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Community Acquired Pneumonia Adult

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					        Guideline for the
  Diagnosis and Management of
Community Acquired
 Pneumonia: Adult
Etiology
                        Usual Pathogens
Outpatients
No comorbid factors   S. pneumoniae
                      M. pneumoniae
                      C. pneumoniae
Comorbid factors      S. pneumoniae
                      H. influenzae
                      S. aureus
                      M. catarrhalis
                      Enterobacteriaceae
                      C. pneumoniae

Hospitalized
Moderate/Severe       S. pneumoniae
Patients              H. influenzae
                      S. aureus
                      Group A streptococci
                      Enterobacteriaceae
                      C. pneumoniae
                      Legionella spp (rare)
Diagnosis
Clinical Assessment
• History
    - Fever +/- chills
    - New onset of cough which may or may not
      be productive
    - Pleuritic chest pain
    - Constitutional symptoms such as
      fatigue, headache, nausea and vomiting,
      abdominal pain, myalgias
•   Identification of Risk Factors:
    - Smoking
    - Comorbid conditions: asthma, smoking,
      lung cancer, chronic obstructive pulmonary
      disease (COPD), diabetes, alcoholism,
      chronic renal or liver failure, congestive
      heart failure (CHF), chronic corticosteroid
      use, malnutrition or acute weight loss
      (>5%), HIV
    - Recent (3 months) antibiotic history*
    - Hospitalization in past 3 months
• Physical examination:
   - Temperature > 37.8°C Note: Basal
     temperature in the frail elderly is often
     lower
   - Tachypnea (respiratory rate ≥ 25 / minute)
     Note: Respiratory rate must be counted for
     a full minute
   - Signs of consolidation: diminished chest
     expansion, increased tactile vocal fremitus,
     dullness on percussion, diminished air
     entry, bronchial breath sounds, whispering
     pectoriloquy, localized crackles, pleural rub

Investigations
   All PAtiEnts
   • Chest x-ray, PA and lateral
   • CBC with differential
   • Sputum gram stain and culture only if
     productive cough
   • Blood cultures* for those who present to
     ER with history of chills/rigors
Additional Tests for Hospitalized Patients
• Blood cultures*
• Chemistry – glucose, electrolytes,
  creatinine, ALT
• Pulse oximetry
• Arterial blood gas if patient:
     - O2 sat <90%
     - Has COPD
     - Receiving chronic oxygen (do on
        baseline O2)
• Thoracentesis should be considered in
  patients with significant pleural effusion
• Serology is not routinely recommended
*Note: 1 set blood culture = 3 vials: 1 vial
aerobic/ 1 vial anaerobic from one site + 1
vial aerobic from a second site AT SAME
TIME
Management
Up to 80% of patients with CAP are treated as
outpatients.1
General
• Ensure adequate hydration
• Adequate analgesics/antipyretics for pain and
  fever
• Cough suppressants are not routinely
  recommended
• For patients who may require admission to
  hospital, calculation of Pneumonia Severity of
  Illness (PSI) score is recommended to guide
  determination of site of care (See Appendix 3
  and 4)
Note: The pneumonia severity of illness score is
a guide and should never replace a physician’s
judgement as to the admission decision.
• Significant pleural effusion (> 10 mm on lateral
  decubitus) should be drained
• Empyema should be drained

Oxygen
• Oxygen therapy is indicated for hypoxemia

Antibiotic Therapy
Due to morbidity and mortality of bacterial
pneumonia, and limitations of microbiologic
diagnosis, empiric therapy is recommended for all
patients with physical findings of pneumonia and
new infiltrate on chest X-ray.
• See Tables 3 and 4 for antibiotic therapy
  recommendations



Follow-up
• Follow-up for outpatients should occur at 48 to
  72 hours
• Follow-up chest X-ray recommended at 6
  weeks to ensure resolution and exclude
  underlying diseases such as empyema, lung
  abscess, and malignancy if:
 - Extensive/necrotizing pneumonia
   - Smoker
   - Alcoholism
   - COPD
   - > 5% weight loss in past month
   - > 50 years old

table 3: Antibiotic Agents in
Outpatient treatment of CAP
      in Adult Patients
 Recommended     Dose
 Agent
 No Comorbid
 Factors1
 Doxycycline     200mg PO first dose then 100mg PO
 OR              bid 7 to 10 days
Azithromycin        500mg PO 1st day then 250mg PO
OR                  daily 4 days

Clarithromycin      250 to 500mg PO bid 7 to 10 days
OR                  OR XL 1 g PO daily for 7 to 10 days

Erythromycin        500mg PO qid 7 to 10 days
   Recent antibiotic therapy (past 3 months)2 Choose a
  different class of agent than previously used and ADD

Amoxicillin         High dose 1g PO tid 7 to 10 days
Comorbid Factors1
Doxycycline         200mg PO first dose then 100 mg PO
OR                  bid 7 to 10 days

Azithromycin        500mg PO 1st day then 250mg PO
OR                  daily 4 days

Clarithromycin      250 to 500mg PO big 7 to 10 days
                    OR XL 1g PO daily for 7 to 10 days

   Recent antibiotic therapy (past 3 months)2 Choose a
  different class of agent than previously used and ADD
Amoxicillin          High dose 1g PO tid 7 to 10 days
OR

Amoxicillin-         875mg PO bid 7 to 10 days
clavulante3
 Failure of 1st Line Agents [Hemodynamic compromise
   (see In-Patient recommendations below or consider
  admission to hospital) OR clinical deterioration after 72
   hours of antibiotic therapy OR no improvement after
completion of antiobiotic therapy]. Choose a regimen not
previously used as first line therapy, or within previous
                  3 months if possible.




[Amoxicillin-        875mg PO bid 7 to 10 days
clavulante3
OR

Cefuroxime           500mg PO bid 7 to 10 days
axetil]
PLUS

[Azithromycin        500mg PO 1st day then 250mg PO
OR                   daily 4 days
Clarithromycin   250 to 500mg PO bid 7 to 10 days or
OR               XL 1 g PO daily for 7to 10 days


Erythromycin     500mg PO qid 7 to 10 days




Alternative
OR


Levofloxacin     500mg PO daily 7 to 10 days OR
OR               750mg PO daily 5 days


Moxifloxacin     400mg PO daily 7 to 10 days
Notes
1. Comorbid/risk factors include: asthma, lung cancer,
COPD, diabetes, alcoholism, chronic renal failure or liver
failure, CHR chronic corticosteroid use, malnutrition or
acute weight loss (>5%), hospitalization in past 3 months,
HIV, smoking
2. Antibiotic therapy within the previous 3 months is a risk
factor for resistant S. pneumoniae. Amoxicillin provides the
best coverage of all oral β-lactams against S. pneumoniae,
even penicillin-intermesiate strains
3. Amoxicillin-clavulamate preferred over amoxicillin if
Gram negative (alcoholism, recent hospitalization) or Staph
(diabetes, recent influenza infection) species are a concern
 table 4: Antibiotic treatment
for Adults Admitted to Hospital
           with CAP
Recommended    Dose
Agent
[Cefuroxime    750mg IV q 8h 10 days
OR
Cefotaxime     1g IV q8h 10 days
OR
Ceftriaxone]   1g IV daily 10 days
PLUS
[Doxycycline   200mg PO 1st dose then 100mg PO
OR             bid 10 days
Macrolide4]
Alternative
Respiratory    10 days
Quinolone5
Severe
[Cefotaxime    1g IV 8h 10 to 14 days
OR
Ceftriaxone]         1g IV daily 10 to 14 days
PLUS
[Macrolide4
OR
Respiratory
Quinolone5]
Cephalosporin
Allergy
Respiratory          10 to 14 days
Quinolone6
PLUS
Another antibiotic   10 to 14 days (exeception is
(clindamycin,        azithromycin for 5 days)
macrolide4,
vancomycin)

Notes
4. Macrolide: Azithromycin (500mg IV/PO 1st day then 250
   mg PO daily 4 days), Clarithromycin (500mg PO bid 10
   days), or Erythomycin (0.5 - 1g IV q6h/500mg PO qid
   10 days)
5. Respiratory Quinolone Levofloxacin (500mg IV/PO daily
   10 days OR 750 mg IV/PO daily 5 days), or Moxifloxacin
   (400 mg IV/PO daily 10 days)
6. Respirator Quinolone: Levofloxacin (500 mg IV/PO daily
   10-14 days), or Moxifloxacin (400 mg IV/PO 10-14 days)
Failure of therapy
• Definition:
  - Hemodynamic compromise
  OR
  - Clinical deterioration after 72 hours of
    antibiotic therapy
  OR
  - No improvement after completion of
    antibiotic therapy.

• Consider:
  − Host-related factors:
    • Noninfectious pulmonary pathology
    • Immunosuppressed
  − Pathogen-related factors:
    • Antibiotic resistance
    • Non-bacterial etiology
    • viruses
    • Mycobacterium spp
    • fungi
− Drug related factors:
  •  Compliance
  •  Malabsoprtion
  •  Drug-drug interactions
  •  Drug fever
Appendix 3 Prediction Model for
 Identification of Patient Risk for
Persons with Community Acquired
            Pneumonia
 See appendix 4 for Pneumonia Specific
 Severity of Illness (PSI) scoring system




               Next page
      Patients with community acquired pneumonia



       Is the patient over 50 years of age?                    Yes

              No


    Does the patient have a history of any
    of the following comorbid conditions?                             Assign patient to
    • Neoplastic disorders                                          risk class II-V based
    • Congestive heart failure                        Yes
                                                                    on prediction model
    • Cerebrovascular disease                                          scoring system
    • Renal disease
    • Liver disease

              No


    Does the patient have any of the
    following abnormalities on physical
    examination?
    • Altered mental status
    • Pulse ≥ 125/minute                                      Yes
    • Respiratory rate ≥ 30/minute
    • Systolic blood pressure <
        90mmHg
    • Temperature < 35oC or ≥ 40oC

              No


      Assign patient to risk class I

Reprinted from: Fine MJ, Auble TE, Yearly DM, et. al. A Prediction rule to identify low-risk
patients with community acquired pneumonia. New England Journal of Medicine, 1997;
336: 243-250
  Appendix 4 Pneumonia Severity of
    Illness (PSI) Scoring System

                                                   Patient’s
Patient Characteristics      Points Assigned
                                                    points
Demographic Factors
  Age (in years)
  Males                           age (in years)
  Females                    age (in years) - 10
  Nursing Home Resident                     +10
Comorbid Illness
  Neoplastic Disease                        +30
  Liver Disease                             +20
  Congestive Heart Failure                  +10
  Cerebrovascular                           +10
  Disease
  Renal Disease                             +10
Physical Exam Findings
  Altered Mental Status                     +20
  Respiratory Rate > 30/           +20
  minute
  Systolic BP < 90 mmHg            +20
  Temperature <350C or             +15
  >400C
  Pulse > 125/minute               +10
Laboratory Findings
  pH < 7.35                        +30
  BUN> 10.7mmol/L or               +20
  creatinine >120mmol/L
  Sodium <130mmol/L                +20
  Glucose>13.9mmol/L               +10
  Hematocrit <30%                  +10
  PO<60mmHg or O2 sat              +10
  <90%
  Pleural Effusion                 +10


                           TOTAL SCORE
 Risk    # of Points       Mortality   Recommendation
 Class                       (%)        for Site of Care
         <50 yrs, no
         comorbidity,
         RR<24, normal
         BP, T<380C,
 I       P<110                   0.1   Outpatient
 II      <70                     0.6   Outpatient
 III     71-90                   2.8   Generally
                                       Outpatient
 IV      91-130                  8.2   Inpatient
 V       >130                   29.2   Inpatient




Reprinted from: Fine MJ, Auble TE, Yearly DM, et.
al. A Prediction rule to identify low-risk patients with
community acquired pneumonia. New England Journal
of Medicine, 1997; 336: 243-250

				
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