The Swedish Society of Infectious Diseases developed guidelines for the management of adults with community-acquired pneumonia. A patient is initially triaged based on disease severity with subsequent therapy determined by clinical status and test results.
Patient selection: immunocompetent adult with community-acquired pneumonia
Parameters of the CURB-65 (based on the CURB score of the British Thoracic Society, above):
(1) mental status (confusion)
(2) blood urea
(3) respiratory rate
(4) blood pressure
(5) age in years
|
Parameters |
Findings |
Points |
|
confusion |
new onset of disorientation OR reduced consciousness |
1 |
|
|
neither |
0 |
|
blood urea |
<= 7 mmol/L |
0 |
|
|
> 7 mmol/L |
1 |
|
respiratory rate |
< 30 breaths per minute |
0 |
|
|
>= 30 breaths per minute |
1 |
|
blood pressure |
systolic >= 90 mm Hg AND diastolic >= 60 mm Hg |
0 |
|
|
systolic < 90 mm Hg OR diastolic < 60 mm Hg |
1 |
|
age in years |
<= 65 years of age |
0 |
|
|
> 65 years of age |
1 |
total score =
= SUM(points for all 5 parameters)
Interpretation:
• minimum score: 0
• maximum score: 5
• The higher the score the more severe the pneumonia.
|
Total Score |
Severity |
Site of Care |
|
0 or 1 |
mild |
home |
|
2 |
moderate |
supervised home therapy or hospital |
|
3 |
severe |
hospital |
|
4 or 5 |
severe |
hospital, preferrably in ICU |
All patients have 2 blood and 2 sputum cultures prior to treatment plus sputum cytology. Patients with severe pneumonia have a more extensive workup (for Legionalla, Mycoplasma, etc.) and patients in the ICU may undergo bronchoscopy.
|
Regimen |
Not Severe (Score 0 to 2) |
Severe (Score 3 to 5) |
|
default |
penicillin OR amoxicillin |
penicillin OR cefuroxime OR cefotaxime |
|
penicillin allergy |
erythromycin OR doxycycline |
clindamycin AND (moxifloxacin OR levofloxacin) |
|
atypical pneumonia |
erythromycin OR doxycycline |
(cefotaxime OR cefuroxime) AND erythromycin; penicillin AND (moxifloxacin OR levofloxacin) |
|
Total Score |
Pathogen |
Duration of Therapy |
|
0 to 2 |
|
7 days |
|
3 to 5 |
Legionella |
10-14 days |
|
3 to 5 |
Staphylococcus aurues |
14-21 days |
|
3 to 5 |
gram negative |
14-21 days |
|
3 to 5 |
other |
10 days |
Patients with severe pneumonia and parenteral therapy are switched to oral therapy when:
(1) clinically improved
(2) afebrile
(3) able to take oral medication
Treatment failure is defined as no clinical improvement after 48 to 72 hours of therapy. The patient should undergo additional testing to try to identify a cause. If the organism has been isolated and susceptibility testing done, then the antibiotic therapy may be changed to a more effective regiment.
Hospitalized patients are discharged when:
(1) clinically improved
(2) stable for 24 hours
(3) receiving oral therapy
Purpose: To evaluate an immunocompetent adult with community-acquired pneumonia using the Swedish guidelines and the CURB-65.
Specialty: Infectious Diseases, Pulmonology
Objective: options
ICD-10: J13, J14, J15, J16, J17, J18,
