SANTISSIMA TRINIDAD HOSPITAL

PINAGBAKAHAN CITY OF MALOLOS, BULACAN

TEL (044) 791 -7331

CLINICAL
PRACTICE GUIDELINES
ON
COMMUNITY
ACQUIRED
PNEUMONIA IN
ADULTS
 SANTISSIMA TRINIDAD HOSPITAL
PINAGBAKAHAN CITY OF MALOLOS, BULACAN
TEL (044) 791 -7331

COMMUNITY ACQUIRED PNEUMONIA IN ADULTS

Clinical Diagnosis

Cough, fever, difficulty of breathing, and/or chills within the past 24 hours to less than 2
weeks (A-II) associated with tachypnea (RR> 20 breaths/min), tachycardia (CR> 100/min),
and fever (T>37.8’c) with at least one abnormal chest finding of diminished breath
sounds, rhonchi, crackles or wheeze [Grade B]6 suggest community acquired pneumonia.

Diagnostic Tests

Chest xray is recommended for all patients clinically diagnosed of pneumonia [A-
II/Grade A]3,6. Gram stain and culture of appropriate pulmonary secretions [Grade A] 6 and
pretreatment blood cultures (A-II)3 may be requested when drug resistance is suspected and
for etiologic diagnosis.

Hospital Admission

Classify patients by risk categories to help determine the need for hospitalization.
Only moderate and high-risk CAP should be admitted. [GRADE A]6 (See Table 15)

Treatment

Initial empiric therapy based on initial risk stratification is recommended. [Grade B] 6.

Among patients with identified etiologic agent, appropriate antimicrobials should be
instituted.
(See Table 16)

Monitoring Response to Initial Therapy

Look for symptom resolution. Follow-up chest x-ray is not needed. [Grade A]6
TABLE 15. CLINICAL FEATURES OF PATIENTS WITH CAP ACCORDING TO RISK
Low Risk CAP Moderate Risk CAP High Risk CAP
Stable vital signs Unstable vital signs: Any of the clinical feature of
*RR< 30 breaths/nmin *RR≥30 breaths/min moderate risk CAP plus any
*PR<125 beats/min *PR≥125 beats/min of the following:
*SBP ≥ 90 mmHg *Temp≥40’C or <35’C
*DPB ≥ 60 mmHg
No cr stable comorbid Unstable comorbid condition Shock or signs of
conditions (i.e. uncontrolled diabetes hypoperfusion
No evidence of mellitus, active malignancies, *altered mental state
extrapulmonary sepsis progressing neurologic *urine output ,30 ml/hr
No evidence of aspiration disease, congestive heart hypoxia (PaO2 > 60 mmHg)
Chest X-ray: failure (CHF) Class II-IV, or acute hypercapnea
*Localized infiltrates unstable coronary artery (PaCO2> 50 mmHg)
*No evidence of pleural disease, renal failure on Chest Xray:
effusion nor abcess dialysis, uncompensated *as in moderate risk CAP
*Not progressive within 24 COPD, decompensated liver
hours disease)

Evidence of extrapulmonary
 SANTISSIMA TRINIDAD HOSPITAL
PINAGBAKAHAN CITY OF MALOLOS, BULACAN
TEL (044) 791 -7331

sepsis (hepatic, hematologic,

gastrointestinal, endocrine)
Suspected aspiration
Chest Xray:
*Multilobar infiltrates
*Pleural effusion or abscess
*Progression of findings to >
50% in 24 hours

These patients are suitable These patients need to be These patients warrant
for outpatient care [Grade hospitalized for parenteral admission in the intensive
A]6 therapy [Grade A]6 care unit [Grade A]6

TABLE 16. USUAL RECOMMENDED DOSAGES OF FORMULARLY ANTIBIOTICS IN 50-

60 KBW ADULTS WITH NORMAL LIVER AND RENAL FUNCTIONS
ANTIBIOTIC DOSAGE ANTIBIOTIC DOSAGE
LOW RISK CAP
(all taken orally) B-lactams with B-
B-lactams: lactamase inhibitor:
Amoxicillin 500 mg TID Co-amoxiclav 625 mg TID or
1 g BID
Trim/sulfonamide Sultamicillin 750 mg BID
Contrimoxazole 160/800 mg BID
2nd gen.
Macrolides Cephalosporins
Azithromycin 500 mg OD Cefuroxime axetil 500 mg BID
Clarithromycin 500 mg BID
MODERATE RISK
CAP
Macrolides 2nd gen. Cephalosporins
Cefuroxime IV
Erythromycin IV 0.5-1 g q 6h Cefoxitin IV (w/ anaerobic 1.5 g q 8h
Azithromycin PO or 500 mg q 24h activity) 1-2 g q 8h
IV
Clarithromycin PO 500 mg q 12h
or IV 3rd gen. Cephalosporins
Gatifloxacin PO or 400 mg Q 24h Ceftriaxone IV
IV Cefotaxime IV
B-lactams with B- 1-2 g q 24h
lactamase inhibitor: 1-2 g q 8h
Sulbactam- 1.5 g q 8h
Ampicillin IV
HIGH RISK CAP
(all routes are IV) 3rd gen. Cephalosporins
Macrolides Ceftriaxone 1-2 g q 24h
Erythromycin 0.5-1 g q 6h Cefotaxime 1-2 g q 8h
Azithromycin 500 mg q 24h Ceftizoxime 1-2 g q 8h
Clarithromycin 500 mg q 12h Anti-psuedomonal B-
Gentamicin 3 mg/kg q 24h lactam 2 g q 8h
Netilmicin 7 mg/kg q 24h Ceftdazidime 2 g q 8-12h
Tobramycin 3 mg/kg q 24h Cefepime 3.2 g q 6-8h
 SANTISSIMA TRINIDAD HOSPITAL
PINAGBAKAHAN CITY OF MALOLOS, BULACAN
TEL (044) 791 -7331

Ticarcillin-clavulanate 2.25-4.5 g q 6-
B-lactams w/ B- Piperacillin-tazobactam 8h
lactamase inhibitor: 1.5 g q 12h
Sulbactam-Ampicillin 1.5 g q 6-8h Sulbactam-cefoperazone 500 mg q 6h
Imipenem 1-2 g q 8h
Meropenem
Others: 1-2 g q 4-6h
Oxacillin 600 mg q 8h
Clindamycin 500 mg 6-8h
Metronidazole

Supportive Care

Oxygen, hydration and antipyretics may be given if needed.

Streamlining empiric antibiotic therapy

In selected patients, switch to oral therapy when signs of infection are resolving within 72
hours. (Grade A) (See Table 16)

Hospital Discharge

Patients with stable vital signs for 24 hours and able to maintain oral intake may be
discharged. (Grade B)

TABLE 17. ANTIBIOTIC DOSAGE OF ORAL AGENTS FOR STREAMLINING OR

SWITCH THERAPY
ANTIBIOTIC DOSAGE
Cefuroxime 500 mg BID
Cefixime 100-200 mg BID
Co-amoxiclav 1 g BID
Sultamicillin 750 mg BID
Azithromycin 500 mg OD
Clarithromycin 500 mg BID
Gatifloxacin 400 mg OD
Moxifloxacin 400 mg OD

TABLE 18. GRADES OF RECOMMENDATION

GRADE DEFINITION
A Good evidence to support a recommendation
for use
B Moderate evidence to support a
recommendation for use
C Poor evidence to support a recommendation
for or against use
D Moderate evidence to support a
recommendation against use
E Good evidence to support a recommendation
against use
 SANTISSIMA TRINIDAD HOSPITAL
PINAGBAKAHAN CITY OF MALOLOS, BULACAN
TEL (044) 791 -7331

TABLE 19. IDSA GRADING SYSTEM FOR RATING RECOMMENDATION

CATEGORY DEFINITION
GRADE
STRENGTH OF RECOMMENDATION
A Good evidence to support a recommendation
for use
B Moderate evidence to support a
recommendation for use
C Poor evidence to support a recommendation
D Moderate evidence to support a
recommendation against use
E Good evidence to support a recommendation
against use
QUALITY OF EVIDENCE
I Evidence from ≥1 properly randomized,
controlled trial
II Evidence from ≥1 well-designed clinical trial,
without randomization; from cohort or case
controlled analyctic studies (preferably from>
one center); from multiple time-series; or
from dramatic results of uncontrolled
experiments
III Evidence from opinions of respected
authorities, based on clinical experience,
descriptive studies, or reports of expert
committees