Pneumonia

Our Approach in Managing Pneumonia

The first 6 hours of pneumonia management determine the trajectory. Our pneumonia specialist pulmonologist team in Mumbai, India uses a structured triage-to-treatment protocol that does not wait for culture results before initiating appropriate empirical therapy, while simultaneously collecting the microbiological data that allows de-escalation once organisms are identified.
 

1. Clinical Assessment & Severity Scoring

Not every pneumonia patient needs admission. Not every admitted patient is adequately monitored.

• CURB-65 score: Confusion, Urea >7 mmol/L, Respiratory rate ≥30, BP <90/60, Age ≥65 - score 0–1: outpatient; 2: consider admission; 3–5: hospital, consider ICU
• PSI (Pneumonia Severity Index) - more granular scoring for hospitalised patients guiding ICU versus ward allocation
• Vital signs: respiratory rate, SpO2, heart rate, BP, temperature - the clinical severity determinants
• Oxygen saturation trending - SpO2 below 92% on room air requires immediate escalation

2. Diagnostic Workup

• Chest X-ray - confirms consolidation, identifies distribution (lobar, multilobar, interstitial), excludes complications (effusion, empyema)
• CT chest - for atypical presentations, immunocompromised patients, or suspected complications
• Blood cultures × 2 - before antibiotics in moderate to severe pneumonia
• Sputum culture and Gram stain - where patient can produce a good sample
• Pneumococcal and Legionella urinary antigen tests - rapid identification of the two most common severe CAP organisms
• Nasopharyngeal swab for respiratory viruses - influenza, COVID-19, RSV in appropriate context
• Procalcitonin and CRP - severity markers and antibiotic stewardship guides

3. Antibiotic Therapy - Empirical Then Targeted

Antibiotic therapy for pneumonia must be prompt - delays beyond 4 hours worsen outcomes.

• Mild CAP (outpatient): oral Amoxicillin ± Azithromycin for atypical cover; Doxycycline as alternative
• Moderate CAP (ward): IV Beta-lactam (Ampicillin-sulbactam, Cefotaxime) + Macrolide or respiratory fluoroquinolone (Levofloxacin)
• Severe CAP (ICU): IV Beta-lactam + Macrolide or respiratory fluoroquinolone; add Vancomycin or Linezolid if MRSA risk; Piperacillin-tazobactam if Pseudomonas risk
• De-escalation at 48–72 hours based on culture results and clinical response
• Antibiotic duration: 5 days for mild-moderate CAP responding well; 7 days for severe; extended for specific organisms (Legionella, S. aureus)
• Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP): broader spectrum empirical therapy guided by local resistance patterns

4. Respiratory Support

• Controlled oxygen - target SpO2 94–98% (88–92% in COPD patients)
• High-Flow Nasal Cannula (HFNC) - for hypoxaemic respiratory failure; reduces intubation rates compared to conventional oxygen
• Non-invasive ventilation (BiPAP) - for hypercapnic patients or those with underlying lung disease
• Invasive mechanical ventilation - for respiratory failure unresponsive to HFNC/NIV; lung-protective ventilation strategy (low tidal volume, PEEP)
• Prone positioning - for severe ARDS complicating pneumonia with PaO2/FiO2 <150

5. Managing Complications

• Parapneumonic effusion - thoracocentesis for diagnostic and therapeutic drainage; pleural fluid pH, glucose, LDH to distinguish exudate from empyema
• Empyema - chest tube drainage; surgical decortication if organised
• Lung abscess - prolonged antibiotic therapy; bronchoscopic or percutaneous drainage for non-responding abscesses
• Septic shock - IV fluid resuscitation, vasopressors, source control, and ICU transfer
• Respiratory failure - escalation through oxygen → HFNC → NIV → intubation pathway based on clinical trajectory

6. Pneumonia Recovery & Discharge Planning

Pneumonia recovery and complications monitoring extends beyond hospital discharge.

• Clinical response expected within 48–72 hours of appropriate antibiotics - failure to improve triggers reassessment
• Radiological resolution lags clinical recovery by 4–6 weeks - repeat X-ray not needed before 4 weeks in uncomplicated cases
• Post-discharge follow-up at 4–6 weeks with repeat chest X-ray - persistent opacity requires further investigation to exclude malignancy
• Pneumococcal and influenza vaccination before discharge for high-risk patients
• Rehabilitation for post-severe-pneumonia patients - fatigue, reduced exercise capacity, and psychological impact are common.