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Information

Both confirmation of the diagnosis and assessment of the likely etiology are required. Although no data have demonstrated that treatment directed at a specific pathogen is superior to empirical treatment, an etiologic diagnosis allows narrowing of the empirical regimen, identification of organisms with public safety implications (e.g., Mycobacterium tuberculosis, influenza virus), and monitoring of antibiotic susceptibility trends.

Treatment: Community-Acquired Pneumonia

Deciding Whether to Hospitalize PTS

  • Two sets of criteria identify pts who will benefit from hospital care. It is not clear which set is superior, and application of each tool should be tempered by a consideration of factors relevant to the individual pt.
    • - Pneumonia Severity Index (PSI): Points are given for 20 variables, including age, coexisting illness, and abnormal physical and laboratory findings. On this basis, pts are assigned to one of five classes of mortality risk.
    • - CURB-65: Five variables are included: confusion (C); urea >7 mmol/L (U); respiratory rate 30/min (R); blood pressure, systolic 90 mmHg or diastolic 60 mmHg (B); and age 65 years (65). Pts with a score of 0 can be treated at home, pts with a score of 2 should be hospitalized, and pts with a score of 3 may require management in the ICU.

Antibiotic Therapy

  • For recommendations on empirical antibiotic treatment of CAP, see Table 132-1. U.S. guidelines always target S. pneumoniae and atypical pathogens. Retrospective data suggest that this approach lowers the mortality rate.
  • Pts initially treated with IV antibiotics can be switched to oral agents when they can ingest and absorb drugs, are hemodynamically stable, and are improving clinically.
  • CAP has historically been treated for 10-14 days, but a 5-day course of a fluoroquinolone is sufficient for cases of uncomplicated CAP. A longer course may be required for pts with bacteremia, metastatic infection, or infection with a particularly virulent pathogen.
  • Fever and leukocytosis usually resolve within 2-4 days. Pts who have not responded to therapy by day 3 should be reevaluated, with consideration of alternative diagnoses, antibiotic resistance in the pathogen, and the possibility that the wrong drug is being given.

Outline

Section 9. Pulmonology