This document provides information on the prevention, diagnosis, and treatment of community-acquired pneumonia (CAP). It discusses who is at increased risk for CAP and should receive pneumococcal and influenza vaccines. Key symptoms that should lead to consideration of a CAP diagnosis are discussed. Common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, and atypical pathogens; viruses are also often involved. Factors that increase the risk of specific pathogenic organisms are outlined.

1. in the clinic
in the clinic
Community-
Acquired
Pneumonia
Prevention page ITC4-2
Diagnosis page ITC4-3
Treatment page ITC4-7
Practice Improvement page ITC4-14
CME Questions page ITC4-16
Section Co-Editors The content of In the Clinic is drawn from the clinical information and
Christine Laine, MD, MPH education resources of the American College of Physicians (ACP), including
Sankey Williams, MD PIER (Physicians’ Information and Education Resource) and MKSAP (Medical
Knowledge and Self-Assessment Program). Annals of Internal Medicine
Physician Writer editors develop In the Clinic from these primary sources in collaboration with
Michael Niederman, MD the ACP’s Medical Education and Publishing Division and with the assistance
of science writers and physician writers. Editorial consultants from PIER and
MKSAP provide expert review of the content. Readers who are interested in these
primary resources for more detail can consult http://pier.acponline.org and other
resources referenced in each issue of In the Clinic.
CME Objectives: To review prevention, diagnosis, treatment, and practice
improvement for community-acquired pneumonia.
The information contained herein should never be used as a substitute for clinical
judgment.
© 2009 American College of Physicians

2. ommunity-acquired pneumonia (CAP) can vary from a mild out-
C patient illness to a more severe disease requiring admission to a hos-
pital or even an intensive care unit (ICU). Along with influenza,
CAP is the eighth leading cause of death in persons older than age 65 in the
United States and is the leading cause of death from infectious diseases. In
contrast to hospital-acquired pneumonia, CAP occurs in the community.
This distinction is becoming increasingly blurred because persons in contact
with health care environments, such as nursing homes and chronic hemodial-
ysis centers, and those recently discharged from the hospital may be infected
with multidrug resistant organisms. These infections have been termed “health
care–associated pneumonia.” The key management decisions are recognizing
and treating CAP in a timely and effective manner, defining the appropriate
site of care (home, hospital, or ICU), and ensuring effective prevention.
Prevention
Who is at increased risk for CAP? special environments, such as long-
Persons with a comorbid illness and term care facilities; if they are
elderly persons are at increased risk Alaskan natives or American Indi-
for pneumonia and for having a ans; or if they have any of the fol-
more complex illness. In 2005, 1.3 lowing chronic illnesses: congestive
million hospitalizations for pneu- heart failure, other cardiovascular
monia occurred in the United disease, COPD, asthma,,
1. American Lung Asso-
ciation. Trends in
States, and approximately 60% diabetes mellitus, alcoholism,
pneumonia and in- were in persons older than 65 years chronic liver disease, cerebrospinal
fluenza morbidity
and mortality, July (1). Comorbid illnesses that are as- fluid leaks, or functional or
2007. Accessed at
www.lungusa.org/atf
sociated with an increased inci- anatomic asplenia (including sickle
/cf/%7B7a8d42c2- dence of CAP include respiratory cell disease). Although vaccine effi-
fcca-4604-8ade-
7f5d5e762256%7D/A disease, such as chronic obstructive cacy may be reduced, immuno-
LA_LDD08_INFLUEN- pulmonary disease (COPD); car- compromised patients should be
ZA_FINAL.PDF on 24
August 2009. diovascular disease; and diabetes vaccinated, including patients with
2. Nuorti JP, Butler JC,
Farley MM, et al. Ciga-
mellitus. In addition, cigarette HIV infection, leukemia, lym-
rette smoking and in- smoking and alcohol abuse are phoma, Hodgkin disease, multiple
vasive pneumococcal
disease. Active Bacte- quite common in those with severe myeloma, generalized malignant
rial Core Surveillance forms of CAP, and cigarette smok- conditions, chronic renal disease,
Team. N Engl J Med.
2000;342:681-9. ing is a risk factor for bacteremic nephrotic syndrome, and immuno-
[PMID: 10706897]
3. Walker FJ, Singleton
pneumococcal infection (2). Other suppressive therapy (including
RJ, Bulkow LR, et al. common illnesses in those with long-term corticosteroids).
Reactions after 3 or
more doses of pneu- CAP include malignant conditions
mococcal polysac- and any neurologic illness that pre- Use the 23-valent polysaccharide
charide vaccine in
adults in Alaska. Clin disposes to aspiration, including vaccine in adults; the 7-valent con-
Infect Dis.
seizures. jugate vaccine that is used in chil-
2005;40:1730-5.
[PMID: 15909258] dren has not been approved for
4. Jackson LA, Neuzil Who should receive pneumococcal adults. In persons older than 65
KM, Yu O, et al. Effec-
tiveness of pneumo- vaccination and when should they years, revaccinate once after 5 years
coccal polysaccha-
ride vaccine in older receive it? anyone who was initially vaccinated
adults. N Engl J Med. All high-risk persons should be before age 65. Revaccinate
2003;348:1747-55.
[PMID: 12724480] vaccinated. The timing of vaccina- immunocompromised patients once
5. Fisman DN, Abrutyn
E, Spaude KA, et al.
tion depends on the indication. All 5 years after the initial vaccination.
Prior pneumococcal persons older than 65 years should Consider vaccinating anyone hospi-
vaccination is associ-
ated with reduced be vaccinated, and risk factors talized for a medical illness, be-
death, complications,
and length of stay
should be reviewed for other per- cause they are at increased risk for
among hospitalized sons, with a special effort in those pneumonia. Do not worry about
adults with commu-
nity-acquired pneu- older than 50 years. Vaccination harm from repeat vaccination, be-
monia. Clin Infect Dis. should be offered to immuno- cause less than 1% of patients who
2006;42:1093-101.
[PMID: 16575726] competent patients if they live in received at least 3 pneumococcal
© 2009 American College of Physicians ITC4-2 In the Clinic Annals of Internal Medicine 6 October 2009

3. vaccinations had an adverse reac- conjugate vaccine may be more
tion, and no reaction was severe, immunogenic in patients with sickle
even if repeat vaccination was in cell disease than the 23-valent
less than 6 years (3). polysaccharide vaccine, more data
are needed, and necrotizing pneu-
Vaccination reduces the frequency monia caused by nonvaccine strains
of bacteremic pneumonia in healthy, may be more frequent in children
immunocompetent adults. Ran- who receive this vaccine (6).
domized, controlled trials (RCTs)
have not found reductions in the What is the role of influenza
frequency of bacteremic pneumonia vaccination in the prevention of
in adults with chronic illness, al- CAP and its complications?
though case–control studies report All patients at increased risk for
reductions from 56% to 81%. influenza complications and persons
who can transmit the infection to
Efficacy in nonbacteremic illness is less
high-risk patients, such as health care
certain. In 1 study of 47 365 patients older
than age 65, pneumococcal vaccine re-
workers, should be immunized yearly.
duced the incidence of pneumococcal In 1 meta-analysis of 20 studies, influenza
bacteremia (odds ratio, 0.56) but had no vaccine was shown to reduce pneumonia
impact on the frequency of CAP treated in by 53%, hospitalization by 50%, and mor-
or out of the hospital (4). In another study, tality by 68% (7). In addition, observational
pneumococcal vaccination reduced mor- studies suggest that influenza vaccine can
tality, shortened the length of hospital stay, reduce all-cause mortality during influen-
and decreased the frequency of respiratory za season by 27% to 54% and be cost-
failure and other complications (5). effective because of its ability to reduce 6. Bender JM, Ampofo
hospitalization rates for congestive heart K, Korgenski K, et al.
Efficacy has not been established in Pneumococcal
failure and pneumonia in elderly persons necrotizing pneumo-
patients with sickle cell disease, (8). Recent analyses question these bene- nia in Utah: does
chronic renal failure, immunoglob- fits, noting that few RCTs have been
serotype matter? Clin
Infect Dis.
ulin deficiency, Hodgkin disease, conducted in this population and that 2008;46:1346-52.
[PMID: 18419434]
lymphoma, leukemia, or multiple selection bias may lead to vaccination be- 7. Gross PA, Hermo-
myeloma. Although the 7-valent ing given to healthier persons (9, 10). genes AW, Sacks HS,
et al. The efficacy of
influenza vaccine in
elderly persons. A
meta-analysis and re-
Prevention... Elderly persons and those with a comorbid illness are at increased view of the literature.
risk for pneumonia. Identify persons at risk for CAP and its complications and of- Ann Intern Med.
1995;123:518-27.
fer them pneumococcal and influenza vaccination. Offer influenza vaccine yearly [PMID: 7661497]
to persons at risk for the disease, including health care workers. Repeat pneumo- 8. Nichol KL, Margolis
KL, Wuorenma J, et al.
coccal vaccination once after 5 years in persons who received the first dose be- The efficacy and cost
fore age 65 and in immunocompromised patients. Consider giving both vaccines effectiveness of vacci-
to patients hospitalized with a medical illness. nation against in-
fluenza among elder-
ly persons living in
the community. N
CLINICAL BOTTOM LINE Engl J Med.
1994;331:778-84.
[PMID: 8065407]
9. Centers for Medicare
Diagnosis & Medicaid Services.
Hospital Quality Ini-
tiative Overview. Ac-
Which symptoms should lead sweats, and weight loss. Fever and cessed at
clinicians to consider the chills have a sensitivity of 50% to www.cms.hhs.gov/H
ospitalQualityInits/Do
diagnosis of CAP? 85%, but may be absent in elderly wnloads/Hospi-
taloverview.pdf on 24
Pneumonia usually presents with persons. Dyspnea has a sensitivity August 2009.
both respiratory and systemic of 70% for the diagnosis of CAP, 10. Nelson JC, Jackson
ML, Weiss NS, et al.
symptoms, particularly in young whereas purulent sputum has a sen- New strategies are
patients and in those with an intact sitivity of only 50%. Hemoptysis needed to improve
the accuracy of in-
immune response. It should be sus- suggests necrotizing infection, such fluenza vaccine ef-
fectiveness esti-
pected when the patient has cough, as lung abscess, tuberculosis, or mates among
purulent sputum, pleuritic chest gram-negative pneumonia. Many seniors. J Clin Epi-
demiol 2009; 62:
pain, dyspnea, chills, fever, night older patients and those with 687-694.
6 October 2009 Annals of Internal Medicine In the Clinic ITC4-3 © 2009 American College of Physicians

4. chronic illness have a less-intense A cohort study of 3339 patients with invasive
immune response, and the disease pneumococcal infection found that if the
may go unrecognized because the patient had received penicillin, macro-
lide, fluoroquinolone, or trimethoprim–
patient has only nonrespiratory sulfamethoxazole in 3 months before the
symptoms. These include confu- onset of bacteremia, the organism was
sion, weakness, lethargy, falling, more likely to be resistant to the antibiotic
poor oral intake, and decompensa- that the patient had received (11).
tion of a chronic illness (for exam-
Viruses also can cause CAP, and 1
ple, congestive heart failure). Most
recent study found that they were
patients with CAP present with an
present in 18% of all patients who
acute illness of 1 to 2 days’ dura- had paired serologies. The most
tion, but symptoms may be present common viral organisms were in-
for longer in elderly persons. fluenza and parainfluenza virus,
followed by respiratory syncytial
Which organisms cause CAP?
virus and adenovirus. Nearly half of
The most commonly identified these patients had viral infection as
bacterial pathogens for CAP are part of a mixed infection, often
11. Toronto Invasive Streptococcus pneumoniae (pneumo-
Bacterial Disease with bacterial pathogens (12, 13).
Network. Predicting coccus); Haemophilus influenzae; and
antimicrobial resist-
ance in invasive atypical pathogens, such as My- Gram-negative bacteria have been
pneumococcal in-
coplasma pneumoniae, Chlamydophila found in up to 10% of patients with
fections. Clin Infect
Dis. 2005;40:1288-97. pneumoniae, and Legionella. Drug- CAP, particularly in those with a
[PMID: 15825031]
12. de Roux A, Marcos resistant pneumococcus (DRSP) is history of chronic cardiopulmonary
MA, Garcia E, et al. disease, residence in a nursing
Viral community-ac- more likely to be the cause in pa-
quired pneumonia home, multiple medical comorbid
tients older than 65 years and in
in nonimmunocom- conditions, recent antibiotic thera-
promised adults.
Chest.
those with alcoholism, noninvasive py, renal insufficiency, chronic liver
2004;125:1343-51. disease, antibiotic therapy within 3 disease, diabetes, or active malig-
[PMID: 15078744]
13. Falsey AR, Hen- months, multiple medical comorbid nant conditions (14). Pseudomonas
nessey PA, Formica
MA, et al. Respiratory conditions, exposure to children in aeruginosa should be considered in
syncytial virus infec-
tion in elderly and
a day care center, or immuno- persons with bronchiectasis, recent
high-risk adults. N suppressive illness (Table 1). hospitalization, or recent antibiotic
Engl J Med.
2005;352:1749-59.
[PMID: 15858184]
14. Arancibia F, Bauer TT,
Ewig S, et al. Com-
munity-acquired Table 1. Modifying Factors That Increase the Risk for Infection
pneumonia due to
gram-negative bac- With Specific Pathogens
teria and Organism Modifying Factor Putting Patient at Risk
pseudomonas
aeruginosa: inci- Penicillin-resistant and Age >65 years
dence, risk, and
prognosis. Arch In- drug-resistant pneumococci β-lactam therapy within the past 3 months
tern Med. Alcoholism
2002;162:1849-58.
[PMID: 12196083] Immune-suppressive illness (including therapy
15. El-Solh AA, Pietran- with corticosteroids)
toni C, Bhat A, et al.
Microbiology of se- Multiple medical comorbid conditions
vere aspiration Exposure to a child in a day care center
pneumonia in insti-
tutionalized elderly.
Am J Respir Crit Care Enteric gram-negative bacteria Residence in a nursing home
Med. 2003;167:1650-
4. [PMID: 12689848] Underlying cardiopulmonary disease
16. Carratalà J, Mykietiuk Multiple medical comorbid conditions
A, Fernández-Sabé
N, et al. Health care- Recent antibiotic therapy
associated pneumo-
nia requiring hospi- Pseudomonas aeruginosa Structural lung disease (bronchiectasis)
tal admission:
epidemiology, an- Corticosteroid therapy (prednisone, >10 mg/d)
tibiotic therapy, and
clinical outcomes.
Broad-spectrum antibiotic therapy for >7 d
Arch Intern Med. in the past month
2007;167:1393-9. Malnutrition
[PMID: 17620533]
© 2009 American College of Physicians ITC4-4 In the Clinic Annals of Internal Medicine 6 October 2009

5. therapy. Although anaerobic organ- pleural effusion. Specific findings
isms should be considered when that are associated with a poor out-
aspiration is a possibility (for exam- come include a respiratory rate
ple, in elderly patients with neuro- greater than 30 breaths/min, dias-
logic or swallowing disorders), in 1 tolic blood pressure less than
study the most common organisms 60 mm Hg, systolic blood pressure
identified in those at risk for aspi- less than 90 mm Hg, heart rate
ration were gram-negative bacteria greater than 125 beats/min, and
(15). Klebsiella pneumoniae has been temperature less than 35°C or
reported in patients with alco- greater than 40°C.
holism. Although some studies
suggest that health care–associated When should clinicians use chest
pneumonia pathogens are more radiography in the diagnosis of
similar to those in hospital-acquired CAP?
pneumonia than to those in CAP, Obtain a chest radiograph in any
not all studies confirm these find- patient with clinical features sug-
ings. Patients with health care– gesting CAP. Studies show that the
associated pneumonia who are clinical diagnosis of pneumonia is
most at risk for drug-resistant or- inaccurate; the clinical impression
ganisms are those with poor func- of pneumonia has an overall sensi-
tional status, severe illness, recent tivity ranging from 70% to 90%,
antibiotic therapy, and recent hos- and a specificity ranging from 40%
pitalization. Methicillin-resistant to 70% (17).
S. aureus can occur in patients with
health care–associated pneumonia When history and physical examination
findings were used to predict the presence 17. Mandell LA, Marrie
and also in previously healthy per- TJ, Grossman RF, et
sons after influenza (15, 16). of radiographic pneumonia in a study of al. Canadian guide-
lines for the initial
129 patients with lower respiratory tract in- management of
What is the role of history and fection (26 with pneumonia), no combina- community-ac-
quired pneumonia:
physical examination in the tion of findings was highly accurate. The an evidence-based
diagnosis of CAP? positive predictive value of each finding update by the Cana-
dian Infectious Dis-
varied from 17% to 43% (18).
History and physical examination eases Society and
the Canadian Tho-
are valuable for suggesting the It is especially important to have a racic Society. The
Canadian Communi-
presence of pneumonia, for predict- chest radiograph if the diagnosis is ty-Acquired Pneu-
ing the etiologic pathogen, and for uncertain or if pleural effusion,
monia Working
Group. Clin Infect
helping to define the severity of lung abscess, necrotizing pneumo- Dis. 2000;31:383-421.
illness. The history also should nia, or multilobar illness is suspect-
[PMID: 10987698]
18. Graffelman AW, le
identify risk factors for health care- Cessie S, Knuistingh
ed. If a pleural effusion is present, Neven A, et al. Can
associated pneumonia, such as hos-
obtain a decubitus film or comput- history and exam
pitalization or antibiotic therapy in alone reliably predict
ed tomography. Assume pneumonia pneumonia? J Fam
the past 90 days, residence in a Pract. 2007;56:465-
is present in the absence of a 70. [PMID: 17543257]
long-term care facility, chronic
radiographic infiltrate if the patient 19. Hopstaken RM, Wit-
dialysis, outpatient wound care, or braad T, van En-
has a convincing history and focal gelshoven JM, et al.
home infusion therapy. The history Inter-observer varia-
physical findings. A follow-up
should also focus on recent travel to tion in the interpre-
the southwestern United States radiograph may show an infiltrate. tation of chest radi-
ographs for
(endemic fungi), or southeast Asia Interobserver variability in chest pneumonia in com-
munity-acquired
or China (melioidosis, epidemic vi- radiographic interpretation was lower respiratory
ral pneumonia). Exposure to birds, shown in 1 study that compared tract infections. Clin
Radiol. 2004;59:743-
bats, farm animals, and rabbits the readings of at least 2 radiolo- 52. [PMID: 15262550]
20. Syrjälä H, Broas M,
should also be documented. gists. Positive agreement (59%) was Suramo I, et al. High-
less frequent than negative agree- resolution comput-
ed tomography for
Physical examination findings that ment (94%) (19). Computed the diagnosis of
community-ac-
suggest pneumonia include crack- tomography may show an infiltrate quired pneumonia.
les, bronchial breath sounds, when the chest radiograph is Clin Infect Dis.
1998;27:358-63.
tachypnea, fever, and findings of negative (20). [PMID: 9709887]
6 October 2009 Annals of Internal Medicine In the Clinic ITC4-5 © 2009 American College of Physicians

6. What is the role of other is effective. For example, when
laboratory tests in diagnosing CAP? pathogen-directed treatment was
For outpatients, perform pulse compared with empirical treatment
oximetry to assess oxygenation. using a broad-spectrum antibiotic,
No other testing is needed. the 2 groups did not significantly
differ in the length of hospital stay,
For inpatients, additional testing is 30-day mortality, clinical failure, or
done to define disease severity and to resolution of fever (22).
identify pathogens. Measure arterial
blood gasses in patients suspected of Measurement of serum levels of C-
having carbon dioxide retention. reactive protein or procalcitonin may
Collect sputum for Gram stain and be helpful, although current guide-
culture before starting therapy in pa- lines do not recommend their use.
tients suspected of infection with a C-reactive protein may identify
drug-resistant or unusual pathogen, which patients with acute respiratory
but only evaluate sputum if it is of symptoms have pneumonia; levels
good quality and is processed rapidly. are higher in patients who require
Collect 2 sets of blood cultures, and hospitalization and in patients with
test the urine for Legionella and pneumococcal and Legionella infec-
pneumococcal antigens when pa- tion. Low levels of procalcitonin
tients have severe pneumonia. Limit identify patients who do not benefit
blood cultures to patients with severe from antibiotic therapy whereas per-
illness; they are positive in only 10% sistently high levels identify patients
to 20% of all patients with CAP. who have a poor prognosis.
Culture an endotracheal aspirate in
patients who are intubated and me- A randomized trial of 302 patients with CAP
compared patients managed by usual care
chanically ventilated. The utility of
with those managed by an algorithm rec-
real-time polymerase chain reaction ommending the use of antibiotics and the
testing of sputum samples has not duration of therapy on the basis of serial
been demonstrated. measurement of procalcitonin using the
highly-sensitive Kryptor assay. Procalci-
One recent study of 13 043 Medicare pa- tonin was measured on admission and af-
tients identified the following predictors of ter 6 to 24 hours, 4 days, 6 days, and 8 days.
a true-positive blood culture: no previous The procalcitonin-guided group had signif-
antibiotics, underlying liver disease, systolic icantly fewer antibiotic prescriptions on ad-
blood pressure less than 90 mm Hg, fever mission and less antibiotic usage, and the
less than 35°C or greater than 40°C, pulse duration of therapy was reduced from 12 to
greater than 125/min, blood urea nitrogen 5 days with similar clinical success (23).
greater than 10.71 mmol/L (30 mg/dL),
serum sodium less than 130 mmol, and What other disorders should
leukocyte count less than 5 or greater than clinicians consider in patients
20 × 109 cells/L. The diagnostic yield of
suspected of having CAP?
blood cultures increased in patients with 1
21. Metersky ML, Ma A,
or more risk factor and in those who had If the patient does not respond to
Bratzler DW, et al.
Predicting bac- not received antibiotics before blood was empirical therapy after 48 to 72
teremia in patients
with community-ac- collected (21). hours, consider the possibility of
quired pneumonia. viruses or unusual bacterial
Am J Respir Crit Care
Med. 2004;169:342-
Even with extensive diagnostic pathogens, such as Mycobacterium
7. [PMID: 14630621] testing, a specific etiologic diagno- tuberculosis, Coxiella burnetii (Q
22. van der Eerden MM,
Vlaspolder F, de sis is obtained in less than half of fever), Burkholderia pseudomalle
Graaff CS, et al. Com-
parison between
all patients with CAP. Do not per- (melioidosis), Chlamydia psittaci
pathogen directed form serologic tests for viruses and (psittacosis), Paragonimiasis, En-
antibiotic treatment
and empirical broad atypical pathogens, because they demic fungi (histoplasmosis, coc-
spectrum antibiotic require convalescent titers 6 to 8 cidioidomycosis, blastomycosis),
treatment in pa-
tients with commu- weeks after the initial test to iden- Pasteurella multocida, Bacillus
nity acquired pneu-
monia: a prospective
tify infection. Establishing a specific anthracis, Actinomyces Israeli,
randomised study. etiologic diagnosis usually is not Francisella tularensis (tularemia),
Thorax. 2005;60:672-
8. [PMID: 16061709] necessary, because empirical therapy Leptospira spp, Nocardia spp,
© 2009 American College of Physicians ITC4-6 In the Clinic Annals of Internal Medicine 6 October 2009

7. Rhodococcus equi, and Yersinia pestis When should clinicians consider
(plague). Also consider noninfec- specialty consultation for the
tious possibilities, such as bron- diagnosis of pneumonia, and
chiolitis obliterans, organizing which types of specialists should
pneumonia, pulmonary vasculitis, they consult?
hypersensitivity pneumonitis, inter- Consultation is most valuable
stitial diseases, lung cancer, lym- when patients do not respond to
phangitic carcinoma, lymphoma, initial therapy. An infectious dis-
and congestive heart failure, par- ease specialist can help identify
ticularly if the patient is younger unusual infections and infectious
than 55 years, is a nonsmoker, and complications of pneumonia.
has a nonfocal lung infiltrate. If A pulmonary specialist can help
the patient starts to respond to identify inflammatory lung dis-
therapy and then his condition ease and pulmonary embolus,
deteriorates, consider pulmonary perform a bronchoscopy, and
embolus, antibiotic-induced coli- perform a transbronchial biopsy.
tis, empyema, meningitis, and en- A surgeon can perform an open-
docarditis. lung biopsy.
Diagnosis... Clinical findings are less dramatic in elderly persons. History is particularly
valuable for defining risk factors for specific pathogens, whereas physical findings
help define disease severity. Confirm the diagnosis of CAP with a chest radiograph,
although this test is not always diagnostic early in the course of illness. Laboratory
testing has limited value; its main use is to define pneumonia severity and to identify
systemic and respiratory complications. Diagnosing specific pathogens early is less
useful because most initial therapy is empirical. If the patient does not respond to
initial therapy, consult specialists and consider bronchoscopy and lung biopsy.
CLINICAL BOTTOM LINE
How should clinicians determine
Treatment
condensed into the “CURB-65,”
whether a patient with CAP which is based on the presence of
requires outpatient, inpatient, or Confusion, blood Urea nitrogen
ICU care? greater than 7.0 mmol/L (19.6
Many site-of-care decisions can be mg/dL), Respiratory rate of 30
facilitated with the Pneumonia
breaths/min or greater, systolic
Severity Index (PSI) or the British
Thoracic Society (BTS) rule. These Blood pressure less than 90 mm Hg
tools predict the risk for dying; pa- or diastolic blood pressure no greater
tients with a high risk are generally than 60 mm Hg, and age 65 years or
managed in the hospital, and those older. Patients meeting at least 2 of 23. Christ-Crain M, Stolz
with the highest risk are managed in these criteria are usually admitted to D, Bingisser R, et al.
Procalcitonin guid-
the ICU. The PSI stratifies patients the hospital, whereas those with at ance of antibiotic
therapy in commu-
into 5 categories by using a scoring least 3 criteria are considered for nity-acquired pneu-
system based on patient age, comor- ICU admission. monia: a random-
ized trial. Am J
bid illness, physical examination Respir Crit Care Med.
findings, and laboratory data. One prospective study of 3181 patients 2006;174:84-93.
[PMID: 16603606]
Patients in classes IV and V are seen in 32 different emergency depart- 24. Aujesky D, Auble TE,
Yealy DM, et al.
generally admitted to the hospital, ments compared the PSI with the CURB Prospective compar-
those in classes I and II are often and CURB-65 criteria and found that both ison of three validat-
ed prediction rules
treated as outpatients, and those in approaches were successful in identifying for prognosis in
community-ac-
class III have the site-of-care deci- low-risk patients. The CURB-65 was better quired pneumonia.
sion based on careful clinical assess- for predicting mortality risk in high-risk Am J Med.
2005;118:384-92.
ment. The BTS rule has been patients (24). [PMID: 15808136]
6 October 2009 Annals of Internal Medicine In the Clinic ITC4-7 © 2009 American College of Physicians

8. In another prospective study of 1651 pa- quionolone (gemifloxacin, levo-
tients, measurement of serum procalcitonin floxacin, or moxifloxacin) or a
supplemented the data obtained by prog- combination of a β-lactam (amoxi-
nostic scoring, and patients who had a low cillin, 3 g/d; amoxicillin–clavulanate,
value of procalcitonin had a low mortality,
cefpodoxime, or cufuroxime) with a
regardless of PSI class or number of CURB-65
points (25).
macrolide or doxycycline. If the
patient has received an antibiotic
Current guidelines suggest ICU care in the past 3 months, avoid using an
if the patient needs assisted ventila- antibiotic in the same class.
tion or has septic shock requiring
vasopressors or if the patient has at How long should outpatients
least 3 of the following: respiratory continue antibiotic treatment?
rate of 30 breaths/min or greater, Base the duration of therapy on the
PaO2 /FiO2 ratio no greater than 250, patient’s clinical response, severity
multilobar infiltrates, confusion or of illness, and probable pathogen.
disorientation, blood urea nitrogen Treat outpatients with mild-to-
7.1 mmol/L (20 mg/dL) or greater, moderate CAP for 7 days or fewer
leukocyte count less than 4 × 109 if there is a good clinical response,
cells/L, platelet count less than 100 × no fever for 48 to 72 hours, and no
109 cells/L, temperature less than sign of extrapulmonary infection.
36°C, and hypotension requiring ag- Azithromycin has such a long half-
25. GenIMS Investiga-
tors. Risk prediction gressive fluid resuscitation (26), al- life that therapy for 1 or 3 days
with procalcitonin
though 1 study has questioned the may be effective.
and clinical rules in
community-ac-
quired pneumonia.
utility of using only minor criteria to A meta-analysis of 15 RCTs of mild-to-
Ann Emerg Med. define the need for ICU care (27). moderate CAP found that therapy for 7
2008;52:48-58.e2.
[PMID: 18342993] days or fewer was as effective as longer
26. Infectious Diseases What is the role of nondrug therapy with regard to clinical failure, mor-
Society of America.
Infectious Diseases
therapies in treating CAP? tality, adverse events, and bacteriologic
Society of Ameri- In outpatients, focus nondrug therapy eradication. The trials compared only
ca/American Tho-
racic Society con- on encouraging oral hydration. For monotherapies, and 13 of the short-dura-
sensus guidelines on
the management of
hospitalized patients, nondrug thera- tion trials used azithromycin, fluoro-
community-ac- pies include intravenous hydration quinolones, or ketolides, which provide
quired pneumonia
in adults. Clin Infect and oxygen for hypoxemia. Chest coverage for both pneumococcal and
Dis. 2007;44 Suppl physiotherapy has not been widely atypical pathogens. Only 2 short-duration
2:S27-72.
[PMID: 17278083] studied, but it has been shown to trials used β-lactam monotherapy (29).
27. Liapikou A, Ferrer M,
Polverino E, et al. Se-
improve the outcome of patients
vere community-ac- with pneumonia who have more How should clinicians follow
quired pneumonia:
than 30 mL/d of sputum and im- patients during outpatient
validation of the In-
fectious Diseases So- paired clearance of secretions (28). treatment of CAP?
ciety of Up to 10% of patients initially
America/American
Thoracic Society When using outpatient treatment managed at home do not respond
guidelines to predict
an intensive care for CAP, which antibiotics should to outpatient therapy and require
unit admission. Clin
Infect Dis.
clinicians prescribe? hospitalization. To identify these
2009;48:377-85. For patients with no cardiopul- patients early, the physician and
[PMID: 19140759]
28. Graham WG, Bradley monary disease and no factors that patient should agree on a plan to
DA. Efficacy of chest
physiotherapy and
increase risk for infection with monitor the response to therapy.
intermittent posi- DRSP or enteric gram-negative Ask patients to measure an oral
tive-pressure breath-
ing in the resolution bacteria (Table 1), prescribe a temperature every 8 hours and to
of pneumonia. N macrolide (azithromycin, clari- report if it increases higher than
Engl J Med.
1978;299:624-7. thromycin, or erythromycin) or 38.3°C (101°F) or if it does not
[PMID: 355879]
29. Li JZ, Winston LG, doxycycline (Table 2). For outpa- decrease below 37.2°C (99°F) after
Moore DH, et al. Effi- tients who have cardiopulmonary 48 hours. Encourage patients to
cacy of short-course
antibiotic regimens disease or factors that increase the drink at least 1 to 2 quarts of liquid
for community-ac-
quired pneumonia: a
risk for infection with DRSP or daily, and ask them to report if they
meta-analysis. Am J enteric gram-negative bacteria, cannot achieve this goal. Instruct
Med. 2007;120:783-
90. [PMID: 17765048] prescribe an antipneumococcal patients to report symptoms of
© 2009 American College of Physicians ITC4-8 In the Clinic Annals of Internal Medicine 6 October 2009

9. Table 2. Drug Treatment for Community-Acquired Pneumonia
Agent Mechanism of Action Dosage Benefits Side Effects and Notes
Macrolides Bacteriostatic, binds to Azithromycin, 500 mg on Cover pneumococcus, Nausea, vomiting, diarrhea, QT
Azithromycin the 50S ribosomal subunit, day 1 (IV or PO), followed atypical pathogens, prolongation, dyspepsia
Clarithromycin and inhibits bacterial by 500 mg (IV or PO) for and Haemophilus (clarithromycin). Use as
protein synthesis. 7–10 d for hospitalized influenzae. monotherapy only in patients
patients. 250 mg on d without cardiopulmonary disease
2–5 for outpatients. or modifying factors. Otherwise,
Azithromycin in the micro- combine with a β-lactam agent.
spheres oral extended- Erythromycin is less expensive but
release formulation, 2 g on not recommended because of the
day 1 (PO) without follow- need for more frequent dosing,
up dosing for outpatients. more intestinal upset, and no
Clarithromycin, 500 mg coverage of H. influenzae.
bid PO, or 1000 mg/d PO
(extended-release
preparation) for outpatients.
Penicillins Bactericidal, interferes Amoxicillin/clavulanate, Active against Anaphylaxis, rash, nausea,
Amoxicillin/clavulanate with peptidoglycan 875 mg bid PO; Ampicillin, pneumococci and vomiting, diarrhea, phlebitis,
Ampicillin cross-linking, and 500–1000 mg tid PO; β-lactamase-producing seizures (high doses), hypokalemia
Ampicillin/sulbactam prevents formation of Ampicillin/sulbactam, H. influenzae. (high doses), elevated liver tests,
the bacterial cell wall. 1–2 g q6h IV. prolonged prothrombin time
(especially if on coumadin). Do not
use alone in CAP. Combine with a
macrolide.
Antipseudomonal Bactericidal, interferes Piperacillin/tazobactam, Active against Anaphylaxis, rash, nausea,
β-lactams with peptidoglycan 3.375 mg q4–6h IV; pneumococci and vomiting, diarrhea, phlebitis,
Piperacillin/tazobactam cross-linking, and Cefepime, 1–2 g q12h IV; Pseudomonas seizures (high doses), hypokalemia
Cefepime prevents formation of Imipenem, 1 g q8h IV aeruginosa. (high doses), elevated liver tests,
Imipenem the bacterial cell wall. or 500 mg q6h IV; prolonged prothrombin time
Meropenem Meropenem, 1 g q8h IV. (especially if on coumadin).
Seizure potential greater with
imipenem than meropenem. Only
use for patients with pseudomonal
risk factors, although generally ac-
tive against DRSP. Can dose daily
if patient has renal insufficiency.
Cephalosporins Bactericidal, interferes Cefuroxime, 500 mg bid PO; Active against Anaphylaxis, rash, nausea,
Cefuroxime with peptidoglycan Cefpodoxime, 400 mg bid PO; pneumococci and vomiting, diarrhea, elevated liver
Cefpodoxime cross-linking, and Ceftriaxone, 1–2 g q12–24h H. influenzae, including function test results, interstitial
Ceftriaxone prevents formation of (usually q24h); β-lactamase–producing nephritis, altered coagulation,
Cefotaxime the bacterial cell wall. Cefotaxime, 1 g q8h. organisms. pseudomembranous colitis. Not
to be used alone in CAP. Combine
with a macrolide. Although
cefuroxime can be used as oral
therapy, it should not be used IV,
because it is not as active against
DRSP as other cephalosporins.
Quinolones Bactericidal, interferes Ciprofloxacin, 400 mg q8-12h Ciprofloxacin and Levo- Seizures, hypersensitivity, photo-
Ciprofloxacin with bacterial DNA gyrase. IV; Gemifloxacin, 320 mg/d floxacin are active against sensitivity, tendon rupture, nausea,
Gemifloxacin Kills bacteria in a (PO only); Levofloxacin, P. aeruginosa, atypicals, vomiting, diarrhea, QT prolongation.
Levofloxacin concentration-dependent 750 mg/d (IV or PO); and H. influenzae. Ciprofloxacin: only to be used in
Moxifloxacin fashion. Moxifloxacin, 400 mg/d Levofloxacin and severe CAP. Not always reliable
(IV or PO). Moxifloxacin are the against pneumococci, and should
“respiratory quinolones” be combined with other agents if
with activity against DRSP is possible. If used in severe
DRSP, H. influenzae, CAP, do not use as monotherapy.
and atypical pathogens.
Tetracyclines Bacteriostatic, binds to Doxycycline, 100 mg bid Active against key Nausea, vomiting, diarrhea,
Doxycycline 30S ribosomal subunit, (IV or PO). bacterial and atypical photosensitivity. Not always fully
and interferes with pathogens. reliable against pneumococci.
bacterial protein synthesis.
bid = twice daily; CAP = community-acquired pneumonia; DNA = deoxyribonucleic acid; DRSP = drug-resistant Streptococcus pneumonia; IV = intra-
venous; PO = oral; tid = three times daily.
6 October 2009 Annals of Internal Medicine In the Clinic ITC4-9 © 2009 American College of Physicians

10. chest pain, severe or increasing 75.9% to 58.9% after the initiation
shortness of breath, or lethargy. of a program to give more patients
Encourage patients to take their antibiotics within 4 hours of arrival
30. Meehan TP, Fine MJ, antibiotic therapy on schedule and in the emergency department (31).
Krumholz HM, et al.
Quality of care,
to continue taking antibiotic thera-
process, and out- py after they begin feeling better Give hospitalized patients who are
comes in elderly pa-
tients with pneumo- until they have taken all of it. not in the ICU intravenous
nia. JAMA. azithromycin if they have no cardio-
1997;278:2080-4.
[PMID: 9403422] If the response to therapy is satis- pulmonary disease and no factors
31. Kanwar M, Brar N, factory, ask the patient to return for that increase the risk for DRSP or
Khatib R, et al. Misdi-
agnosis of commu- a repeat examination within 10 to gram-negative bacteria (26, 32).
nity-acquired pneu-
monia and
14 days. Give pneumococcal and For hospitalized patients not in the
inappropriate utiliza- influenza vaccinations if they have ICU who have cardiopulmonary
tion of antibiotics:
side effects of the 4- not previously been given. Obtain a disease or factors that increase the
h antibiotic adminis-
tration rule. Chest.
repeat chest radiograph no sooner risk for DRSP or gram-negative
2007;131:1865-9. than 1 month after starting pneu- bacteria, give an intravenous
[PMID: 17400668]
32. Feldman RB, Rhew monia therapy. Exclude lung can- quinolone (levofloxacin, 750 mg,
DC, Wong JY, et al. cer, immunodeficiency, and other when renal function is normal or
Azithromycin
monotherapy for pa- possibilities during follow-up visits. moxifloxacin, 400 mg/d) or the
tients hospitalized
with community-ac- combination of a β-lactam (cefo-
quired pneumonia: a When patients require hospital- taxime, ceftriaxone, ampicillin–
31/2-year experi- ization for CAP, how soon after
ence from a veter- sulbactam, or high-dose ampicillin,
ans affairs hospital. admission should antibiotics be but not cefuroxime) with a macro-
Arch Intern Med.
2003;163:1718-26. started, and which antibiotics lide or doxycycline (26). The addi-
[PMID: 12885688] should patients receive if they do tion of a macrolide to a β-lactam
33. Gleason PP, Kapoor
WN, Stone RA, et al. not need ICU care? has been associated with a reduc-
Medical outcomes
and antimicrobial
Patients should receive initial anti- tion in mortality and length of hos-
costs with the use of biotic therapy as soon as possible pital stay (33, 34) even for bac-
the American Tho-
racic Society guide- after the diagnosis of pneumonia is teremic pneumococcal pneumonia
lines for outpatients
with community-ac-
established and before the patient (35). Specific β-lactams are pre-
quired pneumonia. leaves the emergency department. ferred if DRSP is suspected. Cef-
JAMA. 1997;278:32-9.
[PMID: 9207335] A large Medicare study found that triaxone and cefotaxime are as
34. Brown RB, Iannini P,
Gross P, et al. Impact
antibiotic administration within 4 effective against DRSP with mean
of initial antibiotic hours of arrival to the hospital was
choice on clinical inhibitory concentration values up
associated with a lower mortality
outcomes in com- to 2 mg/L as they are against non-
munity-acquired and a shorter length of stay. As a
pneumonia: analysis resistant organisms (36). Cefurox-
result, prompt antibiotic adminis-
of a hospital claims-
made database.
ime may not be an ideal β-lactam if
tration has become a widely used
Chest. DRSP is suspected, because 1 study
2003;123:1503-11. measure of the quality of pneumo-
[PMID: 12740267] showed increased mortality when
35. Martínez JA, Horca- nia care (9, 30). However, delayed
this agent was used in patients with
jada JP, Almela M, et administration of antibiotics may
al. Addition of a bacteremic DRSP (37).
macrolide to a beta- be only a surrogate for other factors
lactam-based empir-
ical antibiotic regi- that are the direct causes of in- One international study of 4337 hospital-
men is associated creased mortality; for example, ized patients with CAP showed that
with lower in-hospi-
tal mortality for pa- immunocompromised patients approximately 20% had evidence of
tients with bac- atypical pathogen infection and that
teremic
probably have higher mortality
pneumococcal rates and have atypical presenta- therapy directed against these organisms
pneumonia. Clin In- decreased the time to clinical stability,
fect Dis. tions that probably delay the start
2003;36:389-95. of therapy. Too strong a focus on length of stay, total mortality, and CAP-
[PMID: 12567294] related mortality (38). However, another
36. Lujan M, Gallego M, timely antibiotic therapy can result
Fontanals D, et al. study of 2209 hospitalized Medicare pa-
Prospective observa- in unnecessary antibiotic use in pa-
tients with bacteremic pneumonia found
tional study of bac- tients who do not have pneumonia. that therapy directed at atypical patho-
teremic pneumo-
coccal pneumonia: In 1 study, the final diagnosis of gens led to reduced 30-day mortality and
Effect of discordant
therapy on mortality.
pneumonia in patients suspected of 30-day readmission rate, but the benefits
Crit Care Med. having pneumonia in the emer- occurred only with macrolides and not
2004;32:625-31.
[PMID: 15090938] gency department decreased from with fluoroquinolones (39).
© 2009 American College of Physicians ITC4-10 In the Clinic Annals of Internal Medicine 6 October 2009

11. Which antibiotics should be given What are the other components
to patients admitted to an ICU? of ICU care for CAP?
No patient in the ICU should receive Consider hydration, supplemental
empirical monotherapy. Assess these oxygen, and chest physiotherapy, 37. International Pneu-
patients for risk factors for P. aerugi- but the major issue is ventilatory mococcal Study
Group. An interna-
nosa. Treat those without risk factors support for respiratory failure. Use tional prospective
study of pneumo-
with intravenous ceftriaxone or cefo- intubation and mechanical ventila- coccal bacteremia:
taxime plus either azithromycin or a tion in patients who have oxygen correlation with in
vitro resistance, an-
quinolone, such as levofloxacin or saturation less than 90% on maxi- tibiotics adminis-
tered, and clinical
moxifloxacin. Treat patients who mal mask oxygen, inability to clear outcome. Clin Infect
have risk factors with an intravenous, secretions, inability to protect the Dis. 2003;37:230-7.
[PMID: 12856216]
antipseudomonal β-lactam (cefe- airway, or hypercarbia. If the pa- 38. Community-Ac-
pime, piperacillin–tazobactam, tient has only hypoxemia or hyper- quired Pneumonia
Organization (CAPO)
imipenem, meropenem) plus an in- carbia and is alert and cooperative, Investigators. A
worldwide perspec-
travenous quinolone effective against it may be possible to use noninva- tive of atypical
Pseudomonas (ciprofloxacin or high- sive positive pressure ventilation, pathogens in com-
munity-acquired
dose levofloxacin). Alternatively, treat which may be associated with fewer pneumonia. Am J
Respir Crit Care Med.
patients who have risk factors with complications than endotracheal 2007;175:1086-93.
an intravenous, antipseudomonal intubation, including ventilator- [PMID: 17332485]
39. Metersky ML, Ma A,
β-lactam (cefepime, piperacillin– associated pneumonia. Houck PM, et al. An-
tazobactam, imipenem, meropenem) tibiotics for bac-
teremic pneumonia:
combined with an aminoglycoside Consider systemic corticosteroids, Improved outcomes
with macrolides but
(amikacin, gentamicin, or tobra- especially if relative adrenal insuf- not fluoro-
mycin) plus either an intravenous ficiency is suspected. Because quinolones. Chest.
2007;131:466-73.
macrolide (azithromycin or erythro- many patients with severe CAP [PMID: 17296649]
40. Rello J, Catalán M,
mycin) or intravenous antipneumo- also have systemic sepsis, consider Díaz E, et al. Associa-
coccal quinolone (levofloxacin or using drotrecogin α, aggressive tions between em-
pirical antimicrobial
moxifloxacin). In studies of patients hydration, vasopressors, and meas- therapy at the hospi-
admitted to the ICU with severe urement of serum lactate. Do not tal and mortality in
patients with severe
CAP, mortality was reduced when use granulocyte-colony stimulating community-ac-
quired pneumonia.
combination therapy was used; factor routinely for patients with Intensive Care Med.
monotherapy, even with a quinolone, severe CAP. 2002;28:1030-5.
[PMID: 12185421]
was not as effective. In general, the 41. International Pneu-
addition of a macrolide to therapy In 1 study of 40 patients with severe CAP, mococcal Study
Group. Combination
with a β-lactam (either a cephalo- when random serum cortisol levels were antibiotic therapy
measured in the first 72 hours, 65% of pa-
sporin or β-lactam or β-lactamase
lowers mortality
among severely ill
tients met criteria for adrenal insufficiency,
inhibitor) led to the best outcomes patients with pneu-
and 63% of the 19 patients with CAP and mococcal bac-
(40). In patients with bacteremic septic shock also had adrenal insufficiency teremia. Am J Respir
Crit Care Med.
pneumococcal pneumonia and critical (43). In 4 studies, including randomized tri- 2004;170:440-4.
illness, studies have found that mor- als, evidence was inconsistent for a benefit [PMID: 15184200]
42. Micek ST, Dunne M,
tality was lower with combination from routine corticosteroid therapy, but if Kollef MH. Pleu-
ropulmonary com-
therapy than with monotherapy (41). the patient required this therapy for anoth- plications of Panton-
er reason (such as underlying COPD), corti- Valentine
If community-acquired methicillin- costeroid therapy seemed to cause no leukocidin-positive
community-ac-
resistant S. aureus is suspected, add ei- harm (44). quired methicillin-re-
sistant Staphylococ-
ther linezolid alone or vancomycin in cus aureus:
combination with clindamycin, be- In a randomized, placebo-controlled tri- importance of treat-
cause both of these regimens are anti- al, drotrecogin α led to reduced mortality ment with antimi-
crobials inhibiting
bacterial and inhibit the production for patients with severe sepsis, including exotoxin production.
the 35.6% of patients who had severe Chest.
of bacterial toxins. Vancomycin alone 2005;128:2732-8.
CAP. Patients who were vasopressor- [PMID: 16236949]
is antibacterial but cannot inhibit tox- dependent and were treated with the 43. Salluh JI, Verdeal JC,
in production (42). These regimens drug had a relative risk reduction in mor-
Mello GW, et al. Cor-
tisol levels in pa-
are recommended, even though the tality of 28% at 28 days. The survival ben- tients with severe
community-ac-
organisms are often sensitive in vitro efit was most pronounced in patients quired pneumonia.
to trimethoprim–sulfamethoxizole with severe CAP and S. pneumoniae and Intensive Care Med.
2006;32:595-8.
and quinolones. in patients with severe CAP at high risk [PMID: 16552616]
6 October 2009 Annals of Internal Medicine In the Clinic ITC4-11 © 2009 American College of Physicians

12. for death as indicated by Acute Physiolo- When should a consultation be
gy and Chronic Health Evaluation II score requested for hospital patients,
25 or greater, PSI score IV or greater, or and which types of specialists or
CURB-65 score 3 or greater (45). subspecialists should be
consulted?
When can clinicians switch
Ask for an infectious disease or pul-
hospitalized patients from
monary consultation if there are
intravenous to oral antibiotics? questions about the selection of ini-
Switch from intravenous to oral tial antibiotic therapy or when the
antibiotics once the symptoms of patient does not respond to initial
cough, sputum production, and therapy. Ask for a pulmonary or crit-
dyspnea improve; the patient is ical care consultant for patients with
afebrile on 2 occasions 8 hours severe illness to help select anti-
apart; and the patient is able to biotics, decide about using vasopres-
take medications orally. This sors, determine the appropriate site
switch can be made as early as 24 of care, decide about the need for
to 48 hours after admission and is ventilatory support, and aid in man-
made by day 3 in up to half of all aging the mechanical ventilator. Ask
patients. The switch to oral thera- for a pulmonary consultant if a pleu-
py can be done safely even if ral effusion is documented and help
pneumococcal bacteremia has been is needed with a thoracentesis. Ask
documented, although these pa- for a pulmonary or thoracic surgical
tients may take longer to respond. consultation for placement of a chest
Longer durations of therapy may tube if a complicated parapneumonic
be needed for patients infected effusion or empyema is found on
with P. aeruginosa or S. aureus or thoracentesis, because early therapy
for those with extrapulmonary can reduce hospital stay and avoid
complications, such as empyema complications. A thoracic surgeon
or meningitis. Select an oral regi- can perform surgical decortication
men that covers all organisms iso- for advanced and loculated pleural
44. Salluh JI, Póvoa P, lated in blood or sputum cultures effusion and empyema. A cardiology
Soares M, et al. The
role of corticos- and reflects the intravenous thera- consultation may be needed if com-
teroids in severe py. For some patients, this will
community-ac-
plications of cardiac ischemia or con-
quired pneumonia: a mean a β-lactam–macrolide com- gestive heart failure occur. In a study
systematic review.
Crit Care. bination or a quinolone alone. In of 170 patients with pneumococcal
2008;12:R76.
[PMID: 18547407]
patients who have responded to a pneumonia, 19.4% had at least 1
45. PROWESS Clinical β-lactam–macrolide combination, major cardiac event, including 12
Evaluation Commit-
tee. Severe commu- therapy can be continued on a with acute myocardial infarction, 8
nity-acquired pneu-
monia as a cause of
macrolide alone unless cultures with new-onset atrial fibrillation or
severe sepsis: data justify dual therapy. ventricular tachycardia, and 13 with
from the PROWESS
study. Crit Care Med. newly diagnosed or worsening heart
2005;33:952-61. To facilitate the switch to oral therapy, failure without other cardiac compli-
[PMID: 15891319] hospitals should consider using a stand-
46. Fishbane S, Nieder- cations. The patients with cardiac
man MS, Daly C, et ing order set supplemented by prospec- events had a significantly higher
al. The impact of
tive case management. In a cohort study,
standardized order mortality rate (27.3% vs. 8.8%) (47).
sets and intensive patients were managed in each of 3 suc-
clinical case man-
agement on out-
cessive time periods with conventional When can inpatients be
comes in communi- therapy, a guideline-based order set sup- discharged from the hospital?
ty-acquired
ported by prospective case management
pneumonia. Arch In- Discharge patients once the switch
tern Med. that provided feedback to clinicians, and
2007;167:1664-9. to oral therapy is made, because no
[PMID: 17698690] a guideline-based order set alone. In all 3
47. Musher DM, Rueda time periods, the time to clinical stability
proven benefit exists for observa-
AM, Kaka AS, et al.
was similar, but prospective case man- tion in the hospital. In 1 study,
The association be-
tween pneumococ- agement led to the greatest reductions in two-thirds of clinically stable
cal pneumonia and
acute cardiac events. the time to oral antibiotics, time from patients were observed on oral
Clin Infect Dis. oral therapy to discharge, and overall therapy before discharge, and no
2007;45:158-65.
[PMID: 17578773] length of stay (46). deterioration occurred during this
© 2009 American College of Physicians ITC4-12 In the Clinic Annals of Internal Medicine 6 October 2009