Pneumonia: Drug Therapy

Therapeutic target

• Elimination of the pathogens
• Avoidance of complications

Patients with pneumonia should be treated according to their assignment to one of the three forms:

1. Community-acquired pneumonia (AEP;community-acquired pneumonia, CAP): outside the hospital, patient immunocompetent.
2. Nosocomial-acquired pneumonia (hospital-acquired pneumonia, HAP): in hospital (> 48 h after hospital admission or in the first 3 months after hospital discharge), patient immunocompetent.
3. Pneumonia acquired under immunosuppression (pneumonia in the immunosuppressed host): outside or in hospital, patient immunosuppressed.

Therapy recommendations

• Clinically stable patients with community-acquired pneumonia can be treated at home.
• Hospital treatment should be given if individual risk factors are present:
  • Age ≥ 65 years
  • Poor general condition
  • Pulmonary comorbidity (concomitant disease)
  • Hospitalization in the last month
  • Defensive weakness
  • Antibiotic pretreatment
  • Steroid therapy ≥ 4 weeks
  • Other diseases are present (see also CRB-65 score).
• Community-acquired pneumonia (AEP): antibiotic therapy should be initiated immediately!
  • Absent risk factors: Amoxicillin (first-line agent).
  • With risk factors in terms of comorbidities (concomitant diseases): amoxicillin/clavulanic acid (first-line agent).
  • With severe AEP:
    • Regardless of body temperature (there is no correlation between fever increase and high bacterial load in blood) – at least 2 blood culture (BK) pairs at separate puncture sites before administration of antibiotics.
    • Combination therapy of a broad-spectrum β-lactam antibiotic (piperacillin/tazobactam, cefotaxime or ceftriaxone) and a macrolide.
    • Macrolide should be discontinued after 3 days if no “atypical” bacterial pathogens have been detected
  • In individual cases, consider the use of systemic steroids (glucocorticoids; dexamethasone: 5 mg i.v. for 4 days; this leads to a significant reduction in the length of hospital stay) Attention! Higher incidence of hyperglycemia requiring insulin.
• Hospital-acquired nosocomial pneumonia:
  • Without risk for Pseudomonas infection: piperacillin + tazobactam first-line agent).
  • With risk for Pseudomonas infection: piperacillin + tazobactam.
• Pneumonia acquired under immunosuppression:
  • Notice:
    • Germ spectrum to include defined “opportunistic pathogens”.
    • Here, in addition to bacterial pathogens, fungal infections (mainly Aspergillus; increasingly also filamentous fungi such as Mucor or Zygomycetes) and viral infections (e.g. cytomegaly) play a major role.
• A clinical review of the success of therapy is required after 48-72 hours.
• Duration of therapy over seven days does not improve the success of therapy.
• After two to three weeks, the disease should be cured without permanent consequences. A strong and young person should be able to return to his usual life about a week after the end of the disease.
• See also under “Further therapy”.

Whether a pneumonia patient can be treated at home can be estimated with the four points of the prognosis score CRB-65 score. In the CRB-65, 1 point is given for each of the following possible symptoms:

• Confusion.
• Respiratory rate (breathing rate) > 30/min. [see also on respiratory rate under sequelae/prognostic factors].
• Blood pressure (blood pressure) below 90 mmHg systolic or below 60 mmHg diastolic and.
• Age (age) > 65 years

Prognosis score CRB-65 score

Further notes

• Diabetic patients with community-acquired pneumonia (AEP) may benefit from short-term corticosteroid therapy (prednisone: 50 mg/d): time to clinical stability (TTCS), defined as stable vital signs at two consecutive measurements at least 12 hours apart, was significantly and equally shortened by therapy in diabetic and nondiabetic patients (from 6.8 to 4.5 and from 5.8 to 4.6 days, respectively). This led to higher mean glucose levels and increased hyperglycemia in the diabetics – as was to be expected. However, the additional insulin consumption in the treated diabetics was not higher than in the placebo group.
• Inpatients with severe pneumonia benefited from add-on therapy with corticosteroids: Mortality risk decreased by 33%, acute respiratory distress syndrome (ARDS) rate decreased by 76%, and patients could be discharged one day sooner.
• Note: If Klebsiella pneumoniae is detected, also think of the “Klebsiella pneumoniae associated invasive liver abscess syndrome”, which is rare in Europe and so far only occurs in Asia.

Medications used to relieve symptoms include:

• Antitussives (antitussives).
• Secretolytics (expectorants).
• Antipyretics (antipyretic agents, such as acetaminophen).