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Essentials of Diagnosis
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Productive cough, fever, rigors, dyspnea, early pleuritic chest pain
Consolidating lobar pneumonia on chest radiograph
Lancet-shaped gram-positive diplococci on Gram stain of sputum
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General Considerations
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High fever, productive cough, occasional hemoptysis, and pleuritic chest pain
Rigors may occur initially but are uncommon later in the course
Bronchial breath sounds are an early sign
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Diagnosis requires isolation of the organism in culture, although the Gram stain appearance of sputum can be suggestive
Sputum and blood cultures, positive in 60% and 25% of cases of pneumococcal pneumonia, respectively, should be obtained prior to initiation of antimicrobial therapy in patients who are admitted to the hospital
A good-quality sputum sample (< 10 epithelial cells and > 25 polymorphonuclear leukocytes per high-power field) shows gram-positive diplococci in 80–90% of cases
A rapid urinary antigen test for Streptococcus pneumoniae, with sensitivity of 70–80% and specificity > 95%, can assist with early diagnosis
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Chest radiograph shows findings of consolidation, often with a lobar distribution, infiltrates, pleural effusion
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Amoxicillin, 750 mg twice daily orally for 7–10 days
Cephalosporins may also be used
Cefpodoxime, 200 mg orally twice daily
Cefdinir, 300 mg twice daily
Alternatives include
Azithromycin, one 500-mg dose orally on the first day and 250 mg orally for the next 4 days
Clarithromycin, 500 mg twice daily orally for 7 days
Doxycycline, 100 mg twice daily orally for 7 days
Levofloxacin, 750 mg orally for 5–7 days
Moxifloxacin, 400 mg orally for 7–14 days
Outpatients with high-risk comorbid conditions (such as pulmonary disease, diabetes, cardiac disease, or alcohol use disorder) may benefit from broader combination therapy (eg, amoxicillin/clavulanate or cephalosporin plus doxycycline or a macrolide), unless a fluoroquinolone is chosen for monotherapy
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Ceftriaxone, 1 g every 24 hours intravenously
Azithromycin or doxycycline are typically added for coverage of atypical organisms
For a highly penicillin-resistant strain, one of the following may be used:
Vancomycin, 1 g every 12 hours intravenously
Levofloxacin, 750 mg intravenously or orally once daily
Moxifloxacin, 400 mg intravenously or orally once daily
Total duration of therapy is not well defined but 5–7 days is appropriate for patients who ...