DIAGNOSIS AND EMPIRIC MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA AMONG ILMUNOCOMPETENT ADULTS - 2010 UPDATERISK STRATIFICATION /CLINICAL FEATURES

LOW RISK CAP

Stable vital signs:- RR < 30 breaths/min - PR < 125 beats/min-SBP>90mmHg - DBP > 60 mmHg- Temp > 36°C or <40°CNo altered mental state of acute onsetNo suspected aspirationNo or stable co-morbid conditionsChest X-ray:- localized infiltrates- no evidence of pleurai effusion nor abscess

DIAGNOSTIC WORK-UP

Chest X-raySputum GS/CS (optional & when avail-able)

POTENTIAL PATHOGIES

Streptococcus pneumoniaeHaemophiius influenzaeChlamydophila pneumoniaeMycoplasma pneumoniaeMoraxella catarrhalisEnteric Gram-negative bacilli (among thosewith co-morbid illness)

EMPIRIC TREATMENT

Previously healthy

AmoxicillinOR

Extended macrolides3 (suspected atypical pathogen)

With stable comorbid illness:

fi-lactam/fi-lactamase inhibitor combination (BLIC)b or 2nd generation oralcephalosporinsc +/- Extended macrolides

Alternative: 3rd generation oral cephalosporin3 +/- Extended macrolide

MODERATE RISK CAP

Unstable vital signs:- RR > 30 breaths/min - PR >125 beats/min- SBP < 90 mmHg - DBP < 60 mmHg- Temperature < 36°C or > 40°CAltered mental state of acute onsetSuspected aspirationUnstable / Decompensated comorbid condition-uncontrolled diabetes mellitus, activemalignancies, neurologic disease in evolution,congestive heart failure (CHF) Class II-IV,unstable coronary artery disease, renal failure ondialysis, uncompensated COPD, decompensatedliver diseaseChest X-ray:- multilobar infiltrates- (+) pleurai effusion or abscess

Chest X-rayBlood CSSputum GS/CSWhen available:

- Urine Ag test for L. pneumophila- Direct Fluorescent Ab (DFA) test forLpneumophila

Streptococcus pneumoniaeHaemophiius influenzaeChlamydophila pneumoniaeMycoplasma pneumoniaeMoraxella catarrhalisEnteric Gram-negative bacilliLegionella pneumophilaAnaerobes (among those with risk of aspiration)

IV non-antipseudomonal li-lactam (BLIC, cephalosporin or carbapenem)6+

Extended macrolide

OR

IV non-antipseudomonal (i-lactam (BLIC, cephalosporin or carbapenem)6+

Respiratory fluoroquinolones' (FQ)

HIGH RISK CAP

Any of the clinical feature of Moderate riskCAP plus any of the following:

Severe Sepsis and Septic Shock

OR

Need for mechanical ventilation

Chest X-rayBlood CSSputum GS/CSABGWhen available:

- Urine Ag test for L. pneumophila- DFA test for L. pneumophila

Streptococcus pneumoniaeHaemophiius influenzaeMycoplasma pneumoniaeChlamydophila pneumoniaeMoraxella catarrhalisEnteric Gram-negative bacilliLegionella pneumophilaAnaerobesStaphylococcus aureusPseudomonas aeruginosa

No risk for P. aeruginosa:IV non-antipseudomonal fi-lactam (BLIC. cephalosporin or carbapenem)*

+IV Extended macrolide or IV Respiratory fluroquinolone

With risk for P. aeruginosa:IV antipneumococcal antipseudomonal U-lactam (BLIC, cephalosporin or

carbapenem)9 + IV Extended macrolide + aminoglycosideh

ORIV antipneumococcal antipseudomonal (i-lactam (BLIC, cephalosporin or

carbapenem)9 + IV Ciprofloxacin or Levofloxacin (high dose)

Extended Macrolides - Azithroinycin dihydrate, ClarithromycinOral IS-lactam/R-lactamase inhibitor combination (BLIC) - Amoxicil/in-clavulanic acid. Amoxicillin-sulbactam, SultamicillinOral Second generation cephalosporin - Cefaclor. Cefuroxitne axetilOral Third generation cephalosporin - Cefdinir, Cefixime. Cefpodoxime proxetilIV non-antipseudomonal R-lactam (BLIC, cephalosporin or carbapenem) - Amoxicillin-clavulanic acid. Ampicillin-sulbactam, Cefotiam. Cefoxitin. Cefuroxime Na. Cefoiaxime. Ceftizoxime. Ceftriaxone, ErtapenemRespiratory fluroquinolones - Levofloxacin. MoxifloxacinIV Antipneumococcal antipseudomonal li-lactam (BLIC, cephalosporin or carbapenem) - Cefoperazone-sulbactam. Piperacillin-tazobactam. TicarcilHnclavutanic acd. Cefipime. Cefpirome. Imipenem-cilastatin, MeropenemAminoglycosides - Gentamicin. Tobramycin. Netilmicin, Amikacin

CAP-x Algorithm for the Management-Oriented Risk Stratification of CAP among

Immunocompetent Adults

Any of the ff:RR > 30/minPR> 125/minTemp. > 40°C or < 36°CSBP<90mmHg orDBP<60mmHgAltered mental status ofacute onsetSuspected aspirationUnstable co-morbidconditionsChest x-ray: multilobar,pleural effusion, abscess

NO

LowRISK CAP

OUT PATIENT

Any of the ff:1. Severe sepsis

and septic shock2. Need for

mechanicalventilation

YES

NO

MODERATERISK CAP

HIGHRISK CAP

ICUADMISSION

1 r

WARDADMISSION 1

Recommended Vaccination for thePrevention of CAP

Vaccine

Pneumococcal Vaccine

Influenza Vaccine

Dose

0.5 ml IM or SC

0.5 ml IM

Frequency

one-time, re-vaccinationmay be given after 5 years

once a year

TASK FORCE ONCOMMUNITY-ACQUIRED PNEUMONIA

Thelma E. Tupasi, MDManolito L. Chua, MDMa. Lourdes A. Villa, MDMarissa M. Alejandria, MDAbundio A. Balgos, MDJoselito R. Chavez, MDVilma M. Co, MDRemedies F. Coronel, MDJose Paolo M. De Castro, MDRaquel Victoria M. Ecarma, MDBenilda B. Galvez, MDPolicarpio B. Joves, MDIsaias A. Lanzona, MDMyrna T. Mendoza, MDLeonardo Joseph Obusan, MDIsabelita M. Samaniego, MDMa. Bella R. Siasoco, MD

PSMIDPSMIDPSMIDPSMIDPCCPPCCPPSMIDPSMIDPAFPPSMIDPCCPPAFPPCCPPSMIDPCRPAFPPCCP

AdviserChairRapporteurMemberMemberMemberMemberMemberMemberMemberMemberMemberMemberMemberMemberMemberMember

Secretariat:Philippine Society for Microbiology and Infectious Diseases

2nd Floor PSMID BIdg., No. 116 9th Ave., Cubao, Quezon City 1109 PhilippinesTel. No.: (632) 912-6036 • Tel./Fax: (632) 911-6986