Cap draft

NewYork-Presbyterian Hospital
Guidelines for the Empiric Management of Adult Patients with Community-Acquired Pneumonia
(CAP) and IV to PO Conversion
Typical diagnostic work-up
Pneumonia diagnosed by radiograph and symptoms
Vital signs Chest x-ray (PA and lateral) Complete blood count (CBC) with differential Basic metabolic panel Initiate diagnostic work-up
Hepatic profile Pulse oximetry and/or ABGIn addition, the following are recommended for Risk Class III-V and should be considered for Risk Class I-II: Initiate appropriate empiric antibiotic therapy
(see drug therapy algorithmn)
Sputum for Gram's stain and culture (if possible)
Additional diagnostics to consider:
Legionella urinary antigen
S. pneumoniae urinary antigen (at CUMC only)
Pneumonia PORT
Severity Index
Immunocompromised (including HIV): Consider other causes of pneumonia (e.g. fungal, viral, TB, PCP) and other diagnostics Influenza season: Nasopharyngeal swab for influenza and RSV Special circumstances: Risk Class I / II
Risk Class III
Risk Class IV / V
Pneumonia Severity
Pneumonia Severity
Pneumonia Severity
Index < 70 points
Index 71-90 points
Index > 91 points
Pneumonia PORT Severity Index Score
Characteristic
Consider
Consider hospitalization
treatment as
hospital
outpatient
Consider
admission to ICU
for severe
pneumonia
Evaluate empiric antibiotic therapy
Evaluate results of microbiology and diagnostic tests
Modify antibiotic therapy if necessary
PO2 < 60 mmHg or O2 saturation < 90% TOTAL SCORE
Evaluate patient for
Severe pneumonia
IV to PO conversion
Major criteria (need one):
Need for mechanical ventilation
Septic shock with need for pressors
Minor criteria (need at least three):
Evaluate for discharge based on the following criteria:
Stable comorbid illnesses and significant improvement in pneumonia Multilobar disease PaO2/FiO2 ratio ≤ 250 Should also fulfill the following criteria (unless baseline status):
temperature < 37.8°C ( > 16 hours and in the absence of antipyretics )pulse < 100 beats/min respiratory rate < 24 breaths/min Thrombocytopenia (platelets <100,000 cel s/mm3) Hypotension requiring aggressive fluid resuscitation Criteria for IV to PO conversion
Clinical improvement in pulmonary signs and symptoms
For all appropriate patients, prior to discharge, consider :
Afebrile or consistent improvement in fever over a 24- influenza vaccination
pneumococcal vaccination
smoking cessation
Infection being treated does not require IV therapy (e.g. endocarditis, meningitis) GI absorption likely normal Discharge from hospital with oral antibiotic if necessary to
(absence of vomiting or abnormal GI anatomy) complete a course of therapy
Ability to receive oral dosage form either orally or via tube (concomitant oral or via tube administration of other meds) Empiric Antibiotic Therapy Options for CAP and Recommendations for PO Conversion
- Modification of antibiotic therapy may be necessary in patients with antibiotics in the past month, history of resistant pathogens (especially
PCN-R S. pneumoniae), recently hospitalized, or severely immunocompromised
- In immunocompromised patients (HIV+, solid organ transplant recipients, etc), consider other causes of pneumonia (e.g. viral, PCP, TB, etc.)
- All doses provided are for ~70 kg adults with normal renal and hepatic function
NON-ICU ADMISSION
Beta-lactam (penicillin) allergy:
Azithromycin 250 mg PO daily (5 days total) Levofloxacin 500 mg PO daily (7 days total) 2,3,4,6 1. In the absence of meningitis, penicillin-susceptible and -intermediate S. pneumoniae (MIC < 0.06 - 1 mcg/mL) may be treated with ampicillin 2 g IV Q4-6h or ceftriaxone 1 g IV dailyfollowed by amoxicllin 1 g PO Q8h 2. In the absence of meningitis, oral conversion to levofloxacin is recommended if penicillin-resistant S. pneumoniae (MIC > 2 mcg/mL) is isolated 3. Oral administration of levofloxacin requires separation from concomitant administration of Mg+2-, Ca+2-, Al+3 - containing antacids, sucralfate, calcium supplements, and iron products due to adsorption of the levofloxacin limiting its oral bioavailability. Separate administration times of these products from oral levofloxacin by about 2 hours. 4. Routine anaerobic coverage is not specifically needed in the majority of CAP cases. If a true aspiration pneumonia is suspected (pleuropulmonary syndrome in patients with a history of loss of consciousness as a result of alcohol/drug overdose or after seizures in patients with concomitant gingival disease or esophageal motility disorders), then consider the need for improved anti-anaerobic coverage: Piperacillin/tazobactam 4.5 g IV Q8h + Azithromycin 500 mg PO x1, then 250 mg daily OR for beta lactam allergy, Levofloxacin 500 mg IV daily + Clindamycin 600 mg IV Q8h. Documentation in the medical record should indicate the need for this coverage due to aspiration and risk of multi-drug resistant organisms.
ICU ADMISSION 5
- Initial antibiotic therapy should be individualized where appropriate based on recent hospitalization, prior antibiotic history,
immunocompromised state, recent positive cultures, etc.
- Antibiotic therapy should be guided by culture and susceptibility results when available
- Once admitted to a general patient care area, patients initially admitted to the ICU may be switched to oral therapy (as above) and treated for 7-
10 days total. In these patients, oral azithromycin should be continued at a dose of 500 mg daily for a total of 7-10 days.
Suspect
Beta-lactam (penicillin) allergy:
Pseudomonas aeruginosa:
Suspect
Pseudomonas aeruginosa:
5. Routine anaerobic coverage is not specifically needed in the majority of CAP cases. If a true aspiration pneumonia is suspected (pleuropulmonary syndrome in patients with a history of loss of consciousness as a result of alcohol/drug overdose or after seizures in patients with concomitant gingival disease or esophageal motility disorders), then consider the need for improved anti-anaerobic coverage. No additional coverage is necessary in patients receiving piperacillin/tazobactam, but the addition of Clindamycin 600 mg IV Q8h OR Metronidazole 500 mg IV Q8h is necessary for patients with beta-lactam allergy. Documentation in the medical record should indicate the need for this coverage due to aspiration and risk of multi-drug resistant organisms.
6. Piperacillin/tazobactam, levofloxacin, tobramycin, aztreonam, cefuroxime, cefotaxime, and amoxicillin/clavulanic acid require dose adjustment in patients with renal dysfunction 7. Tobramycin IV dosing based on weight and renal function. Use extended-interval (“once-daily”) dosing where appropriate. See NYP aminoglycoside dosing guidelines for criteria and details.

Source: http://www.id.hs.columbia.edu/documents/CAP_viseo_rev5-10.pdf