QUEST Integration – Community-Acquired Pneumonia

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Guideline summary

• Community acquired pneumonia (CAP) patients present with fever or hypothermia, rigors, sweats, new cough with or without sputum production or change in the color of respiratory secretion in a patient with chronic cough, chest discomfort or onset of dyspnea.
• Chest X-ray should be obtained in patients with signs and symptoms of CAP and all patients when hospitalization is a consideration.
• Patients with high fever (>40°C), increased pulse rate (³125/min), increased respiratory rate (³30/min) decreased O2 sat (<92%), alteration in mental status, serious comorbid conditions or advanced age should be carefully evaluated for hospitalization. (Consider using PORT scoring to establish risk).
• The majority of CAP patients can be treated safely in the outpatient setting with macrolides, fluoroquinolones and doxycycline.
• Duration of antibiotic therapy is dictated by the presumed etiologic agent and the patient’s clinical course. The course should be from seven days to two weeks in most cases. IV antibiotics may be required as initial inpatient therapy but may be changed to oral in most patients when they have a clearing response.

Introduction

Community acquired pneumonia (CAP) is an acute infection of the lung parenchyma associated with significant morbidity and mortality. CAP is characterized by acute signs and symptoms of infection and may include the presence of an acute infiltrate on chest radiograph or auscultory findings (such as altered breath sounds and/or localized rales) consistent with pneumonia.

Goals/desired outcomes

The goals of this CAP guideline are to reduce morbidity and mortality from CAP. Outcomes may be measured by a reduction in hospitalization, length of hospital stay and adherence to the recommendations of these guidelines.

Diagnosis

Patients presenting with CAP may have fever or hypothermia, rigors, sweats, new cough (with or without mucous production) or change in color or texture of the sputum in patients with chronic cough, onset of dyspnea, or chest discomfort. Patients rarely have less than two of the preceding symptoms. Patients with signs and symptoms of pneumonia generally should have a chest radiograph performed. It is not necessary for patients without a localized finding in a physical exam and viral symptoms to get a chest X-ray. To avoid the unnecessary use of antibiotics, appropriate diagnosis is essential. Blood cultures and a sputum gram stain are recommended for hospitalized patients and selected non-hospitalized patients. Seriously ill patients also should have arterial blood gases or oximetry reading, BUN, serum sodium, glucose and hematocrit testing to assist in determining level of care and appropriateness of hospitalization.

Treatment

Treatment Algorithm [PDF]

The decision whether or not to hospitalize a patient should take into account age, comorbid conditions including immunocompromised conditions (such as AIDS, patients with organ transplants, splenectomy), and severity of illness at the time of presentation. Inappropriately admitting a patient can lead to nosiconial secondary infection.

The antibiotic classes macrolides, fluoroquinolones and doxycyclines are recommended for outpatient treatment. Macrolides are favored for the younger patient (younger than 40) to cover the atypical pneumonias more common in this age group. A beta-lactam agent with good antipneumococcal coverage (cefuroxime, amoxicillin or amoxicillin-clavulanate) is recommended when the clinical setting or laboratory tests indicate an acute bacterial infection.

Inpatient therapy is directed toward the specific etiologic agent when known. Empiric therapy includes coverage for atypical pneumonia plus a beta-lactam agent. Multiple antibiotics with broad coverage are recommended for the severely ill patient. The recommended duration of therapy is at least seven days, with 10 to 14 days for more severely ill patients.

Step 1: Lowest severity level

• Age < 50 years
• No significant comorbid conditions
• Normal or mildly damaged vital signs
• Normal mental status

Initial Risk Reduction Algorithm [PDF]

Step 2: Pneumonia severity index

Notes:

[1] A total point score for a given patient is obtained by adding the patient’s age in years (age 21 for females) and the points for each applicable patient characteristic. Points assigned to each predictor variable were based on co-efficients obtained from the logistic regression model used in step 2 of the prediction rule.

[2] Any cancer except basal or squamous cell cancer of the skin that was active at the time of presentation or diagnosed within one year of presentation.

[3] A clinical or histologic diagnosis of cirrhosis or other form of chronic liver disease such as chronic active hepatitis.

[4] Systolic or diastolic ventricular dysfunction documented by history and physical examination, as well as chest radiography, echocardiography, MUGA scanning, or left ventriculography.

[5] A clinical diagnosis of stroke, transient ischemic attack, or stroke documented by MRI or computed axial tomography.

[6] A history of chronic renal disease or abnormal blood urea nitrogen and creatinine values documented in the medical record.

[7] Disorientation (to person, place, or time, not known to be chronic), stupor or coma.

[8] In the Pneumonia Patient Outcome Research Team cohort study, an oxygen saturation value <90 percent on pulse oximetry or intubation before admission also was considered abnormal.

Risk-Level scoring

Use the table below with the Initial Risk Reduction Algorithm [PDF] and Treatment Algorithm [PDF]:

Source: Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336 (4):243-50.

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Reference Sources

1. Mandell LA, Bartlett JG, Dowell SF, File TM, Musher DM, Whitney C. (2003). Practice guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis, 31:347-82. (Based on Infectious Diseases Society of America / American Thoracic Society Consensus)

Revision History