COMMUNITY ACQUIRED PNEUMONIA

Pam Charity, MDCathryn Caton , MD, MS

Objectives Define pneumonia

Review criteria for diagnosis

Review criteria for admission

Review treatment options

Pneumonia Fever Leukocytosis Infiltrate on CXR

Diagnosis History

Physical Exam

Laboratory Data

Radiographic findings

Hospital Admission Decision

Severity of Illness Scores – CURB-65 (confusion, uremia, respiratory rate, low blood pressure, age 65 or greater)

Consider other factors – ability to safely and reliably take oral medication, support resources

CURB-65 > or = 2, more intensive treatment

ICU Admission Decision Major criteria

Septic shock requiring vasopressors Acute respiratory failure requiring intubation and

mechanical ventilation Minor Criteria

Respiratory rate >30 PaO2/FiO2 ratio <250 Multilobar infiltrates Confusion BUN >20 Leukopenia, thrombocytopenia Hypothermia

Outpatient Treatment Healthy and no risk factors for drug

resistant S. Pneumoniae

Macrolide – azithromycin

Doxycycline

Outpatient Treatment Patients with

co-morbid conditions – chronic heart, lung, renal disease; DM; ETOH; malignancies; asplenia; immunosuppressing drugs

use of abx within last 3 months or other risk for drug resistant S. Pneumoniae Then use

fluoroquinolone B – Lactam plus macrolide or amoxicillin-

clavulanate

Inpatient, non –ICU Treatment

Fluoroquinolone B-Lactam plus a macrolide

First dose of antibiotics should be administered in the ED after blood cultures are obtained.

Inpatient, ICU Treatment

B-Lactam plus either azithromycin or a fluoroquinolone

For pseudomonas use B-Lactam plus fluoroquinolone or B-Lactam plus an aminoglycoside and

azithromycin or B-Lactam plus an aminoglycoside and a

fluoroquinolone

Switch from IV to Oral

Patients should be switched when Hemodynamically stable Clinically improving Able to tolerate oral medications

Patients should be discharged as soon as clinically stable without other active issues

Duration of Antibiotic Therapy

Minimum of 5 days

Afebrile for 48-72 hours

No more than 1 CAP associated sign of clinical instability

References IDSA / ATS Guidelines Clinical Infectious Diseases 2007;

44:S27-72