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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