VASF Community Acquired Pneumonia (CAP) Treatment Guidelines

Site: 
VA Medical Center San Francisco
Modified Date: 
November 29, 2023
Category: 
Syndrome Specific Guidelines

Community Acquired Pneumonia (CAP)

Diagnosis

Requires the presence of clinical features (cough, fever, sputum production, pleuritic chest pain) AND chest infiltrate demonstrated on imaging

Common Causative Organisms

Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Respiratory viruses

Outpatient Empiric CAP Treatment

Previously healthy

AND

no antibiotics in the past 3 months

Doxycycline 100 mg PO BID (preferred)

OR

Amoxicillin 1 gm PO TID (alternative)

Antibiotic use in prior 3 months

OR

Presence of co-morbidities

  • Immunosuppression
  • Chronic heart, lung, liver, or renal disease
  • Diabetes mellitus
  • Alcoholism
  • Malignancy
  • Asplenia

Combination Therapy (preferred):

Doxycycline 100 mg PO BID

PLUS

Amoxicillin 1 gm PO TID

OR

Cefpodoxime 200 mg PO BID

 

Monotherapy (alternative)

Levofloxacin* 750 mg PO daily

* Contact ASP PharmD (preferred) or ID fellow for approval unless patient has severe penicillin allergy

Suggested Duration of Therapy

  • Patients should be treated for a minimum of 5 days
  • Most patients are treated for 5-7 days

Clinical Pearls

  • Routine sputum cultures and urine antigen tests are not recommended
  • Consider testing for influenza and COVID-19 if patient exhibits flu-like symptoms during periods of high flu and SARS-CoV-2 activity
  • Signs and symptoms of CAP may be lacking or altered in elderly patients
  • Cough and chest X-ray abnormalities may take up to 6 weeks to improve and are NOT a valid reason to extend antibiotic courses

Inpatient Empiric CAP Treatment

Suggested Duration of Therapy

  • Patients should be treated for a minimum of 5 days unless the patient has confirmed MRSA or Pseudomonas aeruginosa infection in which case the minimum duration is 7 days
  • Azithromycin 500 mg PO/IV q24h x 3 doses is sufficient for atypicals; if legionella is suspected treat for 7 days
  • Patient should be afebrile for 48-72h, and should have no more than 1 of the following before stopping antibiotics:
  • Heart rate > 100 beats/min
  • Respiratory rate > 24 breaths/min
  • Systolic blood pressure < 90 mmHg
  • Arterial O2 saturation < 90%
  • Altered mental status

Clinical Pearls

  • Sputum cultures should be obtained for hospitalized patients with severe CAP or when strong risk factors for MRSA or Pseudomonas are identified
  • MRSA nares should be obtained if empiric vancomycin therapy is initiated for pneumonia to assist with de-escalation (strong negative predictive value)
  • For suspected influenza, obtain nasopharyngeal swabs for influenza antigen testing and respiratory virus DFA; if patient is hospitalized, place on droplet precautions until tests are negative, and treat with oseltamivir 75 mg PO bid for 5 days (reduce dose in renal insufficiency). ICU patients, immunocompromised patients, and obese patients may require higher doses and/or prolonged therapy.

 

References:

Metlay, Joshua P., et al. "Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America." American journal of respiratory and critical care medicine 200.7 (2019): e45-e67.