Using usual hospital protocols for prompt antibiotic treatment plus avoiding delays in optimizing oxygenation are primary ways to improve maternal-fetal outcomes. Start empiric antibiotics initially directed at common causes of CAP, keeping in mind the local antibiotic resistance profile. In healthy pregnant women with no recent antibiotic exposure and no risk factors for drug resistant Strep. pneumoniae, a macrolide is recommended, per IDSA. In patients with comorbid conditions such as diabetes mellitus, alcoholism, chronic heart, lung, kidney, or liver disease, immunocompromised state, or use of antimicrobials in the past three months, a beta lactam plus a macrolide (strong recommendation; level I evidence) (High-dose amoxicillin [1 g 3 times daily] or amoxicillin-clavulanate [2 g 2 times daily] is preferred; alternatives include ceftriaxone, cefpodoxime, and cefuroxime [500 mg 2 times daily] OR use a respiratory fluoroquinolone such as moxifloxacin or levofloxacin.

Symptomatic Treatment: Since fever may pose risks to the fetus and newborn, pregnant patients should be encouraged to treat fever, with acetaminophen being an optimal choice. For cough, consider usual antitussive opiates, as well as bronchodilators for those with bronchospasm. However, there may be an association between 1st trimester pregnancy maternal opioid analgesic treatment and certain birth defects. This information should be considered by women and their physicians who are making treatment decisions during pregnancy.

Antihistamines that appear safe in pregnancy include: tripelennamine (PBZ, PBZ-SR), chlorpheniramine (generic), or hydroxyzine (generic, Atarax). Tripelennamine appears to have a very good experience record and may be a good first choice.

Ipratropium nasal spray (Atrovent® .03% for allergic rhinitis and .06% for colds) can be prescribed as 1-2 sprays each nostril bid to tid. It appears to be safe in pregnancy.

Coughing and rib injuries: Pregnant women appear to be at increased risk for rib injuries including fractures caused by coughing. The anatomical changes caused near term by the enlarging uterus on the lower rib cages predisposes to excess stress on these ribs during the large intrapleural cough pressures generated before the glottis opens. Treatment includes narcotic analgesics for pain and antitussive effects.

Hospitalization: Arrange inpatient treatment of pregnant women with pneumonia, if they meet severity criteria listed below. As respiratory compromise can affect fetus, consider conservative decision making for admission of any patient exhibiting any respiratory distress even without meeting these severity parameters.

• Respiratory rate 30 breaths/min or higher
• PaO2/FiO2 ratio 250 or less
• Temperature 39°C or higher or 36°C or lower
• Hypotension requiring aggressive fluid resuscitation
• Altered mental status
• Multiorgan dysfunction or septic shock
• Multilobar infiltrates
• Pulmonary cavitation
• Uremia
• Leukopenia (white blood cell count lower than 4,000 cells/mm3)
• Thrombocytopenia (platelet count lower than 100,000 cells/mm3)

Influenza

Note: Much of the information is based on current CDC recommendations. Physicians are encouraged to keep abreast of CDC recommendations