Tutorial

Clinical Guidelines for the Management of Adults with Community-Acquired Penumonia

Despite the introduction of potent new antimicrobials and effective vaccines, pneumonia remains to be a common and serious illness. In fact, it is the sixth leading cause of death in the United States and the leading cause of death from infectious diseases. As many as 4 million cases of community-acquired pneumonia occur annually, resulting in $4 billion in direct and indirect costs in treatment of pneumonia.

The American Thoracic Society recently released guidelines on the management of community-acquired pneumonia with recommendations for a general approach to pneumonia.

In recent years, there has been a change in the epidemiology and microbiology of community-acquired pneumonia. While streptococcus remains the primary cause of community-acquired pneumonia, patients today are more likely to present with disease caused by atypical pathogens. Mycoplasma pneumonial, chlamydia pneumoniae, and Legionella species are encountered more frequently today as compared with 10 to 15 years ago. As a result of evolution of bacterial resistance. Beta-lactamase production is increasingly common, decreasing the sensitivity to traditional antibiotics.

The clinical presentation and radiographic findings with community-acquired pneumonia are often non specific. Available tests are usually unable to provide a quick and accurate identification of the etiologic pathogens. As a result, therapy for pneumonia is often administered on a empiric basis. Thus, it is important to know the likelihood that a certain pathogen is responsible for the disease in a given patient. The 3 most useful variables in predicting the likely infecting pathogens and therefore influencing the initial treatment approach to pneumonia are:

The severity of illness
The need for hospitalization
The presence of advanced age or co-existing illness

After collecting your information at the initial evaluation, each patient can be placed into one of four categories listed in Table #1: Four Major Patient Categories based on Initial Evaluations (Categories 1 and 2 are mild to moderate disease.)

The common pathogens and treatment plans are summarized in Table #2: Outpatient Pneumonia without Co morbidity in Patients <= 60 Years, and Table #3: Outpatient Pneumonia with Co morbidity in Patients >= 60 Years, respectively. They can often be managed in the outpatient setting. (Categories 3 and 4 are moderate to severe and severe diseases.)

The common pathogens and treatment plans are summarized in Table #4: Hospitalized Patients with Community-Acquired Pneumonia and Table #5: Hospitalized Patients with Severe Pneumonia. Most of these patients need hospitalized. Mortality ranged from 5% to 25% for category 3 patients and can approach 50% for category 4 patients. Therefore, recognition of patients with severe disease is crucial. Table #6: Risk Factors that Increase Mortality and Complications, Table #7: Physical Findings Predictive of a Complicated Course, and Table #8: Laboratory Findings Predictive of a Complicated Course list risk factors in the history and findings in the physical and the laboratory testing that should alert us of a potentially at risk patient.