1. RFs
1.1. MDR pathogens
1.1.1. CAP Liver/kidney -B Lactam Tx in past 90days -Elderly -Alcoholics -Immunosuppressant Tx
1.1.2. HAP -AB use in the past 90 days -Current hospitalization >5days -HCAP origin -Immusupp
1.2. Pseudomonas
1.2.1. -Severe pulmDx; COPD; CF -Recent BroadSpec ABs use for >7days -Corticosteroid use >10g prednisone use daily.
1.3. CA-MRSA
1.3.1. -Presence of Cavitary lesions on imaging -IVDA -ESRD (with HDD) -Recent Viral pneumonia
2. Infecting Pathogens
2.1. CAP S. pneumo H. influenza Moraxella Mycoplasma Chylmdia Legionella Staph Aureus Pseudomonas
2.2. HAP Klebsiella E. coli Enterobacter Serratia Proteus Anerobes possible with aspiration
3. Diagnosing
3.1. ROS/PE
3.1.1. -Obvious, but look for travel hx or comorbid lung conditions. -Chest Auscultation
3.2. Radiology
3.2.1. Infiltrates present and possible pleural effusions
3.3. In-patient criteria
3.3.1. CURB-65 Confusion Uremia; BUN>20 RR>30 BP; SPB<90; DBP<60 65years easier to use, need 2
3.3.2. PSI-Pneumonia Severity Index. harder to use
3.4. ICU-criteria
3.4.1. Major Criteria for Severitty -Need for Mech Ventilation -Shock with need for Pressors -Need just one
3.4.2. Minor Criteria for Severity -RR>30 -Hypoxia -Leukopenia <4000 -Plts <100k -Confusion -Hypothermia
3.4.3. Criteria to de-escalate (IV to PO) Afebrile >48hrs Normal Mental Status WBCs WNLs Stable vitals GI motility
4. CAP
4.1. Treatment Empiric
4.1.1. OutPt
4.1.1.1. Azithro/Erythro/Clarithro
4.1.1.1.1. Zpak; 500mg day1 then 250mg day 2-5.
4.1.1.2. Doxycyline 100mg qd
4.1.2. OutPt with MDR RFs
4.1.2.1. Levo/Moxi
4.1.2.1.1. Levo: (500mg qd x 1-2weeks) (750mg qd x 5days)
4.1.2.2. Amox/Augmentin/Ceftriaxone + Macrolide
4.1.3. InPt
4.1.3.1. Levo/Moxi
4.1.3.2. Ampicillin/Ceftriaxone/Cefotaxime + Macrolide
4.1.3.2.1. ceftriaxone is most common B-lactam: 1g qd. 2g for severe inf or rst organism
4.1.4. InPt ICU
4.1.4.1. Unasyn/Ceftriaxone/Cefotaxime + (Levo/Moxi or Azithro)
4.1.4.1.1. for B-lactam allergy, sub Aztreonam
4.1.4.2. Suspected Pseudo
4.1.4.2.1. B-Lactam (+) Levo/Cipro (+/-) AG
4.1.4.2.2. B-Lactam (+) Azithro (+) AG
4.1.4.2.3. Zosyn/cefepime/Imipenem/meropenem Levo/Cipro Azithro Gentamicin/Amikacin/Tobramycin For B-lactam allergy use cefepime
4.1.4.3. Suspected CA-MRSA
4.1.4.3.1. Add to regimen: Vancomycin/Linezolid
5. HCAP
5.1. Diagnose
5.1.1. Parameters
5.1.1.1. -Recent hospitalization of >48hrs in the past 90 days. -Woundcare, chemo, or antibiotic use in past 30 days -Residing in a longterm care facility or nursing home -Hemodialysis pt
5.1.2. Significance
5.1.2.1. Proper Empiric for proper spectrum coverage
5.1.2.2. Pts presenting from the "community" may actually have HCAP. HCAP presents with different pathogens and it is improper to treat with empiric CAP therapy by mistake.
6. HAP/VAP
6.1. Diagnose
6.1.1. Pneumonia occurring >48hrs after hospitalization. HAP
6.1.2. Pneumonia occurring >48hrs after intubation. VAP
6.2. Treatment Empiric
6.2.1. Early onset <5 days hospitalization
6.2.1.1. MxTx appropriate
6.2.1.2. -Ceftriaxone/Unasyn -Cipro/levo/moxi *erta for select pts
6.2.2. Late onset >5 days hospitalization or (+) for MDR risk factors
6.2.2.1. MxTx innappropriate
6.2.2.2. AntiPseudo B-lactam (+) AntiPseudo FQ or AG (+) Vanco/Linezolid
6.2.2.2.1. -Cefepime/ceftazidime/Zosyn/Imipenem/Meropenem -Levo/Cipro -Gentamicin/Tobramycin/Amikacin -Vanco/Linezolid