Guidelines
Community-Acquired Pneumonia

Community-Acquired Pneumonia

Decision Support

Has the patient traveled outside of Canada or had antibiotics in the past 90 days?

Management

  • Smoking cessation

  • Vaccinations (influenza and Pneumococcal)

  • Hand and cough hygiene

  • Reversing gastric acid suppression if applicable

  • Antibiotics past 90 days (esp. same class)

  • Travel history outside of Canada

  • Post-influenza or URTI as a Staph aureus risk factor

  • MRSA

  • ETOH

  • Outbreak associated

  • Aspiration without infection (no fever or no ↑ WBC)

  • Heart failure

  • Neoplasm

  • Non-Influenza Viral infection

  • COPD exacerbation / Bronchitis

  • Mycoplasma and other atypicals

  • Mycobacterial

  • Pertussis

  1. Initial Chest X-Ray (Upon Presentation): Consider chest x-ray to support the clinical diagnosis of pneumonia for outpatients

  2. Follow-up Chest X-Ray: Consider a follow-up chest x-ray 6-8 weeks after initial diagnosis of pneumonia for patients who fit into one or more of the following categories: recurrent pneumonia in the last year, smokers, OR age greater than 50 years

1st Line Tests:

  • Throat swab for Mycoplasma PCR +/- Mycoplasma serology

  • Viral respiratory screen (Flu and RSV)

  • Legionella (serogroup 1) urine antigen (travel associated or severe disease)

2nd Line Tests for non-responders or immunocompromised:

  • Viral respiratory panel (13 Viruses)

  • Coxiella serology

  • Sputum/induced sputum for mycobacterium, cytology, and Pneumocystis

  • CMV shell vial +/- CMV viral load

  • Legionella serology (rarely used)

  • Fungal: Histoplasmosis Blastomyces testing

  • Before discontinuing therapy, the IDSA CAP guidelines recommends that patients with CAP should be:

    • treated for a minimum of 5 days
    • afebrile for 48-72h
    • have no more than 1 CAP-associated sign of clinical instability
  • Longer durations of therapy are usually not necessary since most patients become clinically stable in 3–7 days.

  • Criteria for clinical stability:

    • Temperature ≤ 37.8°C
    • Heart rate ≤ 100 beats/minute
    • Respiratory rate ≤ 24 breaths/minute
    • Systolic blood pressure ≥ 90 mmHg
    • Arterial oxygen saturation ≥ 90% or pO2 ≥ 60 mmHg on room air

About This Guideline

  • Antibiotics are listed in the numerical order of preference.

  • Avoid using the same class of antibiotics if used within the last 90 days.

  • Tailoring of treatment after susceptibilities are known is highly recommended.

  • CURB-65 score may have utility to determine if hospitalization is required.

  • See link to assessment above.

More Information

  1. Mandell LA, Wunderink RG, Anzueto A, et al. (2007). Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, Clinical Infectious Diseases; 44:S27-72.
  2. Mandell LA, Marrie TJ, Grossman RF, et al. (2000). Summary of Canadian Guidelines for the Initial Management of Community-Acquired Pneumonia: An evidence-based update by the Canadian Infectious Disease Society and the Canadian Thoracic Society, Can Respir J; 7(5):371.
  3. Blondel-Hill E. and Fryters S. Bugs & Drugs 2012.
  4. Anti-infective Review Panel. Anti-infective guidelines for community-acquired infection. Toronto: MUMS Guidelines Clearinghouse; 2013.
  5. Thirion DJG (Ed). Thorion’s Snippets for Snappy Antimicrobial Therapy – A Concise Canadian Guide Third Edition. Montreal: Publications PRISM inc.; 2013.
  6. Antimicrobial Agents Subcommittee, District Drugs and Therapeutics Subcommittee. Antimicrobial Handbook - 2012. Capital Health, Halifax. 2012
  7. Antibiotics, Why and Why Not. Dalhousie CME Academic Detailing Service. March 2012. http://cme.medicine.dal.ca/ad_resources.htm
  8. NB Provincial Health Authorities Anti-infective Stewardship Committee. Antimicrobial Treatment Guidelines for Common Infections. November 2014.
  9. INESSS Clinical Guides in Antibiotic Treatment – 1st Series. Community-Acquired Pneumonia in Adults. Quebec. October 2009. https://www.inesss.qc.ca
  10. The Ottawa Hospital (TOH) Guidelines for Empiric Antibiotic Therapy (2012)
  11. Antimicrobial Subcommittee of the Pharmacy & Therapeutics Committee. Antimicrobial Handbook 2013. Sunnybrook Health Sciences Centre. July 2013.
  12. Vancouver Coastal Health ASPIRES Programme. VCH Community-Acquired Pneumonia (CAP) Management Guidelines for Adults. March 2014.
  13. Vancouver Island Health Authority (VIHA) Cowichan District Hospital. Antimicrobial Empiric Prescribing Guidelines – Adults. 2011 (Edition 2)
  14. Johns Hopkins Medicine Antibiotic Guidelines 2014-2015: Treatment Recommendations for Adult Inpatients.
  15. Aoki FY, Allen UD, Stiver HG et al. (2013) AMMI Canada Guideline: The use of antiviral drugs for influenza: A foundation document for practitioners. Canadian J Infect Dis Med Microbiol 24 Suppl C:1C-15C.
  16. Health PEI Antibiogram 2014.
  17. Lim WS, van der Eerden MM et al. (2003). Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58:377-382.
  18. Jain S, Self WH, Wunderink RG et al. (2015). Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. The New England Journal of Medicine; 373:415.
  19. Solensky R. (2012). Penicillin-allergic patients: Use of cephalosporins, carbapenems, and monobactams. UpToDate (accessed Jan 3, 2013)
  20. Romano A. et al. (2007). Brief Communication: Tolerability of Meropenem in Patients with IgE-Medicated Hypersensitivity to Penicillins. Annals of Internal Medicine 146:266.
  21. Atanasković-Marković M. et al. (2008). Tolerability of Meropenem in Children with IgE-mediated Hypersensitivity to Penicillins. Allergy 63:237.
  22. Lim WS, van der Eerden MM et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58:377-382

Health PEI Physician Reviewers: Dr. Nicole Drost, Dr. Nicole Fancy, Dr. Greg German, Dr. Ayodeji Harris-Eze, Dr. Heather Morrison, Dr. Huy Nguyen, Dr. Aaron Sibley

Pharmacists: Wendy Cooke (QEH ICU/CCU Clinical Pharmacist), Jennifer Boswell (Antimicrobial Stewardship Pharmacist)