ADULT COMMUNITY ACQUIRED PNEUMONIA (CAP - LOW RISK)

History (1point) Physical Examina on Diagnos cs Diagnosis Treatment/Management Referral Nonpharmacologic Discharge
(2 Points) (1 Point) (1 Point) (Any is 1 Point) (1 Point, Treatment/ Advise
Op onal) Preven ve
Management

1. Acute onset of illness
2. Pleuri c chest pain
3. Cough
4. Sputum
5. Fever, though not
necessarily present
6. No comorbidi es
*Indicate either posi ve or
nega ve
Mycoplasma and
Viral Pneumonias
Cough: Dry and hacking
Sputum: O en mucoid
Associated Symptoms and Se ng:
An acute febrile illness, o en with
malaise, headache, and possibly
dyspnea
Bacterial Pneumonias
Cough and Sputum: With
pneumococcal infec on, mucoid or
purulent; may be blood streaked,
diffusely pinkish, or rusty. With
Klebsiella, similar to pneumococcal,
or s cky red and jellylike.
Associated Symptoms and Se ng:
An acute illness with chills, high
fever, dyspnea, and chest pain; o en
preceded by acute upper respiratory
infec on. Klebsiella o en in older
alcoholic men.
STABLE VITAL SIGNS: CBC COMMUNITY A. The following an bio cs should be started for Pneumococcal
RR: <30/mi n Chest X-Ray ACQUIRED empiric treatment of pa ents with low risk CAP polysaccharide vaccine
PR: <125/mi n PNEUMONIA without co-morbidi es: (PPSV) or pneumococcal
SBP: ≥ 90 mmHg (CAP - LOW RISK) conjugate vaccine (PCV)
DBP: >60 mmHg 1. Amoxi ci l l i n 1 gra m, TID a re recommended for
Temp: >36 °C or <40 °C OR the preven on of
(-) Al tered menta l s ta te of 2. Cl a ri thromyci n 500mg, BID i nva s i ve pneumococca l
a cute ons et OR di s ea s e i n adults 50 years
(-) wi th s us pected a s pi ra on 3. Azi thromyci n 500mg OD old and older.
(-) Severe s eps i s a nd Sep c
s hock
Pneumococcal
B. The following an bio cs should be started for
(-) need for mecha ni ca l
empiric treatment of pa ents with low risk CAP with polysaccharide vaccine i s
ven l a tor
stable co-morbidi es: recommended for a dul ts
to prevent
(Focused Chest PE)
Beta -l a cta m (a ) pneumococca l
1. Co-a moxi cl a v (a moxi ci l l i n/cl a vul a na te) 500 pneumoni a ,
Inspec on:
mg/125 mg TID (b) morta l i ty from IPD or
Increa s ed res pi ra tory ra te
OR pneumoni a a nd
Us e of a cces s ory mus cl es of
2. Amoxi ci l l i n/ cl a vul a na te 875 mg/125 mg BID (c) pneumoni a a mong
res pi ra on
OR hi gh-ri s k groups a nd
3. Cefuroxi me 500mg, BID adults 50 years and above.
Palpa on:
Increa s ed or decrea s ed
PLUS OR MINUS (+/-)
ta c l e fremi tus
Ma crol i de
Percussion:
1. Cl a ri thromyci n 500mg, BID
Dul l to fla t
OR
2. Azi thromyci n 500mg OD
Ausculta on:
OR
Increa s ed hea rt ra te
3. Doxycycl i ne 100mg, BID
Cra ckl es , bronchi a l brea th
s ounds
Pos s i bl y a pl eura l fri c on rub

*As s oon a s di a gnos i s i s es ta bl i s hed, trea tment of communi ty a cqui red pneumoni a , rega rdl es s of ri s k, s houl d be ini ated within 4 hours.
*Among pa ents wi th low to modera te risk CAP, a treatment dura on of 5 days i s recommended a s l ong a s the pa ent i s cl i ni ca l l y s ta bl e (a febri l e wi thi n 48 hours , a bl e to ea t, norma l bl ood pres s ure, norma l hea rt ra te,
norma l res pi ra tory ra te, norma l oxygen s a tura on, a nd return to ba s el i ne s ens ori um).
 ADULT COMMUNITY ACQUIRED PNEUMONIA (CAP - MODERATE RISK)

History (1point) Physical Examina on Diagnos cs Diagnosis Treatment/Management Referral Nonpharmacologic Discharge
(2 Points) (1 Point) (1 Point) (Any is 1 Point) (1 Point, Op onal) Treatment/ Advise
Preven ve
Management

1. Acute onset of illness UNSTABLE VITAL SIGNS: CBC COMMUNITY The following an bio cs should be started Refer to IM-Pulmo Pneumococcal *The pa ent may be
2. Pleuri c chest pain RR: >30/mi n Chest X-Ray ACQUIRED for empiric treatment of pa ents with Service for polysaccharide vaccine discharged once
3. Cough PR: >125/mi n GS/CS PNEUMONIA moderate risk CAP without MDRO co-management (PPSV) or pneumococcal clinically stable and oral
SBP: <90 mmHg BLOOD CULTURE (CAP - MODERATE infec on conjugate vaccine (PCV) therapy is ini ated.
4. Sputum DBP: ≤60 mmHg
RISK) a re recommended for the
5. Fever, though not Temp: ≤36 °C or ≥40 °C preven on of i nva s i ve
Non-pseudomonal Beta-lactam an bio c Duri ng the 24 hours
necessarily present (+) Al tered menta l s ta te of pneumococca l di s ea s e before di s cha rge, the
a cute ons et i n adults 50 years old and
Ampi ci l l i n-s ul ba cta m 1.5–3 g every 6 h pa ent s houl d ha ve the
(+) wi th s us pected a s pi ra on
6. Presence of Unstable or OR older. fol l owi ng cha ra cteri s cs
(-) Severe s eps i s a nd Sep c
Cefota xi me 1–2 g every 8 h (unl es s thi s repres ents
decompensated s hock
OR the ba s el i ne
(-) need for mecha ni ca l Pneumococcal
Uncontrol l ed di a betes Ce ri a xone 1–2 g da i l y polysaccharide vaccine is s ta tus ):
ven l a tor
mel l i tus PLUS recommended for a dul ts 1. Tempera ture of
to prevent 36-37.5°C
Ac ve ma l i gna nci es (Focused Chest PE) Macrolide (a ) pneumococca l 2. Pul s e < 100/mi n
Neurol ogi c di s ea s e i n Azi thromyci n 500 mg da i l y 3. Res pi ra tory ra te
pneumoni a ,
evol u on Inspec on: OR between 16-24/mi nute
(b) morta l i ty from IPD or
Conges ve hea rt fa i l ure
Increased respiratory rate Cl a ri thromyci n 500 mg twi ce da i l y pneumoni a a nd 4. Sys tol i c
Use of accessory muscles of (c) pneumoni a a mong BP >90 mmHg
Cl a s s II-IV 5. Bl ood oxygen
respira on *Among pa ents with low to moderate risk hi gh-ri s k groups a nd
Uns ta bl e corona ry CAP, a treatment dura on of 5 days is s a tura on >90%
adults 50 years and above.
a rtery di s ea s e 6. Func oni ng
Palpa on: recommended as long as the pa ent is
ga s troi ntes na l tra ct
Rena l fa i l ure on Increased or decreased tac le clinically stable (afebrile within 48 hours,
di a l ys i s fremitus able to eat, normal blood pressure, normal
Uncompens a ted COPD heart rate, normal respiratory rate, normal
Percussion: oxygen satura on, and return to baseline
Decompens a ted l i ver
Dull to flat sensorium).
di s ea s e

Ausculta on:
Increased heart rate
Crackles, bronchial breath
sounds
Possibly a pleural fric on rub
*As s oon a s di a gnos i s i s es ta bl i s hed, trea tment of communi ty a cqui red pneumoni a , rega rdl es s of ri s k, s houl d be ini ated within 4 hours.
*A repeat chest X-ray i s recommended duri ng a fol l ow-up vi s i t, a pproxi ma tel y 4 to 6 weeks a er hospital discharge to es ta bl i s h a new ra di ogra phi c ba s el i ne a nd to excl ude the pos s i bi l i ty of ma l i gna ncy a s s oci a ted wi th CAP,
pa r cul a rl y i n ol der s mokers .
 ADULT COMMUNITY ACQUIRED PNEUMONIA (CAP - HIGH RISK)

History (1point) Physical Examina on Diagnos cs Diagnosis Treatment/Management Referral Nonpharmacologic Discharge
(2 Points) (1 Point) (1 Point) (Any is 1 Point) (1 Point, Op onal) Treatment/ Advise
Preven ve
Management

1. Acute onset of illness UNSTABLE VITAL SIGNS: CBC COMMUNITY The following an bio cs should be started Refer to IM-Pulmo Pneumococcal *The pa ent may be
2. Influenza-like illness RR: >30/mi n Chest X-Ray ACQUIRED for empiric treatment of pa ents with Service for polysaccharide vaccine discharged once
PR: >125/mi n GS/CS PNEUMONIA high risk CAP without MDRO infec on: co-management (PPSV) or pneumococcal clinically stable and oral
symptoms:
SBP: <90 mmHg BLOOD CULTURE (CAP - HIGH RISK) conjugate vaccine (PCV) therapy is ini ated.
s ore throa t DBP: ≤60 mmHg
INFLUENZA TEST FIRST LINE THERAPY Refer to a re recommended for the
rhi norrhea Temp: ≤36 °C or ≥40 °C preven on of i nva s i ve
LEGIONELLA TEST IM-Infec ous DIsease Duri ng the 24 hours
(+) Al tered menta l s ta te of pneumococca l di s ea s e
body ma l a i s e Non-pseudomonal Beta-lactam an bio c Service for before di s cha rge, the
a cute ons et i n adults 50 years old and
Ampi ci l l i n-s ul ba cta m 1.5–3 g IV every 6 h co-management pa ent s houl d ha ve the
joi nt pa i ns (+) wi th s us pected a s pi ra on older.
OR fol l owi ng cha ra cteri s cs
3. Any of the following risk (+/-) Severe s eps i s a nd Sep c
Cefota xi me 1–2 g IV every 8 h (unl es s thi s repres ents
s hock a
factors: OR Pneumococcal the ba s el i ne
(-/+) need for mecha ni ca l
Ce ri a xone 1–2 g IV da i l y polysaccharide vaccine is s ta tus ):
Aged 60 yea rs a nd a bove ven l a tora
PLUS recommended for a dul ts 1. Tempera ture of
Pregna nt to prevent 36-37.5°C
(Focused Chest PE) Macrolide 2. Pul s e < 100/mi n
As thma c (a ) pneumococca l
Azi thromyci n 500 mg PO/IV da i l y pneumoni a , 3. Res pi ra tory ra te
Other co-morbidi es: Inspec on: OR between 16-24/mi nute
(b) morta l i ty from IPD or
uncontrol l ed di a betes Increa s ed res pi ra tory ra te Erythromyci n 500 mg PO every 6 hours pneumoni a a nd 4. Sys tol i c
mel l i tus , a c ve Us e of a cces s ory mus cl es of OR (c) pneumoni a a mong BP >90 mmHg
ma l i gna nci es , neurol ogi c res pi ra on Cl a ri thromyci n 500 mg PO twi ce da i l y hi gh-ri s k groups a nd 5. Bl ood oxygen
di s ea s e i n evol u on, adults 50 years and above. s a tura on >90%
Palpa on: ALTERNATIVE THERAPY 6. Func oni ng
conges ve hea rt fa i l ure
Increa s ed or decrea s ed ga s troi ntes na l tra ct
cl a s s II-IV, uns ta bl e ta c l e fremi tus Non-pseudomonal Beta-lactam an bio c
corona ry a rtery di s ea s e,
PLUS
rena l fa i l ure on di a l ys i s , Percussion: Respiratory fluoroquinolone*
uncompens a ted COPD, Dul l to fla t Levofloxa ci n 750 mg PO/IV da i l y
decompens a ted l i ver OR
Ausculta on: Moxi floxa ci n 400 mg PO/IV da i l y
di s ea s e
Increa s ed hea rt ra te * gi ven a s 1 hour IV i nfus i on
*Indicate either posi ve or Cra ckl es , bronchi a l brea th
nega ve s ounds

a
Hi gh ri s k CAP: Any of the clinical feature of moderate risk CAP plus any of the following: Severe s eps i s a nd Sep c s hock OR need for mecha ni ca l ven l a tor
*As s oon a s di a gnos i s i s es ta bl i s hed, trea tment of communi ty a cqui red pneumoni a , rega rdl es s of ri s k, s houl d be ini ated within 4 hours.
*A repeat chest X-ray i s recommended duri ng a fol l ow-up vi s i t, a pproxi ma tel y 4 to 6 weeks a er hospital discharge to es ta bl i s h a new ra di ogra phi c ba s el i ne a nd to excl ude the pos s i bi l i ty of ma l i gna ncy a s s oci a ted wi th CAP,
pa r cul a rl y i n ol der s mokers .
Appendix A. Determining Sepsis and Shock