What’s the difference between urgent care and emergency medicine? Urgent care is the initial intention. You don’t think they’re getting admitted; you think they’re going home. Once you think they’re getting admitted, they’re not an urgent care patient anymore.
For pneumonia, we use the CURB-65 rule to determine urgent care (outpatient) versus emergency medicine (inpatient). Let me tell you why I don’t like this rule. I don’t like this line of judgment because by the time a patient hits CURB-65, they’re pretty sick. Hospitalists will admit pneumonia cases easily, even if the patient falls off CURB-65.
- Confusion: If someone has an altered mental status with pneumonia, I’m never sending them home. That just doesn’t make any sense.
- Uremia: When a patient’s B-1, or uremia, is up, it suggests a degree of dehydration. They’re more likely to come in.
- Respiratory rate: Respiratory rate is the Rodney Dangerfield vital sign. It’s the most disrespected, so you need to take it yourself.
- Blood pressure: If they’re hypotensive, I wouldn’t send them home over the age of 65.
- 65: Over the age of 65, they’re less likely to go home.
Using the CURB-65 rules, a patient with a score of one can probably be sent home. The literature says you can safely discharge with a score of one.
But use common sense. Proceed with caution, use your clinical judgment and look at comorbidities. I will not send home someone with an altered mental status and pneumonia home. That doesn’t make any sense. I would never do that. Same goes for respiratory rates. A respiratory rate of over 30 means I’m not discharging them. They’re going to be admitted.
A CURB-65 score of more than one should absolutely be hospitalized.
Chest X-Ray Interpretation
I do a lot of chest x-ray interpretation classes. At my classes, I show a chest x-ray from a patient with missed pneumonia. They came in with a cough, fever and a little sputum production. The provider said, “Chest x-ray is normal. You have bronchitis, go home.” Three days later, and you have the x-ray I show my classes. Three days after that, the patient dies due to Streptococcus pneumoniae bacteremia.
People die from pneumonia. It’s the number one cause of infectious disease death. That’s why you need to proceed with caution in urgent care medicine.
If you’re doing outpatient treatment, macrolides are recommended. That’s because we have three germs in the throat: strep pneumoniae, m-cat and h-flu. If it goes into the lung, we have to add atypicals in there. That’s mycoplasma chlamydia legionella. Macrolides cover all of them. Your choices are azithromycin or clarithromycin. Clarithromycin is a stronger antibiotic and that’s what I typically use.
If the patient had antibiotics in the last three months, we want to use a combination. The standard regime for inpatient treatment of community-acquired pneumonia is ceftriaxone and azithromycin. If they’ve had antibiotics in the last three months, we should do an upgraded regime of a macrolide with a stronger antibiotic such as amoxicillin, Augmentin or Levaquin.