Pneumonia

Community Acqired Pneumonia (CAP)

For CAP, you have to get a CURB-65 score to see if you will treat them as an inpatient or outpatient.

• 1 point each: Confusion, Urea >19, Respiratory Rate >=30, Blood pressure <90 SBP or <=60 DBP, age >=65
• Score = 0 or 1: can treat as outpatient
• Score = 1: consider admission, but can closely watch as outpatient
• Score = 2: Inpatient admission, consider ICU

In-Patient Treatment

Previously healthy and no antibiotics in the last 90 days	Macrolides for 3 days or Doxycycline for 5 days
Comorbidities (CHF, lung, liver, renal disease, diabetes, alcoholism, malignancies, asplenia, immunosuppression, antimicrobial in past 3 months)	Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or 750 mg of levofloxacin) or B-Lactam (high dose amoxicillin 1 g TID, amoxil/clavulanic acid 2 g BID, ceftriaxone, cefpodoxime, cefuroxime AND a macrolide or doxycycline

Out-Patient Treatment

Non-ICU	Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or 750 mg of levofloxacin) or B-Lactam (cefuroxime, ceftriaxone or ampicillin or ertapenem in select patients) AND a macrolide or doxycycline Prednisone 20-80/day for 7 days can decrease the need for mechanical ventilation but increases hospital stay
ICU	ALWAYS 2 B-Lactam (cefoxtaxime, ceftriaxone or ampicillin) AND Azithromycin or respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or 750 mg of levofloxacin) PCN Allergy: aztreonam AND respiratory fluoroquinolone Consider treating for MRSA or Pseudomonas
Pseudomonas	Pip/Tazo or ticarcillin AND Cipro or levofloxacin
Community Acquired MRSA	Add vancomycin or linezolid to above

Treat for 5 days with at least 48/72 hours afebrile

Hospital Associated Pneumonia (HAP):

See CAP.

Hospital Acquired or Ventilator Associated Pneumonia (HAP/VAP):

Usually staph aureus, Pseudomonas or gram -.   Patients need one agent for staph and at least one forn Pseudomonas.

Multidrug-resistant Factors:

• HAP: The multi-drug resistant factors for HAP is ONLY IV antibiotics within the last 90 days.
• VAP: Antibiotics within the last 90 days plus: septic shock, hospital stay > 5 days, ARDs, real therapy
• If the patient has MDRs, they need 2 antipseudomonal agents.  They also need 2 if the monotherapy agent is resistant greater then 10%.
• If patient has MDRs, or >10% of facility’s staph is MRSA, they need an MRSA agent
• That means patients with MDRs need at least 3 agents.

Agents:

• Staph:
  • MRSA needed: vancomycin or linezolid
  • MRSA not needed: pip/tazo, cefepime, levofloxacin, imipenem or meropenem
  • If confirmed MSSA, use oxacillin, nafcillin or cefazolin.
• Antipseudomonals:
  • First antipseudomonal needs to be a B-Lactam: ceftazidime, cefepime, imipenem, meropenem, pip/tazo or aztreonam
  • If second need, second should be: aminoglycosides, FQs (ciprofloxacin or levofloxacin) or colistin.  Aztreonam can be used with another beta-lactam if you have no other option
• Treat for 7 days
• Everyone needs at least 2 agents.  Most patients (patients with MDRs) will need at least 3.