CAP GUIDELINES (BOOKLET) 2010 UPDATE

1 1 CAP GUIDELINES 2010 UpdatePhilippine Clinical Practice GUIDELINES on the Diagnosis, Empiric Management, and Prevention of Community-acquired Pneumonia (CAP) in Immunocompetent Adults2010 UpdateJoint Statement of thePhilippine Society for Microbiology and Infectious DiseasesPhilippine College of Chest PhysiciansPhilippine Academy of Family Physicians Philippine College of Radiology PHILIPPINE SOCIETY FOR MICROBIOLOGY AND INFECTIOUS DISEASES---1970 AD---2 CAP GuidelinesTASK FORCE ON COMMUNITY-ACQUIRED PNEUMONIAM anolito L. Chua, PSMID ChairMa. Lourdes A. Villa, PSMID RapporteurMarissa M.

2 Alejandria, PSMID MemberAbundio A. Balgos, PCCP MemberJoselito R. Chavez, PCCP MemberVilma M. Co, PSMID MemberRemedios F. Coronel, PSMID MemberJose Paolo M. De Castro, PAFP MemberRaquel Victoria M. Ecarma, PSMID MemberBenilda B. Galvez, PCCP MemberPolicarpio B. Joves, PAFP MemberIsaias A. Lanzona, PCCP MemberMyrna T. Mendoza, PSMID MemberLeonardo Joseph Obusan, PCR MemberIsabelita M. Samaniego, PAFP MemberMa. Bella R. Siasoco, PCCP MemberThelma E. Tupasi, , FPSMIDA dviserPANEL OF EXPERTSPSMID Angeles Tan-Alora, Mediadora C.

3 Saniel, Thelma E. Tupasi, Roberto A. Barzaga, Teresita S. de Guia, Camilo C. Roa, Jr., Cynthia L. Hipol, Zorayda E. Leopando, Reynaldo A. Olazo, Emmanuel D. Almasan, GUIDELINES 2010 UpdateTABLE OF CONTENTSF oreword .. 6 Methodology .. 7 Introduction .. 10 Executive 11 PART ONE: CLINICAL DIAGNOSIS 1. Can CAP be diagnosed accurately by history and physical examination? .. 16 Table 1. Accuracy of history and physical examination for the diagnosis of community-acquired pneumonia.

4 18 Table 2. Accuracy of predicting pneumonia by physicians clinical judgment .. 19 2. Is there any clinical feature that can predict CAP caused by an atypical pathogen? .. 19 PART TWO: CHEST RADIOGRAPHY 3. What is the value of the chest radiograph in the diagnosis of CAP? .. 24 4. What specifi c views of chest radiograph should be requested?.. 24 5. Are there characteristic radiographic features that can predict the likely etiologic agent from the chest radiograph?

5 25 6. How should a clinician interpret a radiographic fi nding of pneumonitis ?.. 25 7. What is the signifi cance of an initial normal chest radiograph in a patient suspected to have CAP? .. 26 8. Should a chest radiograph be repeated routinely? .. 26 9. What is the role of the chest CT scan in CAP? .. 26 Table 3. Chest radiographic fi ndings which may predict a complicated course .. 28 PART THREE: SITE-OF-CARE DECISIONS 10. Which patients will need hospital admission? .. 30 Table 4. Clinical features of patients with community- acquired pneumonia according to risk categories.

6 314 CAP GuidelinesFigure 1. Algorithm for the management-oriented risk stratifi cation of community-acquired pneumonia .. 32 PART FOUR: MICROBIOLOGIC STUDIES 11. What microbiologic studies are necessary for CAP? .. 43 Table 5. Incidence of atypical pathogens .. 45 Table 6. Diagnostic tests for Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella pneumophila .. 47 PART FIVE: TREATMENT 12. When should antibiotics be initiated for the empiric treatment of CAP? .. 50 13. What initial antibiotics are recommended for the empiric treatment of CAP?

7 50 Table 7. Empiric antimicrobial therapy in community- acquired pneumonia .. 52 Table 8. Usual recommended dosages of antibiotics in 50 to 60 kilogram adults with normal liver and renal functions .. 54 Table 9. Resistance rates of Streptococcus pneumoniae and Haemophilus infl uenzae (Antimicrobial Resistance Surveillance Program, 2004-2008) .. 59 Table 10. Levofl oxacin resistance pattern among Enterobacteriacea (Antimicrobial Resistance Surveillance Program 2008) .. 61 14.

8 How can response to initial therapy be assessed? .. 65 15. When should de-escalation of empiric antibiotic therapy be done? .. 65 Table 11. Indications for streamlining of antibiotic therapy .. 66 16. Which oral antibiotics are recommended for de-escalation or switch therapy from parenteral antibiotics? .. 66 Table 12. Antibiotic dosage of oral agents for streamlining or switch therapy .. 66 Table 13. Benefi ts of intravenous to oral sequential antibacterial therapy .. 67 17. How long is the duration of treatment for CAP?

9 67 Table 14. Duration of antibiotic use based on etiology .. 685 CAP GUIDELINES 2010 UPDATE 18. What should be done for patients who are not improving after 72 hours of empiric antibiotic therapy? .. 68 Table 15. Factors to consider for nonresponding pneumonia or failure to improve .. 69 19. When can a hospitalized patient with CAP be discharged? .. 69 Table 16. Recommended hospital discharge criteria .. 70 PART SIX: PREVENTION 20. How can CAP be prevented? .. 86 a. Pneumococcal vaccine .. 86 Table 17. Recommendations for pneumococcal vaccination .. 88 b.

10 Infl uenza vaccine .. 89 Table 18. Recommendations for infl uenza vaccination .. 92 c. Smoking cessation .. 92 APPENDICESA ppendix 1. Grading system for recommendation .. 101 Appendix 2. Winthrop-University Hospital infectious disease division s point system for diagnosing Legionnaire s disease in adults (modifi ed) .. 1026 CAP GuidelinesFOREWORDS ince the Philippine Clinical Practice GUIDELINES on the Diagnosis, Empiric Management, and Prevention of Community-acquired Pneumonia (CAP) was published in 1998, new developments in CAP have emerged.