PulmENT Hopkins 8/24: CAP

CAP differentiation

acquired outside hospital, symptoms show <48 hours from admission

this definition excludes immunocompromised and patients with structural lung disease (cystic fibrosis, emphysema)

preferred OUTPATIENT empiric ABX for outpatient CAP: with comorbidities, without comorbidities

no comorbidities: amoxicillin or doxycycline

comorbidities present (heart disease, alcoholism, DM, lung disease, renal disease, liver disease, cancer, alcoholism, asplenia): two drugs

1. amox/clav OR cephalosporin (-oximes) for g-pos, g-neg coverage

2. doxycycline OR azithromycin/clarithromycin for atypical coverage

may use respiratory FQ if comorbidities are present and PT has severe allergy to penicillins

what is CURB-65

determines whether to treat CAP outPT or inPT

C: (new) confusion

U: uremia (BUN > 20)

R: RR < 30

B: BP —> SBP ≤90 or DBP≥60

65: age ≥65

for each factor, add one point

if 2 or more points —> treat inPT

preferred empiric INPATIENT therapy for non-severe CAP: no MRSA/PsA RFs, prior PsA, prior MRSA, prior IV ABX 90d

no MRSA, PsA:

1. ceftriaxone OR ampicillin/sulbactam OR cefotaxime OR ceftaroline

2. azithromycin/clarithromycin OR doxycycline

— — —

prior PsA respiratory culture: replace beta-lactam with

piperacillin/tazobactam or cefepime

prior MRSA respiratory culture: ADD vancomycin or linezolid

prior IV ABX 90d: assess if PT needs MRSA/PsA coverage

preferred empiric INPATIENT: standard, prior PsA, prior MRSA, prior IV ABX 90d

standard

1. ceftriaxone OR Unasyn OR cefotaxime OR ceftaroline

2. azithromycin/clarithromycin OR doxycycline OR levo/moxifloxacin

— — —

prior PsA: replace beta lactam with cefepime OR Zosyn

prior MRSA: add vancomycin OR linezolid

prior IV ABX 90d: include PsA and MRSA coverage, test and deescalate as needed

duration of CAP therapy with clinical stability: outpatient CAP, non-severe inPT, severe inPT

outpatient: 3-5 days

non-severe inPT: 3-5 days

severe inPT: 5+ days

criteria for IV to PO for CAP

clinical stability

• afebrile ≤37.8 C

• HR < 100

• RR < 24

• SBP ≥ 90

functioning GI tract

able to swallow medication

when and when not to use corticosteroids for CAP

do not use for non-severe cases

should use for severe CAP UNLESS pneumonia is secondary to influenza