View source for Management Of Community Acquired Pneumonia

==Diagnostic Tests==
*CBCD, electrolytes, glucose, BUN, Cr
*ABG on RA
*blood cultures (draw 2 before treatment, at least 10 min. apart)
*sputum gram stain and culture
*CXR (PA and lateral)
*acid fast stain of sputum if cough > 1 month or suspicious CXR for TB
*thoracocentesis if pleural effusions present 
**stain, culture, pH, leukocyte count, differential

==General Management==
*analgesics/antipyretics
*ensure adequate hydration
*oxygen therapy to O2 sat ≥ 90%
*consult RT, PT, OT, speech language pathologist, dietician as needed

==Hospitalization==
*When to admit
**Age >65 yrs
**Decreased immunity (cancer, diabetes, AIDS, splenectomy)
**Mental status changes
**Increased A-a gradient
**Two or more lobes involved
**No home
**Organ failure (↑Cr, bone marrow suppression, severe hypotension, liver failure)
**WBC > 30,000/mm3 or < 4000/mm3 (sepsis)

==Treatment==
*if no pathogen identified, empirically treat
**NO COMORBIDITIES: po macrolide or doxycycline
**WITH COMORBIDITIES: po beta-lactam plus macrolide, or fluoroquinolone, quinolones (levofloxacin)
**if suspect ASPIRATION: amoxicillin-clavulanate or levofloxacin and metronidazole
*treat empirically until pathogen identified by sputum or blood culture, then use specific therapy

*OUTPATIENT: treat for 10 - 14 days
**Followup with GP, CXR in 8-12 weeks

*INPATIENT: treatment length based on response to therapy, comorbid illnesses, complications
**usually treat bacterial infections until patient is afebrile for >72 hours
***resolution of respiratory symptoms, fever, PaO2 level, WBC, and findings on serial CXR

*give influenza and pneumococcal vaccine on day of discharge
*smoke cessation

Poor prognostic factors
*age, men, nursing home
*comorbidities: cancer, liver, CHF, CVD, renal
*O/E: LOC, RR, BP, pulse, temperature
*labs: pH, pO2, ↓hematocrit, ↑BUN, ↓Na, ↑glucose, pleural effusion

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