0521779407-B01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:52
Bacterial Pneumonia 219■Serologic studies not helpful in acute management
■CBC, electrolytes, glucose, creatinine and oxygen saturation to deter-
mine need for hospitalization
differential diagnosis
■Other noninfectious causes of pulmonary infiltrates (tumor, collagen
vascular diseases, atalectasis, congestive heart failure, etc)management
What to Do First
■Determine need for hospitalization:
■Elderly with comorbid diseases (neoplastic, liver, CHF, renal) have
high mortality and should be admitted; altered mental status, ta-
chypnea (RR>30), hypotension (BP<90), tachycardia (P>125), tem-
perature<35 or>40, acidosis (pH<7.35), hyponatremia (Na<130),
hyperglycemia (glucose>250), elevated BUN (>30) and hypoxia
(oxygen saturation<90%) associated with poor prognosis-presence
of several of these, even in otherwise healthy young adult, should
prompt admission
■Supplemental oxygen, as needed
■Obtain specimens for culture
specific therapy
■Empirical:
➣Outpatient: doxycycline, a macrolide, ketolide or a fluoro-
quinolone with activity against S pneumoniae (levofloxacin,
moxifloxacin, gatifloxacin). Fluoroquinoles and ketolides gen-
erally not necessary in young, otherwise healthy adults unless
macrolide-resistant S. pneumo is prevalent in the community.
➣Hospitalized (ward): extended-spectrum cephalosporin (ceftri-
axone, cefotaxime) plus a macrolide or a fluoroquinolone alone
➣Hospitalized (ICU): extended-spectrum cephalosporin or
beta-lactam+beta-lactamase inhibitor (ampicillin-sulbactam,
piperacillin-tazobactam) in combination with a macrolide or a
fluoroquinolone
➣Aspiration: amoxicillin or clindamycin
➣Nosocomial: piperacillin-tazobactam or ceftriaxone or van-
comycin plus fluoroquinolone (choice depends upon local
microbiology and resistance patterns)
■Organism-specific therapy:
➣S pneumoniae: susceptibilities should be determined because
of increasing prevalence of resistance; penicillins, doxycycline,