Approach to the Initial Management of a Patient with Pneumonia

(Adapted from ATS-IDSA Guidelines)

Sputum culture Patient with

Core measures clinical evidence Sepsis?
(Table 2) of pneumonia

Yes
Contact &
CAP* HCAP** droplet Sepsis bundles
ISOLATION!

Antibiotics per ATS-IDSA Antibiotics per ATS-IDSA

Guideline for CAP Guideline for HCAP

1 major
criterion or 3
PSI*** class IV & V minor criteria Yes ICU
for severe CAP
(Table 1)

No PCU or Med-surg

PSI class III Observe

PSI class I & II Discharge

TABLE 1 TABLE 2
Minor criteria Quality Core Measures
Respiratory rate ≥ 30 breaths/min
PaO2/FiO2 ratio ≤ 250 Oxygen assessment
Multilobar infiltrates Blood culture before 1st antibiotic
Confusion/disorientation Pneumococcal and influenza vaccination status
Uremia (BUN level, ≥ 20 mg/dL)
Adult smoking cessation advice/counseling
Leukopenia (WBC count, < 4000 cells/mm3)
Thrombocytopenia (platelet count, < 100,000 cells/mm3) Initial antibiotics received within 4 hours of
hospital arrival (3 hours for sepsis)
Hypothermia (core temperature, < 36ºC)
Appropriate initial antibiotic selection
Hypotension requiring aggressive fluid resuscitation
A need for noninvasive ventilation can substitute for a Non-ICU
respiratory rate ≥ 30 breaths/min or a PaO2/FiO2 ratio ≤ 250 ICU
Major criteria
Invasive mechanical ventilation
Septic shock with the need for vasopressors

*CAP: Community-Acquired Pneumonia

**HCAP: Health-Care Associated Pneumonia includes any patient who was hospitalized in an acute care hospital for two
or more days within 90 days of the infection; resided in a nursing home or long-term care facility; received recent
intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection; or attended
a hospital or hemodialysis clinic (ATS-IDSA Guideline 2005)
***PSI: Pneumonia Severity Index
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Pneumonia Severity Index

Patient Characteristics Points

Demographics
Male Age (years)
Female Age (years) – 10
Nursing home resident + 10
Comorbid illness
Neoplastic disease + 30
Liver disease + 20
Congestive heart failure + 10
Cerebrovascular disease + 10
Renal disease + 10
Physical examination findings
Altered mental status + 20
Respiratory rate ≥ 30 breaths per minute + 20
Systolic blood pressure < 90 mm Hg + 20
Temperature < 35°C (95°F) or > 40°C (104°F) + 15
Pulse rate ≥ 125 beats per minute + 10
Laboratory and radiographic findings
Arterial pH < 7.35 + 30
Blood urea nitrogen ≥ 30 mg per dL (11 mmol per L) + 20
Sodium < 130 mEq per L (130 mmol per L) + 20
Glucose ≥ 250 mg per dL (14 mmol per L) + 10
Hematocrit < 30% + 10
Partial pressure of arterial oxygen < 60 mm Hg or oxygen percent saturation < 90% + 10
Pleural effusion + 10

Total points: _______

Point total Risk Risk class Mortality % (No. of patients) Recommended site of care
No predictors Low I 0.1 (3,034) Outpatient
≤ 70 Low II 0.6 (5,778) Outpatient
71 to 90 Low III 2.8 (6,790) Observation
91 to 130 Moderate IV 8.2 (13,104) Inpatient
>130 High V 29.2 (9,333) Inpatient
 

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 ATS-IDSA Recommended Empirical Antibiotics
For Community Acquired Pneumonia (2007)
(UPPER CASE indicates Salmon Creek Hospital Formulary)
Outpatient treatment
1. Previously healthy and no use of antimicrobials within the previous 3 months
A macrolide (strong recommendation; level I evidence)
Doxycyline (weak recommendation; level III evidence)
2. Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes
mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of
immunosuppressing drugs; or use of antimicrobials within the previous 3 months (in which case
an alternative from a different class should be selected)
A respiratory fluoroquinolone (MOXIFLOXACIN, gemifloxacin, or levofloxacin [750
mg]) (strong recommendation; level I evidence)
A b-lactam PLUS a macrolide (strong recommendation; level I evidence)
3. In regions with a high rate (> 25%) of infection with high-level (MIC ≥ 16 mg/mL) macrolide-
resistant Streptococcus pneumoniae, consider use of alternative agents listed above in (2) for
patients without comorbidities (moderate recommendation; level III evidence)
Inpatients, non-ICU treatment
A respiratory fluoroquinolone (strong recommendation; level I evidence)
A b-lactam PLUS a macrolide (strong recommendation; level I evidence)
Inpatients, ICU treatment
A b-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS either
azithromycin (level II evidence) OR a respiratory fluoroquinolone (level I evidence)
(strong recommendation)
For penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are
recommended
Special concerns
1. If Pseudomonas is a consideration,
An antipneumococcal, antipseudomonal b-lactam (PIPERACILLIN-TAZOBACTAM,
CEFEPIME, imipenem, or MEROPENEM) PLUS either CIPROFLOXACIN or levofloxacin
(750 mg)
OR
The above b-lactam PLUS an aminoglycoside (PER PHARMACY PROTOCOL) and
azithromycin
OR
The above b-lactam PLUS an aminoglycoside and an antipneumococcal
fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for above b-
lactam) (moderate recommendation; level III evidence)
2. If CA-MRSA is a consideration,
Add VANCOMYCIN (PER PHARMACY PROTOCOL) or linezolid (moderate
recommendation; level III evidence)
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 ATS-IDSA Recommended Empirical Antibiotics
For Health-Care Associated Pneumonia (2005)
(UPPER CASE indicates Salmon Creek Hospital Formulary)
PLEASE CHOOSE ONE FROM EACH GROUP

GROUP 1
Antipseudomonal cephalosporin (CEFEPIME, Ceftazidime)
OR
Antipseudomonal carbepenem (imipenem or MEROPENEM)
OR
β-Lactam/β-lactamase inhibitor (PIPERACILLIN-TAZOBACTAM)

PLUS
GROUP 2
Linezolid or VANCOMYCIN (Per pharmacy Protocol)‡

PLUS
GROUP 3
Antipseudomonal fluoroquinolone† (CIPROFLOXACIN or levofloxacin)
OR
Aminoglycoside (amikacin, tobramycin, or GENTAMICIN per pharmacy
protocol) ONLY AS SECOND LINE.

BASED ON LOCAL RESISTANCE PATTERN,

THE INITIAL ANTIBIOTIC REGIMEN OF CHOICE AT
LEGACY SALMON CREEK HOSPITAL IS:
Piperacillin–tazobactam OR cefepime OR meropenem PLUS
Vancomycin per pharmacy protocol.
Add Ciprofloxacin only for ICU patients or patients coming from
outside sources with extensive resistance (PAC Specialties, OHSU,
Emanuel)

* Initial antibiotic therapy should be adjusted or streamlined (DE-ESCALATED) on the

basis of microbiologic data and clinical response to therapy.

† If an ESBL+ strain, such as K. pneumoniae, or an Acinetobacter species is suspected, a

carbepenem is a reliable choice. If L. pneumophila is suspected, the combination antibiotic
regimen should include a macrolide (e.g., azithromycin) or a fluoroquinolone (e.g., ciprofloxacin or
levofloxacin) should be used rather than an aminoglycoside.

‡ If MRSA risk factors are present or there is a high incidence locally.

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ATS-IDSA Recommended Initial Intravenous, Adult Doses
Of Antibiotics For Empiric Therapy
Of Health-Care Associated Pneumonia
(UPPER CASE indicates Salmon Creek Hospital Formulary)

Antipseudomonal cephalosporin
Ceftazidime 2 g every 8 h
CEFEPIME 2 g every 8–12 h

Carbepenems
MEROPENEM 1 g every 8 h
Imipenem 500 mg every 6 h or 1 g every 8 h

β-Lactam/β-lactamase inhibitor

PIPERACILLIN–TAZOBACTAM 4.5 g every 6 h

Aminoglycosides per pharmacy protocols

GENTAMICIN
Tobramycin
Amikacin

Antipseudomonal quinolones
CIPROFLOXACIN 400 mg every 8 h
Levofloxacin 750 mg every d

Anti-MRSA agents
VANCOMYCIN per pharmacy protocols
Linezolid 600 mg every 12 h

* Dosages are based on normal renal and hepatic function.

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 Antibiotic De-escalation for Health-Care Associated Pneumonia (HCAP)
(Adapted from ATS-IDSA Guidelines)

Patient Admitted
for HCAP

Day 2 & 3, check cultures and assess clinical response

(temperature, WBC, chest X-ray, oxygenation, purulent
sputum, hemodynamic changes and organ function)

Clinical
Improvement on
Day 2 or 3?

NO YES

Culture negative Culture positive Culture negative Culture positive

Search for other Adjust antibiotic De-escalate antibiotics, if

pathogens, therapy, search for possible. Treat selected
complications, other pathogens, Consider stopping patients for 8 days (14
other diagnoses complications, other antibiotics days for pseudomonas
or other sites of diagnoses or other aeruginosa) and reassess
infection sites of infection

6
Criteria for Switching from Intravenous to Oral Therapy and Discharge

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