Conditions Alcoholism COPD and/or smoking Aspiration Lung abscess Exposure to bat or bird droppings Exposure to birds or rabbits

Exposure to farm animals or parturient cats HIV (early) HIV (late) Hotel or cruise ship stay in last 2 weeks Travel to or living in SW US Travel to or living in SE & E Asia Influenza active in community Cough > 2 wks w/whoop or post-tussive vomiting Structural lung disease Injection drug use Endobronchial obstruction Bioterrorism Patient Group Outpatient (healthy & no use of abx in last 3 mos) Outpatient (w/comorbidities or abx in last 3 mos) Inpatient non-ICU Inpatient ICU

Common Pathogens S. pneumo, oral anaerobes, Klebsiella, Acinetobacter, M. tuberculosis H. flue, Pseudomonas, Legionella, S. pneumo, M. catarrhalis, C. pneumo Gram negative enteric pathogens, oral anaerobes CA-MRSA, oral anaerobes, endemic fungal pneumonia, M. tuberculosis, atypical mycobacteria Histoplasma C. psittaci or F. tularensis Coxiella burnetti S. pneumo, H. flue, M. tuberculosis early pathogens + Pneumocystis, Cryptococcus, Histoplasma, Aspergillus, atypical mycobacteria (esp M. kansasii), Pseudomonas, H. flue Legionella Coccidioides, Hantavirus Burkholderia pseudomallei, avian influenza, SARS Influenza, S. pneumo, S. aureus, H. flue B. pertussis Pseudomonas, Burkholderia cepacia, S. aureus S. aureus, anaerobes, M. tuberculosis, S. pneumo Anaerobes, S. pneumo, H. flue, S. aureus B. anthracis, Y. pestis, F. tularensis

If Pseudomonas is a consideration

If CA-MRSA is a consideration

Empiric Therapy macrolide OR doxycycline quinolone OR B-lactam (amoxicillin, ceftriaxone) + macrolide Quinolone OR B-lactam + macrolide B-lactam (ceftriaxone, unasyn) + azithromycin OR B-lactam + quinolone If PCN-allergic: quinolone + aztreonam B-lactam (zosyn, cefepime, imipenem, meropenem) + ciprofloxacin or levofloxacin OR B-lactam + aminoglycoside + azithromycin OR B-lactam + aminoglycoside + quinolone If PCN-allergic: aztreonam + aminoglycoside + quinolone Add vancomycin or linezolid

PSI a.male (0 points) b.female (-10 points) a.age (1 point for each year) b.nursing home resident (10 points) a.neoplastic disease (20 points) b.liver disease (20 points) c.heart failure (10 points) d.cerebrovascular disease (10 points) e.renal disease (10 points) a.altered mental status (20 points) b.RR >/= 30/min (20 points) c.SBP < 90 mmHg (20 points) d.temp < 35 C or >/= 40 C (15 points) e.pulse >/= 125/min (10 points) a.arterial pH < 7.35 (30 points) b.BUN >/= 30 mg/dL (20 points) c.Na < 130 mEq/L (20 points) d.Glucose >/= 250 mg/dL (10 points) e.Hct < 30% (10 points) f.PaO2 < 60 mmHg or O2 sat < 90% (10 points) g.Pleural effusion (10 points)

CURB-65

SCAP a.arterial pH < 7.3 = 13 points b. SBP < 90 mmHg = 11 points a.RR > 30 breaths/min = 9 points b. PaO2/FIO2 < 250 mmHg = 6 points c. BUN > 30 mg/dL = 5 points d. altered mental status = 5 points e. age >/= 80 yrs = 5 points f. multilobar/bilateral infiltrates on CXR = 5 points

Sex

Confusion = 1 point Urea > 20 mg/dL = 1 point

Major criteria Minor criteria

Demographic Factors

Comorbidities

RR >/= 30 breaths/minute = 1
point

PE Findings

Low SBP (< 90 mmHg) or low DBP (</- 60 mmHg) = 1 point

Labs/CXR

Age >/= 65 yo = 1 point

Classification
0-50 points: Class I (0.1% mortality) 51-70 points: Class II (0.6% mortality) 71-90 points: Class III (0.9% mortality) 91-130 points Class IV (9.3% mortality) 131-395 points: Class V (27.0% mortality)

Classification
0-1 points: low severity (risk of death < 3%); outpatient therapy 2 points: moderate severity (risk of death = 9%); consider hospitalization 3-5 points: high severity (risk of death 15-40%); hospitalize & assess for ICU admission esp if score is 4 or 5

Classification
Score > 10 (1 major criteria or 2/6 minor criteria) = consider ICU