Community – Acquired Pneumonia (CAP)

Pathogens Associated with CAP

  • S pneumoniae, H influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae , methicillin-sensitive Staphylococcus aureus, Klebsiella pneumoniae, other Gram-negative rods, Legionella sp., seasonal viruses (influenza, RSV, etc.)

Consider

  • Nasopharyngeal swab (NPS) – place patients in droplet precautions until further results
  • Sputum gram stain + culture and sensitivity
  • Blood culture x 2
  • Urine antigen for legionella

Antibiotic Therapy

  • Consider empiric oseltamivir during influenza season
  • Evaluate risk of resistant organisms
  • Narrow regimen based on culture and susceptibility results if applicable
  • Consider transition to po therapy if hemodynamically stable and functioning GI tract
  • Duration: minimum of 5 days if clinical improvement and afebrile after 48-72 hours
  • Longer treatment may be required if:
    1. Initial treatment was not active against identified pathogen
    2. Isolation of resistant pathogen
    3. Extra-pulmonary infection or bacteremia present
    4. Complicated pneumonia (e.g. empyema)
Requiring admission but NOT ICU
Co-morbidities (no risk factor for resistant organisms or neutropenia)Ceftriaxone 1g IV q24h. Consider adding azithromycin 500mg PO on day 1 and 250mg daily x 4 days if concern of atypical pathogens
OR
Levofloxacin (1) 750mg once daily x 5 days (HHS only)
OR
Moxifloxacin 400mg once daily x 5 day (SJHH only)
Admission to ICU
Ceftriaxone 1g IV q24h hours and one of

Levofloxacin (1) 750mg IV / PO daily (HHS only)
OR
Moxifloxacin 400mg IV/PO daily (SJHH only)
OR
Azithromycin 500mg IV daily
Suspected Pseudomonas or resistant organisms or at high risk of Pseudomonas (e.g. neutropenic, CF patients, bronchiectasis) **if documented Pseudomonas, tailor therapy based on susceptibilitiesPiperacillin/tazobactam (1) 4.5g IV q6h and Levofloxacin (1) 750mg IV/PO daily (HHS only)
OR
Ciprofloxacin (1) 400mg IV q12h/ 750mg po bid (SJHH only) OR Ceftazidime (1) 2g IV q8h and Levofloxacin (1) 750mg IV / PO daily (HHS only) OR Moxifloxacin 400mg IV/po daily (SJHH only)
For known or suspected MRSAAdd vancomycin (1) 15mg/kg IV q12h
  • Influenza and pneumococcal vaccines if appropriate
  • Smoking cessation education if applicable

Hospital-Acquired Pneumonia (HAP) / Ventilated Acquired Pneumonia (VAP)

  • Hospital-acquired pneumonia (HAP) – pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission
  • Ventilated-associated pneumonia (VAP) – pneumonia that occurs more than 48 – 72 hours after endotracheal intubation
  • Early onset HAP/VAP occurs within first 4 days of hospitalization
  • Late onset HAP/VAP occurs five days or more of hospitalization

Early Onset

Pathogens associated with early onset HAP/VAP or no known risk factors for resistant pathogens:
Streptococcus pneumoniae, H influenzae, MSSA, antibiotic-sensitive enteric gram negative rods

Treatment Options

  • Ceftriaxone 2g IV once daily
    OR
  • Levofloxacin (1) 750mg IV once daily (in patients with serious beta lactam allergy) (HHS only)
    OR
  • Moxifloxacin 400mg IV/PO once daily (in patients with serious beta lactam allergy) (SJHH only)

* If known colonizer of MRSA, suggest add vancomycin (1) 15mg/kg IV q12h

* If known colonizer of ESBL, use ertapenem (1) 1g IV q24h or meropenem (1) 500mg IV q6h

Late Onset

Pathogens associated with late onset HAP/VAP or known risk factors for resistant pathogens (see below):
Streptococcus pneumoniae, H influenzae, MSSA, MRSA, antibiotic-resistant enteric gram negative rods (e.g. ESBL E.coli), Pseudomonas aeruginosa, Acinetobacter, Legionella

Potential Risk Factors for Resistant Pathogens Causing HAP

  • Prior antibiotics within 90 days
  • Hospitalization for > 2 days within past 90 days
  • Nursing home or extended care facility residence
  • Chronic dialysis
  • Home wound care
  • Family member with resistant pathogen
  • Immunosuppressive disease +/- therapy

Treatment Options

  • Piperacillin-tazobactam (1) 4.5g IV q6h
    OR
  • Meropenem (1) 500mg IV q6h (serious beta lactam allergy, or known colonizer of resistant gram negatives)

* If known colonizer of MRSA, suggest add vancomycin (1) 15mg/kg IV q12h to the above regimen

Points to Consider

  • Treatment duration: patients with a good initial clinical response (and without Pseudomonas) can be treated for as short as 7 days
  • 7 days may not be sufficient for immunocompromised patients, or those infected with S.aureus, Pseudomonas or with delayed response
  1. Requires renal dosage adjustment