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Pneumonia, Viral: Treatment & Medication
Updated: Jun 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Oxygen should be administered to patients with hypoxemia or shortness of breath.
- Emergency medical personnel should administer oxygen if the patient is dyspneic.
- Some prehospital providers can deliver aerosol treatments with beta-agonists, which may improve the patient's breathing.
- Isotonic sodium chloride solution should be administered to patients who are in shock and have no component of congestive heart failure.
Emergency Department Care
Care in the ED may involve use of the following:
- Oxygen, if the patient is dyspneic
- Beta-agonists, if bronchospasm is present
- Fluids, if dehydration is present
- Acyclovir, if varicella or herpes pneumonia is suspected
- Respiratory isolation
- Antibiotics, if infiltrate is seen on the chest radiograph
- Antibiotics chosen depend on whether the infection is community or hospital acquired
- Mechanical ventilation if respiratory failure is present or impending
Medication
Few specific antiviral agents exist. Acyclovir (for varicella and herpes simplex pneumonia) is efficacious. Ganciclovir and immunoglobulin are used in immunocompromised patients with CMV pneumonia.
Beta-agonists
Many patients with viral pneumonia have bronchospasm, which is relieved or improved with the use of beta-agonist drugs.
Albuterol (Proventil)
Beta-agonist for treatment of bronchospasm; relaxes bronchial smooth muscle with its action on beta2-receptors; little effect on cardiac muscle contractility.
Adult
2 puffs qid with metered-dose inhaler; not to exceed 12 inhalations/d; may need to use spacer device to aid inhalation
Pediatric
0.1-0.15 mg/kg PO; not to exceed 2 mg qid
Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation; cardiovascular effects may increase with MAOIs, inhaled anesthetics, tricyclic antidepressants, and sympathomimetic agents
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
Caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders
Antivirals
These agents are used for the treatment of viral infections because they inhibit DNA synthesis and viral replication by competing with deoxyguanosine triphosphate for viral DNA polymerase.
Acyclovir (Zovirax)
Acts by binding viral DNA polymerase (acts as a DNA chain terminator). Virus-infected cells take it up selectively.
Adult
Varicella-zoster infection: 10 mg/kg or 500 mg/m2 q8h IV for 5-7 d
Herpes simplex infection: 5 mg/kg q8h IV or 400 mg PO 5 times/d
Pediatric
Not established
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adverse effects include alteration of renal function and CNS side effects; high-dose bolus injection can cause crystallization in renal tubules and subsequent acute tubular necrosis; dehydration, preexisting renal insufficiency, and higher doses are risk factors for renal toxicity and neurotoxicity (eg, altered sensorium, tremor, myoclonus delirium, seizures, extrapyramidal signs in 1-4% of patients); oral acyclovir, even with high doses, has not been associated with renal toxicity; CNS toxicity after IV administration has been reported
Neuraminidase inhibitors
The surfaces of influenza viruses are dotted with neuraminidase proteins. Neuraminidase is an enzyme that breaks the bonds that hold new virus particles to the outside of an infected, cell thus allowing spread of newly synthesized virus to adjacent cells. Neuraminidase inhibitors block the enzyme's activity and prevent new virus particles from being released, thereby limiting the spread of infection. Those available in the United States include zanamivir (Relenza) and oseltamivir (Tamiflu). Patients who present within 48 hours of illness with influenza A and B should be treated with zanamivir or oseltamivir. These agents have also been used to treat pneumonia from SARS and RSV, but they have not been demonstrated to be effective in the complications of viral disease such as pneumonia. Although these agents are approved for use in influenza A infections and were used in patients with SARS, they have not been shown to be effective in preventing serious influenza-related complications such as pneumonia.
Therefore, they are not recommended for use in patients with viral pneumonia due to influenza A but should be administered to high-risk, nonpregnant patients older than 1 year with influenza who present within 48 hours of onset of illness.
Ganciclovir (Cytovene)
In cells infected with HHV-1 or HHV-2, ganciclovir competitively inhibits incorporation of guanosine triphosphate in viral DNA and terminates chain synthesis. Used for treatment of life-threatening CMV disease. Has been successfully used in immunocompromised patients with CMV retinitis and has been effective in AIDS patients and renal transplant recipients with CMV pneumonia. Has not worked well in marrow transplant recipients with CMV pneumonia unless combined with IV immunoglobulin.
Adult
2.5 mg/kg IV q8h; CMV retinitis dose is 5 mg/kg IV q12h
Pediatric
<3 months: Not established
>3 months: Administer as in adults
Concomitant administration with cytotoxic drugs (eg, dapsone, vinblastine, Adriamycin, pentamidine, flucytosine, vincristine, amphotericin B, trimethoprim-sulfamethoxazole combinations, other nucleoside analogs) may have additive toxicity in the bone marrow, spermatogonia, and germinal layers of skin and GI mucosa; may cause generalized seizures with concurrent administration of imipenem-cilastatin; serum creatinine level may increase after concurrent use with cyclosporine or amphotericin B; probenecid reduces renal clearance; when didanosine is administered 2 h prior or simultaneously, its bioavailability may increase; conversely, steady-state bioavailability may decrease when didanosine is administered 2 h prior but not when the 2 drugs are administered simultaneously; bioavailability may decrease with zidovudine; increases bioavailability of zidovudine; both drugs can cause granulocytopenia and anemia, combination therapy at full dosing may not be possible
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
Clinical toxicity includes granulocytopenia, anemia, and thrombocytopenia; PO route associated with higher rate of CMV retinitis progression compared with IV route; use only when benefits outweigh risks (eg, in advanced HIV disease); half-life and plasma and/or serum concentrations may increase because of reduced renal clearance; doses >6 mg/kg IV may increase toxicity; rapid infusions may increase toxicity; initially, reconstituted solutions of IV ganciclovir have a high pH (pH =11); phlebitis or pain may occur at site of IV infusion despite further dilution of IV fluids; administration should be accompanied with adequate hydration; photosensitization (photoallergy or phototoxicity) may occur
More on Pneumonia, Viral |
| Overview: Pneumonia, Viral |
| Differential Diagnoses & Workup: Pneumonia, Viral |
 Treatment & Medication: Pneumonia, Viral |
| Follow-up: Pneumonia, Viral |
| References |
| Further Reading |
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References
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Further Reading
Clinical guidelines
Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27-72. [335 references] PubMed
Keywords
viral pneumonia, pneumonia influenza, severe acute respiratory syndrome, SARS, coronavirus, CoV, RSV, respiratory syncytial virus, influenza virus, influenza A, parainfluenza 1, parainfluenza 2, parainfluenza 3, adenovirus, parainfluenza virus, rhinovirus, Hantavirus, cytomegalovirus, CMV, Paramyxovirus species, measles, varicella-zoster virus, Epstein-Barr virus, herpes simplex virus, community-acquired pneumonia, Sin Nombre virus, respiratory illness, pneumococcal vaccines
