Management of Community-Acquired Pneumonia

1 Last revised: January 2013 In most circumstances, these guidelinesapply equally to patients residing in long-term care institutions ( Nursing Homes). * Routine coverage of atypical bacteriahas not been proven to be of benefit inthis setting. Please see FAQs for explanation. Outpatient*ICU or Step-down/Step-up*amoxicillin-clavulanic acid 875/125mg po bid x 7 days(Some experts recommend a longer duration for patients with structural lung disease.)if -lactam allergic: levofloxacin 750mg or moxifloxacin 400mg iv dailyMRSA colonization known/suspected: Add vancomycin 15-20mg/kg iv q12h (or dose according to institutional guidelines )If patient is septic: Manage as per local sepsis protocols. Blood cultures before *+/-+/-amoxicillin-clavulanic acid 875/125mg po bidazithromycin 500mg iv dailyManagement of Community-Acquired Pneumonia cefotaxime 1g q8h or ceftriaxone 1g q24h ivazithromycin 500mg iv dailyandazithromycin 500mg po dailycefotaxime 1g q8h iv or ceftriaxone 1g q24h ivorif -lactam allergic: levofloxacin 750mg po/iv daily or moxifloxacin 400mg po/iv dailyif -lactam allergic: levofloxacin 750mg ormoxifloxacin 400mg po daily x 5 daysRisk stratify usingclinical judgmentCRB-65 Assign 1 point each for:Confusion (MMSE < 9 or new disorientation to person, place or time)SBP < 90mmgHg or DBP < 60mmHgRR 30 breaths/minAge 65 yearsDiagnose Community-Acquired Pneumonia .

2 Consider alternate diagnoses.(CHF, PE, and others)If patient is at risk for antimicrobial-resistant organisms ( recent antimicrobial therapy or structural lung disease), consider modifications and/or expert Risk0 pointsThirty day mortality: Risk3 - 4 pointsThirty day mortality: - 2 pointsThirty day mortality: RiskStreptococcus pneumoniae resistance AntibioticResistance in Pneumococcal Isolatespenicillin G(non-meningitis) influenzaeresistance to amoxicillin outpatient 18%inpatients 22% Adult specimens submitted to CBSN fromOntario laboratories in 2008-2009 whichwere resistant to ampicillin/amoxicillin. Data courtesy of Dr. Donald Low. * Costs can only be provided as estimatesas of October 2012, and may vary for bothinpatient and outpatient pharmacies. Adult respiratory specimens from Ontariolaboratories participating in the Canadian Bacterial Surveillance Network/Toronto Invasive Bacterial Diseases Network, 2010-11.

3 Data courtesy of Community-Acquired Pneumonia : Additional ToolsThis includes (but is not limited to) patients with: Recent or current use of immunomodulating drugs ( high-dose corticosteroids, cyclosporine, infliximab, etanercept, etc.) HIV with low (known or suspected) CD4 count Solid organ transplantation Stem cell transplantation Chemotherapy-associated neutropeniaThis algorithm is NOTfor patients with significantimmunocompromise thatmight alter the choice ofempiric antimicrobial Antimicrobial Costs*AntibioticCost / CourseLimited Use Codeamoxicillin-clavulanate 875/125mg po bid x 7d$ 750mg po daily x 5d$ (using 500mg tabs)337 (co-morbidity), 339 (step-down),or 977 (allergy to alternatives).750mg tabs is not an ODB benefit. Dispense 500mg tabs x 8. Take 1 and 1/2 tabs 400mg po daily x 5d $ (co-morbidity), 339 (step-down),or 977 (allergy to alternatives).

4 AntibioticCost / Dayceftriaxone 1g iv daily$5cefotaxime 1g iv q8h$20azithromycin 500mg po daily$ 500mg iv daily$8levofloxacin 750mg iv or moxifloxacin 400mg iv daily$24