Adult Inpatient CAP - Alaska
The following guidelines were prepared by the Alaska Antimicrobial Stewardship Collaborative (A2SC), and are reproduced here as a service to practitioners in the state.
These guidelines have not been reviewed or approved by the Sanford Guide Editorial Board.
Severity and Risk Factor Considerations
Major Criteria
- Septic shock with need for vasopressors
- Respiratory failure requiring mechanical ventilation
Minor Criteria
- Respiratory rate ≥ 30 breaths/min
- Pao2/Fio2 ratio ≤ 250
- Multilobar infiltrates
- Confusion/disorientation
- Uremia (BUN ≥ 20 mg/dl)
- Leukopenia (WBC < 4,000 cells/μl)
- Thrombocytopenia (plts <100,000/μl)
- Hypothermia (<36o C)
- Hypotension requiring aggressive fluid resuscitation
**NOTE: Prior categorization of healthcare-associated pneumonia (HCAP) has been abandoned. The following are NOT predictive of multi-drug resistant pneumonia and should NOT be used alone as an indication for empiric broad-spectrum coverage:
- Hospitalized in an acute care hospital for 2 or more days within 90 days of infection
- Resided in a nursing home or long term care facility
- Received recent chemotherapy or wound care in last 30 days
- Attended a hemodialysis clinic in the last 30 days
Treatment Recommendations
**NOTE: Dosage recommendations based upon an assumed CrCl > 60 ml/min. If patient has diminished renal function, doses should be dose-reduced.
Non-Severe Infection
Standard Treatment
- Preferred Therapy:
- Ceftriaxone 1g IV q24hr PLUS
- Azithromycin 500mg PO/IV q24hr x3 days
- Anaphylactic β-Lactam Allergy:
- Levofloxacin 750mg PO/IV q24hr
Hospitalized within 90 days PLUS IV antibiotics
- Empiric treatment for MRSA or P. aeruginosa not recommended
- Escalate based upon culture results
Prior MRSA in Respiratory Culture
- Preferred Therapy:
- Vancomycin 15mg/kg x1 then (Pharmacy to Dose)
- Ceftriaxone 1g IV q24hr PLUS Azithromycin 500mg PO/IV q24hr x3 days
- Anaphylactic β-Lactam Allergy:
- Vancomycin 15mg/kg x1 then (Pharmacy to Dose)
- PLUS Levofloxacin 750mg PO/IV q24hr
**NOTE: Prior positive cultures within 1 year. If empiric treatment for MRSA or P. aeruginosa, blood and respiratory cultures should be collected prior to antibiotic administration
Prior Pseudomonas in Respiratory Culture
- Preferred Therapy:
- Cefepime 2gm IV q8hr PLUS Azithromycin 500mg PO/IV q24hr x3 days
- Anaphylactic β-Lactam Allergy:
- Levofloxacin 750mg PO/IV q24hr PLUS
- Aztreonam 2gm IV q8hr
**NOTE: Prior positive cultures within 1 year. If empiric treatment for MRSA or P. aeruginosa, blood and respiratory cultures should be collected prior to antibiotic administration
Severe Infection (1 major or ≥ 3 minor criteria)
Standard Treatment
- Preferred Therapy:
- Ceftriaxone 1g IV q24hr PLUS
- Azithromycin 500mg PO/IV q24hr x3 days
- Anaphylactic β-Lactam Allergy:
- Levofloxacin 750mg PO/IV q24hr +/- Vancomycin 15mg/kg (Pharmacy to Dose)
Hospitalized within 90 days PLUS IV antibiotics
- Empiric MRSA treatment:
- Add Vancomycin 15mg/kg (Pharmacy to Dose)
- Empiric P. aeruginosa treatment:
- Substitute Cefepime 2g IV q8h for ceftriaxone
**NOTE: If empiric treatment for MRSA or P. aeruginosa, blood and respiratory cultures should be collected prior to antibiotic administration
Duration
- 5 days for patients without immunosuppression or structural lung disease
- 7 days for patients with moderate immunosuppression or structural lung disease
- 10-14 days for poor clinical response, initial inappropriate treatment, or significant immunosuppression
**NOTE: Severe immunosuppression: Neutropenia (WBC < 4 or ANC < 500), HIV+ with CD4 < 200, active chemotherapy, undergone solid organ transplant on active immunosuppression; Moderate immunosuppression: all other diseases (including long-term steroid use with prednisone at 10mg/day or equivalent)
Patients should be afebrile for 48-72hr and demonstrate signs of clinical stability before therapy is discontinued
Aspiration pneumonia
- Addition of anaerobic therapy is NOT recommended unless lung abscess or empyema is suspected.
Suspected or confirmed Influenza
- Oseltamivir 75mg PO BID x5 days
- Certain patient populations are at a higher risk for influenza related complications and may require treatment in absence of confirmed influenza. Refer to local guidelines.
IV to PO
**NOTE: Total duration IV + PO as above; patient should complete macrolide therapy
-
Oral options to consider for de-escalation of β-lactam
- Preferred Therapy:
- Amoxicillin 1g PO TID (If known Strep pneumo and/or cefinase negative H. influenzae / M.catarrhalis use high-dose amoxicillin)
- Augmentin 875mg BID
- Consider additional amoxicillin 1g BID in addition to Augmentin for CAP complicated by empyema, asplenia or Strep pneumo PenG MIC 2-4
- Non-Anaphylactic Penicillin Allergy:
- Cefuroxime axetil 500mg PO BID
- Preferred Therapy:
Penicillin Allergy
- If patient reports penicillin allergy, inquire about onset and severity of symptoms, as well as prior beta-lactam exposure and update patient medical record.
- Severe or life-threatening allergic reactions may include: anaphylaxis, angioedema, urticaria, Stevens-Johnson Syndrome (SJS), etc.
Reference
- Metlay JP, et al. Diagnosis and treatment of adults with community-acquired pneumonia, clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200(7):e45-e67.
Metadata
Approved A2SC Advisory April 2021