Community Acquired Pneumonia (CAP)
Last revised January 2016 by Michelle Le
Objectives
• Diagnosis of CAP
• Level of care assessment
• Therapeutic recommendations
Case Vignette
A 68 y/o Vietnamese male presented to the ED with SOB and
productive coughing for 2 days. Reports poor oral intake since
onset due to nausea and intermittent vomitting. His wife had
similar symptoms 1 week ago which improved with an unknown
antibiotic. Patient is requesting to go home with antibiotic. He
previously had tongue swelling and skin rash with use of
augmentin. Reports good health otherwise so he has not seen
his PCP for past 5 years. Denies chest pain, swelling of
extremities, or diarrhea.
His vital signs are T 38.5 C, P 76, BP 128/82, spO2 94%, RR 16.
Patient is alert and oriented. Crackles were heard over left lower
lung field. Labs showed WBC 14, BUN 20 mg/dL. Chest X-ray had
a consolidation in left lower lobe.
Case Vignette
What is the best way to further manage this patient?
A. Send home with oral azithromycin
B. Send home with oral levofloxacin
C. Admit to medicine floor with iv levofloxacin
D. Admit to medicine floor with iv ceftriaxone and po azithromycin
E. Admit to ICU with iv ceftriaxone and iv azithromycin
Don’t worry... We will revisit this case at the END of our mini-lecture!
Definitions – Pneumonia (PNA)
• Community acquired PNA (CAP)
– Infection of lung parenchyma in pt who is not hospitalized or living in a long-term care
facility for ≥2 weeks
• Hospital-acquired PNA (HAP)
– Occurs ≥48 hours after admission; not intubating on admission
• Healthcare-associated PNA (HCAP)
– Non-hospitalized pt with extensive healthcare contact and ≥1 criteria from below:
•
•
•
•
IV therapy, wound care, or IV chemotherapy within the prior 30 days
Residence in a nursing home or other long-term care facility
Hospitalization in acute care hospital for ≥2 days within the prior 90 days
Attendance at a hemodialysis clinic within the prior 30 days
• Ventilator-associated PNA (VAP)
– Arises >48-72 hours after endotracheal intubation
Severity of PNA
• Severity-of-illness scores can help guide whether a pt needs hospital
admission and should always be supplemented with clinical judgement
• CURB-65 criteria
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–
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Confusion
Urea >19 mg/dL
Respiratory rate ≥30
Blood pressure (SBP <90 or DBP ≤60)
≥65 year old
≥2 criteria then needs hospital admission and ≥3 criteria may need ICU
level of care
• Can also use Pneumonia Severity Index (PSI) instead of CURB-65
CAP Pathogens
CAP Treatment - Outpatient
•
No comorbidities or recent antibiotics use
 1st line: azithromycin (Z-Pak)
 2nd line: doxycycline
•
Have comorbitidies or antibiotic use in last 3 months
 Preferred: moxifloxacin OR levofloxacin
 Alternative: augmentin + azithromycin
CAP Treatment - Inpatient
• Non-ICU
 moxifloxacin OR levofloxacin
 azithromycin + [unasyn OR zosyn OR ceftriaxone OR
meropenem]
• ICU
 Preferred: azithromycin + [unasyn OR zosyn OR
ceftriaxone OR meropenem]
 Alternative: moxifloxacin OR levofloxacin
• If has PCN allergy
 aztreonam + [moxifloxacin OR levofloxacin]
Case Vignette
A 68 y/o Vietnamese male presented to the ED with SOB and
productive coughing for 2 days. Reports poor oral intake since
onset due to nausea and intermittent vomitting. His wife had
similar symptoms 1 week ago which improved with an unknown
antibiotic. Patient is requesting to go home with antibiotic. He
previously had tongue swelling and skin rash with use of
augmentin. Reports good health otherwise so he has not seen
his PCP for past 5 years. Denies chest pain, swelling of
extremities, or diarrhea.
His vital signs are T 38.5 C, P 76, BP 128/82, spO2 94%, RR 16.
Patient is alert and oriented. Crackles were heard over left lower
lung field. Labs showed WBC 14, BUN 20 mg/dL. Chest X-ray had
a consolidation in left lower lobe.
Case Vignette
What is the best way to further manage this patient?
A. Send home with oral azithromycin
B. Send home with oral levofloxacin
C. Admit to medicine floor with iv levofloxacin
D. Admit to medicine floor with iv ceftriaxone and po azithromycin
E. Admit to ICU with iv ceftriaxone and iv azithromycin
Case Vignette
What is the best way to further manage this patient?
A. Send home with oral azithromycin
B. Send home with oral levofloxacin
C. Admit to medicine floor with iv levofloxacin
D. Admit to medicine floor with iv ceftriaxone and po azithromycin
E. Admit to ICU with iv ceftriaxone and iv azithromycin
Summary
• CAP: infection of lung parenchyma in pt who is not
hospitalized or living in a long-term care facility for ≥2 weeks
• CURB-65 and Pneumonia Severity Index (PSI) are severity-ofillness scores which help guide level of care in conjuction with
clinical judgement
• Appropriate antibiotic regimen will provide coverage for both
Strept pneumoniae and atypical pathogens
References
• Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases
Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired
pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
• American Thoracic Society, Infectious Diseases Society of
America. Guidelines for the management of adults with hospitalacquired, ventilator-associated, and healthcare-associated
pneumonia. Am J Respir Crit Care Med 2005; 171:388.
• Schuetz P, Christ-Crain M, Thomann R, et al. Effect of
procalcitonin-based guidelines vs standard guidelines on
antibiotic use in lower respiratory tract infections: the ProHOSP
randomized controlled trial. JAMA 2009; 302:1059.