Diagnosis and initial antimicrobial treatment

Basic resuscitation is required if there is cardiorespiratory compromise. Appropriate treatment of the infection depends on CXR and culture findings, although empiric 'best guess' antibiotic treatment may be started before culture results are available. Treatment includes physiotherapy and methods to aid sputum clearance.

Clear CXR

Acute bronchitis is associated with cough, mucoid sputum and wheeze. In previously healthy patients a viral aetiology is most likely and there is often an upper respiratory prodrome. Symptomatic relief is usually all that is required. Likely organisms in acute on chronic bronchitis include Strep. pneumoniae, H. in. uenzae or Staph. aureus. Appropriate antibiotics include cefuroxime or ampicillin and .ucloxacillin. Viral pneumonia may be confused by the presence of bacteria in the sputum but secondary bacterial infection is common.

Pulmonary cavitation on CXR

Cavitation should alert to the possibility of anaerobic infection (sputum is often foul smelling). Staph. aureus, K.

pneumoniae or tuberculosis are also associated with cavitation. Appropriate antibiotics include metronidazole or clindamycin for anaerobic infection, flucloxacillin for Staph. aureus and ceftazidime and gentamicin for K. pneumoniae. A foreign body or pulmonary infarct should also be considered where there is a single abscess.

Consolidation on CXR

The recent history is important for deciding the cause of a pneumonia:

• Hospital acquired pneumonia — enteric (Gram negative) organisms treated with ceftazidime and gentamicin, Staph. aureus treated with ceftazidime and gentamicin, Staph. aureus treated with flucloxacillin (or teicoplanin/vancomycin if multiresistant).

• Recent aspiration — anaerobic or Gram negative infection treated with clindamycin or cefuroxime and metronidazole.

• Community acquired pneumonia in a previously healthy individual— Strep. pneumoniae (often lobar, acute onset) or atypical pneumonia (insidious onset, known community outbreaks, renal failure and electrolyte disturbance in Legionnaire's disease). Appropriate antibiotic therapy is cefuroxime and clarithromycin.

• Pneumonia complicating influenza — Staph. aureus treated with flucloxacillin. Both Staph. aureus and H. influenzae are common in those debilitated by chronic disease (e.g. alcoholism, diabetes, chronic airflow limitation or the elderly).

• Immunosuppressed — opportunistic infections (e.g. tuberculosis, Pneumocystis carinii Herpes viruses, CMV or fungi).

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