Diagnosis and Assessment of Disease
Evaluation and Initial Management of CAP History, physical examination, chest radiograph
No infiltrate: manage/evaluate for alternative diagnosis
Infiltrate + compatible clinical features supporting diagnosis of pneumonia*
Consider PSI, CURB-65, hypoxemia, patient factors† Determine site of care:
Empirical therapy (Table 2)
(PSI risk classes I, II, III; CURB-65 score 0-1) Mitigating factors
Manage as outpatient
no response to oral therapy, severe social or psychiatric problems, substance abuse, unstable living situation, homelessness)
(eg, frail condition, hypoxemia,
(PSI risk classes III, IV, V;
CURB-65 score ≥ 2)
* Compatible clinical features include but are not limited to fever, hypothermia, rigors, sweats, new cough with/without sputum production, change in color of secretions, chest discomfort, or onset of dyspnea. † Severity-of-illness scores, such as the CURB-65 criteria, or prognostic models, such as the PSI, can be used to identify patients with CAP who may be candidates for outpatient treatment. Such scores should always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. Certain patients with low PSI or CURB- 65 scores require hospital admission, even to the ICU (see "Key Points"). Hypoxemia on room air is a mitigating factor for admission.
Table 1. CURB-65 Severity Scores for CAP Clinical Factors
Confusion
Blood urea nitrogen > 20 mg/dL Respiratory rate ≥ 30 breaths/min
Systolic blood pressure < 90 mm Hg or diastole ≤ 60 Age > 65 Years
Total Points:
CURB-65 Score 0 1 2 3
4 or 5 2
Deaths (%)* 0.6 2.7 6.8
14.0 27.8
Recommendations†
Low risk; consider home treatment Low risk; consider home treatment Admit to ward
Severe pneumonia; hospitalize and consider admitting to intensive care
CURB-65 = Confusion, Urea Nitrogen, Respiratory rate, Blood pressure, 65 years of age and older. *Data are weighted averages from validation studies. †Recommendations are consistent with British Thoracic Society guidelines. Clinical judgment may overrule guideline recommendations.
Points 1 1 1 1 1
Hospitalize patient