Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Standard view
Full view
of .
Look up keyword
Like this
0 of .
Results for:
No results containing your search query
P. 1
Pneumonia Guidelines

Pneumonia Guidelines



|Views: 3,180|Likes:
Published by IYERBK

More info:

Published by: IYERBK on Nov 03, 2008
Copyright:Attribution Non-commercial


Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less





Dr. B. K. Iyer
Guidelines for the Empiric Managementof Adult Patients withCommunity-Acquired Pneumonia (CAP)andIV to PO Conversion
Formulary & Therapeutics Committee
Last updated
Based on
 Guidelines for the Empiric Management of Adult Patients withCommunity-Acquired Pneumonia (CAP) and IV to PO Conversion
These guidelines serve to aid clinicians in the diagnostic work-up, assessment of severity of illness,empiric antibiotic treatment, and follow-up of adult patients with community-acquired pneumonia (CAP).
These guidelines have been developed based on published literature including the most recent CAPguidelines and expert clinical opinions.
The recommendations serve as a guide and clinicians areencouraged to use clinical judgment to manage all cases.
Initial approach -----------------------------------------------------------------------------------
See algorithm
Diagnostic studies-
Patient stratification
Pneumonia PORT Severity Index
Patients with asthma have increased risk of complications and may warrant hospitaladmission.-
 Need for hospitalization
In general, patients in risk Class I and II may be managed as outpatients. Outpatientmanagement of patients in risk Class III may be considered after assessment of  patient’s clinical condition, follow-up, and home environment.-
 Need for admission to an intensive care unit
Empiric antibiotic therapy ----------------------------------------------------------------------
See algorithm
Outpatient therapy-
Inpatient antibiotic therapy
Risk factors
Initial therapy should be individualized where appropriate based onantibiotic history, recent hospitalization, immune status, and culture history.
 Non-ICU admission
**every effort should be made to initiate antibiotic therapy within 4 hours of presentation** **antibiotic therapy should always be targeted to culture and susceptibility data when available** 
IV to PO Conversion -----------------------------------------------------------------------------
See algorithm
Recommendations for oral conversion are provided based on initial IV therapy. The choice of oral antibiotics may be influenced by results of microbiologic studies, favoring more-narrowspectrum agents when possible.-
Recommendations have been made to convert intravenous ceftriaxone, a third generationcephalosporin, to oral cefuroxime, a second-generation cephalosporin. Intravenousceftriaxone has no definitive oral equivalent and conversion to cefuroxime (Ceftin
) should be adequate following initial therapy with ceftriaxone. If a specific pathogen is identified,therapy should be modified accordingly.
Discharge ------------------------------------------------------------------------------------------
See algorithm
Prior to discharge, all patients should be screened for influenza vaccination during influenzaseason, pneumococcal vaccination, and the need for smoking cessation counseling.
Mandell LA, Bartlett JG, Dowell SF,
et al 
. Update of practice guidelines for the management of community-acquired pneumonia inimmunocompetent adults.
Clin Infect Dis
2003; 37: 1405-33.2.
Bartlett JG, Dowell SF, Mandell LA,
et al 
. Practice guidelines for the management of community-acquired pneumonia in adults. InfectiousDiseases Society of America.
Clin Infect Dis
. 2000 Aug;31(2):347-82.3.
 Niederman MS, Mandell LA, Anzueto A,
et al 
. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis,assessment of severity, antimicrobial therapy, and prevention.
 Am J Respir Crit Care Med 
2001 Jun; 163(7): 1730-54.4.
Centers for Disease Control. Influenza (Flu).http://www.cdc.gov/flu/ 5.
Centers for Disease Control. Adult immunization schedule.http://www.cdc.gov/nip/recs/adult-schedule.htm 6.
Centers for Disease Control. Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on Immunization Practices(ACIP).
April 04, 1997; 46(RR-08); 1-24.
Last updated
Pneumonia diagnosed by radiograph and symptomsInitiate diagnostic work-upConsider treatment asoutpatientAdmit tohospital
Azithromycin 500 mg PO x 1, then250 mg PO daily x 4 days
Levofloxacin 500 mg PO dailyx 7-10 days
Pneumonia PORT Severity Index Score
Evaluate for discharge based on the following criteria:
Stable comorbid illnesses and significant improvement in pneumonia
Should also fulfill the following criteria (
unless baseline status):
temperature < 37.8°C ( > 16 hours and in the absence of antipyretics ) pulse < 100 beats/minrespiratory rate < 24 breaths/minSBP > 90 mmHg O
saturation > 90%ability to maintain oral intake
Discharge from hospital with oral antibiotic if necessary tocomplete a course of therapyEvaluate patient for IV to PO conversionTypical diagnostic work-up
Vital signsChest x-ray (PA and lateral)Complete blood count (CBC) with differentialBasic metabolic panelHepatic profilePulse oximetry and/or ABG
In addition, the following are recommended for Risk Class III-V and should be considered for Risk Class I-II:
Blood cultures x 2Sputum for Gram's stain and culture (if possible)
Additional diagnostics to consider:
urinary antigen
S. pneumoniae
urinary antigen
(at CUMC only)
Immunocompromised (including HIV):
Consider other causes of pneumonia (
fungal, viral,TB, PCP) and other diagnostics
Influenza season:
Nasopharyngeal swab for influenza and RSV
Special circumstances:
SARS, bioterrorism
Criteria for IV to PO conversion
Clinical improvement in pulmonary signs and symptomsAfebrile or consistent improvement in fever over a 24-hour periodWBC count normalizingInfection being treated does not require IV therapy(e.g. endocarditis, meningitis)GI absorption likely normal(absence of vomiting or abnormal GI anatomy)Ability to receive oral dosage form either orally or viatube (concomitant oral or via tube administration of other meds)
New York-Presbyterian HospitalGuidelines for the Empiric Management of Adult Patients with Community-Acquired Pneumonia(CAP) and IV to PO Conversion
Age (years)Male Age =Female Age - 10 =Nursing Home residentCo-exising illnessNeoplasmLiver diseaseCongestive heart failureCerebrovascular diseaseRenal diseasePhysical exam findingsAltered mental statusRespiratory rate > 30 breaths/minSystolic BP < 90 mmHgTemp < 35°C or > 40°CHeart rate > 125 beats/minLab and X-ray findingsArterial pH < 7.35BUN > 30 mg/dLNa < 130 mEq/LGlucose > 250 mg/dLHct <30%PO
< 60 mmHg or O
saturation < 90%Pleural effusion
Initiate appropriate empiric antibiotic therapy(see drug therapy algorithmn)Pneumonia PORTSeverity IndexScoreRisk Class I / II
Pneumonia SeverityIndex < 70 points
Risk Class IV / V
Pneumonia SeverityIndex > 91 points
Risk Class III
Pneumonia SeverityIndex 71-90 points
Consider hospitalization
(May be treated as outpatient after evaluation of other factors includinghome environment and follow-up)
Consider admission to ICUfor severepneumonia
Severe pneumonia
Respiratory rate > 30 breaths/minNeed for mechanical ventilationSeptic shockSBP < 90 mmHgMultilobar diseasePaO
ratio <250Increasing infiltrate by 50% in 48 hoursOliguriaRequiring pressors
Evaluate empiric antibiotic therapyEvaluate results of microbiology and diagnostic testsModify antibiotic therapy if necessaryFor all appropriate patients, prior to discharge, consider :influenza vaccinationpneumococcal vaccinationsmoking cessation

Activity (20)

You've already reviewed this. Edit your review.
1 hundred reads
1 thousand reads
Laili Khairani liked this
Rizka Fadila liked this
Ronald Liem liked this
then_lexa liked this

You're Reading a Free Preview

/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->