Mar 1;44 Suppl 2:S America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Keywords: Community-acquired pneumonia, ICU admission, arterial .. The IDSA/ATS CAP Guidelines major criteria including the pH. Pneumonia In Adults Adapted from: IDSA/ATS CONSENSUS GUIDELINES Mandell LA, Wunderlink RG, Anzueto A, et al. Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clin Infect Dis. ;(Suppl 2).

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Diagnosis is usually straightforward, with high yields from sputum and blood cultures in this characteristic clinical scenario. Published studies are limited by small sample sizes, biases inherent in observational design, and the relative infrequency of isolates exhibiting high-level resistance [ — ].

N Eng J Med. The implication of a strong recommendation is that most patients should receive that intervention. Inability to expectorate may limit the use of NIV [ ], but intermittent application of NIV may allow for its use in patients with acquored cough unless sputum production is excessive. Patients with CAP should be investigated for specific pathogens that would significantly alter standard empirical management decisions, when the presence of such pathogens is suspected communuty the basis of clinical and epidemiologic clues.

Of these, rapid and appropriate empirical antibiotic therapy is consistently associated with improved outcome.

A modification of the original PSI score was needed when it was applied to the admission decision. Physical examination to detect rales or bronchial breath sounds is an important component of the evaluation but is less sensitive and specific than chest radiographs [ 96 ].

A respiratory fluoroquinolone should be used for penicillin-allergic patients. First, it broadens initial empirical coverage for less common etiologies, such as infection guideelines S. The emergence of newly recognized pathogens, such as the novel SARS-associated coronavirus [ ], continually increases the challenge for appropriate management. However, approximately one-third of patients with severe CAP were previously healthy [ 73 ].

Improving the 2007 IDSA/ATS severe Community-Acquired Pneumonia criteria to predict ICU admission

Once again, Gram stain and culture of an adequate sputum specimen are usually adequate to exclude the need for empirical coverage of these pathogens. The spectrum of antibiotic therapy can be broadened, narrowed, or completely altered on the basis of diagnostic testing. False-positive blood culture results are associated with prolonged hospital stay, possibly related to changes in management based on preliminary results showing gram-positive cocci, which eventually prove to be coagulase-negative staphylococci [ 95].

Ays patterns clearly vary by geography.


Given these results, concern regarding nonresponse should be tempered before 72 h of therapy. Retrospective studies of outpatient CAP management usually show that diagnostic tests to define an etiologic pathogen are infrequently performed, yet most patients do well with empirical antibiotic treatment [ 42].

Communitu criteria appear to function well except among patients with underlying renal insufficiency and among elderly patients [ 5253 ]. Many delayed transfers to the ICU represent rapidly progressive pneumonia that is not obvious on admission.

Community Acquired Pneumonia Guidelines

The emergence of drug-resistant pneumococcal isolates is well documented. Oriol SibilaMD, 1, 2 G. For example, not all investigators have found it acwuired to have the white blood cell count improve. In table 12the different risk and protective factors and their respective odds ratios are summarized.

Patient groups in which routine diagnostic testing is indicated and the recommended tests are listed in table 5.

Practice Guidelines

Mortality among nonresponding patients is increased several-fold in comparison with that among responding patients [ ]. Grading of guideline recommendations. Antibiotic trials have not demonstrated a need to specifically treat these organisms in the majority of CAP cases.

This assumption is clearly not valid in all cases. Influenza is often suspected on the basis of typical symptoms during the proper season in the presence of an epidemic.

Early clinical features of H5N1 infection include persistent fever, cough, and respiratory difficulty progressing over 3—5 days, as well as lymphopenia on admission to the hospital [, ]. We assessed these measures either at the time of presentation to the emergency department, or for those who were admitted directly from clinic, at time of hospital admission. More concerning is a recent study suggesting that many outpatients given a fluoroquinolone may not have even required an antibiotic, that the dose and duration of treatment were often incorrect, and that another agent often should have been used as first-line therapy.

The diagnostic criteria defined in this review are particularly important for use in prospective studies of CAP, because most prior reports used liberal criteria, which resulted in exaggerated rates. A randomized, parallel group study introduced a pneumonia guideline in 20 of 36 small Oklahoma hospitals [ 29 ], with the identical protocol implemented in the remaining hospitals in a second phase.

For patients admitted through the emergency department EDthe first antibiotic dose should be administered while still in the ED. Recommendations for such testing will evolve on the basis of the features of the pandemic, and guidance should be sought from the CDC and WHO Web sites http: In general, patients in higher PSI classes take longer to reach clinical stability than do patients in lower risk classes [ ].

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Small-volume aspiration at the time of intubation should be adequately handled by standard empirical severe CAP treatment [ ] and by the high oxygen tension provided by mechanical ventilation. The 2 major criteria—mechanical ventilation with endotracheal intubation and septic shock requiring vasopressors—are absolute indications for admission to an ICU.

Pretreatment blood samples for culture and acqulred expectorated sputum sample for stain and culture in patients with a productive cough should be obtained from hospitalized patients with the clinical indications listed in table 5 but are optional for patients without these conditions. Delays in starting antibiotic therapy that result from the need to obtain specimens, complications of invasive diagnostic procedures, and unneeded antibiotic changes and additional testing for false-positive tests are also important considerations.

We identified episodes of CAP among hospitalized patients during the study period, Many guixelines the factors predictive of positive guidelinees culture results [ 95 ] overlap with risk factors for severe CAP table 4.

Implementing a guideline in the ED halved the time to initial antibiotic dose [ 22 ]. Because respiratory failure is commuhity major reason for delayed transfer to the ICU, simple cardiac monitoring units would not meet the criteria for a high-level monitoring unit for patients with severe CAP. The need for diagnostic testing to determine the etiology of CAP can be justified from several perspectives.

Third, specific interventions more easily performed in the ICU e. Improving the care of patients with community-acquired pneumonia CAP has been the focus of many different organizations. Subsequent publication of studies documenting that care that deviates from guidelines results in better outcomes will stimulate revision of the guidelines.

Wunderink, Antonio Anzueto, John G. Interpretation is improved with quantitative cultures of respiratory secretions from any source sputum, tracheal aspirations, and bronchoscopic aspirations or by interpretation based on semiquantitative culture results [, ]. In general, when switching to oral antibiotics, either the same agent as the intravenous antibiotic or the same drug class should be used. Outcome parameters that can be used to measure the effect of implementation of a Isda guideline within an organization are listed in table 3.

Serial measurement of key process measures showed significant improvement in time to first antibiotic dose and other variables, first in the initial 20 hospitals and later in the remaining 16 hospitals.