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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
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