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Pneumonia Guidelines

Pneumonia Guidelines

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Published by: IYERBK on Nov 03, 2008
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02/28/2013

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Dr. B. K. Iyer
 
Guidelines for the Empiric Managementof Adult Patients withCommunity-Acquired Pneumonia (CAP)andIV to PO Conversion
Formulary & Therapeutics Committee
Last updated
today
 
 
Based on
Hospital
Management
 Guidelines for the Empiric Management of Adult Patients withCommunity-Acquired Pneumonia (CAP) and IV to PO Conversion
 
Purpose:
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.
1-3
The recommendations serve as a guide and clinicians areencouraged to use clinical judgment to manage all cases.
Components:
 
Initial approach -----------------------------------------------------------------------------------
See algorithm
 -
 
Diagnostic studies-
 
Patient stratification
o
 
Pneumonia PORT Severity Index
o
 
Patients with asthma have increased risk of complications and may warrant hospitaladmission.-
 
 Need for hospitalization
o
 
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
o
 
Risk factors
 
Initial therapy should be individualized where appropriate based onantibiotic history, recent hospitalization, immune status, and culture history.
o
 
 Non-ICU admission
o
 
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.
4-6
 
References
1.
 
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).
MMWR
April 04, 1997; 46(RR-08); 1-24.
Last updated
today
 
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
or 
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:
Legionella
urinary antigen
S. pneumoniae
urinary antigen
(at CUMC only)
HIV testEKG
Immunocompromised (including HIV):
Consider other causes of pneumonia (
e.g.
fungal, viral,TB, PCP) and other diagnostics
Influenza season:
Nasopharyngeal swab for influenza and RSV
Special circumstances:
 
e.g.
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
LAST UPDATED
TODAY
Characteristic
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
2
< 60 mmHg or O
2
saturation < 90%Pleural effusion
TOTAL SCOREPoints
+10+30+20+10+10+10+20+20+20+15+10+30+20+20+10+10+10+10
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
2
/FiO
2
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

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