Treatment of CAP in adults who require hospitalization

1. Treatment of CAP in adults
who require hospitalization

2. Likely pathogenes
01
Risk facto
Risk factor for organism resistant
02
Initial Empiric Therapy
03

3. Likely pathogenes

4. Likely Pathogens
Streptococcus pneumoniae, Respiratory
viruses (eg, influenza, parainfluenza,
respiratory syncytial virus, rhinovirus),
and, less often, Mycoplasma
pneumoniae, Haemophilus influenzae,
and Legionella spp
S. pneumoniae is the most
common, but Legionella, gram-
negative bacilli, Staphylococcus
aureus, and influenza are also
important
Medical Ward ICU

5. MRSA :Strong risk factors
Known MRSA colonization
Prior MRSA infection
Detection of gram-positive
cocci in clusters on a good-
quality sputum Gram stain

6. MRSA : Other factors that should raise suspicion for infection
 Recent hospitalization or antibiotic
use, particularly hospitalization with
receipt of IV antibiotics in the prior 3
months
 Recent influenza-like illness
 Risk factors for MRSA colonization,
including: End-stage renal disease
 Crowded living conditions (eg,
incarceration)
 Injection drug use
 Contact sports participation
 Men who have sex with men
 Necrotizing or cavitary pneumonia
 Empyema
 Immunosuppression

7. Pseudomonas
Known Pseudomonas colonization
Recent hospitalization
or stay in a long-term
care facility
Detection of gram-negative rods
on a good-quality sputum Gram
stain
Prior Pseudomonas infection
Hospitalization with receipt of IV
antibiotics in the prior 3 months
Frequent COPD exacerbations
requiring glucocorticoid and/or
antibiotic use
Other structural lung diseases (eg,
bronchiectasis, cystic fibrosis)

8. Determining whether a patient with CAP can be safely treated as an
outpatient or requires admission to an observation unit, general
medical ward, or higher acuity level of inpatient care, such as an
ICU, is an Essential First Step.
Severity of illness is the most critical factor in making this
determination, but other factors should also be taken into account.

9.  Antibiotic recommendations for hospitalized patients
with CAP are divided by the site of care (Medical ward
or ICU]).
 Most hospitalized patients are initially treated with an
IV regimen but can transition to oral therapy as they
improve.
 Start antibiotic therapy as soon as we are confident that CAP is the appropriate working diagnosis and, ideally,
within four hours of presentation for patients being admitted to the general medical ward .
 In patients with septic shock, antibiotics should be started within one hour.

12. Pneumonia Severity Index

13. CURB-65 pneumonia severity score

14. Among the available scoring systems for determining
the need for admission in patients with CAP, we prefer
the PSI because it is the best studied and validated.
If a less complex scoring system is desired, the CURB-
65 score is a reasonable alternative, although its
effectiveness and safety in guiding the initial site
of treatment have not been empirically assessed.

15. Medical Ward Therapy

16. 1. Without suspicion for MRSA or Pseudomonas
1. Combination therapy with Ceftriaxone (1 to 2
g IV daily), Cefotaxime (1 to 2 g IV every 8
hours), Ceftaroline ( 600 mg IV every 12
hours), ertapenem (1 g IV daily), or Ampicillin-
Sulbactam (3 g IV every 6 hours)
PLUS a Macrolide (azithromycin [500 mg IV or
orally daily] or clarithromycin [500 mg twice
daily] or clarithromycin XL [two 500 mg tablets
once daily]).
Doxycycline (100 mg orally or IV twice daily) may
be used as an alternative to a macrolide.

17. 2. Monotherapy with a respiratory fluoroquinolone
(Levofloxacin [750 mg IV or orally daily] or
Moxifloxacin [400 mg IV or orally daily] or
Gemifloxacin [320 mg orally daily]) is an
appropriate alternative for patients who cannot
receive a beta-lactam plus a macrolide.

18. 2.With suspicion for Pseudomonas
Combination therapy with an
antipseudomonal/antipneumococcal beta-lactam
antibiotic and an antipseudomonal fluoroquinolone,
such as the following regimens::
1. Piperacillin-tazobactam (4.5 g every 6 hours) or
2. Imipenem (500 mg every 6 hours) or
3. Meropenem (1 g every 8 hours) or
4. Cefepime (2 g every 8 hours) or
5. Ceftazidime (2 g every 8 hours; activity against
pneumococcus more limited than agents listed above)
PLUS
1. Ciprofloxacin (400 mg every 8 hours) or
2. Levofloxacin (750 mg daily)
 The dose of levofloxacin is the same when given IV and
orally, while the dose of ciprofloxacin is 750 mg orally
twice daily

19. 3.With suspicion for MRSA
Either Vancomycin or Linezolid (600 mg IV every 12 hours).

20. Antiviral treatment is recommended as soon as possible for all
persons with suspected or confirmed influenza requiring
hospitalization or who have progressive, severe, or
complicated influenza infection, regardless of previous health
or vaccination status .
4.Influenza therapy

21. 1. Beta-lactam plus either a Macrolide OR
2. Monotherapy with a Respiratory fluoroquinolone OR
3. Beta-lactam plus Doxycycline.
1. Without suspicion for MRSA or Pseudomonas
 Antipseudomonal/antipneumococcal beta-lactam (eg, Piperacillin-
Tazobactam, Cefepime, Ceftazidime, Meropenem, or Imipenem) PLUS
 Antipseudomonal fluoroquinolone (eg, Ciprofloxacin or Levofloxacin)
2. With suspicion for Pseudomonas
 Anti-MRSA activity, such as Vancomycin or Linezolid
3. With suspicion for MRSA
Medical Ward Empiric Antibiotic for CAP
MRSA Risks Pseudomonas Risks
Strong risk factors
 Known MRSA colonization  Known Pseudomonas colonization
 Prior MRSA infection  Prior Pseudomonas infection
 Detection of gram-positive cocci in clusters on a good-quality
sputum Gram stain
 Detection of gram-negative rods on a good-quality sputum Gram stain
 Hospitalization with receipt of IV antibiotics in the prior 3 months
Other factors that
should raise
suspicion for
infection
 Recent hospitalization or antibiotic use, particularly
hospitalization with receipt of IV antibiotics in the prior 3
months
 Recent hospitalization or stay in a long-term care facility
 Recent influenza-like illness  Recent antibiotic use of any kind
 Necrotizing or cavitary pneumonia  Frequent COPD exacerbations requiring glucocorticoid and/or antibiotic use
 Empyema  Other structural lung diseases (eg, bronchiectasis, cystic fibrosis)
 Immunosuppression  Immunosuppression
 Risk factors for MRSA colonization, including:ESRD
 Crowded living conditions (eg, incarceration)
 Injection drug use
 Contact sports participation
 Men who have sex with men

22. ICU Therapy

23. 1. Without suspicion for MRSA or Pseudomonas
1. IV combination therapy with a potent
antipneumococcal beta-lactam (Ceftriaxone [1 to 2 g
daily], Cefotaxime [1 to 2 g every 8
hours], Ceftaroline [600 mg every 12
hours], Ampicillin-sulbactam [3 g every 6 hours],
or Ertapenem [1 g IV daily]) plus an advanced
macrolide (Azithromycin [500 mg daily]).
 an alternative to Azithromycin is a respiratory
fluoroquinolone (Levofloxacin [750 mg daily]
or Moxifloxacin [400 mg daily]).

24. 2.With suspicion for Pseudomonas
Combination therapy with an
antipseudomonal/antipneumococcal beta-lactam
antibiotic and an antipseudomonal fluoroquinolone,
such as the following regimens::
1. Piperacillin-tazobactam (4.5 g every 6 hours) or
2. Imipenem (500 mg every 6 hours) or
3. Meropenem (1 g every 8 hours) or
4. Cefepime (2 g every 8 hours) or
5. Ceftazidime (2 g every 8 hours; activity against
pneumococcus more limited than agents listed above)
PLUS
1. Ciprofloxacin (400 mg every 8 hours) or
2. Levofloxacin (750 mg daily)
 The dose of levofloxacin is the same when given IV and
orally, while the dose of ciprofloxacin is 750 mg orally
twice daily

25. 3.With suspicion for MRSA
Either Vancomycin or Linezolid (600 mg IV every 12 hours).
Empiric therapy for CA-MRSA should be given to hospitalized patients with
septic shock or respiratory failure requiring mechanical ventilation.

26. • Antiviral treatment is recommended as soon as possible for
all persons with suspected or confirmed influenza
requiring hospitalization or who have progressive, severe,
or complicated influenza infection, regardless of previous
health or vaccination status .
4.Influenza therapy

27. 5.Adjunctive glucocorticoids
For patients with CAP who have septic shock that is refractory to fluid
resuscitation and vasopressor administration or respiratory failure with a FiO2
requirement of >50 % plus one or more of the following features (metabolic
acidosis with an arterial pH of <7.3, lactate >4 mmol/L, or a CRP >150 mg/L).
These patients are at high risk of mortality and are likely to benefit the most.
Methylprednisolone (0.5 mg/kg IV every 12 hours) and treat for a total of 5 days

28.  IV combination therapy with a potent antipneumococcal beta-lactam (Ceftriaxone [1
to 2 g daily], Cefotaxime [1 to 2 g every 8 hours], Ceftaroline [600 mg every 12
hours], Ampicillin-sulbactam [3 g every 6 hours], or Ertapenem [1 g IV
daily]) plus an advanced macrolide (Azithromycin [500 mg daily]).
 Alternative to Azithromycin is a respiratory fluoroquinolone (Levofloxacin [750 mg
daily] or Moxifloxacin [400 mg daily]).
1. Without suspicion for MRSA or Pseudomonas
 Antipseudomonal/antipneumococcal beta-lactam (eg, Piperacillin-
Tazobactam, Cefepime, Ceftazidime, Meropenem, or Imipenem) PLUS
 Antipseudomonal fluoroquinolone (eg, Ciprofloxacin or Levofloxacin)
2. With suspicion for Pseudomonas
 Anti-MRSA activity, such as Vancomycin or Linezolid
3. With suspicion for MRSA
ICU Empiric Antibiotic for CAP
MRSA Risks Pseudomonas Risks
Strong risk factors
 Known MRSA colonization  Known Pseudomonas colonization
 Prior MRSA infection  Prior Pseudomonas infection
 Detection of gram-positive cocci in clusters on a good-
quality sputum Gram stain
 Detection of gram-negative rods on a good-quality sputum Gram stain
 Hospitalization with receipt of IV antibiotics in the prior 3 months
Other factors that
should raise
suspicion for
infection
 Recent hospitalization or antibiotic use, particularly
hospitalization with receipt of IV antibiotics in the prior 3
months
 Recent hospitalization or stay in a long-term care facility
 Recent influenza-like illness  Recent antibiotic use of any kind
 Necrotizing or cavitary pneumonia  Frequent COPD exacerbations requiring glucocorticoid and/or antibiotic use
 Empyema  Other structural lung diseases (eg, bronchiectasis, cystic fibrosis)
 Immunosuppression  Immunosuppression
 Risk factors for MRSA colonization, including:ESRD
 Crowded living conditions (eg, incarceration)
 Injection drug use
 Contact sports participation
 Men who have sex with men

29. 2022
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