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Introduction This is a summary of the clinical recommendations of the UCSF Community-Acquired Pneumonia Task Force, a multidisciplinary group charged with improving the overall quality of care and cost-effectiveness of care for patients hospitalized at Moffitt-Long Hospital with pneumonia. These recommendations are intended to be informative. They are not intended to replace an individual physicianís clinical judgment or responsibility in decision-making. These guidelines focus on the diagnosis and management of immunocompetent adults hospitalized with pulmonary infiltrates and the clinical diagnosis of community-acquired pneumonia. They are not intended to address issues of immunosuppressed patients with pneumonia (defined as HIV disease, AIDS, ANC <1000, current or recent myelosuppressive or immunosuppressive drugs, or on Prednisone >5 mg daily). Other excluded conditions are: aspiration pneumonia, hospital or nursing home-acquired pneumonia, a strong suspicion of non-bacterial infections such as PCP, TB, or fungus, or non-infectious causes of pulmonary infiltrates such as CHF, cancer and collagen vascular disease. Patients with a current diagnosis of cancer or primary lung diseases like cystic fibrosis or bronchiectasis are also excluded. Although most critically ill CAP patients will meet one of the above listed exclusion criteria, we have included recommendations for the initial antibiotic regimen to be used for CAP patients admitted to the ICU. While the decision to admit a patient to the ICU can not be entirely guided by objective criteria, an AHCPR-developed prediction model for risk stratifying CAP patients has been included as an appendix to this guideline. The task force has graded the evidence upon which key guideline recommendations are based. Notations indicating the "best grade of evidence" and appropriate reference citations have been included in the guideline text (for more about evidence grades, see Evidence Grading Criteria.) Etiology of Community-Acquired Pneumonia In most cases of CAP, the etiology is not known (neither in research studies nor in common clinical practice). Information from the history, physical exam, labs, and CXR is not very sensitive or specific for predicting etiology, or even for differentiating typical from atypical organisms or bacterial causes from viral ones. There are no good data on the local incidence of different CAP organisms. Research studies indicate that S. pneumoniae is the most common cause. However, the incidence of Hemophilus influenzae, Legionella, Mycoplasma, Moraxella, and viruses varies greatly among studies. Best Grade of Evidence: II-2 (11, 25, 28, 34) For patients with CAP, concern about clinically important Penicillin-resistant S. pneumoniae is not great at this point in time (8/97). Penicillin-resistance is a more serious issue in patients with pneumococcal meningitis or sinusitis. Best Grade of Evidence: II-1 (23, 31, 32) Microbiology Testing Blood cultures should be obtained on patients with CAP because they have high positive predictive value. However, they are only positive in 6-10% of patients with CAP (most commonly with S. pneumoniae). Sputum gram stain (G/S) and cultures have poor positive and negative predictive values, and generally add little clinically useful information or significantly change antibiotic selection in most cases of CAP (e.g., the positive predictive value of S. pneumoniae on G/S is 40-50%). For the above reasons, we discourage the routine use of sputum G/S or cultures for uncomplicated CAP. The yield of sputum G/S and culture once a patient is on antibiotics is small and should be strongly discouraged (except in the case of presumed antibiotic failure). Best Grade of Evidence: II-3 (6,10,19,30,42) Antibiotic Treatment and Discharge Issues Because of the uncertainty about etiology, antibiotic therapy in almost all cases of CAP is empirical. Care in the Emergency Department Early initiation of IV antibiotics in the first 2-4 hours after presentation is strongly encouraged. Whenever possible, all patients (including those who will eventually require ICU admission) should receive a dose of Ceftriaxone (1.0 gm Q24H) in the ED. No sputum G/S or cultures should be sent from the ED.    Patients should be transferred from the ED to an admission bed as soon as possible. Best Grade of Evidence: III Uncomplicated, Non-Life Threatening CAP In uncomplicated, non-life threatening CAP we recommend Ceftriaxone 1.0 gm Q24H (for typical organism coverage) with the possible addition of Erythromycin 500-1000 mg Q6H or Doxycycline 100mg Q12H (for atypical organism coverage) as the initial, empiric IV antibiotic regimen (see Recommended Antibiotic Regimen). Best Grade of Evidence: III (1,7,8,30,33) Severe Pneumonia Sputum G/S and culture (preferrably by tracheal aspirate) should be collected after the patient arrives in the ICU. For patients over 40 years old who present with severe, life threatening CAP requiring ICU admission we recommend Vancomycin and Ciprofloxacin as the initial empiric antibiotic regimen. This regimen provides the necessary additional coverage for serious Staphylococcus (including MRSA), gram negative, and Legionella pneumonia. Patients under 40 years of age with severe, life threatening CAP are at greater risk for Mycoplasma pneumoniae and should receive an initial antibiotic regimen which includes Vancomycin, Ceftazidime and Erythromycin. If sputum G/S and cultures do not identify a likely etiologic agent patients in both age groups may be switched to IV Ceftriaxone and IV Erythromycin or Doxycycline. PO Erythromycin or Doxycycline can be used if the patient is tolerating PO agents. (PO Azithromycin can be used for patients intolerant of PO Erythromycin or Doxycycline.) Patients at risk for pseudomonal pneumonia (recent hospitalization or antibiotic therapy) or aspiration pneumonia should receive a regimen which includes Vancomycin, Piperacillin-Tazobactam (Zosyn®) and Ciprofloxacin. Critically ill, unstable patients may benefit from early pulmonary or infectious disease consultation. Best Grade of Evidence: III (1,7,8,30,33) Additional Considerations Patients who present after failed oral antibiotics should be considered at higher risk for resistant organisms. Vancomycin is the drug of choice in the event of high level PCN-resistant S. pneumoniae Antibiotic coverage should be narrowed if blood or pleural fluid cultures are positive. Sputum cultures are often inaccurate and can not be routinely relied upon to streamline antibiotic choice in non-intubated patients. Aim for early switch of antibiotics from IV to PO once a patient is stable and at low risk for complications (usually after 2-4 days). Patients still on IV antibiotics on Day 3 should be evaluated to see if they meet the criteria for being at low risk for complications and are ready to be switched to PO ABX (See Criteria For Switch to Oral Antibiotics). Most uncomplicated cases of CAP have an anticipated length of stay of 3-5 days. When necessary, communication with the social worker regarding discharge planning should begin early in the hospitalization. Best Grade of Evidence: II-1 (17,38,39) For oral antibiotic treatment of CAP adequate coverage of Pneumococcus should be emphasized. TMP/SMX, Doxycycline, Amoxicillin and Erythromycin are the preferred drugs because of their broad coverage and low cost. (See Oral ABX Information Table Guideline Summary for costs and spectrum of coverage). While there is no evidence in the medical literature proving that oral ABX treatment after completion of inpatient IV therapy is necessary for patients to completely recover from CAP, standard of care dictates that ABX treatment be continued. Critically ill patients who improved after receiving an inpatient regimen that covers both typical and atypical organisms should receive an outpatient ABX regimen that provides equally broad coverage. If Hemophilus influenzae is strongly suspected, optimal agents include doxycycline, TMP/SMX, azithromycin and Augmentin. Azithromycin may offer better patient compliance because it is taken once a day for five days total. Duration of the total course of antibiotic therapy for CAP is 7 to 14 days. Treatment for Legionella should be longer (usually 14-21 days). Best Grade of Evidence: III (1,7,8,30,33) Approach to Patients Who Fail to Improve or Get Worse During Therapy Is the diagnosis definitively known or not known? Fevers can last for 2-4 days in many uncomplicated cases of CAP. Repeat CXR (PA and lateral) to detect worsening infiltrates or evidence of pleural effusion. Consider decubitus films or ultrasonography if size is unclear or loculation is a concern. Attempt diagnostic thoracocentesis if pleural effusion present. Consider the use of ultrasound guidance if effusion appears small or loculated. Reconsider the etiologic diagnosis. Is a different or resistant organism involved? Could this be TB, PCP, fungus, or post-obstructive or nosocomial pneumonia? Reconsider non-infectious causes of pulmonary infiltrates (CHF, PE, malignancy, pulmonary hemorrhage, collagen vascular disease). Consider a pulmonary or infectious diseases consultation. Best Grade of Evidence: III (5,30) Criteria for Switch to Oral Antibiotics (Adapted from Weingarten) The following criteria can be used to identify CAP patients on Hospital Day 3 who are at low risk for complications and can be safely switched to PO ABX (and discharged shortly thereafter). No obvious reason for continued hospitalization defined by: SBP < 100 mm Hg Dehydration as documented by Na>155 mmol/L, BUN:Creat>20:1, or orthostatic SBP changes >20 mm Hg Acute changes in mentation Hypoxia - RA sat <90% or PO2 <55 mm Hg Acute respiratory acidosis - pH <7.30 Inability to take medications or fluids orally Metastatic sites of infection such as meningitis or endocarditis Other unstable comorbid diseases (COPD, CHF, DM, RF) No high risk pneumonia pathogen: Staph Aureus, mycobacteria, fungus, aspiration pneumonia, or post-obstructive pneumonia No life-threatening complication during hospitalization: Cardiac complications: acute MI, new onset or worsening CHF, VF, VT, asystole, complete heart block, new or unstable AFIB or SVT Pulmonary complications: pneumothorax or empyema Recommended Antibiotic Regimen: Non - ICU Patients No Sputum G/S cultures Ceftriaxone 1 gm Q24H and consider adding Doxycycline 100 mg PO/IV Q12H or Erythromycin** 500-1000 mg IV Q6H Doxycycline and Erythromycin both have excellent activity against Legionella, Mycoplasma, and Chlamydia pneumonia (which the cephalosporins miss). Use the lower dose of Erythro (500 mg) for Pts >70 yrs. or renal or hepatic dysfunction to decrease risk of ototoxicity * Adjust for renal insufficiency ** Adjust for hepatic insufficiency ICU Patients Ceftriaxone 1 Gm Q24H while in ED Sputum G/S & culture (preferably tracheal aspirate) in ICU <40 years: Vancomycin* , Ceftazidime* , and Erythromycin** 40 years or over: Vancomycin* & Ciprofloxacin* Patients at risk for Pseudomonas or life threatening aspiration pneumonia: Vancomycin*, Zosyn®** & Ciprofloxacin*. If sputum G/S & culture negative switch to Ceftriaxone & Erythromycin** or, if taking POs, IV Ceftriaxone & PO Erythromycin** or PO Doxycycline (PO Azithromycin if intolerant of Erythro or Doxy) If sputum G/S & culture positive: Tailor regimen to results * Adjust for renal insufficiency ** Adjust for hepatic insufficiency Oral ABX Information Table Oral Agent % S.pneumoniae Sensitive To Agent^ Avg. Wholesale Price For 7 Day Course^^ Coverage Holes Comments TMP/SMX * DS BID 68% $6 Legionella, Mycoplasma Chlamydia Most commonly prescribed oral agent for CAP at M/L, excellent outcomes Doxycycline 100 mg BID 84% $10 GNR Inexpensive, good coverage for H.influenzae and atypical organisms Amoxicillin* 500 mg TID 96% $8 H.influenzae, M.catarrhalis, Mycoplasma, Legionella, Chlamydia Best pneumococcal agent. Not for patients with COPD or smokers; 30% of H. influenzae may be resistant Erythromycin** 500 mg QID 84% $13 GNR, ± H.influenzae Inexpensive but may cause GI side effects Azithromycin 500 mg x 1, then 250 mg QD x 4 84% $37 GNR, ± H.influenzae Expensive; may be used if patient is intolerant to other agents; 5 day course makes attractive for patients with compliance issues Augmentin* 875mg BID 96% $37 Legionella, Mycoplasma, Chlamydia Expensive, May cause GI side effects; no more effective against oral anaerobes than Amoxicillin NOTE: Azithromycin & Augmentin not covered by Medi-Cal * Adjust for renal insufficiency ** Adjust for hepatic insufficiency ^ Source: UCSF Microbiology Laboratory Data ^^ Source: 1st DataBank Price Alert 6/97