Therapy

Give antibiotics ^a intravenously to patients who are any of the following:

• acutely confused
• immunocompromised
• critically ill
• requiring intropic or respiratory support
• septicaemic
• unable to tolerate oral medication
• pregnant or lactating

Uncomplicated cases can have oral antibiotics ^a  

Give elderly patients any of 

• second or third generation cephalosporins with a macrolide ^b  
• fluoroquinilone ^b  

Monitor your patient's response ^c and repeat investigations if there is no improvement after 72 hours. ^d

Encourage bubble-blowing ^{a
Ask patients to blow bubbles slowly into a bottle through a plastic tube (10 mm in diameter) with an air pressure just sufficient to overcome the resistance of the water 20 times with a rest after 10, every hour from 9am to 8pm with breaks at noon and 5pm. After discharge continue 2 x 10 breaths on 5 occasions each day for 14 days}

Consider transferring patients with any of the following to intensive care ^d

• severe pneumonia
• severe hypoxia or hypercapnia despite high-flow oxygen
• exhausted, drowsy or unconscious patient
• respiratory or cardiac arrest
• shock

Note

• Ventilatory support and aggressive care is poorly cost-effective for high-risk patients (> 50% chance of dying within 2 months)  with acute respiratory failure. ^a

There is no clear benefit from 

• filgrastim in multilobar pneumonia. ^d
• policies to determine when to switch from parenteral to oral antibiotics or when to discharge patients ^d

Parapneumonic effusion

• Insert a chest drain ^a
• Instill streptokinase  ^a or urokinase  ^d (e.g. 250 000 units streptokinase in 20 ml daily)