community acquired pneumonia

1. Community Acquired Pneumonia Infectious Diseases Society of America And American Thoracic Society Guidelines on CAP in adults

2. Community acquired pneumonia Presence of an infiltrate on chest x ray as well as clinical signs and symptoms (such as fever, productive cough and chest pain)

3. Diagnostic testing Patient’s should be screened for hypoxia with pulse oximetry. Outpatients and hospitalized patients without cormobidities pretreatment sputum and blood cultures are optional. Patients with severe cap should have blood and sputum cultures and urinary antigen tests for Legionella pneumophila and streptococcus pneumoniae. Urinary antigen testing is also advised for patients who fail outpatient therapy.

4. Curb-65 criteria One point each for confusion, uremia, respiratory rate, low blood pressure, age 65 or older. And the Pneumonia Severity index can be used to determine treatment setting

5. Determine Treatment Setting Curb-65 of 2 indicates inpatient treatment or intensive home health care services. Depending on several factors such as family support.

6. ICU admission Patients requiring vasopressors or mechanical ventilation. Severe CAP having three of the following; respiratory rate of 30, hypoxemia( PaO2/FiO) of 250, multilobar infiltrates, confusion, uremia, leukopenia, thrombocytopenia or hypotension.

7. Outpatient treatment Healthy patients who’ve had no antibiotic within 3 months. Macrolide ( clarithromycin or erythromycin) or doxycycline. Patients with cormobidities or use of an antibiotic within three months use a respiratory fluroquinolone (moxifloxin, gemifloxacin, or levofloxacin) or a B-lactam plus a macrolide. High dose amoxicillin (1 gm tid)

8. Outpatients continued Or amoxicillin-clavulanate(2 gm bid) alternatives include ceftriaxone,cefpodime and cefuroximine (500 bid) doxycycline is an alternative to the macrolide. Macrolide resistant areas S. pneumoniae infection rates greater than 25% use a flouroquinolone or a b-lactam or cephalosporin and doxycycline.

9. Inpatients Respiratory fluoroquinolone or the combination of B-lactam (cefotaxime, ceftriazone or ampicillin) and macrolide. In some patients ertapenem and macrolide can be used when there is anaerobic and drug resistant S. pneumoniae infection

10. Icu treatment B-lactam (cefotaxime,ceftriaxone, or ampicillin/sulbactam) in combination with Azithromycin or a respiratory fluroquinolone. Penicillin allergies use aztreonam with a fluoroquinolone

11. Icu continued Pseudomonas infection suspected use antipneumococcal, antipseudomonal B-lactam with either cipro or levofloxin. Alternative B-lactam and aminoglycoside and azithromycin or a fluoroquinolone. Community acquired methicillin resistant (MRSA) Add vancomycin or linezolid.

12. Influenza A Treat with Zanamivir or Oseltamivir within 48 hours of symptoms. If symptoms longer and are hospitalized they also can be given either medication.

13. Test the patient for H5N1 infection, place on droplet precautions and treat with both antivirals and antibacterial. Patients with influenza with exposure to live poultry

14. Prevention Pneumococcal polysaccharide vaccine is recommended for patients aged 65 years old and for younger higher risk patients. If given prior to age 65 a second dose is recommended also. Inactivated Influenza vaccine is recommended for patients aged 50 or for younger persons at risk for complications of influenza, household contacts of high risk individuals and health care workers. Therefore, at least 2/3 of US population qualifies for it.

15. In Summary: Decide on appropriate treatment setting. Diagnostic testing should be done when needed. Begin empiric antibiotic therapy Practice preventive measures through immunization of patients.