This document provides guidelines for diagnosing and treating pneumonia. It discusses determining whether a patient requires inpatient or outpatient care based on severity scores like CURB-65. For inpatients, it provides criteria for admission to the ICU versus the general ward. It also covers physical exams, diagnostic tests, antibiotic treatment duration, and signs of clinical instability.
3. *First , we should determine if patient should be treated
outpatient or inpatient .
*Outpatient care: able to take oral medications and
have adequate outpatient care
*º Inpatient care: based on severity-of-illness scores
(eg, CURB-65 criteria [confusion, uremia, respiratory
rate, low blood pressure, 65 years or older]) or
*prognostic models (eg, Pneumonia Severity Index
[PSI]) and professional judgment
5. *
*PSI prognostic model:
* Assess 20 variables and assign points to each variable, this
model classifies patients to 5 classes;
*Risk class 1
*Risk class 2: <70
*Risk class 3: 71-90
*Risk class 4: 91-130
*Risk class 5:>130
*The PSI is less practical in a busy emergency-room setting
because of the need to assess 20 variables.
6. *If CURB-65 is from 0-1 , can be treated outpatient .
*Patients with CURB-65 score ≥2 require hospitalization or
aggressive outpatient care.
*If inpatient treatment required, determine if patient should
be admitted to ICU or general ward
*º ICU admission recommended: 1 major criteria or 3 minor
criteria are present , and CURB-65 of 3 and more .
*Patient who are admitted to ICU usually require:
* vasopressors for septic shock necessitating
* or if he has acute respiratory failure requiring intubation
and mechanical ventilation.
9. *
*Physical exam:
*º Crackles or rales, bronchial breath sounds, hypoxemia,
tachypnic
*º Signs/symptoms of cough, fever, sputum production,
pleuritic chest pain
*• Chest radiograph:
*º Hospitalized for suspected pneumonia but negative chest
radiograph: may receive empiric antibiotics with repeat
chest radiograph 24−48hrs later
10. *
* Lab tests:
*º Pretreatment blood culture and/or expectorated sputum
samples for culture and gram stain should be taken if:
* ICU admission, outpatient antibiotic therapy failure,
cavitary infiltrates, leukopenia, active alcohol abuse,
chronic severe liver and lung disease, asplenia,
positive Legionella or pneumococcal UAT result, pleural
effusion; optional for other indications
*º Tests mentioned above are optional in patients without
these conditions
*Severe CAP: should obtain blood culture, expectorated
sputum culture, urinary antigen tests for Legionella
pneumophila and S. pneumoniae; endotracheal aspirate
sample for intubated patients.
15. *
*Duration: minimum 5 days of treatment, should be afebrile
48−72hrs, and no more than 1 CAP associated sign of
clinical instability before discontinuing therapy.
*• Longer duration of therapy may be warranted in certain
circumstances (eg, initial therapy did not target identified
pathogen, extrapulmonary infections such as meningitis or
endocarditis)
16. *
*Temp ≤37.8°C
*º Heart rate ≤100 beats per min
*º Respiratory rate ≤24 breaths per min
*º Systolic blood pressure ≥90mmHg
*º Arterial 02 saturation ≥90% or pO2 ≥60mmHg
*º Maintain oral intake and normal mental status
*So signs of instability are the opposites of the signs (eg.
< , > )