LRI I

Define CAP, HAP, and VAP

• Community acquired pneumonia (CAP): Pneumonia acquired outside of the hospital setting

• Hospital acquired pneumonia (HAP): Pneumonia occurring ≥48 hours after admission

• Ventilator-acquired pneumonia (VAP): Pneumonia arising >48-72 hours after endotracheal intubation

What are the most common pathogens causing CAP? What about HAP/VAP?

Why don’t we get sputum cultures on all pneumonia patients?

Difficult to obtain, and difficult to interpert (often contaminated)

Can we use sputum gram stains to modify therapy?

for VAP

How should MRSA nares be utilized?

used to RULE OUT MRSA

if a patient doesn't require MRSA therapy, DONT order the lab- dont use MRSA test to add MRSA coverage

How should Procalcitonin be utilized?

Inflammatory marker specfic to bacterial infections- often used to rule out bacterial source of infection

Know how to use the CURB-65 score to determine where a patient with CAP should be treated

Scoring Criteria (1 point for each factor):

• Confusion (disorientation to person, place, or time)

• Uremia (>20 mg/dL)

• Respiratory rate (>30 breaths per minute)

• Blood pressure (SBP <90 mmHg or DBP <60 mmHg)

• Age ≥ 65 years

Interpreting the Score and Treatment Recommendations:

CURB-65 Score	Risk of Mortality	Recommended Site of Care
0-1	Low	Outpatient (home treatment)
2	Intermediate	Supervised treatment or hospitalization (consider admission based on clinical judgment)
≥3	High	Inpatient hospitalization (ICU may be needed for severe cases)

When does a CAP patient require ICU admission?

Major Criteria (Only one needed for ICU admission):

• Hypotension requiring vasopressors

• Respiratory failure requiring mechanical ventilation

Minor Criteria (Need at least three for ICU admission):

• Respiratory rate ≥30 breaths/min

• PaO₂/FiO₂ ratio ≤250 (indicating poor oxygenation)

• Multilobar infiltrates on imaging

• Confusion or disorientation (to person, place, or time)

• Uremia (BUN ≥20 mg/dL)

• Leukopenia (WBC <4,000 cells/mm³)

• Thrombocytopenia (platelet count <100,000 cells/mm³)

• Hypothermia (core temperature <36°C)

• Hypotension requiring aggressive fluid resuscitation

What antibiotics can be used to treat a patient with CAP who is being managed in the outpatient setting? How does this change if they have comorbidities?

*amox doesnt cover atypicals but its ok cuz it proven to work

What antibiotics can be used to treat a patient with CAP who is being admitted to the hospital? What about if they are in the ICU?

Which patients require empiric MRSA coverage for CAP? What antibiotics do you use to cover MRSA?

• History of MRSA cultured in last year—> add coverage to all inpatients

• Hospitilization with IV antibiotics given in last 90 days—> add coverage only if pt is in ICU

Add vanco or linezolid

Which patients require empiric pseudomonas coverage for CAP? What antibiotics do you use to cover pseudomonas?

• History of pseudomonas cultured in last year—> add coverage to all inpatients

• Hospitalization with IV antibiotics given in last 90 days—> add coverage only if pt is in ICU

Replace beta-lactam with: Pip/tazo, cefepime, ceftazidime, aztreonam, meropenem, imipenem

How long should patients with CAP be treated? Why might a patient require longer treatment?

• Minimum duration: 5 days

• To stop antibiotics after 5 days, the patient must:

  • Be afebrile for 48-72 hours

  • Have ≤1 sign of clinical instability

*CAP due to MRSA or Pseudomonas is 7 days tx

Criteria for Clinical Stability:

✔Temperature ≤ 37.8°C

✔ Heart rate ≤ 100 beats/min

✔ Respiratory rate ≤ 24 breaths/min

✔ Systolic blood pressure ≥ 90 mmHg

✔ Arterial oxygen saturation ≥ 90% or PaO₂ ≥ 60 mmHg on room air

✔ Ability to maintain oral intake

✔ Normal mental status