CAP in Outpatient Setting

UPDATE IN OFFICE MANAGEMENT

Treatment of Community-Acquired Pneumonia in an
Ambulatory Setting
a

Saira Butt, MD, Edwin Swiatlo, MD, PhD

a,b

a

Department of Medicine, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson; bVA Medical Center, 
Jackson, Miss.

ABSTRACT
Community­acquired pneumonia continues to be a significant cause of morbidity and mortality despite
broad­spectrum   antibiotics   and   advances   in   critical   care.   Frequently,   the   diagnosis   is   confounded   by
coexisting   cardiac   or   pulmonary   conditions.   Recognition   of   patients   at   risk   for   complications   from
pneumonia is critical when making the decision of how and where to treat. This review summarizes the
diagnosis and treatment of community­acquired pneumonia with oral antibiotics in an outpatient setting.
Specific pathogens and clinical presentations in certain at­risk populations are highlighted. Also presented
are validated algorithms for evaluating and identifying patients who may be at risk for serious complica­
tions of pneumonia and require treatment in an inpatient setting.
Published by Elsevier Inc. • The American Journal of Medicine (2011) 124, 297­300
KEYWORDS: Antibiotics; Pneumonia; Vaccines

cough.   In   contrast,
Community­acquired   pneumonia   is   diagnosed   in   3   to   4“atypical”   pathogens   such
million persons annually and continues to be a leading cause as
 Myco­plasma,
of death in the United States. One study estimated that more Chlamydophila,
 and
than 900,000 cases of community­acquired pneumonia oc­cur
viruses
 
often
 
present
 
with
1
each   year   in   persons   aged   more   than   65   years.   Approx­fe­ver,   nonproductive
imately   80%   of   patients   with   pneumonia   are   treated   as cough,   and   constitutional
outpatients.   Common   risk   factors   for   community­acquired symptoms   that   develop
pneumonia   include   age   greater   than   65   years,   smoking, over   days.  Legionella
alcohol consumption, chronic lung diseases, mechanical ob­
initially   may   produce
struction   of  airways,   aspiration   of   oropharyngeal   or  gastric
primar­ily   gastrointestinal
2
contents, pulmonary edema, uremia, and malnutrition.
symptoms.   A   careful
history,   including   travel,
animal
 
exposure,
CLINICAL PRESENTATION
Typical   bacterial   pathogens   such   as  Streptococcus   pneu­ incarceration,   asplenia,
moniae  (pneumococcus),  Haemophilus   influenzae,   and   en­human   im­munodeficiency
teric gram­negative organisms usually manifest acutely with virus,   and   other
comorbidities,   can   often
high fever, chills, tachypnea, tachycardia, and productive
suggest   an   otherwise
Funding: Department of Medicine, University of Mississippi Medical unsuspected pathogen.
Center and Department of Veterans Affairs.
Systemic   physical
Conflict of Interest: None.
findings   in   pneumonia   are
Authorship: All authors had access to the data and played a role in nonspecific   and   include
writing this manuscript.
fever/chills,
 
fatigue,
Reprint requests should be addressed to Edwin Swiatlo, MD, PhD,
myalgias,
 
or
 
headaches.
VA   Medical   Center   Research   (151),   1500   Woodrow   Wilson   Drive,
Pulmonary   findings   in
Jackson, MS 39216.
pneumonia   are   typically
E­mail address:  [email protected].
localized to a specific lung

zone and may include rales,
rhonchi,   bron­chial   breath
sounds, dullness, increased
fremitus,   and   ego­phony.
Atypical   pneumonia   may
have   absent   or   diffuse
findings   on   lung
examination.
 
Rapid
progression of disease from
mild,
 
nonspecific
symptoms   to   respiratory
failure   can   be   seen   in
severe   pneumococcal,
staphylococcal,   or  Legio­
3,4

nella pneumonia.
The   age   of   the   patient
has   important   implications
in   disease   presentation.
Older   patients   often   have
humoral   or   cellular
immunodeficiencies   as   a
result   of   underlying   dis­
eases,   immunosuppressive
medications,   or   the   aging
pro­cess.   Older   patients
with pneumonia have fewer
symptoms than do younger
patients, and mental  status
changes are commonly the

predominant   presenting   symptom.   Delirium   may   be   theonly   manifestation   of
0002­9343/$ ­see front 
matter Published by 

pneumonia in these pa­

Elsevier Inc. 
06.027
doi:10.1016/j.amjmed.2010.

298

The American Journal of Medicine, Vol 124, No 4, April 2011
Table 1 Pneumonia
tients. Alcoholism, asthma, immunosuppression, and age 70 Severity Index

based   on   5   easily
measurable factors (1 point
for   each)   from   which   its
years are risk factors for community­acquired pneumonia in
name is derived:  confusion
the   elderly.   Among   nursing   home   residents,   advanced   age,
Demographic factors
(based on a specific mental
male   sex,   dysphagia,   inability   to   take   oral   medications, Age for men
test or new disorientation to
profound disability, bedridden state, and uri­nary incontinence Age for women
person, place,
are   risk   factors   for   community­acquired   pneumonia. Nursing home resident
or  time);  blood  urea  nitrogen
20
Aspiration   pneumonia   is   underdiagnosed   in   this   group   of Coexisting illnesses
rate   30 breaths/min; blood pressure (
5
Active neoplastic disease
patients, and tuberculosis always should be considered.
or diastolic   60 mm Hg); and age
Extrapulmonary physical findings can provide clues to the Chronic liver disease
a CURB­65 score of 0 to 1
CHF
can generally be treated as
diagnosis.   Poor   dentition   and   foul­smelling   sputum   may Cerebrovascular disease
outpatients,   those   with   a
indicate   the   presence   of   a   lung   abscess   with   anaerobic Chronic renal disease
score   of   2   should   be
bacteria.   Bullous   myringitis   can   accompany   infection   with Physical examination
admitted to the hospital, and
Mycoplasma   pneumoniae.   An   absent   gag   reflex   or   altered Altered mental status
those  with  a  score  of   3  or
sensorium   raises   the   possibility   of   aspiration   and   polymi­ Respiratory rate 30
more are candidates for an
crobial infection with anaerobes. Encephalitis can compli­cate Blood pressure 90 mm Hg
pneumonia   caused   by  M.   pneumoniae  or  Legionella Temperature 35°C or 40°C intensive   care   unit.10  In
Pulse 125 bpm
pneumophila.   Cutaneous   manifestations   of   infection   can
addition to medical criteria,
Laboratory and radiographic findings
include   erythema   multiforme   (especially  M.   pneumoniae), Arterial pH 7.35
residential   status   also
influences   treat­ment
erythema   nodosum   (Chlamydophila   pneumoniae  or  Myco­ BUN 30 mg/dL
decisions.   Residents   of
bacterium   tuberculosis),   or   ecthyma   gangrenosum   (Pseu­ Sodium 130 mmol/L
chronic   care   facilities,
Glucose 250 mg/dL
domonas aeruginosa).
Hematocrit 30%
homeless   persons,   and
PaO2 60 mm Hg
incarcerated   persons   are
LABORATORY DATA
Pleural effusion
more  likely to  be  admitted
Diagnostic   tests   such   as   sputum   and   blood   cultures   are
CHF congestive heart failure; BUN
than   other   patients   with
optional for an etiologic diagnosis in outpatients with com­ PaO2 partial pressure of arterial oxygen.
similar   severity   scores.
munity­acquired pneumonia. Nasopharyngeal swabs should be
Outpatient   therapy   is
collected for influenza during the appropriate season or when
preferred because
influenza is circulating in the community. Patients with cough
This   decision   involves   3
for more than 1 month, chronic fever, night sweats, weight
steps:   determination   of
loss, or a suggestive chest X­ray should be evaluated for  M. disease severity, assessment
tuberculosis.  A   high   level   of   suspicion   is   necessary   toof   any   preexisting   social
diagnose infections caused by agents of bioterrorism.

6

conditions that compromise
the safety of home care, and
clinical   judg­ment.   The
RADIOGRAPHY
Pneumonia   Severity   Index
The cornerstone of diagnosis is the chest X­ray, which usually
reveals an infiltrate at presentation. However, this finding may be assesses   20   variables   (
absent   in   dehydrated   or   neutropenic   patients.   Also,   the Table 1) and places patients
radiographic   manifestations   of   chronic   diseases   such   as into 5 risk groups that  can
congestive heart failure, chronic obstructive pulmo­nary disease, help to stratify patients for
7therapeutic   and   prognostic
and   malignancy   may   obscure   the   infiltrate   of   pneumonia.
9
purposes.   Patients   in
Although radiographic patterns are usually nonspecific, they can
groups   I   and   II   can   be
sometimes   suggest   a   microbiological   diagnosis.   Focal
treated   as   outpatients,
consolidation   is   seen   in   typical   bacterial   pneumonia,   whereas
patients in group III can be
viruses,  Mycoplasma,  and  Chlamydo­phila  frequently   present
treated   with   a   short
with   an  interstitial  pattern.   Cavitary  lesions   may   be   associated
hospitaliza­tion   or   in
with bacterial abscesses, fungi, or  Nocardia. Rapid progression
observational   units,   and
with   multifocal  lung   involve­ment  may   indicate  Legionella,  S.
patients in groups IV and V
8
pneumoniae, or Staphylo­coccus aureus.
should   be   treated   as
inpatients.
A   more   tractable   model
MANAGEMENT
for
  community­acquired
Choosing the site of care for community­acquired pneumo­nia is
pneu­monia
 
severity
the single most important decision made by clinicians.
9
assessment   is   CURB­65.
The   CURB­65   score   is

Butt and Swiatlo Community-acquired Pneumonia

Table 2 Recommended Empirical Antibiotics for Outpatient
Therapy of Community-Acquired Pneumonia1
Previously healthy, no recent (within 3 mo) antibiotic therapy:
macrolide OR doxycycline
Previously healthy, antibiotics within past 3 mo: azithromycin or
clarithromycin, PLUS high-dose amoxicillin

(4 g/d) or amoxicillin-clavulanate (4 g/d); OR a respiratory
fluoroquinolone alone
Comorbidities (COPD, diabetes, renal or congestive heart
failure, malignancy), no recent antibiotic therapy:
azithromycin or clarithromycin; OR a
respiratory fluoroquinolone alone
Comorbidities, antibiotics within past 3 mo:
azithromycin or clarithromycin, PLUS high-dose amoxicillin,
amoxicillin/clavulanate, cefpodoxime, cefprozil, or cefuroxime;
OR a respiratory fluoroquinolone
COPD

chronic obstructive pulmonary disease.

this is associated with faster return to normal activities than
10
inpatient treatment.

ANTIBIOTICS
Antimicrobial therapy is a critical component of treatment of
community­acquired   pneumonia   in   the   outpatient   setting.
Until   better   diagnostic   tests   are   available,   initial   treatment
remains   largely   empiric.   Antibiotics   recommended   on   the
basis of risk factors and likely pathogens have been pub­lished
1
recently   and   are   summarized   in   Table   2.   Presently,
macrolides   remain   effective   for   patients   with   mild   to  mod­
erately   severe   community­acquired   pneumonia   with   no   risk
factors.
Patients with chronic obstructive lung disease who have not
received   antibiotics   or   oral   steroids   during   the   previous   3
months can be treated in a manner identical to that of patients
without modifying factors, with the ca­veat that only a newer
macrolide (azithromycin or clari­thromycin) be used to ensure
adequate   coverage   of  H.  influenzae.   Patients   with   chronic
obstructive   pulmonary  disorder   and   a   history   of   use   of
antibiotics or oral steroids within the past 3 months may have
an increased risk for infection with  H. influenzae and enteric
gram­negative   bacilli,   in   addition   to   pneumococcus,  C.
pneumoniae,  and  L.   pneumophila,  and   a   “respiratory”
fluoroquinolone   is 
recommended.   A   respiratory
fluoroquinolone   is   one   with   predictable   activity   against
pneumococcus,   such   as   levo­floxacin   or   moxifloxacin.
Fluoroquinolones also are rec­ommended if first­line therapy
fails in the patient, the patient has confirmed allergy to first­
line agents, or when highly resistant pneumococcus (penicillin
minimum in­hibitory concentration 4 g/mL) is prevalent.
For patients who can be treated in the nursing home setting
and   do   not   require   hospitalization,   a   respiratory
fluoroquinolone or amoxicillin­clavulanate plus a macro­lide
is   recommended   as   the   first   choice.   A   second­gen­eration

299
cephalosporin   plus   a
macrolide is an alternative.

Anaerobic   coverage   should
be considered for those pa­
tients with a history of loss
of consciousness or in per­
sons   with   gingival   or
esophageal
 
disease.
Antibiotic se­lection should
always   consider   local
epidemiology
 
and
susceptibility patterns.

FOLLOW-UP
Patients   treated   in   the
outpatient   setting   must   be
monitored   carefully   to
ensure   adherence   to   the
antibiotic   regimen   and
clinical   improvement.
Follow­up by telephone or a
clinic visit within 48 to 72
hours is strongly suggested.
Patients who fail to respond
despite what seems to be an
appropriate   choice   of
antimicrobial   therapy   may
have   complications   of
pneumonia,   such   as
empyema,
 
bronchial
obstruction,
 
ex­
trapulmonary   spread   of
infection,   superinfections,
or   mis­diagnosis   of
noninfectious   causes   (eg,
congestive   heart   fail­ure,
neoplasm,
 
vasculitis,
sarcoidosis,   drug   reaction,
alveolitis,   pulmonary
embolism, or hemorrhage).

PREVENTION
All persons aged more than 6
months   should   receive   inac­
tivated   influenza   vaccine
yearly   as   recommended   by
the   Advisory   Committee   on
Immunization   Practices,
Centers   for   Disease   Control
11

and
 
Prevention.
Pneumococcal
 
poly­
saccharide   vaccine   is
recommended for all persons
aged more than 65 years and
anyone   aged   2   to   64   years
with   a   chronic   health

problem, such as heart disease, lung disease, sickle cell disease,
diabetes, alcoholism, and cirrhosis. All persons aged 2 to 64 years
who have an immunosuppressive condition, such as hematologic
malignancy,   kidney   failure,   nephrotic   syndrome,   human
immunodeficiency virus infec­tion, asplenia, or organ transplant,
should receive vaccine. Anyone aged more than 2 years who lives
in   an   institutional   or   group   setting   is   a   candidate   for
pneumococcal   vaccine.   A   comprehensive   discussion   of   risk
factors for invasive pneu­mococcal infection is published by the
Centers for Disease Control and Prevention.

12

Dis. 2007;44(Suppl 2):S27. 

2. Almirall J, Bolibar I, Balanzo

5. Craven   DE,   Palladino   R,

X, Gonzalez CA. Risk factors
for   community­acquired
pneumonia   in   adults:   a
population­based   case­control
study.
 Eur   Respir   J.
1999;13:349. 

McQuillen   DP.   Healthcare­
associated   pneu­monia   in
adults: management principles
to   improve   outcomes.  Infect
Dis   Clin   North   Am.
2004;18:939. 

3. Rubinstein   E,   Kollef   MH,

6. Hopstaken   RM,   Witbraad   T,

Nathwani   D.   Pneumonia
caused   by   methi­cillin­
resistant   Staphylococcus
aureus.  Clin   Infect   Dis.
2008;46(Suppl 5):S378. 

van   Engelshoven   JM,   Dinant
GJ. Inter­observer variation in
the   interpretation   of   chest
radiographs for pneu­monia in
community­acquired   lower
respiratory   tract   infections.
Clin Radiol. 2004;59:743. 

References
1. Mandell   LA,   Wunderink   RG,   Anzueto   A,   et   al.   Infectious   Diseases 4. Marrie
Society of America/American Thoracic Society consensus guidelines on
the management of community­acquired pneumonia in adults. Clin Infect

2000;31:1066­1078. 

  TJ.   Community­
acquired   pneumonia   in   the
elderly.  Clin   Infect  Dis.

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