Editing Pneumonia (section)

==Management==
{|class="wikitable" align="right" style="margin-left:0.4em;"
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!colspan=2| [[CURB-65]]
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! Symptom !! Points
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| '''C'''onfusion ||style="text-align: center;"|1
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| '''U'''rea>7&nbsp;mmol/L ||style="text-align: center;"|1
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| '''R'''espiratory rate>30 ||style="text-align: center;"|1
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| [[Blood pressure|S'''B'''P]]<90mmHg, D'''B'''P<60mmHg||style="text-align: center;"|1
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| Age>='''65''' ||style="text-align: center;"|1
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|}

[[Antibiotics]] by mouth, rest, simple [[analgesics]], and fluids usually suffice for complete resolution.<ref name=BTS09/> [[Antibiotics]] therapy for children aged 2 to 59 months with non‐severe pneumonia with wheeze may reduce of treatment failure by 20%, however results in little or no difference to clinical cure, in little or no difference to relapse, and treatment harms.<ref>{{Cite journal |last=Lassi |first=Zohra S |last2=Padhani |first2=Zahra Ali |last3=Das |first3=Jai K |last4=Salam |first4=Rehana A |last5=Bhutta |first5=Zulfiqar A |date=2021-01-20 |editor-last=Cochrane Acute Respiratory Infections Group |title=Antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO-defined non-severe pneumonia and wheeze |url=http://doi.wiley.com/10.1002/14651858.CD009576.pub3 |journal=Cochrane Database of Systematic Reviews |language=en |volume=2021 |issue=1 |doi=10.1002/14651858.CD009576.pub3 |pmc=8092454 |pmid=33469915}}</ref> However, those with other medical conditions, the elderly, or those with significant trouble breathing may require more advanced care. If the symptoms worsen, the pneumonia does not improve with home treatment, or complications occur, hospitalization may be required.<ref name=BTS09/> Worldwide, approximately 7–13% of cases in children result in hospitalization,<ref name=Develop11/> whereas in the developed world between 22 and 42% of adults with community-acquired pneumonia are admitted.<ref name=BTS09/> The [[CURB-65]] score is useful for determining the need for admission in adults.<ref name=BTS09/> If the score is 0 or 1, people can typically be managed at home; if it is 2, a short hospital stay or close follow-up is needed; if it is 3–5, hospitalization is recommended.<ref name=BTS09/> In children those with [[Dyspnea|respiratory distress]] or oxygen saturations of less than 90% should be hospitalized.<ref name=PIDS11>{{cite journal | vauthors = Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH, Moore MR, St Peter SD, Stockwell JA, Swanson JT | title = The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America | journal = Clinical Infectious Diseases | volume = 53 | issue = 7 | pages = e25–76 | date = October 2011 | pmid = 21880587 | pmc = 7107838 | doi = 10.1093/cid/cir531 | doi-access = free }}</ref> The utility of [[chest physiotherapy]] in pneumonia has not yet been determined.<ref>{{cite journal | vauthors = Chaves GS, Freitas DA, Santino TA, Nogueira PA, Fregonezi GA, Mendonça KM | title = Chest physiotherapy for pneumonia in children | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD010277 | date = January 2019 | issue = 9 | pmid = 30601584 | pmc = 6353233 | doi = 10.1002/14651858.CD010277.pub3 }}</ref><ref>{{cite journal |last1=Chen |first1=Xiaomei |last2=Jiang |first2=Jiaojiao |last3=Wang |first3=Renjie |last4=Fu |first4=Hongbo |last5=Lu |first5=Jing |last6=Yang |first6=Ming |date=6 September 2022 |title=Chest physiotherapy for pneumonia in adults |journal=The Cochrane Database of Systematic Reviews |volume=2022 |issue=9 |pages=CD006338 |doi=10.1002/14651858.CD006338.pub4 |issn=1469-493X |pmc=9447368 |pmid=36066373}}</ref> Over-the-counter [[cough medicine]] has not been found to be effective,<ref name="Chang2014">{{cite journal |vauthors=Chang CC, Cheng AC, Chang AB |date=March 2014 |title=Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults |journal=The Cochrane Database of Systematic Reviews |volume=2014 |issue=3 |pages=CD006088 |doi=10.1002/14651858.CD006088.pub4 |pmid=24615334|doi-access=free |pmc=11023600 }}</ref> nor has the use of zinc supplementation in children.<ref>{{cite journal | vauthors = Haider BA, Lassi ZS, Ahmed A, Bhutta ZA | title = Zinc supplementation as an adjunct to antibiotics in the treatment of pneumonia in children 2 to 59 months of age | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD007368 | date = October 2011 | volume = 2013 | pmid = 21975768 | pmc = 7000651 | doi = 10.1002/14651858.CD007368.pub2 }}</ref> There is insufficient evidence for [[mucolytics]].<ref name=Chang2014/> There is no strong evidence to recommend that children who have non-measles related pneumonia take [[vitamin A]] supplements.<ref>{{cite journal | vauthors = Ni J, Wei J, Wu T | title = Vitamin A for non-measles pneumonia in children | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD003700 | date = July 2005 | volume = 2005 | pmid = 16034908 | pmc = 6991929 | doi = 10.1002/14651858.CD003700.pub2 }}</ref> Vitamin D, as of 2023, is of unclear benefit in children.<ref>{{cite journal |last1=Das |first1=Rashmi R. |last2=Singh |first2=Meenu |last3=Naik |first3=Sushree S. |date=2023-01-12 |title=Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia |journal=The Cochrane Database of Systematic Reviews |volume=1 |issue=1 |pages=CD011597 |doi=10.1002/14651858.CD011597.pub3 |issn=1469-493X |pmc=9835443 |pmid=36633175 }}</ref> Vitamin C administration in pneumonia needs further research, despite found lower mortality and reduced severity for most ill patient, although it can be given to patient of low plasma vitamin C because it is not expensive and low risk.<ref>{{Cite journal |last=Hemilä |first=Harri |last2=Louhiala |first2=Pekka |date=2013-08-08 |editor-last=Cochrane Acute Respiratory Infections Group |title=Vitamin C for preventing and treating pneumonia |url=http://doi.wiley.com/10.1002/14651858.CD005532.pub3 |journal=Cochrane Database of Systematic Reviews |language=en |volume=2013 |issue=8 |doi=10.1002/14651858.CD005532.pub3}}</ref><ref name=":0" />

Pneumonia can cause severe illness in a number of ways, and pneumonia with evidence of organ dysfunction may require [[intensive care unit]] admission for observation and specific treatment.<ref name=Phua>{{cite journal | vauthors = Phua J, Dean NC, Guo Q, Kuan WS, Lim HF, Lim TK | title = Severe community-acquired pneumonia: timely management measures in the first 24 hours | journal = Critical Care | volume = 20 | issue = 1 | page = 237 | date = August 2016 | pmid = 27567896 | pmc = 5002335 | doi = 10.1186/s13054-016-1414-2 | doi-access = free }}</ref> The main impact is on the respiratory and the circulatory system. [[Respiratory failure]] not responding to normal oxygen therapy may require [[heated humidified high-flow therapy]] delivered through nasal cannulae,<ref name=Phua/> [[non-invasive ventilation]],<ref>{{cite journal |vauthors=Zhang Y, Fang C, Dong BR, Wu T, Deng JL |date=March 2012 |editor1-last=Dong |editor1-first=Bi Rong |title=Oxygen therapy for pneumonia in adults |url=https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006607.pub4/full |journal=The Cochrane Database of Systematic Reviews |volume=3 |issue=3 |pages=CD006607 |doi=10.1002/14651858.CD006607.pub4 |pmid=22419316|pmc=12042648 }}</ref> or in severe cases mechanical ventilation through an endotracheal tube.<ref name=Phua/> Regarding circulatory problems as part of sepsis, evidence of poor blood flow or low blood pressure is initially treated with 30 mL/kg of [[crystalloid solution|crystalloid]] infused intravenously.<ref name="Elena 2015"/> In situations where fluids alone are ineffective, [[Antihypotensive agent|vasopressor]] medication may be required.<ref name=Phua/>

For adults with moderate or severe [[acute respiratory distress syndrome]] (ARDS) undergoing mechanical ventilation, there is a reduction in mortality when people [[proning|lie on their front]] for at least 12 hours a day. However, this increases the risk of endotracheal tube obstruction and pressure sores.<ref>{{cite journal |vauthors=Munshi L, Del Sorbo L, Adhikari NK, Hodgson CL, Wunsch H, Meade MO, Uleryk E, Mancebo J, Pesenti A, Ranieri VM, Fan E |date=October 2017 |title=Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis |url=https://www.atsjournals.org/doi/10.1513/AnnalsATS.201704-343OT |journal=Annals of the American Thoracic Society |volume=14 |issue=Supplement_4 |pages=S280–S288 |doi=10.1513/AnnalsATS.201704-343OT |pmid=29068269 |hdl-access=free |s2cid=43367332 |hdl=2434/531962}}</ref>

===Bacterial===
Antibiotics improve outcomes in those with bacterial pneumonia.<ref name=CochraneTx13/> The first dose of antibiotics should be given as soon as possible.<ref name="Elena 2015"/> Increased use of antibiotics, however, may lead to the development of [[Antimicrobial resistance|antimicrobial resistant]] strains of bacteria.<ref name=Pak2014>{{cite journal | vauthors = Pakhale S, Mulpuru S, Verheij TJ, Kochen MM, Rohde GG, Bjerre LM | title = Antibiotics for community-acquired pneumonia in adult outpatients | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD002109 | date = October 2014 | volume = 2014 | pmid = 25300166 | pmc = 7078574 | doi = 10.1002/14651858.CD002109.pub4 }}</ref> Antibiotic choice depends initially on the characteristics of the person affected, such as age, underlying health, and the location the infection was acquired. Antibiotic use is also associated with side effects such as nausea, diarrhea, dizziness, taste distortion, or headaches.<ref name=Pak2014/> In the UK, [[Empiric therapy|treatment before culture results]] with [[amoxicillin]] is recommended as the first line for community-acquired pneumonia, with [[doxycycline]] or [[clarithromycin]] as alternatives.<ref name=BTS09/> In North America, amoxicillin, doxycycline, and in some areas a macrolide (such as [[azithromycin]] or [[erythromycin]]) is the first-line outpatient treatment in adults.<ref name=EOP10/><ref name=Lutfiyya>{{cite journal | vauthors = Lutfiyya MN, Henley E, Chang LF, Reyburn SW | title = Diagnosis and treatment of community-acquired pneumonia | journal = American Family Physician | volume = 73 | issue = 3 | pages = 442–50 | date = February 2006 | pmid = 16477891 | url = http://www.aafp.org/afp/2006/0201/p442.pdf | url-status = live | archive-url = https://web.archive.org/web/20120409042309/http://www.aafp.org/afp/2006/0201/p442.pdf | archive-date = 9 April 2012 }}</ref><ref name=Met2019/> In children with mild or moderate symptoms, amoxicillin taken by mouth is the first line.<ref name=PIDS11/><ref>{{cite web|url=https://www.who.int/mediacentre/factsheets/fs331/en/|title=Pneumonia Fact Sheet|date=September 2016|website=World Health Organization|language=en-GB|access-date=14 January 2018}}</ref><ref>{{cite journal | vauthors = Lodha R, Kabra SK, Pandey RM | title = Antibiotics for community-acquired pneumonia in children | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD004874 | date = June 2013 | volume = 2013 | pmid = 23733365 | pmc = 7017636 | doi = 10.1002/14651858.CD004874.pub4 }}</ref> The use of [[fluoroquinolones]] in uncomplicated cases is discouraged due to concerns about side-effects and generating resistance in light of there being no greater benefit.<ref name=EOP10/><ref>{{cite journal | vauthors = Eliakim-Raz N, Robenshtok E, Shefet D, Gafter-Gvili A, Vidal L, Paul M, Leibovici L | title = Empiric antibiotic coverage of atypical pathogens for community-acquired pneumonia in hospitalized adults | journal = The Cochrane Database of Systematic Reviews | volume = 9 | issue = 9 | pages = CD004418 | date = September 2012 | pmid = 22972070 | pmc = 7017099 | doi = 10.1002/14651858.CD004418.pub4 | editor1-last = Eliakim-Raz | editor1-first = Noa }}</ref>

For those who require hospitalization and caught their pneumonia in the community the use of a β-lactam such as [[cephazolin]] plus a macrolide such as azithromycin is recommended.<ref>{{cite journal |vauthors=Lee JS, Giesler DL, Gellad WF, Fine MJ |date=February 2016 |title=Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia: A Systematic Review |url=https://jamanetwork.com/journals/jama/article-abstract/2488313 |journal=JAMA |volume=315 |issue=6 |pages=593–602 |doi=10.1001/jama.2016.0115 |pmid=26864413}}</ref><ref name=Met2019/> A [[fluoroquinolone]] may replace azithromycin but is less preferred.<ref name=Met2019/> Antibiotics by mouth and by injection appear to be similarly effective in children with severe pneumonia.<ref name=Roj2006>{{cite journal | vauthors = Rojas MX, Granados C | title = Oral antibiotics versus parenteral antibiotics for severe pneumonia in children | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD004979 | date = April 2006 | volume = 2006 | pmid = 16625618 | pmc = 6885030 | doi = 10.1002/14651858.CD004979.pub2 }}</ref>

The duration of treatment has traditionally been seven to ten days, but increasing evidence suggests that shorter courses (3–5 days) may be effective for certain types of pneumonia and may reduce the risk of antibiotic resistance.<ref>{{cite journal | vauthors = Tansarli GS, Mylonakis E | title = Systematic Review and Meta-analysis of the Efficacy of Short-Course Antibiotic Treatments for Community-Acquired Pneumonia in Adults | journal = Antimicrobial Agents and Chemotherapy | volume = 62 | issue = 9 | date = September 2018 | pmid = 29987137 | pmc = 6125522 | doi = 10.1128/AAC.00635-18 }}</ref><ref>{{cite journal | vauthors = Scalera NM, File TM | title = How long should we treat community-acquired pneumonia? | journal = Current Opinion in Infectious Diseases | volume = 20 | issue = 2 | pages = 177–81 | date = April 2007 | pmid = 17496577 | doi = 10.1097/QCO.0b013e3280555072 | s2cid = 21502165 }}</ref><ref name=Pug2015>{{cite journal | vauthors = Pugh R, Grant C, Cooke RP, Dempsey G | title = Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD007577 | date = August 2015 | volume = 2015 | pmid = 26301604 | pmc = 7025798 | doi = 10.1002/14651858.CD007577.pub3 }}</ref><ref>{{cite journal | vauthors = Haider BA, Saeed MA, Bhutta ZA | title = Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD005976 | date = April 2008 | pmid = 18425930 | doi = 10.1002/14651858.CD005976.pub2 | url = https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1134&context=pakistan_fhs_mc_women_childhealth_paediatr }}</ref> Research in children showed that a shorter, 3-day course of amoxicillin was as effective as a longer, 7-day course for treating pneumonia in this population.<ref>{{cite journal |date=27 May 2022 |title=3 days' antibiotic is effective in childhood pneumonia |url=https://evidence.nihr.ac.uk/alert/short-course-antibiotics-effective-in-childhood-pneumonia/ |access-date=8 June 2022 |website=NIHR Evidence |doi=10.3310/nihrevidence_50885 |s2cid=249937345 |language=en-GB}}</ref><ref>{{cite journal |last1=Barratt |first1=Sam |last2=Bielicki |first2=Julia A. |last3=Dunn |first3=David |last4=Faust |first4=Saul N. |last5=Finn |first5=Adam |last6=Harper |first6=Lynda |last7=Jackson |first7=Pauline |last8=Lyttle |first8=Mark D. |last9=Powell |first9=Colin VE |last10=Rogers |first10=Louise |last11=Roland |first11=Damian |date=4 November 2021 |title=Amoxicillin duration and dose for community-acquired pneumonia in children: the CAP-IT factorial non-inferiority RCT |journal=Health Technology Assessment |language=EN |volume=25 |issue=60 |pages=1–72 |doi=10.3310/hta25600 |pmid=34738518 |s2cid=243762087 |issn=2046-4924 |doi-access=free }}</ref> For pneumonia that is associated with a ventilator caused by non-fermenting Gram-negative bacilli (NF-GNB), a shorter course of antibiotics increases the risk that the pneumonia will return.<ref name=Pug2015/> Recommendations for hospital-acquired pneumonia include third- and fourth-generation [[cephalosporins]], [[carbapenem]]s, fluoroquinolones, [[aminoglycoside]]s, and [[vancomycin]].<ref name=ATS2005/> These antibiotics are often given [[intravenous therapy|intravenously]] and used in combination.<ref name=ATS2005/> In those treated in hospital, more than 90% improve with the initial antibiotics.<ref name=M32/> For people with ventilator-acquired pneumonia, the choice of antibiotic therapy will depend on the person's risk of being infected with a strain of bacteria that is [[Multi-drug resistant bacteria|multi-drug resistant]].<ref name=Ar2016/> Once clinically stable, intravenous antibiotics should be switched to oral antibiotics.<ref name="Elena 2015"/> For those with ''[[Methicillin resistant Staphylococcus aureus]]'' (MRSA) or ''Legionella'' infections, prolonged antibiotics may be beneficial.<ref name="Elena 2015"/>

The addition of [[corticosteroid]]s to standard antibiotic treatment appears to improve outcomes, reducing death and morbidity for adults with severe community acquired pneumonia, and reducing death for adults and children with non-severe community acquired pneumonia.<ref name=Stern2017>{{cite journal | vauthors = Stern A, Skalsky K, Avni T, Carrara E, Leibovici L, Paul M | title = Corticosteroids for pneumonia | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD007720 | date = December 2017 | issue = 12 | pmid = 29236286 | pmc = 6486210 | doi = 10.1002/14651858.CD007720.pub3 }}</ref><ref>{{cite journal |vauthors=Wu WF, Fang Q, He GJ |date=February 2018 |title=Efficacy of corticosteroid treatment for severe community-acquired pneumonia: A meta-analysis |url=https://www.sciencedirect.com/science/article/abs/pii/S0735675717305776 |journal=The American Journal of Emergency Medicine |volume=36 |issue=2 |pages=179–84 |doi=10.1016/j.ajem.2017.07.050 |pmid=28756034 |s2cid=3274763}}</ref> A 2017 review therefore recommended them in adults with severe community acquired pneumonia.<ref name=Stern2017 /> A 2019 guideline however recommended against their general use, unless refractory shock was present.<ref name=Met2019/> Side effects associated with the use of corticosteroids include high blood sugar.<ref name=Stern2017 /> There is some evidence that adding corticosteroids to the standard PCP pneumonia treatment may be beneficial for people who are infected with HIV.<ref name=Ewa2015/>

The use of granulocyte colony stimulating factor (G-CSF) along with antibiotics does not appear to reduce mortality and routine use for treating pneumonia is not supported by evidence.<ref>{{cite journal |vauthors=Cheng AC, Stephens DP, Currie BJ |date=April 2007 |title=Granulocyte-colony stimulating factor (G-CSF) as an adjunct to antibiotics in the treatment of pneumonia in adults |url=https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004400.pub3/full |journal=The Cochrane Database of Systematic Reviews |issue=2 |pages=CD004400 |doi=10.1002/14651858.CD004400.pub3 |pmid=17443546}}</ref>

===Viral===
[[Neuraminidase inhibitors]] may be used to treat [[viral pneumonia]] caused by influenza viruses ([[influenza A]] and [[influenza B]]).<ref name=Lancet11/> No specific [[antiviral drug|antiviral]] medications are recommended for other types of community acquired viral pneumonias including [[SARS|SARS coronavirus]], adenovirus, [[hantavirus]], and parainfluenza virus.<ref name=Lancet11/> Influenza A may be treated with rimantadine or amantadine, while influenza A or B may be treated with oseltamivir, zanamivir or [[peramivir]].<ref name=Lancet11/> These are of most benefit if they are started within 48 hours of the onset of symptoms.<ref name=Lancet11/> Many strains of [[H5N1]] influenza A, also known as [[avian influenza]] or "bird flu", have shown resistance to rimantadine and amantadine.<ref name=Lancet11/> The use of antibiotics in viral pneumonia is recommended by some experts, as it is impossible to rule out a complicating bacterial infection.<ref name=Lancet11/> The [[British Thoracic Society]] recommends that antibiotics be withheld in those with mild disease.<ref name=Lancet11/> The use of corticosteroids is controversial.<ref name=Lancet11/>

===Aspiration===
In general, [[Chemical pneumonitis|aspiration pneumonitis]] is treated conservatively with antibiotics indicated only for aspiration pneumonia.<ref name="PA2011">{{cite journal |vauthors=Marik PE |date=May 2011 |title=Pulmonary aspiration syndromes |url=https://journals.lww.com/co-pulmonarymedicine/Abstract/2011/05000/Pulmonary_aspiration_syndromes.5.aspx |journal=Current Opinion in Pulmonary Medicine |volume=17 |issue=3 |pages=148–54 |doi=10.1097/MCP.0b013e32834397d6 |pmid=21311332 |s2cid=31735383}}</ref> The choice of antibiotic will depend on several factors, including the suspected causative organism and whether pneumonia was acquired in the community or developed in a hospital setting. Common options include [[clindamycin]], a combination of a [[beta-lactam antibiotic]] and [[metronidazole]], or an aminoglycoside.<ref name=OConnor>
{{cite journal|author=O'Connor S |title=Aspiration pneumonia and pneumonitis |journal=Australian Prescriber |volume=26 |issue=1 |year=2003 |pages=14–17 |doi=10.18773/austprescr.2003.009 |doi-access=free }}</ref>
Corticosteroids are sometimes used in aspiration pneumonia, but there is limited evidence to support their effectiveness.<ref name=PA2011/>

===Follow-up===
The British Thoracic Society recommends that a follow-up chest radiograph be taken in people with persistent symptoms, smokers, and people older than 50.<ref name=BTS09/> American guidelines vary, from generally recommending a follow-up chest radiograph<ref>{{cite journal | vauthors = Ramsdell J, Narsavage GL, Fink JB | title = Management of community-acquired pneumonia in the home: an American College of Chest Physicians clinical position statement | journal = Chest | volume = 127 | issue = 5 | pages = 1752–63 | date = May 2005 | pmid = 15888856 | doi = 10.1378/chest.127.5.1752 }}</ref> to not mentioning any follow-up.<ref name=IDSA2007/>