2. PATIENT TYPEETIOLOGY OutpatientStreptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Chlamydophila pneumoniae Respiratory viruses* Non-ICU InpatientS. pneumoniae M. pneumoniae C. pneumoniae H. influenzae Legionella species Aspiration Respiratory viruses* ICU InpatientS. pneumoniae Staphylococcus aureus Legionella species Gram-negative bacilli H. influenzae * Influenza A and B, adenovirus, respiratory syncytial virus, and parainfluenza.

3. CONDITIONORGANISMS AlcoholismStrep pneumo, oral anerobes, Klebsiella, Acinetobacter, Mycobaterium tuberculosis COPD/smokingH flu, Pseudomonas, Legionella, Strep pneumo, Moraxella, Chlamydophila pneumoniae AspirationGram negative enterics, oral anaerobes Lung abscessMRSA, oral anaerobes, M. tuberculosis, atypcial mycobacterium, fungal Exposure to bat/bird droppingsHistoplasma capsulatum Exposure to birdsChlamydophila psittaci Exposure to rabbitsFrancisella tularensis Exposure to farm animalsCoxiella burnetti (Q fever) Injection drug useS. aureus, anaerobes, M. tuberculosis, S. pneumoniae Cough >2weeks with whoopBordetella pertussis Structural lung disease (bronchiectasis)Pseudomonas, Burkholderia, S. aureus

4.  Productive cough  Fever  Pleuritic chest pain  Dyspnea  GI symptoms  Mental status changes

5.  Febrile  RR >24 breaths/minute  Tachycardia  Rales  +egophany

6.  Chest Xray with infiltrate  Leukocytosis  Blood cultures  Sputum – gram stain and culture  Urine antigens  Influenza testing  Viral culture  ABG **If hospitalized within last 90 days or if lives at ECF, received outpatient dialysis then patient would be considered as hospital or healthcare associated pneumonia

7.  Severity Scores  CURB-65  PSI = Pneumonia Severity Index  Helps to determine severity of illness  Helps to determine if patient should be admitted and whether needs admitted to ICU

8.  Confusion  Urea (BUN >20mg/dL)  Respiratory Rate > 30 breaths/minute  Blood Pressure (systolic <90mmHg or diastolic <60mmHg)  Age >65 years * 1 point for each

9. SCORERISK30 DAY MORTALITY MANAGEMENT 0Low0.6%Outpatient 1Low2.7%Outpatient 2Moderate6.8%Inpatient vs Outpatient 3Severe14%Inpatient 4Highest27.8%Inpatient/ICU 5Highest27.8%Inpatient/ICU

10. POINTS Age in Years+ 1 point per year Gender-10 pts for women ECF Resident+ 10 points Cancer+ 30 points Liver Disease+ 20 points CHF+ 10 points CVA+ 10 points CKD+ 10 points Altered Mental Status+ 20 points Respiratory Rate+ 20 points POINTS SBP+ 20 points Temp not 95-104 F+ 15 points HR >125bmp+ 10 points pH <7.35+ 30 points PaO2 <60mmHg+ 10 points Na < 130mEq/L+ 20 points BUN >64 mg/dL+ 20 points Glucose >250+ 10 points Hct <30%+ 10 points Pleural Effusion+ 10 points

11. CLASSPOINTSMORTALITYRISKMANAGEMEN T Class 100.1%LowOutpatient Class 2<700.6%LowOutpatient Class 371-902.8%LowObservation Class 491-1308.2%ModerateInpatient Class 5>13029.2%HighInpatient/ICU

12. PATIENT POPULATIONAntibiotic Option 1Antibiotic Option 2 Non-ICU Patient (without pseudomonal risk) B-lactam (ceftriaxone, unasyn, or ertapenem) + Macrolide (azithromycin) Moxifloxacin ICU Patient (without pseudomonal risk) B-lactam (ceftriaxone or unasyn) (use aztreonam if B-lactam allergy) + Azithromycin or Moxifloxacin Non-ICU or ICU Patient with Pseudomonal risk* Anti-pseudomonal B-lactam (zosyn, cefepime, imipenem) + Aminoglycoside (tobramycin or amikacin) + Azithromycin or Moxifloacin) Anti-pseudomonal B-lactam (zosyn, cefepime, imipenem) + Ciprofloxacin *If B-lactam allergy use aztreonam, moxifloxacin, and amioglycoside

13.  Suspected MRSA- add vancomycin or linezolid  Suspected aspiration- ertapenem or moxifloxacin  *Pseudomonal risk factors =  Bronchiectasis documented on admission  Structural lung disease and h/o pneumonias or chronic steroid use

14.  Switch to Oral Therapy  When clinically improving, hemodynamically stable, able to take oral meds  Duration of Hospitalization  Several studies support that it is not necessary to observe pt overnight after change to PO antibiotics  Consider discharge after no signs of clinical instability which is defined as: Temp >100, RR>24, SBP 100, O2 sat <90, altered mental status, inability to take PO  Duration of Treatment  Minimum of 5 days (most treat 7-14 days)  Before consideration of discontinuing abx need to have: ▪ Afebrile for 48-72 hours ▪ No supplemental O2 ▪ No signs of clinical instability

15.  When should you get a follow up CXR?  No clear evidence  Most recommend f/u CXR for patients >40 years and h/o smoking to document resolution of disease and no underlying malignancy  Obtain CXR 7-12 weeks after completion of treatment

16.  Blood cultures prior to first antibiotic dose  Oxygen assessment  Initial antibiotics within 6 hours of presentation  Appropriate antibiotic selection  Pneumococcal vaccine for pts >65  Influenza vaccine for pts >50 during Oct-March  Smoking cessation counseling