Community Acquired Pneumonia (CAP) - Diagnosis and Management Pneumonia Signs/Symptoms: • Confusion/disorientation (LR + 1.9) • Cough • Dyspnea • Pleuritic chest pain (LR + NS) • Cachexia (LR + 4.0) Physical Examination: • Temperature > 38.0°C or < 35.1°C (LR + 2.2) • Tachypnea with respirations of 30/min or greater (LR + 2.7) • Hypoxia with pulse oximetry < 95% (LR + 3.1) • Auscultatory findings of pneumonia • Heart rate > 100/min (LR + 1.8) • Rales/Crackles (LR + 2.3) • Rhonchi/Wheezing (LR + 0.8) • Dullness of percussion (May appear after day 4 of hospitalization) (LR+ 3.0) • Bronchial breath sounds (LR + 3.3) • Egophony (May appear 1-3 days after hospitalization) (LR + 4.1) • Newly required mechanical ventilation by either intubation or noninvasive ventilation. • PaO2/FiO2 ratio ≤250 • Hypotension requiring aggressive fluid resuscitation Labs: • Total white blood cell count > 10/μL or < 4.5/μL • Bands > 15% • Uremia (blood urea nitrogen level ≥ 20 mg/dl) • Leukopenia (white blood cell count < 4,000 cells/μl) • Thrombocytopenia (platelet count < 100,000/μl) Imaging: • New or increasing infiltrate by chest radiograph or CT Scan Bacterial Pathogens: • Streptococcus pneumoniae • Haemophilus influenzae • Mycoplasmapneumoniae • Staphylococcus aureus • Legionella species • Chlamydia pneumoniae • Moraxella catarrhalis Consider Multidrug-Resistant Organisms (MDRO): • Methicillin-resistant S. aureus (MRSA) • Pseudomonas aeruginosa Clinical Prediction Rules: Pneumonia Severity Index (PSI) (strong recommendation, moderate quality of evidence) over the CURB-65 (low quality of evidence) • PSI • CURB-65 Predictors of Mortality: • Hypotension (LR+ 7.6) • Hypothermia (LR + 3.5) • HR >100/min (LR + 2.1) • RR> 30/min (LR + 2.1) • Oxygen < 90% (LR + 2.8) Testing: • Pretreatment Gram stain and culture: Obtain in severe CAP or treated for MDRO or previous PNA with MDRO (MRSA/Pseudomonas) • Severe CAP: - Blood cultures - Urine for pneumococcal antigen, Legionella antigen • Yield of blood CX is low ranging from 2% (outpatients) to 9% (inpatients) • MRSA Nares screening: High negative predictive value: RESPIRATORY 96.1% • Empiric antibiotic therapy should be initiated in adults with clinically suspected and radiographically confirmed CAP regardless of initial serum procalcitonin level Treatment: • Non-severe Inpatient Pneumonia: β-Lactam + macrolide or respiratory fluoroquinolone • Severe Inpatient Pneumonia: β-Lactam + macrolide or β-lactam + fluoroquinolone • Prior Respiratory Isolation of MRSA: Add MRSA coverage and obtain cultures/nasal PCR to allow de-escalation or confirmation of need for continued therapy • Prior Respiratory Isolation of Pseudomonas Aeruginosa: Add coverage for P. aeruginosa and obtain cultures to allow de-escalation or confirmation of need for continued therapy Ref: https://doi.org/10.1164/rccm.201908 #Pneumonia #CAP #Diagnosis #Management #treatment #Pulmonary #Community #Acquired
