1. Pam Charity, MD Cathryn Caton, MD, MS

2.  Define pneumonia  Review criteria for diagnosis  Review criteria for admission  Review treatment options

3.  Fever  Leukocytosis  Infiltrate on CXR

4.  History  Physical Exam  Laboratory Data  Radiographic findings

5.  Severity of Illness Scores – CURB-65 (confusion, uremia, respiratory rate, low blood pressure, age 65 or greater)  Consider other factors – ability to safely and reliably take oral medication, support resources  CURB-65 > or = 2, more intensive treatment

6.  Major criteria  Septic shock requiring vasopressors  Acute respiratory failure requiring intubation and mechanical ventilation  Minor Criteria  Respiratory rate >30  PaO2/FiO2 ratio <250  Multilobar infiltrates  Confusion  BUN >20  Leukopenia, thrombocytopenia  Hypothermia

7.  Healthy and no risk factors for drug resistant S. Pneumoniae  Macrolide – azithromycin  Doxycycline

8.  Patients with  co-morbid conditions – chronic heart, lung, renal disease; DM; ETOH; malignancies; asplenia; immunosuppressing drugs  use of abx within last 3 months  or other risk for drug resistant S. Pneumoniae  Then use  fluoroquinolone  B – Lactam plus macrolide or amoxicillin-clavulanate

9.  Fluoroquinolone  B-Lactam plus a macrolide  First dose of antibiotics should be administered in the ED after blood cultures are obtained.

10.  B-Lactam plus either azithromycin or a fluoroquinolone  For pseudomonas use B-Lactam plus fluoroquinolone or  B-Lactam plus an aminoglycoside and azithromycin or  B-Lactam plus an aminoglycoside and a fluoroquinolone

11.  Patients should be switched when  Hemodynamically stable  Clinically improving  Able to tolerate oral medications  Patients should be discharged as soon as clinically stable without other active issues

12.  Minimum of 5 days  Afebrile for 48-72 hours  No more than 1 CAP associated sign of clinical instability

13.  IDSA / ATS Guidelines  Clinical Infectious Diseases 2007; 44:S27-72