"Functional neurological symptom disorder (conversion disorder)"

▫️Risk factors:
age ≥ 65 years, chronic comorbidities, concurrent or antecedent
respiratory viral infections, impaired airway protection, smoking, excess alcohol use, and other lifestyle factors (eg, crowded living conditions).

▫️Microbiology (common source)
• Respiratory viruses,
• typical bacteria (eg, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) and
• atypical bacteria (eg, Legionella spp, Mycoplasma pneumoniae, Chlamydia pneumoniae).

▫️Making the Diagnosis:
• demonstration of an infiltrate on chest imaging(PA and lat CXR) in a
patient with a clinically compatible syndrome (eg, fever, dyspnea, cough, and leukocytosis).

🔺CXR findings:
lobar consolidations, interstitial infiltrates, and/or cavitations.
🔺CT:
• high clinical suspicion for CAP but CXR is negative.
• moderate suspicion for CAP but CXR is nondiagnostic(opacities present but not clear if due to pneumonia versus pulmonary
edema, atelectasis, contusion, chronic lung disease, or other etiologies) to R/O CAP
• for immunocompromised to help distinguish among causes (eg,
invasive fungal infections, pneumocystis pneumonia, bacterial pathogens)

☝🏻Determining the severity of illness is based
on clinical judgement and can be supplemented by use of severity scores(e.g CURB-65 or PSI score)
✌🏻We generally prefer the PSI

• Respiratory failure requiring mechanical ventilation
OR
• Sepsis requiring vasopressor support
OR
• Three of these criteria:
- Altered mental status
- Hypotension requiring fluid support
- Temperature < 36°C (96.8°F)
- Respiratory rate ≥ 30 breaths/minute
- Arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2) ratio ≤ 250
- Blood urea nitrogen (BUN) ≥ 20 mg/dL (7 mmol/L)
- Leukocyte count < 4000 cells/microL
- Platelet count < 100,000/microL
- Multilobar infiltrates

• Peripheral oxygen saturations < 92 percent on room air
(and a significant change from baseline)
OR
• PSI scores of ≥ III and CURB-65 scores ≥ 1 (or CURB-65 score ≥ 2 if age > 65 years)
OR
• Practical concerns (eg, inability to take oral medications,
cognitive or functional impairment, substance use or other social issues).

💡We obtain Blood cultures, Sputum Gram stain and culture, PCR (Covid, influenza)

Most patients who are otherwise healthy with normal vital signs (apart from fever) and no concern for complication are considered to have mild pneumonia and can be managed in the ambulatory setting. These patients typically have PSI scores of I to II and CURB-65 scores of 0 (or a CURB-65 score of 1 if age > 65 years).

💡Microbiologic testing is not needed.

🔸For healthy outpatients ,aged < 65 years who have not used antibiotics within the prior three months:
🔺high-dose amoxicillin (1 g orally three times
daily)
plus
🔺either a macrolide or doxycycline.

🔸For aged ≥ 65 years, smokers, and patients with comorbidities and/or recent antibiotic use:
🔺amoxicillin-clavulanate (875 mg orally twice daily or the E.R formulation at 2 g orally twice daily)
plus
🔺either a macrolide or doxycycline.

🔸Penicillin allergy(but able to use cephalosporins), algorithm.
• For patients with mild non-immunoglobulin (Ig)E-mediated reactions to penicillin (eg maculopapular rash) or known tolerance to cephalosporins:
🔺third generation cephalosporin (eg, cefpodoxime) or (2nd generation like Cefuroxime 500 mg orally twice daily)
plus
🔺a macrolide or doxycycline.

🔸For patients with IgE-mediated reactions (eg, urticaria, angioedema, anaphylaxis) or Severe delayed reactions, empiric use of cephalosporins should generally be avoided.
🔺Respiratory fluoroquinolones monotherapy
equally effective as our preferred regimens; however, because of its adverse effect profile(long q-t, C.diff,etc) and potential for promoting drug resistance, we reserve fluoroquinolone use for patients who cannot tolerate these
regimens.

We do not use glucocorticoids for the treatment of CAP in the outpatient setting.

Five-day course is sufficient for most patients in this setting.

* patients who have not clinically responded to treatment after 48 to 72 hours should be re-evaluated.

*Patients should be afebrile for ≥ 48 hours and clinically stable before therapy is discontinued. When this is achieved, the persistence
of other symptoms (eg, dyspnea, cough) is not an indication to extend the course of antibiotic therapy.

💊an antipneumococcal beta-lactam [ceftriaxone (1 to 2 g IV daily),
cefotaxime (1 to 2 g IV every 8 hours),
ceftaroline (600 mg IV every 12 hours),
ertapenem (1 g IV daily), or
ampicillin-sulbactam (3 g IV every 6 hours)]

💊a macrolide [(azithromycin [500 mg IV daily or 500mg orally first day then 250mg daily) or clarithromycin].

💊an anti-MRSA [(vancomycin(15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring) or linezolid (600 mg IV every 12 hours)].

💊an antipseudomonal/antipneumococcal beta-lactam
Piperacillin-tazobactam (4.5 g every 6 hours)
Imipenem (500 mg every 6 hours)
Meropenem (1 g every 8 hours) or
Cefepime (2 g every 8 hours

💊an antipseudomonal fluoroquinolone
Ciprofloxacin (400 mg every 8 hours) or
Levofloxacin (750 mg daily)

💊aminoglycoside [gentamicin(5-7mg/kg/iv daily, tobramycin, or
amikacin]

▫️Strongest risk factors (require treatment with an empiric):
• known colonization or past infection with these organisms
• hospitalization with receipt of intravenous antibiotics within the prior three months.

▫️Other risk factors(raise suspicion for infection with Pseudomonas and generally warrant treatment in those who are severely ill (eg, admitted to the ICU):
• recent antibiotic therapy of any kind,
• recent hospitalization,
• immunosuppression,
• pulmonary comorbidity (eg, cystic fibrosis, bronchiectasis, or repeated
exacerbations of chronic obstructive pulmonary disease [COPD] that require frequent glucocorticoid and/or antibiotic use),
• probable aspiration,
• presence of multiple medical comorbidities (eg,
diabetes mellitus, alcoholism)

▫️Strongest risk factors (require treatment with an empiric):
• Known MRSA colonization or past infection with MRSA


▫️Other risk factors(raise suspicion for infection
with MRSA and generally warrant treatment in those who are severely ill (eg, admitted to the ICU):
• recent antibiotic use (particularly receipt of
intravenous antibiotics during hospitalization within the past three months),
• recent hospitalization (regardless of antibiotic use),
• end-stage kidney disease,
• participation in contact sports,
• injection drug use,
• crowded living conditions,
• men who have sex with men,
• prisoners,
• recent influenza-like illness,
• antimicrobial therapy,
• necrotizing or cavitary pneumonia,
• presence of empyema

• Age > 65 years
• Beta-lactam, macrolide, or fluoroquinolone therapy within the past three to six months
• Alcoholism
• Medical comorbidities
• Immunosuppressive illness or therapy
• Exposure to a child in a daycare center
• prior exposure to the health care setting such as from prior hospitalization or from residence in a long-term care facility

🔸No MRSA or Pseudomonas risk factors:
🔺an antipneumococcal beta-lactam
plus
🔺a macrolide

🔸MRSA risk factors only:
🔺an antipneumococcal beta-lactam
plus
🔺a macrolide
Plus
🔺an anti-MRSA

🔸Pseudomonas risk factors only:
🔺an antipseudomonal/antipneumococcal beta-lactam
Plus
🔺an antipseudomonal fluoroquinolone

🔸MRSA and Pseudomonas risk factors
🔺an anti-MRSA
Plus
🔺an antipseudomonal/antipneumococcal beta-lactam
Plus
🔺an antipseudomonal fluoroquinolone

🔸No MRSA or Pseudomonas risk factors:
🔺Respiratory fluoroquinolone monotherapy

🔸MRSA risk factors only:
🔺Respiratory fluoroquinolone
Plus
🔺an anti-MRSA

🔸Pseudomonas risk factors only:
🔺Respiratory fluoroquinolone
Plus
🔺Aztreonam (2 g IV every 8 hours)
Plus
🔺aminoglycoside

🔸MRSA and Pseudomonas risk factors:
🔺Respiratory fluoroquinolone
Plus
🔺an anti-MRSA
plus
🔺Aztreonam
Plus
🔺aminoglycoside

☝🏻When they are hemodynamically stable, demonstrate some clinical improvement (in fever, respiratory status, white blood count), and are able to take oral medications.

☝🏻generally five to seven days
✌🏻we use procalcitonin to guide the decision to stop antibiotics. We generally obtain a level at the time of diagnosis and repeat the level every two days in patients who are clinically stable.

💊For most immunocompetent patients with respiratory failure due to CAP who require invasive or non-invasive mechanical ventilation OR with significant hypoxemia: we suggest continuous infusion of hydrocortisone 200 mg daily for 4 to 7 days followed by a taper.

❗️We avoid hydrocortisone use in certain infections (eg, influenza,
tuberculosis, fungal infection, herpes viral infections, acute viral hepatitis).

💡While we do not treat CAP with adjunctive glucocorticoids in most other circumstances, we do not withhold glucocorticoids when they are indicated for other reasons (eg, refractory septic
shock, acute COPD exacerbations, COVID-19).

Clinically stable, can take oral medication, has no other active medical problems.

Follow-up:usually within one week.

💡Most patients with clinical resolution after treatment do not require a follow-up chest radiograph.
*A chest X-ray may take 6 to 12 weeks to clear in pneumonia

- Seasonal influenza viruses for all patient
- Pneumococcal vaccination is indicated for all patients ≥ 50 years old and others with specific risk factors (eg, certain comorbidities including chronic heart, lung, and liver disease, immunocompromising conditions, and impaired splenic function).
- Smoking cessation.