Adult Medical Emergency Handbook - Scottish Intensive Care Society

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• Co-morbidity.
• Multilobar involvement.
• Atrial fibrillation.
If none of these, consider outpatient treatment.
IMMEDIATE INVESTIGATIONS
• ABG (record inspired oxygen concentration).
• CXR
• FBC, urea & electrolytes.
• Blood cultures.
• Sputum culture.
• Urine for Legionella antigen.
• Throat swab (for virology and Mycoplasma in viral transport medium)
INITIAL TREATMENT
• Oxygen - high concentration is normally safe in pneumonia; use
enough to relieve hypoxaemia. (monitor arterial pCO 2 in patients
with pre-existing COPD and in those worsening).
• IV fluids to correct hypovolaemia and total body fluid deficits and
prevent renal dysfunction.
Antibiotics: should be started immediately and related to likely
organism and severity of illness.
• Amoxicillin 500mg orally tds suitable for those with CURB-65 score
0-1 who would have been sent home but for social or other reasons
and for elderly patients (as atypical organisms uncommon).
• If not seriously ill but unable to tolerate oral medication: amoxicillin
500 mg tds IV.
• If penicillin allergy: Clarithromycin 500 mg bd oral or IV.
• If severe CAPC CURB-65 score 2 to 5 Co-amoxiclav 1-2g 8 hr
IV plus Clarithromycin 500mg bd orally or IV. If penicillin allergic,
Ceftriaxone 1-2g IV/24h plus Clarithromycin.
• If strong suspicion of Legionella (eg travel history), add
Ciprofloxacin 400 mg bd IV to Co-amoxiclav/Clarithromycin as
above.
Signs and symptoms do not reliably distinguish pneumococcal
pneumonia from “atypical” pathogens Legionella or
Mycoplasma. Therefore patients with severe pneumonia
CURB 65>3 should receive dual therapy. Dual therapy is not
necessary in mild illness.
150 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11