Community-Acquired Pneumonia ©Adam Spivak/Ambulatory Curriculum 2014

Section 1: Diagnostic criteria of community-acquired pneumonia (CAP) Radiographic finding of new infiltrate plus at least two of: fever; cough; chest pain; dyspnea. To qualify as "community- acquired", patient should not o have been hospitalized in an acute care hospital for >2D in past 90 days o be a nursing home or long-care facility resident o received intravenous antibiotic therapy/chemo/wound care in past 30 days o attended a hospital or hemodialysis clinic.

Section 2: Most common etiologic agents of CAP Streptococcus pneumoniae Haemophilus pneumoniae Mycoplasma pneumoniae Chlamydophila pneumoniae Staphylococcus aureus Moraxella catarrhalis

Section 3: Common pathogens in specific clinical scenarios Alcoholism Streptococcus pneumoniae and anaerobes COPD / smoking S. pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Legionella Nursing Home residency S. pneumoniae, gram-negative bacilli, H. influenzae, Staphylococcus aureus, anaerobes, and Chlamydophila pneumoniae Poor dental hygiene Anaerobes HIV infection (early stage) S. pneumoniae, H. influenzae, and Mycobacterium tuberculosis HIV infection (late stage) Above plus P. jiroveci, Cryptococcus, and Histoplasma species Travel to southwestern US Coccidioides species Influenza active in community Influenza, S. pneumoniae, S. aureus, S. pyogenes, and H. influenzae Suspected large volume aspiration Anaerobes (chemical pneumonitis, obstruction) Structural disease of lung Pseudomonas aeruginosa, Burkholderia (Pseudomonas) cepacia, S. aureus Injection drug use S. aureus, anaerobes, M. tuberculosis, and S. pneumoniae Airway obstruction Anaerobes, S. pneumoniae, H. influenzae, and S. aureus

Section 4: Risk stratification in CAP management Step 1: If none of below present, outpatient mgmt. Step 2: Use if any positives in Step 1. Admit if score>70 ok Predictors of increased risk 1 pt. for each year of age (subtract 10 for women) Age > 50 Nursing home: 10 pts. Vital signs: any one of T<35, T>40, P>125, Vital signs: T<35 or T>40: 15pts; P>125:10pts; R>30: R>30, SBP<90, altered mental status 20pts; SBP<90: 20pts; , altered mental status Comorbidities: any one of malignancy, CHF, Comorbidities: Malignancy: 30pts; liver disease: 20pts; cerebrovascular disease, renal disease, liver CHF: 10pts; cerebrovascular disease: 10pts; renal disease: disease 10pts. Data: pH<7.35: 30pts; BUN>30: 20pts; Na<130: 20pts; Glu>250: 10pts; Hematocrit<30: 10pts; pO2<60: 10pts; pleural effusion: 10pts

CURB-65: Confusion; Uremia (BUN>20); RR>30; BP<90 systolic (or 60 diastolic); Age>65: Admit if 2 or more present.

Section 5: CAP treatment based on clinical scenario (Note: treatment duration ranges from 5-14 days) Patient variable Treatment option Healthy, no recent antibiotics (last 3 months) 1. Macrolide (erythromycin, azithromycin, clarithromycin) or 2. Doxycycline Healthy and recent (<3 months) antibiotic use 1. Respiratory fluoroquinolone (moxifloxacin, levofloxacin, gemifloxacin) or 2. Beta-lactam (amoxicillin or amoxicillin/clavulanate preferred) plus macrolide Comorbidities (chronic heart, lung, liver or renal 1. Respiratory fluoroquinolone (moxifloxacin, levofloxacin, disease; DM; alcoholism; asplenia; gemifloxacin) or immunosuppression; malignancy) 2. Beta-lactam (high-dose amoxicillin or amoxicillin/clavulanate preferred) plus macrolide Suspected aspiration with infection Amoxicillin-clavulanate or clindamycin Influenza with bacterial superinfection Beta-lactam or respiratory fluoroquinolone