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 Patients S. pneumoniae 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 Agent Dose No Comorbid Factors1 Doxycycline OR 200mg PO first dose then 100mg PO bid 7 to 10 days Azithromycin OR 500mg PO 1st day then 250mg PO daily 4 days Clarithromycin OR 250 to 500mg PO bid 7 to 10 days 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 OR 200mg PO first dose then 100 mg PO bid 7 to 10 days Azithromycin OR 500mg PO 1st day then 250mg PO 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 OR High dose 1g PO tid 7 to 10 days Amoxicillinclavulante3 875mg PO bid 7 to 10 days 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. [Amoxicillinclavulante3 OR 875mg PO bid 7 to 10 days Cefuroxime axetil] PLUS 500mg PO bid 7 to 10 days [Azithromycin OR 500mg PO 1st day then 250mg PO daily 4 days Clarithromycin OR 250 to 500mg PO bid 7 to 10 days or XL 1 g PO daily for 7to 10 days Erythromycin 500mg PO qid 7 to 10 days Alternative OR Levofloxacin OR 500mg PO daily 7 to 10 days 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 Agent Dose [Cefuroxime OR 750mg IV q 8h 10 days Cefotaxime OR 1g IV q8h 10 days Ceftriaxone] PLUS 1g IV daily 10 days [Doxycycline OR 200mg PO 1st dose then 100mg PO bid 10 days Macrolide4] Alternative Respiratory Quinolone5 10 days Severe [Cefotaxime OR 1g IV 8h 10 to 14 days Ceftriaxone] PLUS 1g IV daily 10 to 14 days [Macrolide4 OR Respiratory Quinolone5] Cephalosporin Allergy Respiratory Quinolone6 PLUS 10 to 14 days Another antibiotic (clindamycin, macrolide4, vancomycin) 10 to 14 days (exeception is azithromycin for 5 days) 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? • Neoplastic disorders • Congestive heart failure • Cerebrovascular disease • Renal disease • Liver disease Assign patient to risk class II-V based on prediction model scoring system Yes No Does the patient have any of the following abnormalities on physical examination? • Altered mental status • Pulse ≥ 125/minute • Respiratory rate ≥ 30/minute • Systolic blood pressure < 90mmHg • Temperature < 35oC or ≥ 40oC Yes 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 Characteristics Points Assigned Demographic Factors Age (in years) Males Females Nursing Home Resident age (in years) age (in years) - 10 +10 Comorbid Illness Neoplastic Disease +30 Liver Disease +20 Congestive Heart Failure +10 Cerebrovascular Disease +10 Renal Disease +10 Physical Exam Findings Altered Mental Status +20 Patient’s points Respiratory Rate > 30/ minute +20 Systolic BP < 90 mmHg +20 Temperature <350C or >400C +15 Pulse > 125/minute +10 Laboratory Findings pH < 7.35 +30 BUN> 10.7mmol/L or creatinine >120mmol/L +20 Sodium <130mmol/L +20 Glucose>13.9mmol/L +10 Hematocrit <30% +10 PO<60mmHg or O2 sat <90% +10 Pleural Effusion +10 TOTAL SCORE Risk Class # of Points Mortality (%) Recommendation 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