Pneumonia Update for Emergency Clinicians.

Abstract

Purpose of Review Many new concepts in diagnosis, management, and risk stratification of patients with pneumonia have been described recently. The COVID pandemic made importance of viruses as dangerous pathogens of pneumonia quite clear while several non-invasive measures for patients with respiratory failure gained a more wide-spread usage.Recent FindingsStudies continue to examine feasibility of bedside ultrasound as a tool in accurate diagnosis of pneumonia in the emergency department, and several new antibiotics have been approved for treatment while others are in late-stage clinical trials. Additionally, the Infectious Diseases Society, American Thoracic Society, and their European counterparts published updated guidelines in recent years. For differences important to emergency medicine clinicians and new emphasis as compared to the prior guidelines, please see Table 1. Several new antibiotics have been approved recently but remain relatively unknown to emergency clinicians as their use is frequently restricted to infectious disease specialists.Table 1Differences important to emergency medicine clinicians and new emphasis [8, 16, 18, 19••, 30, 34]New recommendationsDifference with prior guidelines if anyCommentBlood and sputum cultures recommended in severe disease and in inpatients treated for MRSA or P. aeruginosaSimilar from the ED perspectiveClinical gestalt performs as well as various decision instruments in deciding who needs blood cultures [13]Obtaining procalcitonin level not recommended to guide antibacterial therapyWas not covered in prior guidelinesRecommend using validated risk factors to determine the need for P. aeruginosa or MRSA coverage instead of using hospital-acquired and ventilator-associated guidelinesEmphasized healthcare-associated pneumonia categoryMDRO prevalence varies widely between communities challenging study interpretation [8]Macrolide monotherapy conditional for outpatients based on local resistance patternsWas strongly recommendedS. pneumonia is increasingly resistant to macrolidesAmoxicillin or doxycycline monotherapy for outpatients with no comorbidities or risk factors for MDRO. Amoxicillin/clavulanate or cephalosporin (cefuroxime or cefpodoxime) combined with a macrolide or doxycycline or monotherapy with a respiratory fluoroquinolone such as moxifloxacin for patients with comorbiditiesAmoxicillin, amoxicillin/clavulanate, and doxycycline were not considered prominently in treatment regimensThe recommendation for including doxycycline in the treatment protocols is conditional and is based on weak evidence and is only recommended in patients with contraindications to both macrolides and fluoroquinolones. M. pneumonia is increasingly resistant to macrolides, and tetracyclines and respiratory fluoroquinolones are viable alternatives if a patient with a known M. pneumonia infection does not respond to a macrolide. In admitted patients, the addition of a macrolide to a b-lactam consistently lowers mortality [18]. Amoxicillin does not cover the atypicalsDo not give corticosteroids to pneumonia patients except in possibly decompensated refractory septic shock or known adrenal insufficiencyWas not consideredNote that in certain special forms of pneumonia (not considered CAP), such as Pneumocystis jirovecii pneumonia, corticosteroid therapy may still be necessary. Corticosteroids increase mortality in patients with influenza infection who develop pneumoniaWhen treating a patient with severe CAP b-lactam/macrolide combination preferred over b-lactam/fluoroquinolone combination, the use of anti-influenza therapy is recommended if influenza viral test is positive (expert recommendation)B-lactam/macrolide combination OR b-lactam/fluoroquinolone combination; use of anti-influenza therapy was not consideredInfluenza therapy in hospitalized patients has not been validated in a randomized controlled trialLimiting the length of antibiotic therapy to 7–10 days including in ventilator-associated pneumoniaRecommended 14–21 days of therapyIn one study, CAP patients who received a single dose of intravenous ceftriaxone did just as well as patients who got it daily for 7 days [18]. Since that study compared ceftriaxone to daptomycin (that was later found to be inactivated by surfactant), this can be hypothesis generation onlyFollow-up chest imaging after symptoms of pneumonia improve recommended only as necessary for lung cancer screeningFollow-up chest imaging was not addressedSummaryAs the emergency physicians gain new tools to rapidly diagnose, treat, and appropriately disposition pneumonia cases that appear to become more complex as people unfortunately accumulate more comorbidities, we hope to offer better care and improve outcomes for our patients while allowing staff to enjoy coming to work.