Mar 1;44 Suppl 2:S America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Keywords: Community-acquired pneumonia, ICU admission, arterial .. The IDSA/ATS CAP Guidelines major criteria including the pH. Pneumonia In Adults Adapted from: IDSA/ATS CONSENSUS GUIDELINES Mandell LA, Wunderlink RG, Anzueto A, et al. Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clin Infect Dis. ;(Suppl 2).

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Conversely, the benefit of drotrecogin alfa activated is not as clear when respiratory failure is caused more by exacerbation of underlying lung disease rather than by the pneumonia itself.

Recommendations for the use of highly active agents in patients at risk for infection with DRSP is, therefore, based only in part on efficacy considerations; it is also based on a desire to prevent more resistance from emerging by employing the most potent regimen possible. Table 11 provides a construct for evaluating nonresponse to antibiotic treatment of CAP, based on several studies addressing this issue [ 768184].

In patients with suspected H5N1 infection, droplet precautions and careful routine infection control measures should be used until an H5N1 infection is ruled out. Once again, Gram stain and culture of an adequate sputum specimen are usually adequate to exclude the need for empirical coverage of these pathogens. Whether this risk applies equally to all fluoroquinolones or is more of a concern for less active antipneumococcal agents levofloxacin and ciprofloxacin than for more active agents moxifloxacin and gemifloxacin is uncertain pnejmonia, ].

Exposure to sick and dying poultry in an area with known or suspected H5N1 activity has been reported by most patients, although the recognition of poultry outbreaks has sometimes followed the recognition of human cases [ guidelones. However, the importance of treating multiple infecting organisms has not been firmly established.

Management of patients on the basis of a single acute-phase titer is unreliable [ ], and initial antibiotic therapy will be completed before the earliest time point to check a convalescent-phase specimen.

Improving the IDSA/ATS severe Community-Acquired Pneumonia criteria to predict ICU admission

The alteration in therapy that is potentially most beneficial to the individual is an escalation or switch of the usual empirical regimen because of unusual pathogens e. CAP communiyy should address a comprehensive set of elements in the process of care rather than a single element in isolation. Therefore, dynamic assessment over several hours of observation may be more accurate than a score derived at a single point in time.

We identified episodes of CAP among hospitalized patients during the study period, In addition, 2 prospective observational studies [] and 3 retrospective analyses [ — ] have found that combination therapy for bacteremic pneumococcal pneumonia is associated with lower mortality than monotherapy.


Once general agreement on the separate topics was obtained, the cochairs incorporated the separate documents into a single statement, with substantial editing for style and consistency. Newer agents for MRSA have recently become available, and others are anticipated.

Empirical antibiotic recommendations table 7 have not changed guidelinss from those in previous guidelines. Author information Copyright and License information Disclaimer. Therapy with comkunity respiratory fluoroquinolone alone is not established for severe CAP [ ], and, if the patient has concomitant pneumococcal meningitis, the efficacy of fluoroquinolone monotherapy is uncertain. Agents in the same class as the patient had been receiving previously should not be used to treat patients with recent antibiotic exposure.

This information is often available at the time of consideration for a communiity from parenteral to oral therapy and may be used to direct specific oral antimicrobial choices. Just as it is important not to focus on one aspect of care, studying more than one outcome is also important. Selected oral cephalosporins cefpodoxime and cefuroxime can be used as alternatives [ ], but these are less active in vitro than high-dose amoxicillin or ceftriaxone. Although these guidelines are evidence based, the committee strongly urges that deviations from them not necessarily be considered substandard care, unless they are accompanied by evidence for worse outcomes in a studied population.

cimmunity For inpatients without the clinical indications listed in acquied 5diagnostic testing is optional but should not be considered wrong. Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care. Protocols using guidelines to decrease the duration of hospitalization have also been successful.

Respiratory hygiene measures, including the use of hand hygiene and masks or tissues for patients with cough, should be used in outpatient settings and EDs as a means to reduce the spread of respiratory infections. Patients acquire severe CAP, as defined above, should at least have blood samples drawn for culture, urinary antigen tests for Legionella pneumophila and Streptococcus pneumoniae performed, and expectorated sputum samples collected for culture.

None of the 10 patients with erythromycin-resistant S. Some of the variability among institutions communit from the availability of high-level monitoring or intermediate care units appropriate for patients at increased risk of complications. Of these, rapid and appropriate empirical antibiotic therapy is consistently associated with improved outcome. Elements important in CAP guidelines are listed in table 2. The yield for positive blood culture results is halved by prior antibiotic therapy [ 95 ].

The decision of where to treat a patient with CAP is crucial impacting treatment alternatives, outcomes, and costs [ 6 — 8 ]. In addition, 3 small pilot studies have suggested that there is a benefit to corticosteroid therapy even for patients with severe CAP who are not in shock [ — ].


We performed a logistic regression model with ICU admission as the dependent variables and individual severity criteria as independent variables. Attempts to establish an etiologic diagnosis are also appropriate in selected cases associated with outbreaks, specific risk factors, or atypical presentations.

Small-volume aspiration at the time of intubation should be adequately handled by standard empirical severe CAP treatment [ ] and by the high oxygen tension provided by mechanical ventilation. The most clear-cut indication for extensive diagnostic testing is in the critically ill CAP patient. Community-acquired pneumonia CAP is the leading infectious cause of death in the United States [ 1 ].

Recommendations for therapy table 7 apply to most cases; however, physicians should consider specific risk factors for each patient table 8. Because septic shock and mechanical ventilation are the clearest reasons for ICU admission, the majority of ICU patients would still require combination therapy.

However, certain other patients whose conditions are included under the designation of HCAP are better served by management in accordance with CAP guidelines with concern for specific pathogens.

One report suggested that, if cefuroxime is used to treat pneumococcal bacteremia when the organism is resistant in vitro, the outcome is worse than with other therapies [ ].

In Table 2 we describe the combination of major and minor criteria used in this study. Less common causes of pneumonia include, but are by no means limited to, Streptococcus pyogenes, Neisseria meningitidis, Pasteurella multocidaand H. These 2 priorities often overlap.

Improving the 2007 IDSA/ATS severe Community-Acquired Pneumonia criteria to predict ICU admission

The standard for diagnosis of infection with most atypical pathogens, including Chlamydophila pneumoniae, Mycoplasma pneumoniaeand Legionella species other than L. Therefore, when performed, samples for blood culture should be obtained before antibiotic administration. A longer duration guideljnes therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis.

Direct admission pndumonia an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation. Such efforts at improvement in care are warranted, because CAP, together with influenza, remains the seventh leading cause of death in the United States [ 1 ].

For example, a previously healthy year-old patient with severe hypotension and tachycardia and no additional pertinent prognostic factors would be placed in risk class II, whereas a year-old man with a history of localized prostate cancer diagnosed 10 months earlier and no other problems would be placed in risk class IV [ 42 ].