Attending Version
Community Acquired Pneumonia (CAP) Module
Created by Dr. Wendy Gerstein and Dr. David Gonzales
Objectives:
1. List the 3 most common organisms of CAP
2. Be able to triage patients appropriately based on the pneumonia severity index (PSI)
3. Identify 3 criteria for clinical stability and discharge
References:
1. Management of Community-Acquired Pneumonia, Halm E., Teirstein,A, NEJM
2002 347:2039-2045.
2. Fine MJ, Stone RA, Singer DE, et al. Processes and outcomes of care for patients
with community-acquired pneumonia: results from the Pneumonia Patient
Outcomes Research Team (PORT) cohort study. Arch Intern Med 1999;159: 970980.
CASE
HPI: Patient is a 75 yo male who usually enjoys good health who presents to the ER with
a 3 day history of worsening cough with some production of greenish phlegm. He also
complains of lack of energy and appetite. He admits to some pain with deep inhalation
and mild shortness of breath. He denies fevers or hemoptysis, but has had increased
fatigue and decreased oral intake. He did not receive the flu shot last year and he cannot
recall ever receiving the pneumonia vaccine from his primary care physician.
PMH
No history of MI, lung, liver or kidney disease.
Hypertension diagnosed 10 years ago
Allergic rhinitis for most of life
SH
Retired high school teacher. Married with 3 grown children. Occasion travel outside the
state, last trip 5 months ago to Colorado. Drinks one glass of wine a day, quit smoking
30 years ago, denies drug use.
FMH
Mother: died age 80 due to “old age”
Dad: died age 65 of CAD
ALLERGIES
NKDA
OUTPATIENT MEDICATIONS
HCTZ for hypertension
OTC loratadine for occasional allergies
PE:
BP 104/54 P 108 RR 20 T 99.0 O2 88% RA
General: Healthy appearing male, AAO x 3, NAD
HEENT: PERRLA, EOMI, pharynx w/ post nasal drainage, no LAD, neck supple,
thyroid
normal
Lungs: scattered crackles LLL - otherwise clear, no egophony or dullness noted
CV: RRR no m/r/g, no JVD, equal dp/radial pulses
Abd: soft, nontender, + BS
Back: no tenderness with percussion
Ext: No C/C/E
Neuro: CN 2-12 grossly intact, motor/strength in 4 ext grossly intact
Skin: no rashes
LABS
WBC/H/H/Plt: 12.2/16/48/200
Na/K/Cl/CO2/BUN/Cr/Glu:132/3.8/98/25/12/1.1/96
Ca/Mg:8.3/1.7
LFT’s WNL
CXR: ill defined infiltrate LLL
UA pH 6.0 with negative chemistries
1. What is your diagnosis and what are the most likely pathogens?
The chest x-ray confirmed the clinical suspicion of pneumonia. He is at risk for the most
common CAP pathogens which include S. pneumoniae, M. pneumoniae, H. influenza,
and M. catarrhalis
2. Would you admit this patient? Explain your rationale.
While the patient looked tired, he did not appear to be systemically ill or septic. Utilizing
the Pneumonia Severity Index, a score of 85 {age score (75) + hypoxia score (10) = 85}
was calculated. Based on this score, the decision was made to admit the patient for a
course of IV antibiotics. Patient was started on iv ceftriaxone and oral doxycycline. The
patient had an uneventful hospital course and was discharged after 2 days with oral
antibiotics and home O2.
3. What possible outpatient medications can you use for treatment of CAP, on
discharge from hospital?
Doxycycline, azithromycin, moxifloxacin or levaquin (but levaquin not on formulary for
CAP at VA or UNM).
4. What other intervention can you do that may help this patient in preventing
future respiratory infections?
Patient is eligible for the pneumovax, and should be educated about the importance of
getting the yearly influenza vaccine.
5. What if this patient was 35 years old instead of 75 years old, given same scenario,
his PSI now would be 45. Would you now admit this patient?
Admission is recommended even for Class I patients (PSI <50) who are hypoxemic.
Discussion Outline:
1. Background – why is pneumonia an important problem?:
a. It is the sixth most common cause of DEATH in the United States (45,000
deaths per year).
b. Average mortality of inpatients is 14% (range 2-30% in studies).
c. In just the US there are 2-3 million cases per year; 500,000 hospitalizations, $9
billion per year on costs, $7500 per episode.
d. New pathogens always emerging (SARS, Hantavirus, chlamydia).
e. Resistant bacteria are becoming an increasing problem, which affects treatment.
f. We have an increasing population with immunosuppression or chronic diseases
(which impacts cause and mortality).
2. Etiology
a. Immunocompetent adults (cause identified only 50% of the time):
1. S. pneumoniae (most common overall)
2. M. pneumoniae/C. pneumoniae
3. Viruses
b. Chronic pulmonary/cardiovascular disease:
1. Drug resistant S. pneumoniae
2. H. influenza
3. M. catarrhalis
4. Legionella
c. In alcoholics:
1. Klebsiella pneumoniae,
2. Anaerobes
3. TB
d. IVDU:
1. S. aureus
2. PCP/PJP
3. Anaerobes
e. Post-splenectomy:
1. S. pneumoniae
2. H. influenza
f. Animal exposure:
1. C. psittaci, Cryptococcus neoformans, Histoplasmosis
capsulatum (birds)
2. Tularemia (rabbit)
3. Plague (rodents)
4. Hantavirus (deer mouse),
5. H. capsulatum (bat).
6. Q fever (C. burnetii) – farm animals
g. Travel:
1. SARS (Asia),
2. Coccidioides immitis (SW USA)
3. Legionella (endemic/epidemic areas).
h. Don’t forget
1. Know local epidemiology
2. Know about local and international outbreaks
3. Think TB
4. Increasing incidence of MRSA
3. Risk Stratification and the Decision to Hospitalize
a. Pneumonia Severity Index – see table below for details
1. Validated scoring system based on mortality/morbidity
2. Additive score based on
 Demographic factors
 Co-existing illness(es)
 Physical Exam findings
 Laboratory and Radiographic Findings
3. Scores below 70 or class I or II, consider outpatient treatment
4. Score greater than 91 or class IV or V, consider MICU care
5. Pneumonia Severity Index is a guideline, never to displace clinical
judgment
6. Psychosocial factors such as homelessness, compliance with oral
meds, etc can lead to admission.
b. Early treatment with antibiotics is associated with improved clinical
outcomes. Goal is administration of appropriate antibiotics within 4 hours of
triage in ER.
4. Appropriate regimens for hospitalized patients with suspected CAP:
a. Ceftriaxone 2 grams q 24 hours plus doxycycline 100 mg po/iv q 12 hours.
b. alternative for ceftriaxone is cefotaxime 2 grams iv q 8 hours
c. alternative for doxycycline is azithromycin 500 mg iv/po q day
d. B-lactam allergy:
1. levofloxacin 750 mg po/iv q 24 hours OR
2. moxifloxacin 400 mg po/iv q 24 hours if no pseudomonal coverage
required.
e. If patient bacteremic with S. pneumoniae in setting of pneumonia, outcomes
improved when treated with a b-lactam drug.
5. Criteria for Clinical Stability and Discharge
a. Usual length of stay
1. Three days for Class III
2. Four days for Class IV
3. Five days for Class V
b. When to switch to oral antibiotics?
1. Vital signs stable for 24 hours
2. Can discharge to home on oral antibiotics on same day
c. Discharge criteria
1. Vital signs stable > 24 hours
 Temperature < 37.8
 RR < 24
 HR < 100
 Systolic BP > 90
 O2 sat > 90 % on RA or baseline sat
2. Patient able to take oral antibiotics
3. Patient able to maintain adequate hydration and nutrition
4. Normal mental status or back to baseline mental status
5. No new active clinical or psychosocial problems
Pneumonia Severity Index (PSI)
Characteristic
Points Score
Demographic Factors
Age
Men: Age in years
Women: Age in years
- 10
Nursing home resident
+ 10
Coexisting Illnesses
Neoplastic disease
+ 30
Liver disease
+ 20
Congestive Heart
+ 10
Failure
Cerebrovascular
+ 10
disease
Renal disease
+ 10
Findings on Physical
Examination
Altered mental status
+ 20
Respiratory rate ≥
+ 20
30/min
Systolic blood pressure + 20
< 90 mm Hg
Temperature < 35° C or + 15
≥ 40° C
Pulse ≥ 125 beats/min
+ 10
Laboratory and
Radiographic Findings
Arterial pH < 7.35
+ 30
Blood urea nitrogen ≥ 30 + 20
mg/dl (11 mmol/1)
Sodium < 130 mmol/liter + 20
Glucose ≥ 250 mg/dl (14 + 10
mmol/liter)
Hematocrit < 30%
+ 10
Sa02 < 90%* or Pa02 < + 10
60 mm Hg
Pleural effusion
+ 10
Total PSI
Pneumonia Severity Index (PSI) is used to
determine a patient's risk of death. The
total score is obtained by adding to the
patient's age (in years for men or in years
minus 10 for women) the points assigned
for each additional applicable characteristic.
(Data adapted from Fine et al. N Engl J
Med 1997; 336; 243-50)
Recommendations Based on total PSI
Score
Risk Risk
Mortality Disposition
Score Class
≤ 50 I Low 0.1% Consider outpatient
or observation
status
≤ 70 II Low 0.6% Consider
observation or
admit
71-90 III
0.9% Consider
Low
observation or
admit
91IV
9.3% Admit, consider
130 Mod
MICU
> 130 V
27.0% Admit, consider
High
MICU
Admission is recommended for Class I, II
and III patients who are hypoxemic (RA 02
sat of <90%), and patients who have
important medical or psycho/social
contraindications to outpatient care.
Review Questions:
1. A 54 yo homeless male presents to the ED with 36 hr history of cough, fevers,
hemoptysis, weakness and loss of appetite. Patient has been living at the local homeless
shelter off and on since arriving in Albuquerque four months ago. He admits to not
eating well lately and thinks he has lost some weight. He also admits to drinking cheap
wine for the past few days. The homeless advocate who accompanies the patient to the
ED was told that he was found yesterday “passed out” underneath a bridge and brought to
the homeless shelter where he spent last night. The patient denies any significant past
medical history but in addition to the alcohol history, the patient smokes whenever he can
find cigarettes but stays away from hard drugs. On PE, the patient has mild respiratory
distress and is disheveled and on the thin side. His VS are as follows: T 39.4, RR 24, HR
110 and O2 sat of 85% on RA. He has LLL crackles with some wheezing. The CXR
reveals a LLL infiltrate.
Based on the Pneumonia Severity Index, the patients score is 64 or Class II.
The appropriate treatment for this patient is:
1. Give the patient oral doxycycline in the ED, observe x 12 hours and if
stable, discharge to homeless shelter.
2. Draw blood cultures, start IV Ceftriaxone and oral doxycycline, observe in
ED for 24 hours, if stable discharge to homeless shelter with follow-up in
the General Medicine Clinic the next day
3. Draw blood cultures, start IV Ceftriaxone and oral doxycycline, admit to
the General Medicine Service with a regular floor bed.
4. Draw blood cultures, start IV Ceftriaxone and oral doxycycline, admit to
the General Medicine Service with an isolation room.
The best answer is #4. Despite a low pneumonia severity index of 64 or Class II
(consider OP treatment), this patient needs admission due to his poor social situation. His
differential diagnosis should also include TB with his history of living in a homeless
shelter, hemoptysis and weight loss history. With the possibility of TB, the patient needs
to be placed in an isolation room to prevent the spread of TB.
2) Discharge criteria from the hospital after admission for a patient with community
acquired pneumonia include all of the following except:
1.
2.
3.
4.
5.
Vital signs stable > 24 hours
Afebrile x 24 hrs after switch to oral antibiotics from IV.
Patient able to maintain adequate hydration and nutrition
Normal mental status or back to baseline mental status
No new active clinical or psychosocial problems
The best answer is #2. The patient can be safely discharged to home on day of
discontinuation of IV antibiotics. The literature supports that patients will do well if all
other discharge criteria are met.
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to
Dr. Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment
below:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient
curriculum in general:
6) Please circle one:
Attending
Resident (R2/R3)
Intern
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