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Subject: Pneumonia, Bacterial
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Community-acquired pneumonia (CAP): lower respiratory tract infection not acquired in a hospital, long-term care facility, or during other recent contact with the health care system
Medical care–associated pneumonia
Hospital-acquired pneumonia (HAP): pneumonia within ≥48 hours after admission and did not appear to be incubating at time of admission
Ventilator-associated pneumonia (VAP): Pneumonia that develops >48 hours after endotracheal intubation.
Health care–associated pneumonia (HCAP): Pneumonia that occurs in a nonhospitalized patient with extensive health care contact, such as the following:
IV therapy/wound care within past 30 days
Residing in a nursing home/long-term care
Hospitalization in an acute care hospital for ≥2 days within the past 90 days; hemodialysis clinic within the past 30 days
Influenza and pneumonia are the eight leading cause of death in the United States with about 53,282 deaths in 2013.
HAP is the leading cause of death among nosocomial infections and is one of the leading causes of death in the ICU.
Rates of infection are 3 times higher in African Americans than in whites and are 5 to 10 times higher in Native American adults and 10 times higher in Native American children.
Mortality rate in children is approximately 1.6 million a year. Hospitalization rate for children with CAP is still highest among the very young ages (<18 months). Respiratory viruses are the most commonly detected causes of pneumonia (1).
CAP: 5 to 11 cases/1,000 persons with increased incidence occurring in the winter months
HAP: 5 to 10 cases/1,000 admissions; incidence increase 6- to 20-fold in ventilated patients (2)[A]
Typical (85%): Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, group A Streptococcus, Moraxella catarrhalis
Atypical (15%): Legionella sp., Mycoplasma pneumoniae, Chlamydophila pneumoniae
Aerobic gram-negative bacilli: Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Acinetobacter sp.
Gram-positive cocci: Streptococcus sp. and S. aureus (including MRSA)
Birth to 20 days: E. coli, group B Streptococci, Listeria monocytogenes
3 weeks to 3 months: Chlamydia trachomatis, S. pneumoniae
4 months to 18 years
Typical: S. pneumoniae
Atypical: C. pneumoniae, M. pneumoniae
Age >65 years
Recent antibiotic therapy/resistance to antibiotics
Asthma, CAD, COPD, chronic renal failure, CHF, diabetes, liver disease, VAP, HAP, HCAP
Hospitalization for ≥2 days during past 90 days
Antibiotic therapy in the past 6 months
Poor functional status as defined by activities of daily living score
Immunosuppression (including steroid users) (3)
All children 2 to 59 months of age should be routinely vaccinated with pneumococcal conjugate (PCV13); given at 2, 4, and 6 months of age; a 4th dose at 12 to 15 months of age
Adults ≥65 years who have not received vaccine naïve, ACIP currently recommends PCV13 followed by pneumococcal polysaccharide (PPSV23) ≥1 year interval. If they received PPSV23 vaccine before age 65 years, they should receive a dose of PCV13 followed by a subsequent PPSV23 ≥1 year after PCV13 and at least 5 years have passed since their previous PPSV23 dose.
For adults ≥65 years old who have already received PPSV23, a dose of PCV13 is indicated after ≥1 year.
Adults 19 to 64 years who have chronic diseases, including alcoholism and tobacco use, should receive PPSV23.
Adults ≥19 years old with immunocompromising conditions, asplenia, CSF leaks, cochlear implants who have not received PPSV23 or PCV13 should receive one dose of PCV13 followed by PPSV23 after ≥8 weeks. If a second dose of PPSV23 is recommended, it should be given 5 years after 1st dose. Adults >19 years, previously given PPSV23 should receive a PPCV13 dose ≥1 year after last PPSV23. If additional PPSV23 is required, it should be given ≥8 weeks after PCV13 and 5 years after most recent dose of PPSV23.
Annual influenza vaccine
Fever, chills, rigors, malaise, fatigue
Cough, with/without sputum
Pleuritic chest pain
High fever (>104°F [40°C]), male sex, multilobar involvement, and GI and neurologic abnormalities have been associated with CAP caused by Legionella.
Older adults with pneumonia often present with weakness, mental status change, or history of falls.
Fever >100.4°F (38°C), tachypnea, tachycardia
Rales, rhonchi, egophony, increased fremitus, bronchial breath sounds, dullness to percussion, asymmetric breath sounds, abdominal tenderness
Routine laboratory testing to establish an etiology in outpatients with CAP is usually unnecessary.
For hospitalized patients with CAP, a CBC, sputum Gram stain, procalcitonin, and two sets of blood cultures
More extensive diagnostic testing in patients with CAP is recommended if:
Blood cultures: ICU admission, cavitary infiltrates, leukopenia, alcohol abuse, severe liver disease, asplenia, positive pneumococcal urine antigen test (UAT), pleural effusion
Sputum Gram stain and cultures: ICU admission, failure of outpatient treatment, cavitary infiltrates, alcohol abuse, severe COPD/structural lung disease, positive Legionella UAT, positive pneumococcal UAT, pleural effusion
Legionella UAT: ICU admission, failure of outpatient treatment, alcohol abuse, travel in past 2 weeks, pleural effusion
Pneumococcal UAT: ICU admission, failure of outpatient treatment, leukopenia, alcohol abuse, severe liver disease, asplenia, pleural effusion
A chest x-ray (CXR) is indicated when pneumonia is suspected or with an acute respiratory infection and
Vital signs: temperature >100°F (37.8°C); heart rate (HR) >100 beats/min; respiratory rate (RR) >20 breaths/min
At least two of the following clinical findings: decreased breath sounds, rales, no asthma
Early in disease course, CXR may be negative.
Evidence of necrotizing/cavitary pneumonia should raise suspicion for MRSA pneumonia, especially with history of prior MRSA skin lesions.
For VAP/HAP: By bronchoscopic or nonbronchoscopic means, obtain a lower respiratory tract sample for culture prior to initiation/change of therapy. Serial evaluations may be needed (2)[A].
Safe cessation of antibiotics can be done from a good quality negative sputum culture.
No significant differences in efficacy between antibiotic option in adults
Previously healthy, no antibiotics in past 3 months
Azithromycin 500 mg PO 1 time, then 250 mg PO daily for 4 days; clarithromycin 500 mg PO BID for 10 days; erythromycin 500 mg PO BID for 10 days, or
Doxycycline 100 mg PO BID for 10 days
Comorbid conditions, immunosuppressed, antibiotic use in past 3 months
Levofloxacin 750 mg PO daily for 5 days; moxifloxacin 400 mg PO daily for 5 days; or
Amoxicillin 1 g PO TID; amoxicillin-clavulanate 2 g PO BID + macrolide/doxycycline for 5 days
Treatment may be stopped if
Afebrile for >48 hours
Supplemental oxygen no longer needed
No more than one of the following:
HR >100 beats/min
RR >24 breaths/min
Systolic blood pressure (BP) ≤90 mm Hg
CAP, inpatient (non-ICU)
IV antibiotics initially, then switch to oral after clinical improvement
Treatment duration depends on clinical improvement.
Cefotaxime; ceftriaxone; ampicillin-sulbactam + macrolide (clarithromycin; erythromycin) for 5 to 14 days or
Moxifloxacin; levofloxacin for 5 to 14 days
If Pseudomonas is a consideration
Piperacillin-tazobactam; cefepime; imipenem; meropenem + levofloxacin or
Piperacillin-tazobactam; cefepime; imipenem; meropenem + aminoglycoside and azithromycin or
Piperacillin-tazobactam; cefepime; imipenem; meropenem + aminoglycoside + levofloxacin
If MRSA is a consideration
Add vancomycin or linezolid HCAP/HAP/VAP.
Use IV antibiotics.
Early onset (<5 days) and no risk factors for multidrug-resistant pathogens
Ceftriaxone; ampicillin-sulbactam; ertapenem or
Late onset (≥5 days) or risk factors for multidrug-resistant pathogens (antibiotic therapy in preceding 90 days; high frequency of antibiotic resistance in community/hospital; immunosuppressive disease/therapy; risk factors for HCAP)
MRSA coverage: linezolid or vancomycin + β-lactam cefepime; ceftazidime; imipenem; meropenem; piperacillin-tazobactam + either fluoroquinolone (levofloxacin) or aminoglycoside (amikacin; gentamicin; tobramycin) (level II)
Short-course versus prolonged-course antibiotic therapy for HAP in critically ill adults. For patients with VAP due to NF-GNB, a shorter antibiotic course may increase the risk of recurrence (4)[A].
Drug-resistant S. pneumoniae should be treated with high-dose amoxicillin, amoxicillin/clavulanate, cefpodoxime with a macrolide, or a respiratory fluoroquinolone.
Adult IV antibiotic doses
β-Lactams (ampicillin-sulbactam 3 g q6h; aztreonam 2 g q6h; cefepime 1 to 2 g q8–12h; cefotaxime 1 g q6–8h; ceftazidime 2 g q8h; ceftriaxone 2 g daily; imipenem 500 mg q6h; meropenem 1 g IV q8h)
Aminoglycosides (amikacin 20 mg/kg daily; gentamicin 7 mg/kg daily; tobramycin 7 mg/kg daily)
Fluoroquinolones (levofloxacin 750 mg daily; moxifloxacin 400 mg daily)
Macrolides (azithromycin 500 mg daily; clarithromycin 500 mg daily; erythromycin 500 to 1,000 mg q6h)
Vancomycin 15 mg/kg q12h
Linezolid 600 mg q12h
Telavancin is an antibiotic which covers MRSA infection. Telavancin is approved for the treatment of HAP and VAP caused by S. aureus. This medication is indicated only when alternative agents cannot be used.
Pediatric, outpatient (≥3 months)
Antibiotic treatment in preschool-aged children is not routinely required because viral pathogens are more common (5)[A].
Oral antibiotics are as efficacious as IV in CAP (length of stay and oxygen requirement were reduced in those given oral antibiotics).
Typical bacterial pneumonia
Amoxicillin 90 mg/kg/day PO BID (max 4 g/day) (5)[A]
Amoxicillin-clavulanate 90 mg/kg/day PO BID (max 4 g/day) (5)[A]
Alternative: levofloxacin 16 to 20 mg/kg/day PO BID for children 6 months to 5 years, 10 mg/kg/day daily for children ≥5 years (max 750 mg/day) (5)[C]
Atypical bacterial pneumonia
Azithromycin 10 mg/kg PO on day 1 (max 500 mg), then 5 mg/kg/day (max 250 mg) on days 2 to 5 (4)[C]
Clarithromycin 15 mg/kg/day PO BID (max 1 g/day) (4)[C]
Erythromycin 40 mg/kg/day PO daily (4)[C]
Clinical judgment and use of a validated severity of illness score are recommended to determine if inpatient management is indicated.
The Pneumonia Severity Index (PSI) is a clinical prediction rule used to calculate the probability of morbidity and mortality among patients with CAP. PSI is risk stratified from I to V. PSI risk class from I to III can be treated as outpatients and IV to V should be hospitalized. PSI can be calculated at http://pda.ahrq.gov/clinic/psi/psicalc.asp.
The CURB-65 or CRB 65 (confusion, urea nitrogen RR, BP, age >65 years) (http://www.mdcalc.com/curb-65-severity-score-community-acquired-pneumonia/) is a severity of illness score for stratifying adults with CAP into different management groups.
The SMART-COP (systolic BP, multilobar chest radiography, albumin, RR, tachycardia, confusion, oxygen level, and arterial pH) is a new method to predict which patients will require intensive respiratory/vasopressor support. A score of ≥3 has sensitivity of 92% to identify those patients who will receive intensive treatment.
Patients with COPD or CHF are more likely to require ICU admission when suffering from CAP.
Clinical prediction tools do not replace a physician’s clinical judgment.
Inpatient treatment of children is recommended in the following settings: infants ≤3 to 6 months; presence of respiratory distress (tachypnea, dyspnea, retractions, grunting, nasal flaring, apnea, altered mental status, O2 sat <90%); or if known to have CAP as result of a virulent pathogen such as community-associated MRSA should be hospitalized (6).
Discharge criteria: clinical stability: temperature ≤100°F (37.8°C); HR ≤100 beats/min; RR ≤24 beats/min; systolic BP ≤90 mm Hg; O2 sat ≥90% or PaO2 ≥60 mm Hg on room air; ability to maintain oral intake; normal mental status
J15.9 Unspecified bacterial pneumonia
J15.4 Pneumonia due to other streptococci
J14 Pneumonia due to Hemophilus influenzae
J15.20 Pneumonia due to staphylococcus, unspecified
J15.3 Pneumonia due to streptococcus, group B
J15.5 Pneumonia due to Escherichia coli
J15.8 Pneumonia due to other specified bacteria
J15.0 Pneumonia due to Klebsiella pneumoniae
J13 Pneumonia due to Streptococcus pneumoniae
J15.29 Pneumonia due to other staphylococcus
J15.1 Pneumonia due to Pseudomonas
J15.6 Pneumonia due to other aerobic Gram-negative bacteria
J15.211 Pneumonia due to methicillin suscep staph
J15.7 Pneumonia due to Mycoplasma pneumoniae
J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureus
482.9 Bacterial pneumonia, unspecified
482.30 Pneumonia due to Streptococcus, unspecified
482.2 Pneumonia due to Hemophilus influenzae [H. influenzae]
482.40 Pneumonia due to Staphylococcus, unspecified
482.32 Pneumonia due to Streptococcus, group B
482.1 Pneumonia due to Pseudomonas
482.84 Pneumonia due to Legionnaires’ disease
482.0 Pneumonia due to Klebsiella pneumoniae
482.41 Methicillin susceptible pneumonia due to Staphylococcus aureus
482.31 Pneumonia due to Streptococcus, group A
482.42 Methicillin resistant pneumonia due to Staphylococcus aureus
482.82 Pneumonia due to escherichia coli [E. coli]
482.81 Pneumonia due to anaerobes
482.89 Pneumonia due to other specified bacteria
482.39 Pneumonia due to other Streptococcus
482.83 Pneumonia due to other gram-negative bacteria
482.49 Other Staphylococcus pneumonia
53084003 Bacterial pneumonia (disorder)
34020007 pneumonia due to Streptococcus (disorder)
70036007 Haemophilus influenzae pneumonia
22754005 Staphylococcal pneumonia (disorder)
429271009 ventilator-acquired pneumonia (disorder)
51530003 Pneumonia due to Escherichia coli
425464007 Nosocomial pneumonia (disorder)
409664000 Pneumonia due to anaerobic bacteria (disorder)
64479007 Pneumonia due to Klebsiella pneumoniae
Bacterial pneumonia can usually be treated empirically based on its classification as CAP or HCAP/HAP/VAP.
A severity of illness score is helpful in determining the need for hospitalization of adult patients but does not replace a physician’s clinical judgment.