The following guidelines were prepared by the Alaska Antimicrobial Stewardship Collaborative (A2SC), and are reproduced here as a service to practitioners in the state.
These guidelines have not been reviewed or approved by the Sanford Guide Editorial Board.
Common Etiologies
- Bacterial
- S. pneumoniae
- H. influenzae
- Chlamydia pneumoniae
- Mycoplasma pneumoniae
- M. catarrhalis
- Respiratory viruses
- Influenza A & B
- Adenovirus
- Respiratory syncytial virus
- Parainfluenza
- COVID-19
Diagnostic Criteria Tools
Pneumonia Severity Index (PSI) Scoring Tool
- Demographics
- Age (1 point per year)
- Male (Age)
- Female (Age -10)
- Nursing home residency +10
- Age (1 point per year)
- Comorbidities
- Neoplasia +30
- Liver disease +20
- Heart Failure +10
- Cerebrovascular disease +10
- Renal disease +10
- Physical Exam/Vitals
- Confusion +20
- Resp rate >30 +20
- SBP <90 +20
- Temperature <35C or >40C +15
- HR >125 bpm +15
- Labs/Imaging
- Arterial pH <7.35 +30
- BUN >30mg/dL +20
- Sodium <130 +20
- Glucose >250 +10
- Hematocrit <30% +10
- Pleural Effusion +10
- PaO2 <60 +10
Risk Class (Points) |
Mortality (%) |
Recommended Site of Care |
I (<50) | 0.1 | Outpatient |
II (51-70) | 0.6 | Outpatient |
III (71-90) | 2.8 | Outpatient or brief inpatient |
IV (91-130) | 8.2 | Inpatient |
V (>130) | 29.2 | Inpatient |
Symptoms
- Productive cough
- Chest pain
- Dyspnea/Shortness of breath
- Diminished breath sounds
- Crackles not cleared with coughing
- Abdominal pain
- +/- Fever
Testing/Imaging
- Chest x-ray
- Pulse Oximetry
- PCR respiratory pathogen panel testing is discouraged in the ambulatory setting.
- If concern for viral respiratory illnesses, influenza or COVID PCR can be ordered
Duration of Therapy
- Typically healthy, no structural lung disease: 5 days
- Moderately immunocompromised, suspected or proven MRSA or P. aeruginosa, or moderate structural lung disease (ie. diabetes, asplenia): 7 days
Antibiotic Selection
**NOTE: Azithromycin monotherapy is no longer recommended in any circumstance for treatment of community-acquired pneumonia due to local resistance rates >25%.
No comorbidities or risk factors for MRSA or Pseudomonas aeruginosa
- Preferred Treatment
- Amoxicillin 1gm PO TID x 5-7 days
- Alternative
- Doxycycline 100mg PO BID x 5-7 days
Comorbidities present
- Comorbidities including:
- chronic heart, lung, liver, or renal disease
- diabetes mellitus
- alcoholism
- malignancy
- asplenia
**NOTE: Consider additional Amoxicillin 1g BID in addition to Augmentin for CAP complicated by empyema, asplenia or Strep pneumoniae PenG MIC 2-4
- Preferred Treatment
- Amoxicillin/Clavulanate 875mg/125mg PO BID x 5-7 days PLUS
- Azithromycin 500mg PO daily x 3 days
- Alternatives
- Non-anaphylactic PCN allergy
- Cefuroxime 500mg PO BID x 5-7 days PLUS
- Azithromycin 500mg PO daily x 3 days
- Anaphylactic PCN allergy
- Levofloxacin 750mg PO daily x 5 days
- Non-anaphylactic PCN allergy
Risk factors for MRSA or Pseudomonas aeruginosa
- Prior respiratory isolation of MRSA or P. aeruginosa; OR
- Recent hospitalization AND receipt of parenteral antibiotics in previous 90 days
- Preferred Treatment
- Treatment should be based on previous culture & susceptibility, IV antimicrobials may be required
Influenza
- For patient diagnosed with influenza, it is recommended to also treat with anti-influenza agents; most benefit is seen if started within 48 hours of symptom onset
References
- Metlay et al. IDSA/ATS Consensus Guideline CAP in Adults. Am J Respir Crit Care. 2019;200(7):e45-e67.
Metadata
Approved A2SC Advisory April 2021