Everything You Need to Know About Pneumonia Treatment

Pneumonia can be life threatening. It is a disease of the lungs and respiratory system that is caused by pathogens such as bacteria, viruses, or fungi or it can be the final, fatal disorder in an individual who is already quite ill.

Pneumonia affects the tissue of the lungs called the parenchyma, in which there can be consolidation, meaning the lung stops functioning. There is an accumulation of fluid, excretions, inflammatory cells, and scar tissue or fibrin.

Treatment of lower respiratory diseases, no matter the pathogen, all have common themes. Patients who have respiratory failure, blood infections (sepsis), and overall debilitation require many different support measures.

This article will discuss the mainstays of treatment for bacterial pneumonia, which is highlighted by antibiotic therapy.

What is the general approach in treatment of bacterial pneumonia?

The first task in treating a patient is stabilization of the airway and providing respiratory support and fluids as needed.

One of the main decisions made by healthcare providers when they see a patient with pneumonia is whether the patient can be treated as an outpatient or inpatient, and whether the patient will need intensive care (ICU).

In another article, a description of the CURB-65 and pneumonia severity index (PSI) is presented. These are interactive tools healthcare providers use to classify patients that help to anticipate what a particular patient needs.

These tools are not perfect. They may underestimate or overestimate the patient’s need for hospital admission. The tools can overestimate the mortality risk in higher risk patients.

For example, direct admission to an ICU is recommended for patients who have septic shock or with acute respiratory failure. In some cases, these patients can be stabilized before ICU transfer and intensive care may be avoided altogether.

What are the goals of antibiotic therapy for bacterial pneumonia?

The goals are:

• Eradicate infection.
• Reduce morbidity (illness).
• Prevent complications.

Many of the drugs chosen to treat pneumonia are empiric. Empiric means that the treatment is based on or is verifiable with observation and experience rather than pure scientific evidence.

In other words, the drugs are directed against potential pathogens as determined by the setting in which the infection took place and the potential exposure for pathogens that may be resistant to standard antibiotic treatment.

There are differences between pneumonia that is derived from community-acquired exposure, hospital or healthcare-acquired pneumonia and ventilator-associated pneumonia. Empiric therapy often depends on where the patient is thought to have developed the infection.

An example of this decision-making process is Legionella infection. Legionella pneumonia should always be considered in evaluating patients for community-acquired pneumonia because delaying treatment can significantly increase the odds of mortality in patients who otherwise can be treated successfully.

The most common causative organism in community-acquired pneumonia is Streptococcus pneumonia. Pneumococcal pneumonia can be spread with coughing or sneezing.

What are some examples of the antibiotics used for bacterial pneumonia?

Streptococcus pneumoniae

• Penicillin G.
• If penicillin resistant, then vancomycin or linezolid.

Staphylococcus aureus

• Cephazolin, clindamycin.
• Vancomycin, linezolid, trimethoprim-sulfamethoxazole.

Haemophilus influenza

• Amoxicillin.
• Fluoroquinolone, doxycycline, azithromycin, clarithromycin.
• Second or third generation cephalosporin, amoxicillin/clavulanate, fluoroquinolone, doxycycline, azithromycin, clarithromycin.

Legionella

• Fluoroquinolone, azithromycin, doxycycline.

What are the considerations for outpatient empiric antibiotic therapy?

The main considerations for choices of antibiotics in the outpatient setting include:

• Presence of patient risk factors.
• Presence of patient risk factors.Any recent exposure to particular patients with known pathogens.
• Any recent exposure to antibiotics.
• Comorbidities such as diabetes mellitus, heart disease, COPD, emphysema, asthma, liver or kidney disease, immunosuppression or malignancy, or other diseases.
• Any local trends for antibiotic resistance.

Usually, if a patient is previously healthy with no recent exposure to antibiotics within that past 90 days, the drug of choice is a macrolide or doxycycline. This is again an empiric choice, and it can vary depending on the healthcare provider’s experience and the local trends in a particular community.

Those patients with comorbidities require a respiratory fluoroquinolone or beta-lactam plus a macrolide antibiotic. These are more broad-spectrum antibiotics and can be more effective for patients who may have more difficult clinical situations.

If the patient has taken an antibiotic in the past 90 days, it is essential to consider an alternate drug, usually from a different class or category of antibiotics.

What are some of the common inpatient empiric antibiotic therapies?

For non-intensive care unit (ICU) patients, there is the choice of:

• Beta-lactam: intravenous (IV) or intramuscular (IM) administration) plus macrolide IV or oral (PO).
• Beta-lactam (IV or IM) plus doxycycline (IV or PO).
• Antipneumococcal quinolone monotherapy (IV or IM).
• If the patient is younger than 65 years with no risk factors for drug-resistant organisms, administer macrolide monotherapy (IV or PO).

For ICU patients, there is the choice of:

• IV beta-lactam plus IV macrolide.
• IV beta-lactam plus IV antipneumococcal quinolone.
• If the patient has a documented beta-lactam allergy, administer IV antipneumococcal quinolone plus IV aztreonam.

What are common supportive measures used for bacterial pneumonia?

Supportive measures include the following:

• Analgesia and antipyretics.
• Chest physiotherapy.
• Intravenous fluids (and, conversely, diuretics) if indicated.
• Monitoring – Pulse oximetry with or without cardiac monitoring, as indicated.
• Oxygen supplementation.
• Positioning of the patient to minimize aspiration risk.
• Respiratory therapy, including treatment with bronchodilators and, perhaps, N -acetylcysteine in selected patients.
• Suctioning and bronchial hygiene – Pulmonary toilet may include active suction of secretions, chest physiotherapy, positioning to promote dependent drainage, and incentive spirometry to enhance elimination of purulent sputum and to avoid atelectasis.
• Mechanical ventilatory support with low tidal volumes (6 mL/kg of ideal body weight) in patients with respiratory failure secondary to bilateral pneumonia or acute respiratory distress syndrome.
• Systemic support may include proper hydration, nutrition, and early mobilization to create a positive host milieu to fight infection and speed recovery. Early mobilization of patients, with encouragement to sit, stand, and walk when tolerated, speeds recovery.

What are the recommendations for prevention of bacterial and viral pneumonia?

• Pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13).
• Influenza vaccine.
• A special note for the vaccine for COVID-19.

It should be noted that even though pneumococcal vaccines are effective, unfortunately they are universally underused. Pneumococcal pneumonia is still the most common cause of fatal pneumonia. It occurs mostly in children under two years and in adults over 65 years.

Also, patients who have pneumonia and are treated as an outpatient, it is important to arrange adequate long-term follow-up. The patient’s condition can always be tenuous, and it is not unusual for the patient to experience setbacks.