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Community-onset pneumonia

December 9 2016 by Josh Farkas

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CONTENTS

denitions (denitions)

diagnosis1) does this patient have PNA (does_this_patient_have_pneumonia)

2) post-diagnosis testing (post-diagnosis_testing)

triage who needs ICU (triage_who_needs_ICU)

treatmentantibiotic selection (antibiotic_selection)

resuscitation (resuscitation)

respiratory support (respiratory_support)

adjuvant therapies (adjuvant_therapies)

effusion management (effusion_management)

treatment failure (treatment_failure)

duration of treatment (duration_of_treatment)

checklists amp algorithms (checklists_amp_algorithms)

podcast (podcast)

questions amp discussion (questions_amp_discussion)

pitfalls (pitfalls)

denitions(back to contents) (top)

Frankly this is in a state of disarray Historically patients admitted with pneumonia were divided into two groups

TOC ABOUT THE IBCC TWEET US IBCC PODCAST



Community Acquired Pneumonia (CAP) = patients without signicant healthcare contactHealthcare-Associated Pneumonia (HCAP) = patients with exposure to healthcare (eg chronic dialysis recent hospitalization)

The denition of HCAP was based on expert opinion rather than evidence Over time it became clear that HCAP isnt an accurate predictor ofwhether the patient has drug-resistant organisms Consequently HCAP was eliminated in the recent IDSA ventilator-associated pneumoniaguidelines The elimination of HCAP creates a denitional vacuum because its unclear how to classify these patients currently

Until we have better denitions this chapter is entitled ldquocommunity-onset pneumoniardquo which is quite simply dened as anyone presenting to thehospital with pneumonia This is a combination of the CAP plus HCAP As explored below we will use a personalized strategy to determinewhich patients need broad-spectrum antibiotic coverage (rather than the CAP-vs-HCAP algorithm)

does this patient have pneumonia(back to contents) (top)

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diagnosing pneumonia can be tricky

Diagnosis is generally based on three lines of evidenceImaging evidence of a chest inltrate (eg CXR CT ultrasound)Inammation (eg feverhypothermia rigors night sweats leukocytosis left-shift procalcitonin)Pulmonary symptoms (eg dyspnea cough sputum production pleuritic chest pain) and signs (tachypnea hypoxemia)

Elderly patients may present with non-pulmonary complaints (eg falling delirium sepsis)When in doubt it is reasonable to get cultures and start antibiotics for pneumonia Within the next 24-48 hours the diagnosis may be re-considered and antibiotics discontinued as appropriate More common pneumonia mimics are listed below These can be devilishly hard to nd because youre searching for a needle in ahaystack

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(httpsi0wpcomemcritorgwp-contentuploads201612pnamimicsjpg) avoid pneumonia over-diagnosis

Patients often present to the hospital with septic shock plus pulmonary inltrates on chest X-ray Two possibilities are1) Pneumonia2) Chest inltrates due to atelectasisaspiration plus occult focus of sepsis elsewhere (eg abdominal sepsis)

A common error is to assume that the septic shock must be due to pneumonia when in fact the chest inltrates are a red herring When indoubt err on the side of investigating further to exclude an alternative source of sepsis

CT scan to assist the diagnosis of pneumonia

Some patients with pneumonia will have a negative chest X-ray with a positive CT scan (due to subtle inltrates) However among patientswho are critically ill due to pneumonia there really ought to be some abnormality seen on chest X-rayThe main use for CT scan is differentiation from pneumonia mimics As shown in the table above a CT scan is probably the single mostversatile test to differentiate pneumonia from a mimicCT scan can be helpful to detect pneumonia in patients with chronic lung disease and chronically abnormal chest X-ray

bronchoscopy

Occasionally useful to exclude a pneumonia mimic (eg diffuse alveolar hemorrhage eosinophilic pneumonia)

post-diagnosis testing(back to contents) (top)

tests to obtain after diagnosing pneumonia

Blood culturesRecommended for severe pneumonia although yield is low (~10)If patient already had blood cultures at another hospital dont repeat them (follow up on results from the outside hospital lab)

Sputum for gram stain amp cultureIntubated patient tracheal aspirate is very usefulNon-intubated patient expectorated sputum (low yield but very helpful when high-quality sputum reveals single type of organism)

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Urine legionella antigenSensitivity 80 and specicity of ~95Negative result doesnt exclude legionella but positive result may allow focusing antibiotic therapy on legionella

Urine pneumococcal antigenSensitivity 70 and specicity 95 (may have false-positive due to pneumonia within past several weeks)

Nares PCR for MRSAWinter PCR for inuenza amp respiratory viruses

If nasopharyngeal inuenza PCR is negative and high suspicion remains a lower respiratory tract PCR may be positiveBe careful patients may be co-infected with viral and bacterial pathogens Just because the viral PCR is positive doesnt mean thatyou should stop antibacterial therapy

Procalcitonin Procalcitonin lt05 ngmL argues against typical bacterial pneumonia (but this may still be seen with atypical infections)Procalcitonin is unreliable in immunocompromised patients (eg neutropenia)Daily procalcitonin may help determine timing of antibiotic discontinuation (more on this below (pctdc) )

Epidemiological history (table below)Review of radiograph for diagnostic clues (table below)

epidemiological history

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radiographic patterns

Cannot be entirely relied upon However they can provide useful clues so they shouldnt be ignored eitherIn general radiographic patterns should be used primarily to broaden the differential diagnosis (not to narrow it)

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(httpsi0wpcomemcritorgwp-contentuploads201612wwjpg)

Dense consolidation air bronchograms is suggestive of a lobar pneumonia often due to streptococcus pneumoniae

ultrasonography for eusion

If there is any doubt regarding possible effusion (eg basilar opacities) bedside ultrasonography should be performed to clarify thisUltrasonography should be repeated daily to watch for the development of an effusion or empyema over time

CT scan amp bronchoscopy

Main indications for more advanced evaluationImmunocompromise

UAlbertaCritCareUSUAlberta_CCUS

Air bronchograms on ultrasound explained ABaCCUSRounds UAlberta_ICU UAlbertaAnesth FOAMus POCUS Want more info Recommend blog5minsonocomab UltrasoundMD for further in-depth explanation

54 1214 AM - Nov 15 2017

46 people are talking about this



Unusual chest imaging (eg chest X-ray suggestive of nodularcavitating pneumonia)CT scan may increase the index of suspicion for unusual pathogens for example

Diffuse inltrates with a ground-glass pattern may suggest pneumocystis jiroveci pneumoniaMulti-focal dense nodular inltrates may suggest a fungal pneumonia

Bronchoscopy may be needed to exclude unusual organisms

triage who needs ICU(back to contents) (top)

classic errors in pneumonia triage

(1) Triage solely based on the amount of oxygen the patient requiresA common myth is that if the patient can saturate adequately on nasal cannula then its OK for them to go to the ward This iscompletely and utterly wrong

(2) Triage based on CURB65 and PORT scoresThese are validated as mortality prediction tools they arent designed to determine dispositionNot great at sorting out who needs the ward vs ICU

better approaches to triage

Patients with signicant work of breathing or tachypnea (eg respiratory rate gt30) should be considered for ICU admission and high-ownasal cannula The IDSAATS criteria have been validated for use in ICU triage Patients with three or more criteria may benet from ICU admission

Respiratory rate gt29 breathsminHypotension requiring volume resuscitationPaO2FiO2 lt 250 (patients requiring gt3 liters oxygen) Temperature lt 36CConfusionMultilobar inltratesBUN gt20 mgdLWBC lt4000mm3Platelets lt100000mm3

These criteria are guidelines which wont apply perfectly to every patient When in doubt observe the patient carefully over a few hours anduse your judgement

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11 12

J Christian Foxjchristianfox

Multilobar pneumonia is an independent risk factor for increased mortality in CAP PoCUS

45 1114 AM - Dec 3 2017




antibiotic selection(back to contents) (top)

(httpsi0wpcomemcritorgwp-contentuploads201612abxcapjpg) dont forget atypical coverage

Should always be included in the empiric antibiotic regimen for severe pneumoniaRemember Legionella causes ~10-15 of severe pneumonia This wont be covered by the broadest beta-lactams in the world (egcefepime piperacillin-tazobactam meropenem)Azithromycin is an excellent choice here

Solid track record in pneumoniaRetrospective studies suggest mortality benet even in pneumococcal pneumonia sensitive to beta-lactams (possibly due to anti-inammatory activity or coinfection with atypical pathogens)If the patient is diagnosed with pneumococcus azithromycin should still be continued for 3-5 days Well-tolerated very safe Dont worry about the QT interval the concept that azithromycin causes torsade de pointes is mythological(httpsemcritorgpulmcritmyth-busting-azithromycin-does-not-cause-torsade-de-pointes-or-increase-mortality)

Doxycycline is also an excellent choice for atypical coverage with the following advantagesCovers weird organisms acquired from animal contact (coxiella tularemia psittacosis leptospirosis)Usually active against MRSA in vitro but its unclear whether this is effective for clinical MRSA pneumonia

Fluoroquinolones are a poor choice for atypical coverage in the ICU for several reasons (httpsemcritorgpulmcrituoroquinolone-critical-illness)

beta-lactam backbone

The beta-lactam backbone will cover gram-positives (especially pneumococcus) and gram negativesCeftriaxone is an excellent choice for most patients

Its controversial (httpswwwpharmacyjoecomdose-ceftriaxone-critically-ill-patients-1g-2g) whether to use 1 or 2 grams IV daily Increasing drugresistance over time may be an argument to use 2 grams This should also be considered in obese patients

Pseudomonal beta-lactam (piperacillin-tazobactam or cefepime) may be used in patients with risk factors for pseudomonas for exampleSeptic shock due to pneumoniaStructural lung disease (eg bronchiectasis or advanced COPD with frequent exacerbations)Broad-spectrum antibiotics for gt7 days within past monthHospitalization for gt1 day within past three monthsImmunocompromise (eg chemotherapy chronic use of gt10 mg prednisone daily)Nursing home resident with poor functional status

Patients with penicillin allergyNon-anaphylactic reaction to penicillin may use ceftriaxone or cefepimeAnaphylaxis or angioedema from penicillin may use meropenem (httpsemcritorgpulmcritpulmcrit-mythbusting-anaphylaxis-penicillins-isnt-

contraindication-meropenem)

MRSA coverage is occasionally needed as 3rd drug

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An evidence-based algorithm to guide the use of MRSA coverage is shown above (more detail here (httpsemcritorgpulmcritpneumonia-mrsa) )The key is ongoing thoughtful evaluation of data

Staph generates lots of purulence and is generally not dicult to isolateMRSA coverage should be stopped within 48-72 hours unless there is some objective data that the patient has MRSA

Choice of agentLinezolid is arguably rst-line therapy for MRSA pneumonia (compared to vancomycin linezolid has superior lung penetration causesno nephrotoxicity and suppresses bacterial toxin synthesis) Vancomycin is the traditional option if linezolid is contraindicated Unfortunately resistance to vancomycin is increasing over time Ifsusceptibility testing shows borderline sensitivity to vancomycin (MIC 15-2 mcgmL) this may increase the risk of treatment failure andan alternative agent might be better If the MIC is gt2 mcgmL then a different antibiotic should denitely be usedCeftaroline is a fth-generation cephalosporin active against MRSA It might be superior to vancomycin (particularly for strains withMICgt1 mcgmL) but there is no high-quality evidence available Daptomycin isnt an option here because it is degraded by surfactant and thus cannot treat pneumonia

double-coverage for pseudomonas is not needed

Unless youre living in a post-apocalyptic hellscape where pseudomonas are insanely resistant to beta-lactams this shouldnt be necessary Double-coverage doesnt even appear to benet patients with ventilator-associated pneumonia (which involves a much greater risk ofresistant pseudomonas) More on this here (httpsemcritorgpulmcritdouble-coverage-vap)

anaerobic coverage is not needed for pneumonia

Sometimes there is concern that the patient may have aspirated so they should be covered for anaerobesThe lung is the best oxygenated organ in the body so it is not very susceptible to anaerobic infection The only way anaerobic infection canoccur is if there is an anatomic disruption that creates a poorly oxygenated compartment (abscess or uid collection)

Anaerobic coverage is indicated only for empyema or lung abscess

resuscitation

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(back to contents) (top)

avoid large-volume uid resuscitation

Large volume uid resuscitation may worsen hypoxemic respiratory failure and thereby precipitate the need for intubationMost patients with PNA can be stabilized adequately with small-moderate volumes of uid combined with vasopressors if needed

Consider early institution of vasopressors In many cases a low-dose vasopressor (eg norepinephrine 5-10 mcgmin) maysubstantially reduce the amount of uid which is needed to stabilize the patient

Fluid should be used only if the following conditions are metOrgan hypoperfusion (eg poor urine output) or refractory hypotension PLUSHistory and evaluation indicates true volume depletion (as opposed to hypotension which is merely due to vasodilation) Please notethat a reduced central venous pressure or collapsed inferior vena cava doesnt necessarily indicate (httpsemcritorgpulmcritmythbusting-

empty-ivc-hyperkinetic-heart-E289A0-volume-depletion) volume depletion these ndings can also be caused by systemic vasodilationLactate elevation is not a sign of organ malperfusion (httpsemcritorgpulmcritunderstanding-lactate-in-sepsis-using-it-to-our-advantage) nor is it anindication for uid

respiratory support(back to contents) (top)

high-ow nasal cannula (HFNC)

The FLORALI trial (httppulmcrit hfnc orali) suggested improved mortality among patients with severe hypoxemia treated with HFNCHFNC should be considered in patients with signicant work of breathing andor tachypnea The goal of HFNC is to reduce the work ofbreathing and thereby prevent patients from tiring out In order for this to work HFNC must be started before the patient is exhausted andin extremisAdvantages of HFNC

Oxygenation supportVentilation support due to dead-space washoutHumidication may promote secretion clearanceDoesnt interfere with sputum clearance coughing or eatingPatients may remain on HFNC for several days if needed (often the case for severe lobar pneumonia)

generally avoid BiPAP

BiPAP doesnt allow patients to clear their secretions Patients treated on BiPAP often do well initially but eventually may fail due to retainedsecretions and mucus pluggingBiPAP may be used for limited periods of time to stabilize patients (eg for transportation)Occasional patients with COPD plus pneumonia may benet from a rotating schedule of BiPAP and HFNC Pulmonary toilet and secretionclearance may be performed while the patient is on HFNC

endotracheal intubation

Generally used as a second-line therapy after trying HFNCIndications for intubation in pneumonia are usually

Refractory hypoxemiaProgressively worsening work of breathing respiratory exhaustion

adjuvant therapies(back to contents) (top)

steroid

Several RCTs (httpsemcritorgpulmcritevidence-based-treatment-for-severe-community-acquired-pneumonia) show that steroid may reduce the length ofstay and risk of intubation among pneumonia patients The SCCMESICM guidelines currently recommend steroid for patients with severecommunity-acquired pneumonia21



Steroid should be given to patients with severe PNA in the absence of contraindicationsPatients in whom steroid may be contraindicated

Paralytic infusion (risk of myopathy)Suspicion of pneumonia due to fungus tuberculosis or possibly inuenzaImmunocompromise (HIV chemotherapy neutropenia)

There is no specic regimen of steroid The following are all reasonable optionsPrednisone burst (eg 50 mg PO daily for 5 days) or equivalent dose of methylprednisolone (eg 40 mg IV daily for ve days)Traditional stress dose steroid (50 mg hydrocortisone IV q6hr) ndash this may be preferred for patients in shock

ascorbic acid

One before-after single-center trial suggested a mortality benet from metabolic resuscitation (httpsemcritorgpulmcritmetabolic-sepsis-

resuscitation) The regimen used was hydrocortisone 50 mg IV q6hr thiamine 200 mg IV q12hours and ascorbic acid 15 grams IV q6h5High-dose IV vitamin C is currently under investigation within a multicenter RCT for treatment of acute lung injury (CITRIS-ALI trial(httpsclinicaltrialsgovct2showNCT02106975) )At this point in time metabolic resuscitation for severe PNA is reasonable but not proven Watch this space

eusion management(back to contents) (top)

pleural eusion management

Pleural effusion and empyema are common in severe pneumoniaEffusion should be evaluated upon admission and every 1-2 days thereafter using bedside ultrasonography

management is driven by ultrasonographic features

Effusion is small amp anechoic (black without internal echoes) ==gt follow with daily ultrasonography intervene if the effusion expandsEffusion is large amp anechoic ==gt drain effusion dry (httpsemcritorgpulmcritlarge-volume-thoracentesis-how-much-can-safely-be-removed)

with thoracentesisEffusion contains septations ==gt place pigtail catheter add tPADNAse if complete drainage doesnt occur

treatment failure(back to contents) (top)

22

Hailey Hobbshaileyahobbs

POCUS helped to identify pyothorax in this unstable patient with septic shock secondary to pneumonia leading to rapid drainage and source control (even when I used the wrong preset - oops) arntfield Buchanan_MD westernsono

65 1138 AM - Dec 19 2017




dening treatment failure

No clear denition but clinical improvement should generally be seen within ~3 daysPersistent or rising procalcitonin may be an early sign of treatment failureOngoing deterioration in oxygenation and inltrates gt24 hours after antibiotics is the most concerning featureRadiographic improvement takes weeks so failure for chest x-ray to improve over a few days means nothing

Indeed if the chest x-ray clears up within 24-48 hours that might be suggestive of aspiration pneumonitis rather than true bacterialpneumonia

dierential diagnosis

Wrong initial diagnosis (eg heart failure pulmonary embolism alveolar hemorrhage cryptogenic organizing pneumonia eosinophilicpneumonia ndash see differential diagnosis gure above)Noninfectious complication of hospitalization (iatrogenic volume overload pulmonary embolism drug fever aspiration)Wrong antibiotic (eg multi-drug resistant organism fungal pneumonia Q-fever psittacosis)Inadequate antibiotic dose or penetration into lung tissueIntra-thoracic complication of infection (abscess empyema pleural effusion ARDS)Metastatic infection (endocarditis meningitis arthritis)Weak host

evaluation

Review all data carefully (especially microbiology)CT chest is generally performed to secure the diagnosis of pneumonia and exclude anatomic complication (eg abscess or empyema) orpulmonary embolismRepeat cultures (blood and sputum)Bronchoscopy may be consideredIf a signicant pleural effusion is present it may be drained and sampledProcalcitonin is helpful occasionally to sort out infectious vs non-infectious illness

Negative procalcitonin (lt025 ngml) after three days suggests the presence of a non-infectious complication whereas persistentlyelevated procalcitonin suggests active infectionAmong patients with renal insuciency C-reactive protein might be used in an analogous fashion (with CRP levels lt30 mgL roughlyanalogous to a negative procalcitonin)

duration of treatment(back to contents) (top)

Either time or procalcitonin may be used to guide the length of treatment When in doubt both factors may be considered

time-based strategy

5-7 days of treatment is generally adequateIndications for longer treatment

Bacteremic infection with staph aureus or pseudomonasLegionella pneumoniaMetastatic infection involving other organs (eg meningitis)Anatomic complication (eg necrotizing pneumonia lung abscess)

procalcitonin-based strategy

The following suggest discontinuation of antibioticProcalcitonin level lt025 ngmlProcalcitonin has fallen to lt20 the peak value

May be useful to support antibiotic discontinuation in a patient who remains clinically ill for non-infectious reasons (eg COPD exacerbationARDS)

23



Not applicable in following situationsImmunocompromiseRenal dysfunction (PCT may have sluggish kinetics)Patient has other causes of elevated procalcitonin (eg other site of infection burns trauma surgery pancreatitis)

checklists amp algorithms(back to contents) (top)

main checklist

(httpsi0wpcomemcritorgwp-contentuploads201612pnachk600jpg)

antibiotic selection algorithm

(httpsi0wpcomemcritorgwp-contentuploads201612abxcapjpg) MRSA coverage algorithm




podcast(back to contents) (top)

(httpsi1wpcomemcritorgwp-contentuploads201611apps40518141273331769026097be7b901-15fe-4c27-863c-7c0dbfc26c5c5c278f58-912b-4af9-

88f8-a65fff2da477jpg)

Follow us on iTunes (httpsitunesapplecomcapodcastthe-internet-book-of-critical-care-podcastid1435679111)

The Podcast Episode

Want to Download the EpisodeRight Click Here and Choose Save-As (httptraclibsyncomibccpodcastIBCC_EP4_-_Community_Onset_Pneumonia_nalmp3)

questions amp discussion(back to contents) (top)

To keep this page small and fast questions amp discussion about this post can be found on another page here (httpsemcritorgpulmcritpneumonia)

0000 0000 (javascriptvoid(0))



(httpsi1wpcomemcritorgwp-contentuploads201611pitfalls2gif)

Failure to cover for atypical (eg treating with piperacillin-tazobactam monotherapy)Unnecessary MRSA coverage in patients at low risk for MRSA In particular after 2-3 days if there is no evidence that the patient has MRSA(eg negative nares PCR amp negative sputum) then MRSA coverage should be stoppedTriaging patients based on their oxygen requirement while ignoring tachypnea and work of breathingUnder-utilization of high-ow nasal cannula over-utilization of BiPAPUnder-utilization of steroid (especially in patients who may benet substantially eg underlying asthmaCOPD)Missing a pleural effusion which develops insidiously after admissionEgregiously weird antibiotic regimens for patients with dubious penicillin allergy (ceftriaxone is ne here more on this to come)Using uoroquinolones (its a trap (httpsemcritorgpulmcrituoroquinolone-critical-illness) )Giving clindamycin for anaerobic coverageDouble-coverage of pseudomonasDumping 30 cckg uid into a sick pneumonia patient on the verge of intubation because the lactate is elevated Please please please stopthis madness I beg of you

Going further

PNA generalCommunity Acquired Pneumonia (httpslifeinthefastlanecomccccommunity-acquired-pneumonia) ndash (LITFL CCC Chris Nickson)Evidence-based treatment for severe community-acquired pneumonia (httpsemcritorgpulmcritevidence-based-treatment-for-severe-community-

acquired-pneumonia) (PulmCrit)Radiologic ndash Ultrasonic ndash Pathologic correlation for pneumonia (httpsemcritorgpulmcritproposal-most-community-acquired-pneumonias-with-

extensive-ultrasonographic-consolidation-are-pneumococcus) (PulmCrit)Antibiotics

Which patients with pneumonia need MRSA coverage (httpsemcritorgpulmcritpneumonia-mrsa) (PulmCrit)Update in community acquired pneumonia Macrolide resistance (httprebelemcomupdate-in-community-acquired-pneumonia-cap-treatment-

macrolide-resistance) (Anand Swaminathan Rebel EM)Six reasons to avoid uoroquinolones in the critically ill (httpsemcritorgpulmcrituoroquinolone-critical-illness) (PulmCrit)

Modes of noninvasive supportPneumonia BiPAP secretions and HFNC Lessions learned from FLORALI trial (httpsemcritorgpulmcritpneumonia-bipap-secretions-and-hfnc-

new-lessons-from-orali) (PulmCrit)Mastering the dark arts of BiPAP amp HFNC (httpsemcritorgpulmcritbipap-hfnc) (PulmCrit)

Metabolic therapiesSteroid for community-acquired pneumonia (httpspulmccmorginfectious-disease-sepsis-reviewcorticosteroids-community-acquired-pneumonia)

(PulmCCM Jon-Emile Kenny)Corticosteroids for pneumonia Ready for primetime (httpwwwemdocsnetcorticosteroids-pneumonia-ready-primetime) (emDocs Brit Long)Metabolic resuscitation for severe pneumonia (httpsemcritorgpulmcritvitamin-c-pneumonia) (PulmCrit)

POCUS for pneumoniaThis is super important I didnt emphasize it in the chapter because theres already a lot of great info out there about itPneumonia Five minute sono (http5minsonocompna) (Jacob Avila)Pneumonia US library (httpslifeinthefastlanecomultrasoundlungpneumonia) (LITFL James Rippey)Dynamic Air Bronchograms (httpswwwultrasoundoftheweekcomuotw-34-answer) (Ultrasound of the Week Ben Smith)Ultrasound for PNA amp thoracentesis (httpswwwultrasoundpodcastcom201606ultrasound-pneumonia-thoracentesis-ultrasoundmd-asked-now-got-

foamed) (Ultrasound Podcast)Pneumonia ultrasound case (httpsradiopaediaorgcasespneumonia-ultrasound-1) (Radiopaedia David Carroll)Consolidation Atelectasis vs Pneumonia (httpswesternsonocascreencastslung-ultrasoundlung-ultrasound-consolidation-atelectasis-or-pneumonia)

(Western Sono Yves Landry)

1 Yap V Datta D Metersky M Is the present denition of health care-associated pneumonia the best way to dene risk of infection withantibiotic-resistant pathogens Infect Dis Clin North Am 201327(1)1-18 [PubMed (httpswwwncbinlmnihgovpubmed23398862) ]

2 Kalil A Metersky M Klompas M et al Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia 2016 ClinicalPractice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society Clin Infect Dis 201663(5)e61-e111[PubMed (httpswwwncbinlmnihgovpubmed27418577) ]



3 Lee M Oh J Kang C et al Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia Infect Chemother 201850(2)160-198 [PubMed (httpswwwncbinlmnihgovpubmed29968985) ]

4 Athlin S Lidman C Lundqvist A et al Management of community-acquired pneumonia in immunocompetent adults updated Swedishguidelines 2017 Infect Dis (Lond) 201850(4)247-272 [PubMed (httpswwwncbinlmnihgovpubmed29119848) ]

5 Ison M Lee N Inuenza 2010-2011 lessons from the 2009 pandemic Cleve Clin J Med 201077(11)812-820 [PubMed (httpswwwncbinlmnihgovpubmed21048054) ]

6 Cretikos M Bellomo R Hillman K Chen J Finfer S Flabouris A Respiratory rate the neglected vital sign Med J Aust 2008188(11)657-659[PubMed (httpswwwncbinlmnihgovpubmed18513176) ]

7 Williams J Greenslade J Chu K Brown A Lipman J Utility of community-acquired pneumonia severity scores in guiding disposition fromthe emergency department Intensive care or short-stay unit Emerg Med Australas 201830(4)538-546 [PubMed (httpswwwncbinlmnihgovpubmed29609223) ]

8 Chalmers J Taylor J Mandal P et al Validation of the Infectious Diseases Society of AmericaAmerican Thoratic Society minor criteria forintensive care unit admission in community-acquired pneumonia patients without major criteria or contraindications to intensive care unitcare Clin Infect Dis 201153(6)503-511 [PubMed (httpswwwncbinlmnihgovpubmed21865188) ]

9 Brown S Jones B Jephson A Dean N Infectious D Validation of the Infectious Disease Society of AmericaAmerican Thoracic Society 2007guidelines for severe community-acquired pneumonia Crit Care Med 200937(12)3010-3016 [PubMed (httpswwwncbinlmnihgovpubmed19789456) ]

10 Although not evidence-based if the patient is consistently tachpneic in the 30s I would consider them for ICU admission amp HFNC (even inthe absence of any other criteria)

11 Rice T Wheeler A Bernard G et al Comparison of the SpO2FIO2 ratio and the PaO2FIO2 ratio in patients with acute lung injury or ARDSChest 2007132(2)410-417 [PubMed (httpswwwncbinlmnihgovpubmed17573487) ]

12 This is a rough approximation The whole concept of measuring PF ratio in a patient on nasal cannula is pretty imprecise to begin withhowever

13 Rodriacuteguez A Mendia A Sirvent J et al Combination antibiotic therapy improves survival in patients with community-acquired pneumoniaand shock Crit Care Med 200735(6)1493-1498 [PubMed (httpswwwncbinlmnihgovpubmed17452932) ]

14 Garnacho-Montero J Barrero-Garciacutea I Goacutemez-Prieto M Martiacuten-Loeches I Severe community-acquired pneumonia current managementand future therapeutic alternatives Expert Rev Anti Infect Ther September 20181-11 [PubMed (httpswwwncbinlmnihgovpubmed30118377) ]

15 Mortensen E Halm E Pugh M et al Association of azithromycin with mortality and cardiovascular events among older patientshospitalized with pneumonia JAMA 2014311(21)2199-2208 [PubMed (httpswwwncbinlmnihgovpubmed24893087) ]

16 If anyone has data or opinions about whether doxy is effective for MRSA PNA and might be useful as an empiric antibiotic in patients witha low-moderate risk of MRSA pneumonia please let me know Irsquove been scouring the literature for evidence about this without success

17 Bender M Niederman M Improving outcomes in community-acquired pneumonia Curr Opin Pulm Med 201622(3)235-242 [PubMed (httpswwwncbinlmnihgovpubmed26859379) ]

18 Wunderink R Niederman M Kollef M et al Linezolid in methicillin-resistant Staphylococcus aureus nosocomial pneumonia a randomizedcontrolled study Clin Infect Dis 201254(5)621-629 [PubMed (httpswwwncbinlmnihgovpubmed22247123) ]

19 Cosimi R Beik N Kubiak D Johnson J Ceftaroline for Severe Methicillin-Resistant ltigtStaphylococcus aureusltigt Infections A SystematicReview Open Forum Infect Dis 20174(2)ofx084 [PubMed (httpswwwncbinlmnihgovpubmed28702467) ]

20 Karki A Thurm C Cervellione K Experience with ceftaroline for treatment of methicillin-resistant ltigtStaphylococcus aureusltigt pneumoniain a community hospital J Community Hosp Intern Med Perspect 20177(5)300-302 [PubMed (httpswwwncbinlmnihgovpubmed29147471) ]

21 Pastores S Annane D Rochwerg B Corticosteroid G Guidelines for the diagnosis and management of critical illness-related corticosteroidinsuciency (CIRCI) in critically ill patients (Part II) Society of Critical Care Medicine (SCCM) and European Society of Intensive CareMedicine (ESICM) 2017 Intensive Care Med 201844(4)474-477 [PubMed (httpswwwncbinlmnihgovpubmed29090327) ]

22 Kim W-Y Jo E-J Eom JS et al Combined vitamin C hydrocortisone and thiamine therapy for patients with severe pneumonia who wereadmitted to the intensive care unit Propensity score-based analysis of a before-after cohort study J 201847211-218 doi101016jjcrc201807004 (httpsdoiorg101016jjcrc201807004)

23 Meneacutendez R Martinez R Reyes S et al Stability in community-acquired pneumonia one step forward with markers Thorax200964(11)987-992 [PubMed (httpswwwncbinlmnihgovpubmed19762338) ]

The Internet Book of Critical Care is an online textbook written by Josh Farkas (PulmCrit) an associate professor ofPulmonary and Critical Care Medicine at the University of Vermont

EMCrit is a trademark of Metasin LLC Copyright 2009- This site represents our opinions only See our full disclaimer our privacy policy commenting policy and here for credits

and attribution



Community Acquired Pneumonia (CAP) = patients without signicant healthcare contactHealthcare-Associated Pneumonia (HCAP) = patients with exposure to healthcare (eg chronic dialysis recent hospitalization)

The denition of HCAP was based on expert opinion rather than evidence Over time it became clear that HCAP isnt an accurate predictor ofwhether the patient has drug-resistant organisms Consequently HCAP was eliminated in the recent IDSA ventilator-associated pneumoniaguidelines The elimination of HCAP creates a denitional vacuum because its unclear how to classify these patients currently

Until we have better denitions this chapter is entitled ldquocommunity-onset pneumoniardquo which is quite simply dened as anyone presenting to thehospital with pneumonia This is a combination of the CAP plus HCAP As explored below we will use a personalized strategy to determinewhich patients need broad-spectrum antibiotic coverage (rather than the CAP-vs-HCAP algorithm)

does this patient have pneumonia(back to contents) (top)

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diagnosing pneumonia can be tricky

Diagnosis is generally based on three lines of evidenceImaging evidence of a chest inltrate (eg CXR CT ultrasound)Inammation (eg feverhypothermia rigors night sweats leukocytosis left-shift procalcitonin)Pulmonary symptoms (eg dyspnea cough sputum production pleuritic chest pain) and signs (tachypnea hypoxemia)

Elderly patients may present with non-pulmonary complaints (eg falling delirium sepsis)When in doubt it is reasonable to get cultures and start antibiotics for pneumonia Within the next 24-48 hours the diagnosis may be re-considered and antibiotics discontinued as appropriate More common pneumonia mimics are listed below These can be devilishly hard to nd because youre searching for a needle in ahaystack

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resuscitation

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steroid







ascorbic acid










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65 1138 AM - Dec 19 2017









evaluation





time-based strategy






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main checklist











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and attribution











54 1214 AM - Nov 15 2017















4 6

7 8 9

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11 12



45 1114 AM - Dec 3 2017

















13 14

15

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resuscitation

17 18

19 20



















steroid







ascorbic acid










22



65 1138 AM - Dec 19 2017









evaluation





time-based strategy






23





main checklist











The Podcast Episode









Going further








































and attribution














4 6

7 8 9

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11 12



45 1114 AM - Dec 3 2017

















13 14

15

16












resuscitation

17 18

19 20



















steroid







ascorbic acid










22



65 1138 AM - Dec 19 2017









evaluation





time-based strategy






23





main checklist











The Podcast Episode









Going further








































and attribution
















13 14

15

16












resuscitation

17 18

19 20



















steroid







ascorbic acid










22



65 1138 AM - Dec 19 2017









evaluation





time-based strategy






23





main checklist











The Podcast Episode









Going further








































and attribution












resuscitation

17 18

19 20



















steroid







ascorbic acid










22



65 1138 AM - Dec 19 2017









evaluation





time-based strategy






23





main checklist











The Podcast Episode









Going further








































and attribution



















steroid







ascorbic acid










22



65 1138 AM - Dec 19 2017









evaluation





time-based strategy






23





main checklist











The Podcast Episode









Going further








































and attribution






ascorbic acid










22



65 1138 AM - Dec 19 2017









evaluation





time-based strategy






23





main checklist











The Podcast Episode









Going further








































and attribution








evaluation





time-based strategy






23





main checklist











The Podcast Episode









Going further








































and attribution





main checklist











The Podcast Episode









Going further








































and attribution








The Podcast Episode









Going further








































and attribution





Going further








































and attribution


























and attribution

denitions - emcrit blog · community acquired pneumonia ( cap ) = patients without signicant...

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