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
|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|
|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):
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.
- 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.
- MRSA needed: vancomycin or linezolid
- MRSA not needed: pip/tazo, cefepime, levofloxacin, imipenem or meropenem
- If confirmed MSSA, use oxacillin, nafcillin or cefazolin.
- 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.