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Community-Acquired Pneumonia

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Key Points ÎCommunity-acquired pneumonia (CAP) is an acute infection of the pulmonary parenchyma associated with a constellation of suggestive features and accompanied by the presence of an acute infiltrate demonstrable on chest radiograph—with or without supporting microbiological data—in a patient not hospitalized or residing in a long-term care facility. > Clinical features include cough, fever, sputum production and pleuritic chest pain ÎInitial site of treatment—outpatient, or inpatient in a ward or intensive care unit (ICU)—is one of the most important clinical decisions in managing patients with CAP, often determining: > Selection and route of administering antimicrobial agents > Intensity of medical observation, and > Use of medical resources ÎAlmost all major decisions in the management of CAP depend on initial assessment of severity. ÎPrognostic models such as the Pneumonia PORT Severity Index (PSI) (see Table 1) or severity of illness scores such as CURB-65 (confusion, urea nitrogen, respiratory rate, low blood pressure, age ≥ 65 years) (see Table 1A) can be used to help determine the site of care. ÎSuch scores should be supplemented by physician determination of subjective factors, including: > Ability to safely and reliably take oral medication > Availability of outpatient support resources ÎDirect admission to an ICU is recommended for patients who present with 1 major or 3 of the minor criteria for severe CAP (Table 2): > Major criteria Septic shock requiring vasopressors Acute respiratory failure requiring intubation and mechanical ventilation > Minor criteria Respiratory rate ≥ 30 breaths/min PaO2 Multilobar infiltrates Confusion/disorientation Uremia (blood urea nitrogen [BUN] level ≥ 20 mg/dL) Thrombocytopenia (platelet count < 100,000 cells/mm2 Leukopenia (white blood cell [WBC] count < 4,000 cells/mm3 /FiO2 ) ) Hypotension requiring aggressive fluid resuscitation Hypothermia (core temperature, < 36°C) ÎDiagnostic testing should be done for specific pathogens that would significantly alter empirical management decisions of patients with CAP, when the presence of such pathogens is suspected on the basis of clinical and epidemiologic clues: > These tests are optional for outpatients with CAP. > An aggressive approach to diagnostic testing is warranted in patients with severe CAP. ratio ≤ 250

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