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Initial Assessment

  1. Determine disposition using illness severity score (NICE 2014)

    1. Assess severity: CRB 65 scale (see Table 3-1)

      1. 0: Low risk; <1% mortality

      2. 1–2: Intermediate risk; 1%–10% mortality

      3. 3–4: High risk; >10% mortality

    2. Disposition based on CRB 65 score

      1. 0–1: Care at home

      2. ≥2: Hospital assessment

      3. ≥3: ICU evaluation

  2. Hospital admission determination (IDSA 2007)

    1. Use CURB 65 (CRB 65 plus uremia) to determine need for admission

    2. Use PSI/PORT score to determine severity

    3. Severe CAP if one major or three minor criteria

      1. Major

        1. Invasive mechanical ventilation

        2. Septic shock with need for vasopressors

      2. Minor

        1. RR >30

        2. PaO2/FiO2 ratio ≤250

        3. Multilobular infiltrates

        4. Confusion/disorientation

        5. Uremia (BUN >20 mg/dL)

        6. Leukopenia (WBC <4000)

        7. Thrombocytopenia (platelet <100,000)

        8. Hypothermia (Temp <36°C)

        9. Hypotension requiring aggressive fluid resuscitation

    4. ICU admission if

      1. Severe CAP

      2. Septic shock requiring vasopressors

      3. Acute respiratory failure requiring intubation and mechanical ventilation

    5. Laboratory testing (NICE 2014)

      1. CBC, CMP, lactate, HIV (if not tested recently)

      2. CXR, 2-view

      3. ABG if severe symptoms

      4. CRP initially and repeat at 48–72 hours; if clinically indicated:

        1. Do not routinely offer antibiotic therapy if the CRP <20 mg/L

        2. Delay antibiotic prescription if CRP 20–100 mg/L

        3. Use antibiotic if CRP >100 mg/L

      5. Microbiological testing

        1. Obtain testing within 4 hours of presentation

        2. Low severity community-acquired pneumonia (CAP): No routine microbiological tests

        3. Moderate to high severity CAP: Obtain blood and sputum cultures, consider pneumococcal and Legionella urinary antigen test prior to antibiotic administration

        4. For testing based on risk factors, see Table 3-2

    6. Evaluation of suspected HAP/VAP (IDSA 2016)

      1. Cultures

        1. Noninvasive sampling with semiquantitative cultures is adequate; do not perform invasive sampling (i.e., BAL)

        2. If invasive means performed, but specimen below diagnostic threshold for VAP, consider withholding antibiotics

        3. Treatment based on results of noninvasive samples and deescalate antibiotic therapy based upon respiratory and blood culture results

      2. Procalcitonin, C-reactive protein, sTREM-1 (soluble triggering receptor expressed on myeloid cells): Use clinical criteria alone rather than using these lab markers to decide to initiate antibiotics

Acute Medical Management

  1. NICE: Initiate antibiotic therapy within 4 hours of admission

  2. CAP

    1. Antibiotic therapy

      1. Low severity CAP, outpatient management

        1. Choice of antibiotic

          1. NICE 2016

            1. Give amoxicillin rather than macrolide or tetracycline for low severity CAP

            2. Give macrolide or tetracycline if penicillin allergic

          2. IDSA 2007

            1. Do not routinely offer fluoroquinolone or dual antibiotic therapy (IDSA 2007)

            2. If healthy and no risk for resistant S. pneumoniae: Macrolide (preferred) or doxycycline

            3. If comorbidities are present (chronic heart, lung, liver, renal disease; diabetes; alcoholism; malignancy; asplenia, immunosuppression; recent antimicrobials within past 3 months), give:

              1. Respiratory fluoroquinolone

              2. Beta-lactam (amoxicillin 1 g TID or Amox-clav 2 g BID, or ceftriaxone, cefpodoxime, cefuroxime) + (macrolide (preferred) or doxycycline)

        2. Duration (NICE 2016)

          1. 5-day course of single antibiotic

          2. Extend course >5 days for low severity CAP with symptoms not improving after 3 days

  3. Moderate and high severity CAP

    1. Choice of antibiotic

      1. NICE

        1. Dual therapy with amoxicillin and macrolide

        2. Dual antibiotic with beta-lactamase and macrolide for high severity ...

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