II. Management: Children
III. Management: Disposition (outpatient versus hospitalization versus ICU admission)
-
Severe Community Acquired Pneumonia Criteria
- Indications for ICU admission
-
Mortality Prediction Tool for Patients with Community Acquired Pneumonia (CURB-65)
- Consider as disposition triage tool used by both outpatient and emergency providers
- Indications for outpatient, inpatient or ICU admission
- Caveats
- Add Hypoxia as admission criteria (not included in CURB-65)
- Poor Test Sensitivity (use other prediction tools for low scores)
- High Test Specificity (strongly consider ICU admission for higher scores)
-
Pneumonia Severity Index
- Indications for outpatient, observation or admission
-
Pneumonia IRVS Prediction Tool (SMART-COP)
- Indications for ICU admission (predicts Mechanical Ventilation and pressor support)
-
Pneumonia in the Elderly
- See Pneumonia Hospitalization Criteria in the Elderly
-
Pneumonia SOAR Score
- Disposition of Nursing Home resident with Pneumonia (outpatient, inpatient or ICU admission)
IV. Management: General Measures
- Early mobilization
- Sitting up for >20 minutes on first hospital day
- Mundy (2003) Chest 124:883-9 [PubMed]
- Additional management
- Consider Influenza management (e.g. Tamiflu)
- Consider Corticosteroids (may reduce risk of ARDS, prolonged ICU stays, and overall morbidity)
V. Management: Antibiotics
- See Pneumonia Accelerated Diagnostic Protocol
- Start antibiotic within 4 hours of hospitalization
- Decreases mortality
- Decreases length of stay
- Houck (2004) Arch Intern Med 164:637-44 [PubMed]
- Be aware of Antibiotic Resistance
- See Streptococcus Pneumoniae resistance
- Reserve use of Fluoroquinolones to prevent resistance
- Course of antibiotics
- Course of 10-14 days has been used historically
- Course of 7 days appears to be equally effective
- Course of 5 days (and 2-3 days afebrile) is sufficient in low severity Community Acquired Pneumonia
VI. Management: Outpatient in adults
- Low risk for Antibiotic Resistance
- Indications
- Community Acquired Pneumonia in previously healthy patients
- No daycare exposure
- No antibiotics in last 3 months
- First-line Options (select one)
- Doxycyline
- Dose: 100 mg orally twice daily for 5 days
- Activity against streptococcal Pneumonia, Mycoplasma, h. Influenzae and atypicals
- High-Dose Amoxicillin
- Dose: 1000 mg orally three times daily for 5 days
- Augmentin is not needed as Streptococcus Pneumoniae is not a beta-lactamase producer
- Doxycyline
- Alternative Options
- Macrolide antibiotics (Azithromycin, Clarithromycin)
- Caution: High pneumococcus resistance rate in U.S. (>25%)
- No longer recommended as first-line antibiotic in Community Acquired Pneumonia
- Macrolide antibiotics (Azithromycin, Clarithromycin)
- References
- (2019) Presc Lett 26(12):67
- Indications
- Higher risk for Antibiotic Resistance (or higher risk patients)
- Indications
- See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)
- Comorbidities (COPD, CAD, Cirrhosis, DM, Chemical Dependency, Asplenia, cancer)
- Antibiotics in the last 3 months
- Daycare exposure
- Fluoroquinolones (review risk of Fluoroquinolone adverse effects with patient)
- Levofloxacin
- Gatifloxacin
- Grepafloxacin
- Moxifloxacin
- Sparfloxacin
- Combination (in lobar Pneumonia, reasonable to start beta-lactam alone)
- Macrolide (Azithromycin, Clarithromycin) or Doxycyline AND
- Beta-lactam (choose one)
- High dose Amoxicillin
- Amoxicillin-clavulanate (Augmentin)
- Cefpodoxime (Vantin)
- Cefprozil (Cefzil)
- Cefuroxime (Ceftin)
- Cefdinir (Omnicef)
- Indications
VII. Management: Inpatient Management in adults
- See inpatient indications as above
- Convert to oral antibiotic within 72 hours if possible
- Criteria to switch to oral antibiotics
- Temperature <100.9 F (37.8 C)
- Heart Rate <100 beats per minute
- Respiratory Rate <24 breaths per minute
- Systolic Blood Pressure >90 mmHg
- Oxygen Saturation >90%
- Baseline cognitive status
- Tolerating oral agents
- Base option: Single agent using broad spectrum Fluoroquinolone (see adverse effects)
- Levofloxacin
- Gatifloxacin
- Grepafloxacin
- Moxifloxacin
- Sparfloxacin
- Base option: Combination protocol using beta-lactam with a Macrolide
- General
- Use one option from antibiotic 1 and one from antibiotic 2
- Cephalosporin with Macrolide offers best outcomes
- Brown (2003) Chest 123:1503-11 [PubMed]
- Antibiotic 1 (choose one)
- Cefotaxime (Claforan)
- Ceftriaxone (Rocephin)
- Ampicillin-Sulbactam (Unasyn)
- Antibiotic 2: Macrolide
- Azithromycin 500 mg IV (especially ICU patient)
- General
- Modification for ICU patients
- Choose one of the 2 base options
- If a Fluoroquinolone is used, add Aztreonam
- Modification if risk of MRSA
- See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)
- Add Vancomycin, Linezolid (Zyvox) or Ceftaroline
- Modification if risk for Aspiration Pneumonia (Anaerobic Bacteria)
- Consider following loss of consciousness, Alcoholism or stroke with bulbar symptoms
- See Aspiration Pneumonia
- Antibiotic coverage includes carbapenems, Clindamycin, Flagyl, zosyn, Unasyn (or Augmentin)
- Modification in uncomplicated Community Acquired Pneumonia
- Beta-Lactam monotherapy has similar mortality to combination therapy
- Beta-Lactam monotherapy was not inferior to combination therapy in moderately severe CAP
- However combination therapy with Macrolide had better clinical response in atypical cases
- Garin (2014) JAMA Intern Med 174:1894-901 +PMID:25286173 [PubMed]
- Recommend combination therapy until further data
- If monotherapy used, consider Legionella urine Antigen testing
- Atypical cases
- Risk for Legionella pneumonia (e.g. returning from cruise)
- (2015) Presc Lett 22(6): 32-3
- If monotherapy used, consider Legionella urine Antigen testing
VIII. Management: Inpatient Management if risk of Pseudomonas infection
- See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)
- Combination protocol - use antibiotic 1 and antibiotic 2 in combination
- Antibiotic 1
- Ticarcillin-clavulanate (Timentin)
- Piperacillin-Tazobactam (Zosyn)
- Cefepime
- Imipenem-Cilastin (Primaxin)
- Meropenem (Merrem)
- Doripenem (Doribax)
- Antibiotic 2
- Option: Fluoroquinolone (choose one)
- Option: Macrolide AND Aminoglycoside (use both)
- Option: Fluoroquinolone AND Aminoglycoside (use both)
IX. Management: Refractory Cases
- See Community Acquired Pneumonia Refractory to Standard Management
- Other antibiotic options for Community Acquired Pneumonia
X. Prevention
XI. References
- Bartlett (1998) Clin Infect Dis 26:811-38 [PubMed]
- Bartlett (2000) Clin Infect Dis 31:347-82 [PubMed]
- Kaysin (2016) Am Fam Physician 94(9); 698-706 [PubMed]
- King (1997) Am Fam Physician 56:544-50 [PubMed]
- Lim (2009) Thorax 64(suppl 3):1-55 [PubMed]
- Lutfiyya (2006) Am Fam Physician 73:442-50 [PubMed]
- Mandell (2007) Clin Infect Dis 44(suppl 2): S27-72 [PubMed]
- Niederman (1993) Am Rev Respir Dis 148:1418-26 [PubMed]
- Thibodeau (2004) Am Fam Physician 69:1699-706 [PubMed]
- Watkins (2011) Am Fam Physician 83(11): 1299-306 [PubMed]
- Wunderink (2014) N Engl J Med 370:543-51 [PubMed]