Last edited: 9/11/2021

1. PNEUMONIA
Pneumonia | Treatment and Prevention Medical Editor: Maxine Abigale R. Bunao

OUTLINE

I) MAIN HEADING IN
II) CONTENT FORMATTING
III) APPENDIX
IV) REVIEW QUESTIONS
V) REFRENCES

I) COMMUNITY ACQUIRED PNEUMONIA MANAGEMENT

● Duration of therapy:
o At least 5 days
o Have to be afebrile for at least 48-72 hours
o <1 symptom of clinical instability based on CURB 65 score
● If duration of therapy is not completed, pathogen might not be eliminated
o May need to change up the antibiotic

(A) ANTIBIOTICS
RECALL:
Table 1. MOA. (2) Outpatient setting: CAP + Underlying comorbidities
+ Recent antibiotic therapy (past 90 days)
Drug Group MOA
Inhibit bacterial cell wall formation Underlying comorbidities:
by binding to penicillin-binding o COPD
B-lactam proteins (which aid in peptidoglycan o Asthma
cross-linking in both Gram (-) and o Heart failure
Gram (+) bacteria) o Chronic kidney disease
Inhibit B-lactamase enzyme which o Diabetes mellitus
B-lactamase inactivate B-lactam ring found o Cancer
inhibitors commonly in beta-lactam o Immunosuppressive disease or therapy
antimicrobials o Asplenia
Inhibit bacterial cell wall formation  Prevents the body to be able to fight off
Carbapenem by binding to penicillin-binding encapsulated bacteria
proteins • S. pneumoniae
Inhibit bacterial cell wall through ↓ • H. influenza
Cephalosporin synthesis of peptidoglycan layer • Klebsiella
(component) • N. meningitidis
Macrolide Inhibit protein synthesis Table 3. DOC for CAP + Underlying comorbidities + Recent
antibiotic therapy (past 90 days).
Tetracycline
Drug Group Drug of Choices
Inhibit the peptidoglycan-synthesis
Respiratory Levofloxacin >
process of bacteria
Monobactam fluoroquinolone Moxifloxacin
Only activity for gram-negative
Gemifloxacin
bacteria
Macrolide/ Azithromycin/ Doxycycline
Respiratory Inhibit DNA synthesis
Tetracycline + A/B
fluoroquinolone
Penicillin/ B- ↑ dose Amoxicillin / Augmentin (↑
(1) Outpatient setting: CAP + No comorbidities + No A lactamase coverage for resistant bacteria)
recent antibiotic therapy (past 90 days) inhibitor
Table 2. DOC for CAP + No comorbidities + No recent antibiotic B 3rd Gen. Cephalosporin
therapy (past 90 days).
Drug Group Drug of Choices
Macrolide Azithromycin (broad coverage)
Tetracycline Doxycycline

PNEUMONIA RESPIRATORY PATHOLOGY: Note #6. 1 of 4

(3) CAP + Serious illness graded with CURB 65 (4) Pseudomonas suspect
Curb 65 score: Table 6. DOC for CAP - Pseudomonas suspect.
o Criteria: Drug Group Drug of Choices
 Confusion B-lactamase inhibitor – Tazobactam (Zosyn) –
 Uremia: ↑urea levels in the blood B-lactam Piperacillin
+ +
 Respiratory rate
4th Gen Cephalosporin Cefepime
 Blood pressure: low diastolic BP + +
 >65 years old Carbapenem (broad Imipenem, Meropenem
o Scoring: spectrum) + A/B/C
 0-1 of these factors  antibiotics + send patient
A Respiratory Levofloxacin/ Ciprofloxacin
home fluoroquinolone
 2 of these factors  admit into the hospital for
observation B Aminoglycoside + Gentamicin + Azithromycin
Macrolide
 ≥3 of these factors  admit into the ICU
C Aminoglycoside + Gentamicin +
● CURB 65: Fluoroquinolone Levofloxacin
o 2 of these factors  admit into the hospital for
observation (5) CAP MRSA suspect
Table 4. DOC for CAP + Serious illness graded with 2 factors Table 7. DOC for CAP MRSA suspect.
from CURB 65.
Drug Group Drug of Choices
Drug Group Drug of Choices
Glycopeptide antibiotics Vancomycin
Respiratory fluoroquinolone Levofloxacin >
Moxifloxacin Oxazolidinone Linezolid
Gemifloxacin
Macrolide/ Tetracycline + Azithromycin/ Doxycycline
A/B
A Penicillin Ampicillin
B 3rd Gen. Cephalosporin Ceftriaxone
● CURB 65:
o ≥3 of these factors  admit into the ICU
Table 5. DOC for DOC for CAP + Serious illness graded with 3
or more factors from CURB 65.
Drug Group Drug of Choices
3 Gen. Cephalosporin +
rd
Ceftriaxone/ Cefotaxime
A/B
A Macrolide Azithromycin
B Respiratory Levofloxacin
fluoroquinolone
Penicillin-B-lactamase Ampicillin-Sulbactam
(Unasyn)
A
Macrolide
Azithromycin
B Respiratory Levofloxacin
fluoroquinolone
● Penicillin or B-lactamase allergy:
o Have to be careful in giving other Penicillin or B-
lactam antibiotics (Penicillin, Cephalosporin,
Carbapenems, Monobactam)
o Penicillin allergy 
 cross reactivity with other B-lactams
 3-10% chance of developing reaction to
cephalosporin
 1% chance of developing reaction to carbapenems
 <1% chance of developing reaction to
monobactam
 Give a broad-spectrum antibiotic Monobactam
(Aztreonam) instead

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 II) HOSPITAL ACQUIRED PNEUMONIA MANAGEMENT III) GENERAL MANAGEMENT

(1) General considerations (1) General considerations

Criteria MRSA
o >2 days stay in the hospital RECALL:
● Antibiotic therapy: MRSA or Methicillin-resistant Staphylococcus aureus has
o Minimum of 7 days antibiotic therapy beta-lactamases that break down a lot of different types of
o Pseudomonas: minimum of 14 days antibiotic therapy penicillin antibiotics or beta-lactams.
o Signs of clinical improvement in the first 2-3 days  Patients susceptible to MRSA (↑risk):
can change regimen o Recently admitted to the hospital
o Recent antibiotic therapy
(2) HAP Early Onset o History of colonization OR infections
Table 8. DOC for HAP Early Onset. o Healthcare device invasively presented into the body
Drug Group Drug of Choices
Aminoglycoside + Gentamicin + Azithromycin ● Considerations for shifting IV therapy  PO therapy
Macrolide o Hemodynamically stable patient
Respiratory Levofloxacin o Signs of clinical improvement
fluoroquinolone o Able to tolerate oral medications or food
Carbapenem Ertapenem: weaker ones but ● CURB 65
good for early onset HAP o Confusion, Uremia, ↑ RR, ↓ diastolic BP, >65 years old
Penicillin-B-lactamase Ampicillin-Sulbactam
(2) Other medications
(Unasyn)
Analgesics
Duration of stay:
o Lessen the pain
o >2 days BUT <5 days OR
o No MDR pathogen Antitussives or cough suppressants
o Prevent pain from coughing
(3) HAP Late Onset
Table 9. DOC for HAP Late Onset. IV) PREVENTION AND COMPLICATIONS
Drug Group Drug of Choices
(A) PREVENTION
Aminoglycoside OR
Respiratory fluoroquinolone Levofloxacin (1) Pneumococcal Polysaccharide Vaccine (PPSV23)
A B-lactamase inhibitor – Tazobactam (Zosyn) – PPSV23
B-lactam Piperacillin
o 23 stands for the 23 polysaccharide antigens present
B Carbapenem NOT Ertapenem on streptococcal pneumonia bacteria
Choices: Imipenem, o Importance of antigens:
Doripenem,  Account for 85-90% of the invasive S. pneumonia species
Meropenem
Indications:
C 3rd Gen Cephalosporin Ceftazidime
4th Gen Cephalosporin Cefepime o ≥65 years old
o 2-64 years old + immunocompromised state:
Duration of stay:  HIV
o <5 days OR  DM
o With MDR pathogen  Malignancy
Resistant pathogens  hemolytic disorder like sickle cell disease
o Pseudomonas aeruginosa o 19 years old + history of asthma / smoking
o MRSA If administered first before PCV13  wait at least a year
o Enterobacteria before giving PCV13
o Actinobacteria
(2) Pneumococcal Conjugate Vaccine (PCV13)
(4) HAP Pseudomonas positive
PCV13
Table 10. DOC for HAP Pseudomonas positive. o 13 stands for the 13 polysaccharide antigens present
Drug Group Drug of Choices on streptococcal pneumonia bacteria
B-lactamase inhibitor – Tazobactam (Zosyn) – o Important: All of these antigens are the same as
B-lactam Piperacillin the 23 EXCEPT 1
+ +
Respiratory fluoroquinolone/ Levofloxacin/ Indications
Aminoglycoside/ Gentamicin/ o <2 years old: administer during 2, 4, 6, 12-15 months old
Monobactam/ Aztreonam/ Administer first  8 weeks later administer PPSV23
Carbapenem (broad spectrum) Meropenem
Carbapenem (broad spectrum) Imipenem, Meropenem (A) COMPLICATIONS
+ + Septic shock: Extremely dangerous and fatal
Respiratory fluoroquinolone/ Levofloxacin/ Pleural Effusion:
Monobactam Aztreonam o As pneumonia progresses and chronic, this develops
o Can be deadly
(5) HAP MRSA suspect
Table 11. DOC for HAP MRSA suspect. Meningitis
Drug Group Drug of Choices Abscesses
Hypoxia  problems arise from:
Glycopeptide antibiotics Vancomycin o Shortness of breath
Oxazolidinone Linezolid o Improper ventilation
o Improper perfusion

PNEUMONIA RESPIRATORY PATHOLOGY: Note #6. 3 of 4

 V) APPENDIX

Table 12. Abbreviations.

CAP Community acquired pneumonia
DOC Drug of choice
HAP Hospital acquired pneumonia
MOA Mechanism of action

VI) REVIEW QUESTIONS VII) REFRENCES

● Bui, T., & Preuss, C. V. (2020). Cephalosporins. StatPearls
1) Patient Niko, 66/M, with known Type 2 DM diabetes, [Internet].
presented to the emergency room with low diastolic ● Bush, K., & Bradford, P. A. (2016). β-Lactams and β-Lactamase
BP and confusion. Past medical history revealed that Inhibitors: An Overview. Cold Spring Harbor perspectives in
medicine, 6(8), a025247.
she was recently diagnosed with left lower lung https://doi.org/10.1101/cshperspect.a025247
pneumonia. Temperate = 41 degrees Celsius, RR=32, ● Butler, M. S., Hansford, K. A., Blaskovich, M. A., Halai, R., &
BP=100/70, HR=130/min. Laboratory results showed Cooper, M. A. (2014). Glycopeptide antibiotics: back to the future.
The Journal of Antibiotics, 67(9), 631-644.
random blood sugar of 320 mg/dL. What is the ● Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL,
appropriate management? Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth
a) Admit into the hospital and administer Ceftriaxone + Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical; 2018
● Khanna, N. R., & Gerriets, V. (2021). Beta Lactamase Inhibitors.
Levofloxacin / Azithromycin StatPearls [Internet].
b) Admit into the ICU and administer Ceftriaxone + ● Le T. First Aid for the USMLE Step 1 2020. 30th anniversary
Levofloxacin / Azithromycin edition: McGraw Hill; 2020. Williams DA. Pance Prep Pearls.
c) Admit into the ICU and administer Levofloxacin only ● Middletown, DE: Kindle Direct Publishing Platform; 2020.
● Marieb EN, Hoehn K. Anatomy & Physiology. Hoboken, NJ:
d) B & C Pearson; 2020. Boron WF, Boulpaep EL. Medical Physiology.;
2017.
2) After undergoing the regimen selected above for 7 ● Pandey, N., & Cascella, M. (2020). Beta lactam antibiotics.
days, patient Niko showed no signs of clinical StatPearls [Internet].
improvement. When further probed, the patient ● Papadakis MA, McPhee SJ, Rabow MW. Current Medical
Diagnosis &amp; Treatment 2018. New York: McGraw-Hill
revealed multiple trips to the hospital due to his
Education; 2017.
pneumonia and was prescribed with antibiotics of ● Sabatine MS. Pocket Medicine: the Massachusetts General
unrecalled drug class, name, and frequency. What Hospital Handbook of Internal Medicine. Philadelphia: Wolters
resistant pathogen should you consider? Kluwer; 2020.
a) MRSA
b) Pseudomonas aeruginosa
c) Enterobacter
d) All of the above
3) 38 y/o laborer develops cough and a fever. One week
earlier, history revealed he was stabbed on the left
chest that was managed with wound sutures and Co-
Amoxiclav. He is currently in distress, highly febrile,
hypotensive with CXR results showing left lower lung
consolidation/lucencies. You are considering CAP
and suspecting pseudomonas as the inciting
pathogen. What is your management?
a) Tazobactam – Piperacillin + Cefepime + Imipenem +
Ampicillin-Sulbactam
b) Tazobactam – Piperacillin + Cefepime + Imipenem +
Gentamicin
c) Tazobactam – Piperacillin + Cefepime + Imipenem +
Azithromycin
d) Tazobactam – Piperacillin + Cefepime + Imipenem +
Levofloxacin
4) Who should be given a PPSV23 vaccination?
a) 60/M with known HIV
b) 19/F with asplenia
c) 40/M with a 10-pack year smoking history
d) All of the above
5) What complications should you look out for a patient
with pneumonia?
a) Pneumothorax
b) Pleural effusion
c) Septic shock
d) A & C
e) B & C

CHECK YOUR ANSWERS

4 of 4 RESPIRATORY PATHOLOGY: Note #6. PNEUMONIA