate]] 2 g q12h
 ::::::* Alternative regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days
 ::::* 1.2.1.2 '''Bacillus anthracis (inhalational)'''
 :::::* Preferred Regimen :[[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 days {{or}} [[Doxycycline]] 100 mg PO/IV q12h
 :::::* Alternate Regimen : Other [[Fluoroquinolones]] {{or}} B-lactam (if susceptible) {{or}} [[Rifampin]] 600 mg PO/IV q24h for 4 days {{or}} [[Clindamycin]] 150-450 mg PO q6-8h {{or}} [[Chloramphenicol]] 50-100 mg/kg/day IV in divided q6h
 ::::* 1.2.1.3 '''Enterobacteriaceae'''
 :::::* Preferred Regimen: 3rd generation cephalosporin {{or}} Carbapenem- ([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]]) (drug of choice if extended-spectrum b-lactamase producer)
 :::::* Alternate Regimen : b-Lactam / b-lactamase inhibitor- ([[Piperacillin-Tazobactam]] for gram-negative bacilli, {{or}} [[Ticarcillin-Clavulanate]] {{or}} [[Ampicillin-Sulbactam]] {{or}} [[Amoxicillin-Clavulanate]]) {{or}} ([[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h)
 ::::* 1.2.1.4 '''Pseudomonas aeruginosa'''
 :::::* Preferred Regimen: ([[Ticarcillin]] 200-300 mg/kg/day in divided doses q4-6h (maximum: 18 g/day) {{or}} [[Piperacillin]] 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h {{or}} [[Ceftazidime]] 500 mg to 1 g q8h {{or}} [[Cefepime]] 1-2 g q12h for 10 days {{or}} [[Aztreonam]] 2 g IV q6-8h (maximum: 8 g/day) {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 500 mg IV q8h) {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily {{or}} [[Aminoglycoside]])
 :::::* Alternative Regimen: [[Aminoglycoside]] {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily)
 ::::* 1.2.1.5 '''Staphylococcus aureus'''
 :::::* 1.2.1.5.1 '''Methicillin sensitive'''
@@ Line 210: / Line 116: @@
 ::::::* Preferred Regimen : [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days
 ::::::* Alternative Regimen: [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
+::::* 1.2.1.6 '''Klebsiella pneumonia'''<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
-::::* 1.2.1.6 '''Klebsiella pneumonia'''<ref> {{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
 :::::* 1.2.1.6.1 '''Resistant to third generation cephalosporins and aztreonam'''
 ::::::* Preferred regimen (1): [[Imipenem]] 0.5 g IV q6h {{or}} [[Meropenem]]  0.5–1 g IV q8h
@@ Line 220: / Line 124: @@
 ::::::* Note (2): Extended spectrum beta-lactamases inactivates all [[Cephalosporins]], beta-lactam/beta-lactamase inhibitor drug activation not predictable; co-resistance to all [[Fluoroquinolones]] & often [[Aminoglycosides]].
 ::::::* Note (3): Can give IM, but need to combine with “caine” anesthetic due to pain.
 ::::* 1.2.1.7 '''Moraxella catarrhalis'''
 :::::* Preferred regimen: [[Amoxicillin-Clavulanate]] (Augmentin) 2 tablets po bid ( (or)500/125 mg 1 tablet po tid (or) 875/125 mg 1 tablet po bid) {{or}} [[Cephalosporins]]- [[Cefdinir]] 300 mg po q12h (or) 600 mg q24h, {{or}} ([[Cefditoren pivoxil]] 200–400 mg, 2 tabs po bid,{{or}} [[Cefpodoxime proxetil]] 0.1–0.2 g po q12h, {{or}} [[Cefprozil]] 500 mg po q12h), {{or}} [[Cefoxitin]] 1 g q8h–2 g IV/IM q4h, {{or}} ([[Cefuroxime]] 0.75–1.5 g IV/IM q8h,{{or}}[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h, {{or}} [[Ceftazidime]] 1–2 g IV/IM q8–12h) {{or}} [[Trimethoprim-Sulfamethoxazole]] Single-strength (SS) is [[Trimethoprim]] 80 mg / [[Sulfamethoxazole]] 400 mg ,{{or}} (double-strength (DS) [[Trimethoprim]] 160 mg /[[Sulfamethoxazole]] 800 mg)
 :::::*Alternative regimen:  [[Azithromycin]] 500 mg IV q24h ,{{or}} [[Clarithromycin]] 0.5 g po q12h, {{or}} [[Telithromycin]] 800 mg po q24h (two 400 mg tabs po q24h).
 ::::* 1.2.1.8 '''Stenotrophomonas maltophilia'''
 :::::* Preferred regimen: [[Trimethoprim-Sulfamethoxazole]] Single-strength (SS) tablet is [[Trimethoprim]] 80 mg / [[Sulfamethoxazole]]  400 mg, double-strength (DS) tablet is [[Trimethoprim]] 160 mg / [[Sulfamethoxazole]] 800 mg {{or}} IV treatment (base on TMP component): standard 8–10 mg per kg per day divided q6h, q8h, or q12h.
@@ Line 231: / Line 132: @@
 :::::* Note (1): Potential synergy with [[Trimethoprim-Sulfamethoxazole]] {{and}} [[Ticarcillin-Clavulanate]].
 :::::* Note (2): Stenotrophomonas is one of the microorganisms causing hospital-acquired pneumonia usually with mechanical ventilation.
 ::::* 1.2.1.9 '''Bordetella pertussis'''
 :::::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
 :::::* Alternative Regimen: [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
 ::::* 1.2.1.10 '''Anaerobes (aspiration pneumonia)'''
 :::::* Preferred Regimen: [[Piperacillin-Tazobactam]] 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) {{or}} [[Ticarcillin Clavulanate]] 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) {{or}} [[Ampicillin-Sulbactam]] 1500-3000 mg IV q6h {{or}} [[Amoxicillin-Clavulanate]] 250-500 mg PO q8h or 875 mg q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (max: 1800 mg/day)
 :::::* Alternative Regimen: [[Carbapenem]] -([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]])
 ::::* 1.2.1.11 '''Mycobacterium tuberculosis'''
 :::::* 1.2.1.11.1 '''Intensive phase'''
@@ Line 248: / Line 146: @@
 ::::::* Preferred Regimen:[[Isoniazid]] 300 mg/day PO daily for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO daily for 4 months (10 mg/kg/day)
 ::::::* Alternative regimen (1): [[Isoniazid]] 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day)
 ::::* 1.2.1.12 '''Yersinisa pestis'''
 :::::* Preferred Regimen: [[Streptomycin]] 15 mg/kg/day (max 1 g/day) {{or}} [[Gentamicin]] 7 mg/kg/day
 :::::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
 ::::* 1.2.1.13 '''Atypical bacteria'''
 :::::* 1.2.1.13.1 '''Mycoplasma pneumoniae'''
 ::::::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] Oral: 250-500 mg q6h
 ::::::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
 :::::* 1.2.1.13.2 '''Chlamydophila pneumoniae'''
 ::::::* Preferred Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] 250-500 mg PO q6h
 ::::::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
 :::::* 1.2.1.13.3 '''Legionella spp.'''
 ::::::* Preferred Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
 ::::::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h
 :::::* 1.2.1.13.4 '''Chlamydophila psittaci'''
 ::::::* Preferred Regimen: [[Tetracycline]] 250-500 mg PO q6h
 ::::::* Alternate Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
 :::::* 1.2.1.13.5 ''' Coxiella burnetii'''
 ::::::* Preferred Regimen: [[Tetracycline]] 250-500 mg PO q6h
 ::::::* Alternate Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
 :::::* 1.2.1.13.6 '''Francisella tularensis'''
 ::::::* Preferred Regimen: [[Doxycycline]]  100 mg PO/IV q12h
 ::::::* Alternate Regimen: [[Gentamicin]] 7 mg/kg/day {{or}} [[Streptomycin]] 15 mg/kg/day (maximum: 1 g)
 :::::* 1.2.1.13.7 '''Burkholderia pseudomallei'''
 ::::::* Preferred Regimen : [[Carbapenem]] -([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]]) {{or}} [[Ceftazidime]] 0.5-1 g q8h
 ::::::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
 :::::* 1.2.1.13.8 '''Acinetobacter species'''
 ::::::* Preferred Regimen : [[Carbapenem]]-([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]])
 ::::::* Alternate Regimen: [[Cephalosporin]]-[[Aminoglycoside]]  {{or}} [[Ampicillin-Sulbactam]] {{or}} [[Colistin]] 2.5-5 mg/kg/day IM/IV divided q6-12h (maximum: 5 mg/kg/day)
 ::::* 1.2.1.14 '''Gram-positive filamentous bacteria'''
 :::::* 1.2.1.14.1 '''Actinomyces spp.'''<ref name="pmid20582172">{{cite journal| author=Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ| title=Treatment of thoracic actinomycosis: A retrospective analysis of 40 patients. | journal=Ann Thorac Med | year= 2010 | volume= 5 | issue= 2 | pages= 80-5 | pmid=20582172 | doi=10.4103/1817-1737.62470 | pmc=PMC2883202 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20582172  }} </ref><ref name="pmidPMID: 14727221">{{cite journal| author=Sudhakar SS, Ross JJ| title=Short-term treatment of actinomycosis: two cases and a review. | journal=Clin Infect Dis | year= 2004 | volume= 38 | issue= 3 | pages= 444-7 | pmid=PMID: 14727221 | doi=10.1086/381099 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14727221  }} </ref>
@@ Line 303: / Line 191: @@
 :::::::* Note (2): The duration of intravenous therapy varies with the patient's immune status. In immunocompromised patients, maximal tolerated doses should be given intravenously for at least six weeks and until clinical improvement has occurred; in contrast, immunocompetent patients may be successfully treated with a shorter duration of intravenous therapy. Following the intravenous induction phase, patients may be stepped down to oral antibiotics based upon susceptibility studies
 :::::::* Note (3): Serious pulmonary infection is treated for 6 to 12 months or longer.
 :::* 1.2.2 '''Viral pathogens'''
 ::::* 1.2.2.1 '''Influenza virus'''
@@ Line 312: / Line 199: @@
 :::::* Alternative regimen (1): [[Foscarnet]] Induction therapy 60 mg/ kg every 8 h for 14–21 days or 90 mg/kg every 12 h for 14–21 days; maintenance therapy 90–120 mg/kg per day as a single infusion.
 :::::* Alternative regimen (2): [[Cidofovir]] Induction therapy 5 mg/ kg per week for 2 weeks, followed by maintenance therapy every 2 weeks.
 :::* 1.2.3 '''Fungal pathogens'''
 ::::* 1.2.3.1 '''Coccidioides species'''
@@ Line 318: / Line 204: @@
 :::::* Alternative Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
 :::::* Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection
 ::::* 1.2.3.2  '''Histoplasmosis'''
 :::::* Preferred Regimen: [[Itraconazole]] 200 mg q12h
 :::::* Alternative Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
 ::::* 1.2.3.3  '''Blastomycosis'''
 :::::* Preferred Regimen: [[Itraconazole]] 200 mg q12h
 :::::* Alternate Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
 :* 2. '''Health care-associated pneumonia'''<ref name="pmid15699079">{{cite journal| author=American Thoracic Society. Infectious Diseases Society of America| title=Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. | journal=Am J Respir Crit Care Med | year= 2005 | volume= 171 | issue= 4 | pages= 388-416 | pmid=15699079 | doi=10.1164/rccm.200405-644ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15699079  }} </ref>
 ::* 2.1  '''Empiric antimicrobial therapy'''
@@ Line 336: / Line 219: @@
 ::::* Note (2): Trough levels for [[Gentamycin]] and [[Tobramycin]] should be less than 1 g/ml, and for [[Amikacin]] they should be less than 4-5 g/ml.
 ::::* Note (3): Trough levels for [[Vancomycin]] should be 15-20 g/ml.
+==Pneumonia Site of Care Decision==
+===Infectious Diseases Society of America/American Thoracic Society consensus recommendation on site of care for community-acquired pneumonia in adults===
+{{cquote|
+====Hospital Admission Decision====
+* Severity-of-illness scores, such as the [[CURB-65]] criteria ([[confusion]], [[uremia]], [[respiratory rate]], low [[blood pressure]], age 65 years or greater), or prognostic models, such as the [[Pneumonia Severity Index]] ([[PSI]]), can be used to identify patients with CAP who may be candidates for outpatient treatment. '''(Strong recommendation; level I evidence)'''<ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref>
+* Objective criteria or scores should always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. '''(Strong recommendation; level II evidence)'''
+* For patients with CURB-65 scores >2, more-intensive treatment—that is, hospitalization or, where appropriate and available, intensive in-home health care services—is usually warranted. (Moderate recommendation; level III evidence)
+====Intensive Care Unit (ICU) Admission Decision====
+* Direct admission to an ICU is required for patients with [[septic shock]] requiring [[vasopressors]] or with acute respiratory failure requiring [[intubation]] and [[mechanical ventilation]]. '''(Strong recommendation; level II evidence)'''
+* Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed in the Table below. (Moderate recommendation; level II evidence)
+}}
+'''For Level of evidence classification click [[ACC AHA Guidelines Classification Scheme|here]].'''
+===Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Empiric Antibiotic Treatment of community-acquired pneumonia in adults===
+{{cquote|
+====Previously Healthy and No Risk Factors for Drug-resistant Streptococcus Pneumoniae====
+* A [[macrolide]] ([[azithromycin]], [[clarithromycin]], or [[erythromycin]] '''(Strong recommendation; level I evidence)'''<ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref>
+* [[Doxycycline]] (Weak recommendation; level III evidence)
+====Presence of Comorbidities or Other Risks for Drug-resistant Streptococcus Pneumoniae====
+Presence of comorbidities, such as chronic heart, lung, liver, or renal disease; [[diabetes mellitus]]; [[alcoholism]]; malignancies; [[asplenia]]; immunosuppressing conditions or use of immunosuppressing drugs; use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected); or other risks for DRSP infection:
+* A respiratory [[fluoroquinolone]] ([[moxifloxacin]], [[gemifloxacin]], or [[levofloxacin]] [750 mg]) ('''Strong recommendation; level I evidence''')
+* A beta-lactam plus a [[macrolide]] (Strong recommendation; level I evidence) (High-dose [[amoxicillin]] [e.g., 1 g 3 times daily] or amoxicillin-clavulanate [2 g 2 times daily] is preferred; alternatives include [[ceftriaxone]], [[cefpodoxime]], and [[cefuroxime]] [500 mg 2 times daily]; [[doxycycline]] (level II evidence) is an  alternative to the macrolide.)
+====In Regions with a High Rate (>25%) of Infection====
+In regions with a high rate (>25%) of infection with high-level (minimal inhibitory concentration [MIC], >16 micrograms/mL) macrolide-resistant S. pneumoniae, consider the use of alternative agents for any patient, including those without comorbidities. (Moderate recommendation; level III evidence)
+====Inpatient, Non-ICU Treatment====
+The following regimens are recommended for hospital ward treatment.
+* A respiratory fluoroquinolone (Strong recommendation; level I evidence)
+* A beta-lactam plus a macrolide (Strong recommendation; level I evidence) (Preferred beta-lactam agents include cefotaxime, ceftriaxone, and ampicillin; ertapenem for selected patients; with doxycycline (level III evidence) as an alternative to the macrolide. A respiratory fluoroquinolone should be used for penicillin-allergic patients.)
+====Inpatient, ICU Treatment====
+The following regimen is the minimal recommended treatment for patients admitted to the ICU.
+* A beta-lactam ([[cefotaxime]], [[ceftriaxone]], or [[ampicillin-sulbactam]]) plus either [[azithromycin]] (level II evidence) or a [[fluoroquinolone]] (Strong recommendation; level I evidence) (For penicillin-allergic patients, a respiratory fluoroquinolone and [[aztreonam]] are recommended.)
+* For [[Pseudomonas]] infection, use an antipneumococcal, antipseudomonal beta-lactam ([[piperacillin]]-[[tazobactam]], [[cefepime]], [[imipenem]], or [[meropenem]]) plus either [[ciprofloxacin]] or [[levofloxacin]] (750-mg dose)
+'''or'''
+the above beta-lactam plus an [[aminoglycoside]] and [[azithromycin]]
+'''or'''
+the above beta-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for the above beta-lactam). (Moderate recommendation; level III evidence)
+* For community-acquired [[methicillin resistant Staphylococcus aureus]] (CA-MRSA) infection, add [[vancomycin]] or [[linezolid]]. (Moderate recommendation; level III evidence)
+}}
+'''For Level of evidence classification click [[ACC AHA Guidelines Classification Scheme|here]].'''
+===Infectious Diseases Society of America/American Thoracic Society consensus recommendation on pandemic Influenza community-acquired pneumonia in adults===
+{{cquote|
+====Pathogen-Directed Therapy====
+* Once the etiology of CAP has been identified on the basis of reliable microbiological methods, antimicrobial therapy should be directed at that pathogen (Moderate recommendation; level III evidence)<ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref>
+* Early treatment (within 48 h of the onset of symptoms) with oseltamivir or zanamivir is recommended for influenza A. '''(Strong recommendation; level I evidence)'''
+* Use of oseltamivir and zanamivir is not recommended for patients with uncomplicated influenza with symptoms for >48 h (level I evidence), but these drugs may be used to reduce viral shedding in hospitalized patients or for influenza pneumonia. (Moderate recommendation; level III evidence)
+====Pandemic Influenza====
+* Patients with an illness compatible with influenza and with known exposure to poultry in areas with previous H5N1 infection should be tested for H5N1 infection. (Moderate recommendation; level III evidence)
+* In patients with suspected H5N1 infection, droplet precautions and careful routine infection control measures should be used until an H5N1 infection is ruled out. (Moderate recommendation; level III evidence)
+* Patients with suspected H5N1 infection should be treated with oseltamivir (level II evidence) and antibacterial agents targeting S. pneumoniae and S. aureus, the most common causes of secondary bacterial pneumonia in patients with influenza. (Moderate recommendation; level III evidence)
+}}
+'''For Level of evidence classification click [[ACC AHA Guidelines Classification Scheme|here]].'''
+===Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Time, Route, and Duration of Community-acquired Pneumonia in Adults===
+{{cquote
+|====Time to First Antibiotic Dose==== <ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref>
+* For patients admitted through the emergency department (ED), the first antibiotic dose should be administered while still in the ED. (Moderate recommendation; level III evidence)
+====Switch from Intravenous to Oral Therapy====
+* Patients should be switched from intravenous to oral therapy when they are hemodynamically stable and improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. '''(Strong recommendation; level II evidence)'''.
+* Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care. Inpatient observation while receiving oral therapy is not necessary. (Moderate recommendation; level II evidence)
+====Duration of Antibiotic Therapy====
+* Patients with CAP should be treated for a minimum of 5 days (level I evidence), should be afebrile for 48 to 72 h, and should have no more than 1 CAP-associated sign of clinical instability before discontinuation of therapy. (level II evidence) (Moderate recommendation)
+* A longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis. (Weak recommendation; level III evidence)}}
+'''For Level of evidence and classes click [[ACC AHA Guidelines Classification Scheme|here]].'''
+==Other Treatments Consideration==
+===Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on other Treatments Considerations for Acquired Pneumonia in adults===
+{{cquote|
+* This recommendation has been removed due to the market withdrawal of drotrecogin alfa.<ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref>
+* Hypotensive, fluid-resuscitated patients with severe CAP should be screened for occult [[adrenal insufficiency]]. (Moderate recommendation; level II evidence)
+* Patients with hypoxemia or respiratory distress should receive a cautious trial of [[noninvasive ventilation]] (NIV) unless they require immediate intubation because of severe hypoxemia (arterial oxygen pressure/fraction of inspired oxygen [PaO2/FiO2] ratio <150) and bilateral alveolar infiltrates. (Moderate recommendation; level I evidence)
+* Low-tidal-volume ventilation (6 cm3/kg of ideal body weight) should be used for patients undergoing ventilation who have diffuse bilateral [[pneumonia]] or [[acute respiratory distress syndrome]]. (Strong recommendation; level I evidence)
+}}
+'''For Level of evidence and classes click [[ACC AHA Guidelines Classification Scheme|here]].'''
+===Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Non Responding Acquired Pneumonia in Adults===
+{{cquote|
+* Because of the limitations of diagnostic testing, the majority of CAP is still treated empirically. Critical to empirical therapy is an understanding of the management of patients who do not follow the normal response pattern.<ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref>
+}}
+'''For Level of evidence and classes click [[ACC AHA Guidelines Classification Scheme|here]].'''
 ==References==
@@ Line 342: / Line 325: @@
 [[Category:Pneumonia]]
 [[Category:Pulmonology]]
-[[Category:Infectious disease]]
 [[Category:Emergency medicine]]
 [[Category:Pediatrics]]
 [[Category:Disease]]
-[[Category:primary care]]
+[[Category:Infectious Disease Project]]
-[[Category: Infectious Disease Project]]

Pneumonia medical therapy: Difference between revisions

Latest revision as of 23:45, 29 July 2020

Overview

Medical Therapy

General Considerations

Initiation of treatment

Duration of treatment

Pediatrics

Antimicrobial Regimens

Pneumonia Site of Care Decision

Infectious Diseases Society of America/American Thoracic Society consensus recommendation on site of care for community-acquired pneumonia in adults

Hospital Admission Decision

Intensive Care Unit (ICU) Admission Decision

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Empiric Antibiotic Treatment of community-acquired pneumonia in adults

Previously Healthy and No Risk Factors for Drug-resistant Streptococcus Pneumoniae

Presence of Comorbidities or Other Risks for Drug-resistant Streptococcus Pneumoniae

In Regions with a High Rate (>25%) of Infection

Inpatient, Non-ICU Treatment

Inpatient, ICU Treatment

Infectious Diseases Society of America/American Thoracic Society consensus recommendation on pandemic Influenza community-acquired pneumonia in adults

Pathogen-Directed Therapy

Pandemic Influenza

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Time, Route, and Duration of Community-acquired Pneumonia in Adults

Other Treatments Consideration

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on other Treatments Considerations for Acquired Pneumonia in adults

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Non Responding Acquired Pneumonia in Adults

References

Navigation menu