Although treatment of community-acquired pneumonia (CAP) is common in primary care, there are many controversies. Clearly, many patients may be managed on an outpatient basis (Segreti et al., 2005). Use of a formal instrument such as the pneumonia severity index (PSI) or CURB-65 (see Box 16-1) can more accurately identify patients eligible for outpatient treatment (IDSA/ATS, 2007). The choice of oral antibiotic in the outpatient setting must cover common causes of bacterial pneumonia. Many treatment guidelines suggest using antibiotics that cover atypical organisms such as Mycoplasma and Legionella, but there is insufficient evidence to support any specific antibiotic strategy in the outpatient treatment of CAP (Bjerre et al., 2004). Treatment should be continued for a minimum of five days, and at least 48-72 hours beyond the patient's last signs of fever or clinical instability.

In cases of pneumococcal pneumonia with bacteremia, there is limited evidence to suggest that dual therapy with a beta-lactam antibiotic and an antibiotic with coverage of atypical organisms results in lower case-fatality rates than using a p-lactam alone. A meta-analysis of studies comparing the effectiveness of a p-lactam antibiotic with antibiotics active against atypical pathogens in nonsevere CAP found no advantage for the antibiotics that were active against atypical pathogens (Shefet et al., 2005). This was true even on subgroup analysis for patients infected with M. pneumoniae and C. pneumoniae, but there was a significantly lower treatment failure rate in the small number of patients with Legionella infections (relative risk [RR], 0.40) treated with a macro-lide antibiotic (Mills et al., 2005). Patients with significant comorbidities or chronic organ failure and those at risk for drug-resistant S. pneumoniae should be treated with a respiratory fluoroquinolone or combination of p-lactam and mac-rolide antibiotic (IDSA/ATS, 2007).

Indications for hospitalization of any patient include failure to respond or tolerate oral antibiotics, moderate to severe respiratory distress, significant deficit in oxygenation (alveolar-arterial [A-a] O2 gradient), more than one area of lobar consolidation, empyema, immunosuppression, abscess formation, pneumatocele, underlying cardiopulmo-nary disease, and high-risk PSI score. Two additional factors are the patient's age (e.g., infants <2 months, elderly patients) and comorbidities (underlying pulmonary or cardiovascular disease).

Even in the hospital, not all patients must be treated with intravenous antibiotics (Marras et al., 2004). The patient might require hospitalization for dehydration or oxygen therapy, but in select cases, oral antibiotics may be equally effective, cost less, and require fewer days in the hospital than IV antibiotic therapy. Other patients may start receiving IV antibiotics in the hospital, but an algorithm that provides for an early switch to oral antibiotics and early discharge can reduce hospital stay.

Treatment of neonatal pneumonia should target group B streptococci and gram-negative organisms such as E. coli. Older children with suspected bacterial pneumonia should be treated with antibiotics that provide appropriate coverage for H. influenzae and S. pneumoniae. Pneumonia in children older than 5 years should also include macrolide coverage for M. pneumoniae. When symptoms recur or persist for longer than 1 month, further evaluation for an underlying condition should be undertaken (TB skin test, serum immunoglobulin, bronchoscopy, barium swallow, sweat chloride test).

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