CURB-65, PSI, CPIS & Antibiotic

CURB-65
Confusion
Urea >7mmol (19mg/dl)
RR≥30
BP<90/60
≥65 y.o.
Score 0-1 treat as outpx
Score 2 admit at ward
Score ≥3 admit at ICU

PNEUMONIA SEVERITY INDEX SCORING

Demographic Points
Men (age)
Women (age-10)
Nursing home 10
Comorbidities
Neoplasm 30
Liver disease 20
Heart failure 10
Stroke 10
Renal failure 10
Physical exam
Altered sensorium 20
RR ≥30 20
Systolic BP <90 20
Temp <35 or >40 15
HR ≥125 10
Diagnostic
pH <7.35 30
BUN >30 20
Na <130 20
Glucose ≥250 10
HCT <30% 10
PO2 <60 10
Pleural effusion 10

TOTAL POINTS:
<51 class 1: OPD
51-70 class 2: OPD
71-90 class 3: OPD
91-130 class 4: ADMIT
>130 class 5: ADMIT

CPIS points 0 1 2
Secretion rare many purulent
CXR N diffuse localized
Temp ≤38.4 ≤38.9 ≥39/≤36
WBC ≤11 <4/>11same+band≥500
P/F ratio >240 ≤240 or ARDS
C/S rslt (-) (+)
SCORE >6 SUGGESTIVE OF PNEUMONIA
ANTIBIOTIC
OPD:
(1).Healthy, no risk, no AB last 3mo.:
- Macrolide, doxycycline

(2).With comorbidities (chronic heart, lung, liver or renal; DM; alcohol; malignancy; asplenia;
immunosuppressed; use of AB on last 3 mo.):
- Quinolone (Moxi, Gemi, or Levo [750 mg])
- B-lactam plus Macrolide (Amox 3x1g, Amoxi-Clav 2x2g, Ceftriaxone, Cefuroxime 2x500mg)

(3).Regions with high macrolide resistant:

- same as (2)

INPATIENT, NON-ICU:
- Resp Quinolone
- B-lactam plus Macrolide (Cefotaxime, Ceftriaxone, and Ampicillin); Ertapenem (with risk factors);
Doxycycline (as alternative to macrolide)

INPATIENT, ICU:
- B-lactam (Cefotaxime, Ceftriaxone, or Ampi-Sulbact) plus Azithro or Resp Quinolone
- For penicillin-allergic: Resp Quinolone and Aztreonam

Special concerns:
For Pseudomonas:
(1). Antipseudomonal B-lactam (Pip-Tazo, Cefepime, Imipenem, or Meropenem) plus Cipro or Levo
(750mg)
(2). B-lactam plus Aminoglycoside and Azithromycin
(3). B-lactam plus Aminoglycoside and antipneumococcal quinolone

For CA-MRSA, add Vancomycin or Linezolid

HAP, VAP, HCAP

>48hrs admission without symptoms on initial admission
>48hrs after intubation and ventilated
Early onset <4d. Late onse >4d
Risk factors:
 Antimicrobial therapy in preceding 90 d
 Current hospitalization of 5 d or more
 High frequency of antibiotic resistance in the community or in the specific hospital unit
 Presence of risk factors for HCAP:
o Hospitalization for 2 d or more in the preceding 90 d
o Residence in a nursing home or extended care facility
o Home infusion therapy (including antibiotics)
o Chronic dialysis within 30 d
o Home wound care
o Family member with multidrug-resistant pathogen
 Immunosuppressive disease and/or therapy

Regimens:
no risk factors, early onset:
Ceftriaxone or Levo/Moxi/Ciprofloxacin or Ampi-Sulbact or Ertapenem

With risk factors and/or late onset:

Ceftazidime/Cefepime or Imi/Meropenem or Pip-Tazo plus Cipro/Levofloxacin or Amik/Genta/Tobramycin

If MRSA:
Add Vancomycin/Linezolid

Antipseudomonal cephalosporin
 Cefepime 1–2 g/ 8–12 h
 Ceftazidime 2 g/ 8 h
Carbepenems
 Imipenem 500 mg/ 6 h or 1 g/ 8 h
 Meropenem 1 g/ 8 h
B-Lactam/B-lactamase inhibitor
 Piperacillin–tazobactam 4.5 g/ 6 h
Aminoglycosides
 Gentamicin 7 mg/kg/d
 Tobramycin 7 mg/kg/d
 Amikacin 20 mg/kg/d
Antipseudomonal quinolones
 Levofloxacin 750 mg/d
 Ciprofloxacin 400 mg/8 h
Vancomycin 15 mg/kg/ 12 h
Linezolid 600 mg/12 h

ATS criteria for severe CAP (3 minor or 1 major):

Minor criteria
 RR>30 breaths/min
o PaO2/FiO2 ratio<250
o Multilobar infiltrates
o Confusion/disorientation
o Uremia (BUN >20 mg/dL)
o Leukopeniac (WBC <4000 cells/mm3)
o Thrombocytopenia (platelet <100,000 cells/mm3)
o Hypothermia (core temperature <36oC)
o Hypotension requiring aggressive fluid resuscitation
Major criteria
o Invasive mechanical ventilation
o Septic shock with the need for vasopressors

ATS criteria for clinical stability:

Temperature ≤37.8oC
Heart rate ≤100 beats/min
Respiratory rate ≤24 breaths/min
Systolic blood pressure ≥90 mm Hg
Arterial oxygen saturation ≥90% or pO2 ≥60 mm Hg on room air
Ability to maintain oral intake
Normal mental status