Protocolo diagnóstico y tratamiento empírico de la neumonía en el paciente inmunocomprometido

Filamentous fungi, respiratory or herpes group, P. jirovecii, Nocardia and M. tuberculosis viruses can cause pneumonia in the immunosuppressed patient. These are mixed infections in 20% of cases. The type of infiltration (alveolar, interstitial or nodular pattern) and whether it is focal or diffuse can give a guide as to the aetiology of the infection. Bacterial, mycobacterial, fungal and viral stains and cultures from respiratory sampling (sputum, nasopharyngeal exudate, BAL), and detecting markers in BAL fluid (viral or fungal PCR, galactomannan, beta-D-glucan) are essential for diagnosis. Diffuse lesions usually require transbronchial biopsy and nodules require percutaneous CT-guided needle biopsy. Empirical treatment for focal involvement and alveolar pattern will include an antipseudomonal beta-lactam. ± amikacin ± vancomycin or linezolid (+ voriconazole if the image is nodular). Antipseudomonal beta-lactam ± vancomycin or linezolid + cotrimoxazole ± ganciclovir is recommended for cases of bilateral and diffuse involvement (alveolar or interstitial).