eMedicine Specialties > Emergency Medicine > Pulmonary
Pneumonia, Bacterial: Treatment & Medication
Updated: Oct 15, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- For patients with mild shortness of breath, only supplemental oxygen may be required for ventilatory support.
- Patients in respiratory failure may require endotracheal intubation and ventilation. An alternative to intubation may be use of a CPAP mask.
- Patients with hypotension and/or tachycardia may benefit from an intravenous crystalloid bolus in the field.
- Many individuals with pneumonia also have volume depletion. In elderly patients with underlying cardiac disease, take care to avoid aggressive fluid administration, which may cause volume overload.
Emergency Department Care
- Mild dyspnea may resolve with oxygen administered with a nasal cannula.
- Moderate dyspnea requires high oxygen concentrations, such as those provided by a Venti-mask or partial rebreathing face mask. Use these masks with caution in patients with COPD.
- Patients with COPD who need high oxygen concentrations may require intubation.
- Administer ventilatory support when simple supplemental oxygen is not sufficient or when the patient cannot cope with the work of breathing.
- Use of a CPAP mask may be an alternative to intubation in some cases. Patients who are awake and can tolerate mask application may avoid intubation. Nasal CPAP usually is not as well tolerated as a full mask (which covers both the nose and mouth) in the emergent situation.
- Other treatments may include the following:
- Empiric antimicrobial therapy
- Hydration
- Correction of electrolyte levels
- Chest physiotherapy
Consultations
- Consultation with infectious disease and/or pulmonary specialists may be of benefit in unclear or difficult cases.
- Critical care specialists may aid in the treatment of admitted patients who require a CPAP mask or intubation.
- Pharmacy and/or infection control may provide information about typical resistance patterns observed in hospitalized patients.
Medication
The mainstay of drug therapy for bacterial pneumonia is antibiotic treatment. The choice of agent is based on the severity of the patient's illness, host factors (eg, comorbidity, age), and the presumed causative agent. Although intravenous penicillin G is currently not favored, doses in the range of 20-24 million U/d result in serum levels that exceed minimum inhibitory concentration levels of most resistant pneumococci. Second-generation cephalosporins maintain the gram-positive activity of first-generation cephalosporins, and they add activity against Proteus mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis. Third-generation cephalosporins have wider activity against most gram-negative bacteria (eg, Enterobacter, Citrobacter, Serratia, Neisseria, Providencia, Haemophilus species), including beta-lactamase–producing strains.
The role of glucocorticoids in acute bacterial pneumonia is not yet clear. Classic teaching warns that the use of glucocorticoids in infection may impair the immune response. However, findings show that local pulmonary inflammation may be reduced with systemic glucocorticoids. In the future, these drugs may be a useful adjunct in the immunocompetent patient.
Outpatients are given oral agents, and, for the most part, parenteral medications are given to admitted patients. This rationale does not preclude the clinician from giving an initial intravenous dose of antibiotics in the ED and then sending the patient home on oral agents, if the patient's condition warrants such action. The patient's condition, infection severity, and microorganism susceptibility should determine the proper dose and route of administration.
A rational approach may be to administer an oral extended-spectrum macrolide or amoxicillin and clavulanate (Augmentin) to those with mild, outpatient disease. Oral fluoroquinolone may be substituted if a comorbidity or allergy to the first-line agents is present or for good dosing compliance. Admitted patients should receive intravenous therapy, a third-generation cephalosporin alone or with a macrolide. An alternative regimen would be intravenous fluoroquinolones.
Antibiotics
The best initial antibiotic choice is thought to be a macrolide. Macrolides provide the best coverage for the most likely organisms in community-acquired bacterial pneumonia. Macrolides have effective coverage for gram-positive, Legionella, and Mycoplasma organisms. Azithromycin administered intravenously may be an alternative to intravenous erythromycin.
Macrolides, as a class, have the potential disadvantage of causing GI upset. Compared with erythromycin, newer agents have fewer GI adverse effects and drug interactions, although all macrolides have the potential for drug interactions similar to those of erythromycin. Newer macrolides offer improved compliance because of reduced dosing frequency, improved action against H influenzae, and coverage of Mycoplasma species (unlike cephalosporins). The main disadvantage is cost.
Macrolides are primarily recommended for the treatment of community-acquired pneumonia in patients younger than 60 years who are nonsmokers without comorbidity. Give special consideration to recommendations for antibiotic use in patients with comorbidity or those with community-acquired pneumonia who are older than 60 years. While patients in this group are still susceptible to S pneumoniae, they should receive treatment for broader coverage that includes Haemophilus, Moraxella, and other gram-negative organisms. Therefore, a prudent course of action for empiric outpatient therapy is to include (1) one of the macrolide agents described previously plus a second- or third-generation cephalosporin or amoxicillin and clavulanate or (2) trimethoprim and sulfamethoxazole as a single agent.
Second-generation cephalosporins also provide good coverage against Haemophilus and Moraxella species and provide adequate activity against gram-positive organisms. Of these agents, cefprozil, cefpodoxime, and cefuroxime seem to have better in vitro activity against S pneumoniae. Second-generation cephalosporins are not effective against Legionella or Mycoplasma species. These drugs generally are well tolerated, but cost may be a factor. Oral second-generation and third-generation cephalosporins offer increased activity against gram-negative agents and may be effective against ampicillin-resistant S pneumoniae.
The combination of trimethoprim and sulfamethoxazole may be used in the patient with pneumonia and a history of COPD or smoking. It may be used as a single agent in younger patients in whom a Haemophilus species is the suspected agent. It is well tolerated and inexpensive. Allergic reactions more often are associated with drugs in this class than with other antibiotics. Reactions span the spectrum from simple rash (most likely) to Steven-Johnson syndrome and toxic epidermal necrolysis (rare). Many potential drug interactions exist.
Patients who have moderate clinical impairment or comorbidity are best treated with parenteral agents and, unless a particular agent is strongly suspected, broad coverage should be afforded. Regimens for this use include a macrolide plus a second- or third-generation cephalosporin, (as single agents) amoxicillin and sulbactam (Unasyn), piperacillin and tazobactam (Zosyn), or ticarcillin and clavulanate (Timentin). These last 3 are not described in detail here. Please consult the Sanford Guide for more information.
Intravenous cephalosporins may be combined with a macrolide agent. They broaden the gram-negative coverage, and in the case of third-generation agents, they may be effective against resistant S pneumoniae. Also, some third-generation agents are effective against Pseudomonas, whereas second-generation agents are not.
When a severely ill patient has features of sepsis and/or respiratory failure, and/or when neutropenia is known or suspected, treatment with an intravenous macrolide is combined with an intravenous third-generation cephalosporin and vancomycin. An alternative regimen may include imipenem, meropenem, or piperacillin and tazobactam plus a macrolide and vancomycin. A fulminant course also must raise the suspicion of infection with Legionella or Mycoplasma species, Hantavirus, psittacosis, or Q fever.
Fluoroquinolones, including levofloxacin, moxifloxacin, and gatifloxacin, may also be used. They are available in oral and parenteral forms and have convenient dosing regimens, which allow easier conversion to oral therapy that results in good patient compliance. Note that a warning was issued from the FDA regarding risk of tendonitis and tendon rupture in July 2008.2
All agents discussed above are for use in persons older than 5 years. In children younger than 5 years, initial treatment of pneumonia includes intravenous ampicillin or nafcillin plus gentamicin or cefotaxime (for neonates), and ceftriaxone or cefotaxime can be administered as a single agent (for >28 d to 5 y). An alternative regimen includes a penicillinase-resistant penicillin plus an antipseudomonal aminoglycoside.
Outpatient treatment of mild-to-moderate pneumonias in children usually involves agents similar to those used for acute otitis media. Most of the pneumonias in these patients probably have a viral cause. In children who have features suggesting a bacterial etiology (eg, an infiltrate on chest radiograph and/or positive findings at sputum Gram staining), the administration of antibiotics may be good clinical practice. In these cases, many clinicians begin empiric therapy with amoxicillin, but its spectrum of activity is lacking because children in this group who do not have nonviral pneumonia usually have an infection caused by S pneumoniae and Mycoplasma species.
H influenzae type B has been less common since the introduction of the HIB vaccine. Children younger than 2 years may still be at risk for H influenzae type B infection because their immune response is not sufficient, as it is in older children. A typical regimen for outpatient therapy may include a new macrolide agent or a second- or third-generation cephalosporin. Cost is a potential drawback for all agents.
Moxifloxacin (Avelox)
Inhibits the A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription. Indicated for community-acquired pneumonia, including multi – drug-resistant S pneumoniae.
Adult
400 mg PO/IV qd
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, electrolyte supplements reduce absorption; loop diuretics, probenecid, cimetidine increase serum levels; NSAIDs enhance CNS stimulating effect
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); ferrous sulfate decreases bioavailability (administer moxifloxacin 4 h prior or 8 h following ferrous sulfate); coadministration with drugs that prolong QTc interval (quinidine, procainamide, amiodarone, sotalol, erythromycin, tricyclic antidepressants) increase risk of life-threatening arrhythmia
Documented hypersensitivity; known Q-T prolongation, concurrent administration of drugs that cause Q-T prolongation
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); superinfections may occur with prolonged or repeated antibiotic therapy; fluoroquinolones have induced seizures in CNS disorders and caused tendinitis or tendon rupture
Ertapenem (Invanz)
Bactericidal activity results from inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin-binding proteins. Stable against hydrolysis by a variety of beta-lactamases including penicillinases, cephalosporinases, and extended-spectrum beta-lactamases. Hydrolyzed by metallo-beta-lactamases.
Indicated for community-acquired pneumonia due to S pneumoniae (penicillin-susceptible isolates only) including cases with concurrent bacteremia, H influenzae (beta-lactamase negative isolates only), or M catarrhalis.
Adult
1 g IV qd
CrCl <30 mL/min/1.73 m2: 500 mg IV qd
Pediatric
<3 months: Not established
3 months to 12 years: 15 mg/kg IV q12h; not to exceed 1 g/d
>12 years: Administer as in adults
Probenecid may reduce renal clearance of ertapenem and increase half-life, but benefit is minimum and does not justify coadministration
Documented hypersensitivity to drug or amide-type anesthetics
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pseudomembranous colitis may occur; seizures and CNS adverse reactions may occur; when using with lidocaine to administer intramuscularly, avoid inadvertent injection into blood vessel; decrease dose in renal failure; serious and occasionally fatal hypersensitivity reactions may occur with beta-lactams, caution with previous hypersensitivity reactions to penicillin, cephalosporins, other beta-lactams, or other allergens; do not mix or coinfuse in same IV line as other medications; do not mix with dextrose-containing diluents
Azithromycin (Zithromax)
In otherwise uncomplicated pneumonia, initial DOC; covers most potential etiologic agents, including Mycoplasma species. Compared with other drugs, causes less GI upset; potential for good compliance because of reduced dosing frequency. Has better action against H influenzae compared with erythromycin. Main disadvantage is cost.
Adult
Day 1: 500 mg PO
Days 2-5: 250 mg PO qd
Alternative: 500 mg IV qd
Pediatric
Day 1: 10 mg/kg PO
Days 2-5: 5 mg/kg PO qd
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
IV-site reactions can occur; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Clarithromycin (Biaxin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. Another initial DOC in otherwise uncomplicated pneumonia. Appears to cause more GI symptoms (eg, gastric upset, metallic taste) than azithromycin.
Adult
500 mg PO bid for 10 d
Pediatric
<6 months: Not recommended
>6 months: 7.5 mg/kg PO bid for 10 d; not to exceed 500 mg/dose
Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, HMG CoA–reductase inhibitors; levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide
Documented hypersensitivity; coadministration of pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Erythromycin (EES, Erythrocin, Ery-Tab)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. Covers most potential etiologic agents, including Mycoplasma species. Regimen PO may be insufficient to adequately treat Legionella species. Less active against H influenzae. Although standard course of treatment is 10 d, treatment until patient is afebrile for 3-5 d is a more rational approach. May result in GI upset, causing some to prescribe an alternative macrolide or change to tid dosing.
Adult
500 mg PO qid or 333 mg PO tid
Hospitalized patients with severe pneumonia: 1 g IV q6h
Alternative: 15-20 mg/kg/d IV divided q6h
Pediatric
7.5 mg/kg/d PO divided bid
Alternative: 20-40 mg/kg/d IV divided q6h or as constant infusion; not to exceed 4 g/d
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Amoxicillin and clavulanate (Augmentin)
Alternative for patients who are allergic or intolerant to macrolides. Usually well tolerated and provides good coverage to most infectious agents. Not effective against Mycoplasma and Legionella species. Cost is a problem.
Adult
500/125 or 875/125 mg PO bid for 10 d or until afebrile for 3-5 d
Augmentin XR (1000/62.5): 2 tab PO bid for 10 d or until afebrile for 3-5 d
Pediatric
25-45 mg/kg/d PO divided q12h
>3 months: Base dose on amoxicillin content; because of different amoxicillin–clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg
Coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Give for a minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); after treatment, order cultures to confirm eradication of streptococci
Doxycycline (Doryx, Bio-Tab)
Alternative agent for patients who cannot tolerate macrolides or penicillins. Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
100 mg PO bid for 10 d or until afebrile for 3-5 d
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO qd or divided bid; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider determining drug serums in prolonged therapy; tetracycline use during tooth development (last half of gestation through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Vancomycin (Vancocin)
Classified as glycopeptide agent with excellent gram-positive coverage, including methicillin-resistant S aureus. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h before next dose. Use CrCl rate to adjust dose in patients with renal impairment.
Adult
500 mg IV q6h or 1 g IV q12h
Pediatric
10 mg/kg IV q6h
Neonates: 15 mg/kg IV initially; administer over 1 h
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; with concurrent use, risk of nephrotoxicity may increase above that associated with aminoglycoside use alone; neuromuscular blockade may be enhanced when used concurrently with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure, neutropenia; red man syndrome is caused by too-rapid IV infusion (dose given over a few min) but rarely happens when dose given as 2-h administration or PO or IP; red man syndrome is not an allergic reaction
Levofloxacin (Levaquin)
L stereoisomer of the D/L parent compound ofloxacin (D form is inactive). Good monotherapy that gives extended coverage against Pseudomonas species as well as excellent activity against pneumococcus. The 750-mg dose is as well tolerated as the 500-mg dose and is more effective. Agent acts by inhibition of DNA gyrase activity. PO form has bioavailability that reportedly is 99%.
Other fluoroquinolones with activity against S pneumoniae may be useful and include moxifloxacin, gatifloxacin, and gemifloxacin.
Adult
750 mg PO/IV qd for 7-14 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); do not administer within 24 h of live typhoid vaccine (reduces vaccine effects)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, periodically evaluate organ system (eg, renal, hepatic, hematopoietic) functions; adjust dose in renal function impairment (with hemodialysis, CAPD, or CrCl <20 mL/min, administer 250 mg q48h; with CrCl 20-49 mL/min, administer 250 mg q24h); superinfections may occur with prolonged or repeated antibiotic therapy; caution in breastfeeding
Resistance to these compounds emerging
Caution in patients with prolonged QT
Cefprozil (Cefzil)
Binds to one or more of the penicillin-binding proteins, inhibiting cell wall synthesis and resulting in bactericidal activity.
Adult
500 mg PO qd for 10 d
Pediatric
<12 years: 7.5-15 mg/kg/d PO divided q12h for 10 d
>12 years: Administer as in adults
Probenecid increases effect; coadministration with furosemide and aminoglycosides increases nephrotoxic effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dosage in renal impairment
Cefuroxime (Ceftin, Kefurox, Zinacef)
Second-generation cephalosporin maintains the activity against gram-positive organisms that first-generation cephalosporins have. Adds activity against P mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis.
Condition of the patient, severity of infection, and susceptibility of microorganism determines proper dose and route of administration.
Adult
250 mg PO bid for 10 d
Pediatric
<6 months: 20-50 mg/kg/d IV q12h
Infants and children: 75-150 mg/kg/d IV q8h; not to exceed 6 g/d
Disulfiramlike reactions may occur when alcohol is consumed within 72 h after administration; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Administer half dose if CrCl is 10-30 mL/min and quarter dose if CrCl <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum and gram-negative activity, low efficacy against gram-positive organisms, and high efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. Considered DOC for parenteral agents in community-acquired pneumonia.
Adult
0.5 g IV q12h or 2 g IV qd
Pediatric
>7 days to 6 months: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
>6 months: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding and allergy to penicillin
Ceftazidime (Ceptaz, Fortaz, Tazicef, Tazidime)
Third-generation cephalosporin with broad-spectrum and gram-negative activity, low efficacy against gram-positive organisms, and high efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
1-2 g IV q8-12h
Pediatric
<6 months: 30 mg/kg IV q12h
>6 months to <12 years: 30-50 mg/kg/dose IV q8h; not to exceed 6 g/d
>12 years: Administer as in adults
Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Linezolid (Zyvox)
Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process. Bacteriostatic against enterococci and staphylococci and bactericidal against most strains of streptococci. Used as alternative in patients allergic to vancomycin and for treatment of vancomycin-resistant enterococci. Effective against MRSA and penicillin-susceptible S pneumoniae infections.
Adult
400-600 mg PO/IV q12h for 10-28 d
Pediatric
Not established
May cause hypertension when used concomitantly with adrenergic agents including pseudoepinephrine, sympathomimetic agents, vasopressor or dopaminergic agents (reduce dose of dopamine or epinephrine if concurrent use required); serotonin syndrome may occur if used concomitantly with serotonergic agents including tricyclic antidepressants, meperidine, dextromethorphan, trazodone, venlafaxine, and selective serotonin reuptake inhibitors
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Has mild MAOI properties and has potential to have same interactions as other MAOIs; caution in uncontrolled hypertension, pheochromocytoma, carcinoid syndrome, or untreated hyperthyroidism, and patients who are at increased risk for bleeding, have preexisting thrombocytopenia, receive concomitant medications that may decrease platelet count or function, or who may require >2 wk of therapy (monitor platelet counts); unnecessary use may lead to development of resistance to drug
More on Pneumonia, Bacterial |
| Overview: Pneumonia, Bacterial |
| Differential Diagnoses & Workup: Pneumonia, Bacterial |
 Treatment & Medication: Pneumonia, Bacterial |
| Follow-up: Pneumonia, Bacterial |
| Multimedia: Pneumonia, Bacterial |
| References |
| « Previous Page | Next Page » |
References
Mufson MA, Stanek RJ. Bacteremic pneumococcal pneumonia in one American City: a 20-year longitudinal study, 1978-1997. Am J Med. Jul 26 1999;107(1A):34S-43S. [Medline].
Kelly C. FDA Requests Boxed Warnings on Fluoroquinolone Antimicrobial Drugs. US Food and Drug Administration; July 2008. [Full Text].
Arnold FW, Ramirez JA, McDonald LC, Xia EL. Hospitalization for community-acquired pneumonia: the pneumonia severity index vs clinical judgment. Chest. Jul 2003;124(1):121-4. [Medline].
Brown K. Pneumonia. In: Pediatric Emergency Medicine: A Comprehensive Study Guide. 2nd ed. 2002:219-25.
Bryan CS. Treatment of pneumococcal pneumonia: the case for penicillin G. Am J Med. Jul 26 1999;107(1A):63S-68S. [Medline].
Dwyer R, Ortqvist A, Aufwerber E, et al. Addition of a macrolide to a ss-lactam in bacteremic pneumococcal pneumonia. Eur J Clin Microbiol Infect Dis. Aug 2006;25(8):518-21. [Medline].
Flanders WD, Tucker G, Krishnadasan A, et al. Validation of the pneumonia severity index. Importance of study-specific recalibration. J Gen Intern Med. Jun 1999;14(6):333-40. [Medline].
Flood RG, Badik J, Aronoff SC. The utility of serum C-reactive protein in differentiating bacterial from nonbacterial pneumonia in children: a meta-analysis of 1230 children. Pediatr Infect Dis J. Feb 2008;27(2):95-9. [Medline].
Foo RL, Graham SM, Suthisarnsuntorn U, Parry CM. Detection of pneumococcal capsular antigen in saliva of children with pneumonia. Ann Trop Paediatr. Jun 2000;20(2):161-3. [Medline].
Getahun D, Ananth CV, Peltier MR, et al. Acute and chronic respiratory diseases in pregnancy: associations with placental abruption. Am J Obstet Gynecol. Oct 2006;195(4):1180-4. [Medline].
Gilbert DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy. 38th ed. 2008:35-6.
Gowardman J, Trent L. Severe community acquired pneumonia: a one-year analysis in a tertiary referral intensive care unit. N Z Med J. May 12 2000;113(1109):161-4. [Medline].
Khashab MM, Xiang J, Kahn JB. Comparison of the adverse event profiles of levofloxacin 500 mg and 750 mg in clinical trials for the treatment of respiratory infections. Curr Med Res Opin. Oct 2006;22(10):1997-2006. [Medline].
Klugman KP, Madhi SA, Feldman C. HIV and pneumococcal disease. Curr Opin Infect Dis. Feb 2007;20(1):11-5. [Medline].
Moffa DA, Emerman CL. Bronchitis, pneumonia & pleural empyema. In: Emergency Medicine: A Comprehensive Study Guide. 6th ed. 2004:446-51.
Molinos L, Fernandez R, Gullon JA, et al. [Community-acquired pneumonia (CAP) with hospital treatment. The value of the clinical picture and complementary exams in predicting its etiology]. Arch Bronconeumol. May 1997;33(5):230-4. [Medline].
Monton C, Ewig S, Torres A, et al. Role of glucocorticoids on inflammatory response in nonimmunosuppressed patients with pneumonia: a pilot study. Eur Respir J. Jul 1999;14(1):218-20. [Medline].
Mundy LM, Leet TL, Darst K, et al. Early mobilization of patients hospitalized with community-acquired pneumonia. Chest. Sep 2003;124(3):883-9. [Medline].
Musher DM, Alexandraki I, Graviss EA, et al. Bacteremic and nonbacteremic pneumococcal pneumonia. A prospective study. Medicine (Baltimore). Jul 2000;79(4):210-21. [Medline].
Reinert RR, Lutticken R, Lemperle M, Bryskier A. A comparative study of the in-vitro activity of levofloxacin against Streptococcus pneumoniae. J Antimicrob Chemother. Jun 1999;43 Suppl C:5-8. [Medline].
Rittenhouse BE, Stinnett AA, Dulisse B, et al. An economic evaluation of levofloxacin versus cefuroxime axetil in the outpatient treatment of adults with community-acquired pneumonia. Am J Manag Care. Mar 2000;6(3):381-9. [Medline].
Ruiz-Gonzalez A, Falguera M, Vives M, et al. Community-acquired pneumonia: development of a bedside predictive model and scoring system to identify the aetiology. Respir Med. May 2000;94(5):505-10. [Medline].
Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for nosocomial bacterial pneumonia and chronic obstructive pulmonary disease. A systematic review. Ann Periodontol. Dec 2003;8(1):54-69. [Medline].
Spiritus E, Chang RJ, Zhang J. Cost-effectiveness of clarithromycin compared to erythromycin and cefaclor in the treatment of community-acquired pneumonia. Chest. 1997;112(3):5S.
Straus WL, Plouffe JF, File TM, et al. Risk factors for domestic acquisition of legionnaires disease. Ohio legionnaires Disease Group. Arch Intern Med. Aug 12-26 1996;156(15):1685-92. [Medline].
Waterer GW, Kessler LA, Wunderink RG. Medium-term survival after hospitalization with community-acquired pneumonia. Am J Respir Crit Care Med. Apr 15 2004;169(8):910-4. [Medline].
Waterer GW, Wunderink RG. The influence of the severity of community-acquired pneumonia on the usefulness of blood cultures. Respir Med. Jan 2001;95(1):78-82. [Medline].
Wood CA, Bosker G, Jones JS. Antibiotic update 1996: cost effective treatment guidelines for bacterial infections in the ED. Emerg Med Rep. 1996;17(1):1-11.
Further Reading
Keywords
lung infection, bacterial lung infection, bronchopneumonia, lung parenchyma, smoking, chronic obstructive pulmonary disease, COPD, inhaled toxins, Legionella pneumophila infections, bronchiectasis, Staphylococcus aureus pneumonia, Klebsiella infection, pneumococcal pneumonia, Pseudomonas infection, Haemophilus influenzae infection, pneumococcal species, pleuritic chest pain, wheezes, egophony on auscultation, rhonchi, rales, endotracheal intubation, lung tumors, Streptococcus pneumoniae, asthma, chronic alcoholism, diabetes, intravenous drug abuse, stroke, aspiration pneumonia, Moraxella catarrhalis species, Bacteroides species, Peptostreptococcus species, Fusobacterium species, bacterial pneumonia, community-acquired pneumonia, CAP, hospital-acquired pneumonia, HAP, institutional-acquired pneumonia, IAP
