Adult Outpatient CAP - Alaska

last updated Jun 10, 2021 07:54 PM
Alaska Antimicrobial Stewardship Committee, bacterial, viral pneumonia, PSI

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
  • 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

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

  1. 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