ÎCertain patients with low PSI or CURB-65 scores require hospital admission, even to the ICU. Reasons for the admission of low-mortality-risk patients fall into 4 categories:
> Complications of the pneumonia itself > Exacerbation of underlying disease(s) > Inability to reliably take oral medications or receive outpatient care, and/or > Multiple risk factors falling just above or below thresholds for the score. Hypoxemia on room air is a mitigating factor for admission, regardless of PSI class.
ÎRoutine diagnostic tests to identify an etiologic diagnosis are optional for outpatients with CAP. Retrospective studies of outpatient CAP management usually show that diagnostic tests (such as sputum culture or
and pneumococcal urinary antigen tests) to define an etiologic pathogen are infrequently performed, yet most patients do well with empirical antibiotic treatment. Exceptions to this general rule may apply to some pathogens important for epidemiologic reasons or management decisions. The availability of rapid point-of-care diagnostic tests, specific treatment and chemoprevention, and epidemiologic importance make influenza testing the most logical. Other infections that are important to verify with diagnostic studies because of epidemiologic implications or because they require unique therapeutic intervention are community-acquired MRSA (CA-MRSA) infection,
infection, infection,
or endemic fungal infection. Attempts to establish an etiologic diagnosis are also appropriate in selected cases associated with outbreaks, specific risk factors, or atypical presentations.
ÎEmpiric therapy for outpatients (Table 2) should consider:
> If previously healthy and no use of antimicrobials within previous 3 months > If presence of comorbidities or use of antimicrobials within the previous 3 months > If from a region with a high rate of infection with macrolide-resistant S. pneumoniae
ÎRecommendations are generally for a class of antibiotics rather than for a specific drug, unless outcome data clearly favor one drug.
> More potent drugs are given preference because they may decrease the risk of selecting for antibiotic resistance.
ÎPatients with CAP should be afebrile for 48-72 hours, and should have no more than one CAP-associated sign of clinical instability before stopping therapy.
ÎRecommendations:
> The Centers for Disease Control and Prevention provide additional recommendations for ways to help prevent certain infectious diseases in at-risk populations. For more information please visit www.cdc.gov.
ÎSmoking cessation should be a goal for all patients with CAP.
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