CAP GUIDELINE SUMMARY

Criteria for exclusion from CAP Guideline:

• Age < 17 years
  
• Transfer from SNF or other facility where hospitalized > 24 hours or previously
  hospitalized less than 10 days ago
  
• Need for mechanical ventilation or sepsis
  
• Any of the following comorbid conditions:
  
  • Aspiration pneumonia
    
  • AIDS or HIV disease
    
  • Cystic Fibrosis/Bronchiectasis
    
  • Current diagnosis of cancer
    
  • Immunosuppression defined as: Myelosuppressive drugs within last
    3 months, ANC < 1000, current immunosuppressive drugs or
    chemotherapy, or Prednisone > 5 mg daily

Recommended Antibiotic Regimen:

Non - ICU Patients

ICU Patients

No sputum G/S or 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.

Ceftriaxone 1 Gm Q24H while in ED Sputum G/S & culture in ICU (preferably tracheal aspirate) <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

Criteria for Low Risk of Complications on Day 3 & Switch to PO ABX.
The following criteria can be used to identify CAP patients on Day 3 who are at low risk of complications & can be safely switched to oral antibiotics & discharged shortly thereafter.

No Obvious Reason for Continued Hospitalization - defined as:

• 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 conditions (COPD, asthma, diabetes, liver or renal failure, among others)
No High Risk Pneumonia Pathogen:
S. 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

Age > 65 yrs or chronic medical condition (including DM, CHF, COPD, renal failure, nephrotic syndrome, liver failure, sickle cell disease, malignancy, among others). Hospital-based immunization following an illness is felt to be safe and effective.