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:
- Initial treatment was not active against identified pathogen
- Isolation of resistant pathogen
- Extra-pulmonary infection or bacteremia present
- 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 susceptibilities | Piperacillin/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 MRSA | Add 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
- Requires renal dosage adjustment