User Tools

Site Tools


cap

community acquired pneumonia (CAP) in adults

introduction

  • CAP means pneumonia acquired in the community and NOT following a period of recent hospitalisation where there would be a much higher risk of antibiotic resistant or different organisms causing the pneumonia
  • for a clinical diagnosis of CAP, one generally would like to see:
    • typical clinical picture of cough, fever, SOB, and purulent sputum, combined with
    • CXR infiltrate consistent with pneumonia
  • patients with bilateral interstitial changes may still be pneumococcal but other causes should be considered such as:

initial Ix and Mx in the ED for suspected CAP in the adult patient

  • supplemental oxygen Rx if SaO2 < 92%
  • FBE, U&E, glucose
  • consider iv access and iv fluids if confused, dehydrated or hypotensive, or likely to need admission
  • CXR
  • if patient likely to be admitted, send the following cultures:
  • aim to start antibiotic Rx ASAP and within 4 hours of presentation

assess severity and Mx accordingly

mild CAP which may be suitable for outpatient Mx with oral antibiotics

usual criteria includes ALL of the following to be present

  • age < 50
  • heart rate < 125/min
  • temp > 35deg C and < 40 deg C
  • no comordities such as cancer, congestive cardiac failure, renal disease or CVD
  • CORB score = 0
  • SMART-COP score < 3

outpatient Mx in Australia as at 2011

  • amoxycillin o 1g tds for 7 days
  • +/- doxycycline o 200mg stat then 100mg bd for 5 days

moderate CAP requiring admission and iv antibiotics

usual criteria

  • not mild CAP as above, and,
  • CORB score < 2
  • SMART-COP < 5

inpatient Mx in Australia as at 2011

  • benzyl penicillin iv 1.2g 6hrly, plus,
  • doxycycline o 200mg stat then 100mg bd for 7 days
  • plus, if Gram negatives suspected or found in cultures, add gentamicin iv 5mg/kg stat dose
  • continue iv benzyl penicillin until significant improvement then switch to amoxycillin o 1g tds for 7 days
patients with immediate HS to penicillin
  • discuss with Infectious Diseases consultant
  • examples of regimes in 2012 as per ETG:
    • moxifloxacin 400mg iv daily, AND
    • azithromycin 500mg iv daily
patients with HS to penicillin but not immediate
  • substitute benzyl penicillin with ceftriaxone iv 1g daily until significant improvement, then cefuroxime o 500mg bd for 7 days.

severe CAP requiring HDU or ICU admission and iv antibiotics

usual criteria

  • not mild or moderate CAP as above, and,
  • CORB score > 1
  • SMART-COP > 4

inpatient Mx in Australia as at 2011

  • ceftriaxone iv 1g daily, plus,
  • azithromycin iv 500mg daily
  • use culture results to determine appropriate antibiotic for oral Rx
  • consider other risk factors such as immunosuppression, HIV / AIDS, etc.
contact infectious diseases to decide antibiotic Rx if either
  • allergic to above
  • a returned traveler (including from Northern Territory)
  • risk factors for Staph. aureus infection

pneumonia severity scoring tools

CORB

  • score 1 point for each of:
    • Confusional state (acute)
    • Oxygen saturation ⇐ 90% in room air
    • Respiratory rate >= 30/min
    • BP: systolic < 90mmHg or diastolic BP ⇐ 60mmHg
  • a score of > 1 has sensitivity 81%, specificity 68%, PPV 18%, NPV 98% and area under ROC 0.74 for requiring intensive respiratory or vasopressor support.

SMART-COP

  • all items get 1 point EXCEPT BP, Oxygen and pH parameters which get 2 points, giving a maximum score of 11
  • different calculators depending on age
risk of needing intensive respiratory or vasopressor support
  • scores 0-2 = low risk
  • scores 3-4 = moderate risk (1 in 8 chance)
  • scores 5-6 = high risk (1 in 3 chance)
  • scores 7 or more = very high risk (2 in 3 chance)
  • a score of 3 or more gives sensitivity 92%, specificity 62%, PPV 22%, NPV 99%, area under ROC 0.84
age <= 50 years
  • Systolic BP < 90mmHg
  • Multilobar CXR involvement
  • Albumin < 35g/L
  • Respiratory rate >= 25/min
  • Tachycardia >= 125/min
  • Confusion (acute)
  • Oxygen low (PaO2 < 70mmHg, or SaO2 ⇐ 93%, or PaO2/FiO2 < 333)
  • pH < 7.35
age > 50 years
  • Systolic BP < 90mmHg
  • Multilobar CXR involvement
  • Albumin < 35g/L
  • Respiratory rate >= 30/min
  • Tachycardia >= 125/min
  • Confusion (acute)
  • Oxygen low (PaO2 < 60mmHg, or SaO2 ⇐ 90%, or PaO2/FiO2 < 250)
  • pH < 7.35

CURB-65

  • score 1 point for each of:
    • Confusion
    • Urea > 7mmol/L
    • Respiratory rate >= 30/min
    • BP: systolic < 90mmHg or diastolic BP ⇐ 60mmHg
    • 65: Age > 65 years
  • a score of > 1 suggests inpatient Mx is needed
  • a score of > 2 suggests HDU/ICU Mx may be needed - particularly if score 4 or 5

Pneumonia Severity Index (PSI)

  • a more complicated tool, but better validated.
NCEMI eTool
cap.txt · Last modified: 2018/07/26 00:58 (external edit)