Pneumonia, Community Acquired

Description

General Measures

Medicine Treatment

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J13/J14/J15.0-9/J16.0/J16.8/J18.0-2/J18.8-9

DESCRIPTION

Pneumonia is an acute infection of the lung parenchyma. Early appropriate antibiotic therapy decreases mortality. The decision to hospitalise a patient and choice of initial antibiotic therapy is guided by age, comorbid diseases (such as HIV infection, diabetes or chronic respiratory disease), and severity. Socioeconomic circumstances should form part of the clinical assessment when deciding if a patient is suitable for outpatient treatment.

GENERAL MEASURES

Diagnosis:

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Clinical features include cough, fever, tachypnoea, and signs of consolidation on chest examination.
CXR almost invariably shows a focal area of opacification or consolidation.
However, empiric antibiotic therapy can be considered for severely ill, hospitalised patients with suspected pneumonia, and a negative CXR.
Pneumonia may be excluded if a repeat CXR after 24-48 hours still shows no opacification. Diffuse, bilateral, interstitial infiltrates in a patient with HIV infection and hypoxaemia is suggestive of Pneumocystis jirovecii pneumonia.

All patients should be offered HIV testing, as HIV infection is associated with a markedly increased risk of bacterial pneumonia.

Even in typical cases of pneumonia, exclude tuberculosis by sending sputum for Xpert® MTB/RIF Ultra.

A follow-up CXR should be done 4–6 weeks after completion of therapy in patients >50 years of age, or if symptoms persist.

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Follow-up CXRs are indicated earlier only when complications are suspected, e.g. empyema, abscess, or pneumothorax.

MEDICINE TREATMENT

• Oxygen, if saturation <94%.

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Adequate analgesia for pleuritic chest pain, if present. See Medical conditions associated with severe pain.

Antimicrobial therapy
Duration of antibiotic therapy is guided by clinical response, but should be 5–7 days, with a minimum of 7 days for MRSA or Pseudomonas.

Longer duration of antibiotic therapy recommended for:

• Identified pathogen that is not susceptible to initial empiric therapy
• Extrapulmonary infection (e.g., meningitis or endocarditis)
• Empyema, lung abscess, or necrotizing pneumonia
• Unusual organism present

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Prolonged fever and clinical signs may be due to unrecognised TB, complications (such as empyema), incorrect choice of antibiotic (e.g. atypical bacteria), or an underlying bronchial obstruction (foreign body or carcinoma). These patients should be further investigated. 

Community-acquired pneumonia without features of severe pneumonia (see below for definition) and without co-morbidity and in patients <65 years of age:

• Ampicillin, IV, 1 g 6 hourly.

In haemodynamically stable patients with respiratory rate <25 breaths/min and the temperature <37.8°C switch to:

•  Amoxicillin, oral, 1 g 8 hourly for 5 days i.e. total duration of 5 days for IV and oral antibiotics combined.

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Severe penicillin allergy: (Z88.0)

•  Moxifloxacin, oral, 400 mg daily for 5 days.

If response is poor after 48 hours, exclude TB and consider atypical bacterial pneumonia, which requires treatment with a macrolide.

Community-acquired pneumonia without features of severe pneumonia (see below for definition) in patients >65 years of age or co-morbidity (e.g. COPD, HIV, cardiac failure, diabetes):

• Ceftriaxone, IV, 2 g daily.

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In haemodynamically stable patients with respiratory rate <25 breaths/min and temperature <37.8°C switch to:

• Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 days.

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Severe penicillin allergy: (Z88.0)

• Moxifloxacin, oral, 400 mg daily for 5 days.

If response is poor after 48 hours, exclude TB and consider atypical bacterial pneumonia, which requires treatment with a macrolide.

Severe pneumonia (cyanosis, confusion, hypotension or respiratory rate >30 breaths/min):

• Ceftriaxone, IV, 2 g daily

Mechanical ventilation may be required (refer to a centre, if needed).

In haemodynamically stable patients with respiratory rate <25 breaths/min and temperature <37.8°C, switch to:

• Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 days.

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AND

• Azithromycin, 500 mg, slow IV (over not less than 60 minutes) daily for 3 days.

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Severe penicillin allergy: (Z88.0)

• Moxifloxacin, IV, 400 mg daily.

In haemodynamically stable patients with respiratory rate <25 breaths/min and temperature <37.8°C, switch to:

• Moxifloxacin, oral, 400 mg daily for 5 days.

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Note:

There is no need to add a macrolide, as moxifloxacin has adequate cover for the atypical bacteria.

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HIV infected with bilateral diffuse interstitial infiltrates on CXR:

Clinical presentation includes a dry cough of <12 weeks’ duration and significant tachypnoea.
Treat as Pneumocystis jirovecii pneumonia (exclude TB) - see  Pneumocystis pneumonia.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.1_16 September 2024

Chapter 16: Respiratory Disorders _16.6 Pneumonia, Community Acquired