MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA (CAP) IN ADULTS: ASSESSMENT OF SEVERITY USING CURB-65 SCORE AND TREATMENT GUIDELINES

These guidelines do not apply to children, aspiration pneumonia or exacerbation of chronic airways limitation (CAL). The CURB-65 assessment, based on the British Thoracic Society guidelines, is presented since many regional centres may lack easy access to specialised testing such as blood pH monitoring. Assessment of CAP using the Pneumonia Severity Index (Therapeutic Guidelines: Antibiotic V12, 2003) is also recommended but requires additional clinical and laboratory information. Only a minority of patients (c. 10%) will meet the criteria for severe pneumonia. It is important that treatment is matched with disease severity. The clinical status may change following initial assessment and alter the risk category. CHEST X-RAY CLINICAL FEATURES SUGGESTIVE OF PNEUMONIA
CONSOLIDATION, PNEUMONIA LIKELY NO CONSOLIDATION CONSIDER OTHER DIAGNOSIS

CURB-65 SCORE (1 point each) CONFUSION (acute onset) UREA > 7 mmol/L RESPIRATORY RATE 30/min BLOOD PRESSURE (SBP < 90 mmHg or DBP 60 mmHg) AGE 65

OTHER INVESTIGATIONS AS APPROPRIATE full blood picture blood glucose level arterial blood gas analysis or O2 saturation microbiology - blood cultures, sputum for Gram stain and culture, if good quality specimen is available

CURB-65 score = 0 or 1

CURB-65 score = 2

CURB-65 score = 3, 4 or 5

GROUP 1

GROUP 2

GROUP 3

MAY BE SUITABLE FOR ORAL ANTIBIOTICS AND OUTPATIENT MANAGEMENT Need to consider comorbidities, social supports, likelihood of compliance. Advise outpatients to seek additional medical attention if their condition deteriorates.

LIKELY TO REQUIRE HOSPITAL ADMISSION FOR IV ANTIBIOTICS

MANAGE AS SEVERE PNEUMONIA IN HOSPITAL Consider for intensive monitoring, especially if score 4 or 5.

benzylpenicillin
(1.2 g IV 6 hourly) OR

azithromycin
(500mg IV daily) OR (500mg IV 6 hourly) PLUS

(1g orally 8 hourly) PLUS EITHER

amoxycillin

amoxycillin
(1g IV 6 hourly) PLUS EITHER

erythromycin

roxithromycin
(300mg orally daily) OR (200mg day one then 100mg daily)

roxithromycin
(300mg orally daily) OR (200mg day one then 100mg daily) ADD (4 to 6mg/kg IV daily) if significant Gram negative bacilli are identified in blood cultures or sputum [adjust dose for age & renal function]

benzylpenicillin / amoxycillin
(1.2 g IV 4 hourly) / (2 g IV 6 hourly) AND (4 to 6mg/kg IV daily) [adjust dose for age & renal function]

doxycycline

doxycycline

gentamicin

gentamicin

If signicant renal impairment, replace benzylpenicillin/amoxycillin and gentamicin with ceftriaxone (1 g IV daily)

PENICILLIN HYPERSENSITIVITY (excluding immediate hypersensitivity*)

PENICILLIN HYPERSENSITIVITY (excluding immediate hypersensitivity*)

PENICILLIN HYPERSENSITIVITY (excluding immediate hypersensitivity*)

(500mg orally 12 hourly) PLUS

cefuroxime

(1g IV 8 hourly) PLUS EITHER

cephazolin

ceftriaxone
(1g IV daily) PLUS

roxithromycin
(300mg orally daily) OR (200mg day one then 100mg daily)

roxithromycin
(300mg orally daily) OR

azithromycin
(500mg IV daily) OR

doxycycline

(200mg day one then 100mg daily)

doxycycline

(500mg IV 6 hourly)

erythromycin

* For patients with a history of IMMEDIATE (ANAPHYLACTIC) PENICILLIN HYPERSENSITIVITY (urticaria, angioedema, bronchospasm or anaphylaxis within 1 hour of drug administration), use moxifloxacin 400mg orally daily for 7 days for patients with less severe pneumonia, and moxifloxacin 400mg intravenously daily until significant clinical improvement for patients with severe pneumonia.

Consultation for appropriate antibiotics can be obtained by contacting one of the following hospital switchboards, and asking for the on-call Clinical Microbiology or Infectious Diseases consultant. Sir Charles Gairdner Hospital Phone (08) 9346 3333 Royal Perth Hospital Phone (08) 9224 2244 Fremantle Hospital Phone (08) 9431 3333 A record of the consultation and any adivce given should be documented in the relevant Patient Medical Record.
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IN TROPICAL REGIONS (KIMBERLEY) FOR PATIENTS WITH SEVERE PNEUMONIA AND PATIENTS WITH LESS SEVERE PNEUMONIA AND ADDITIONAL RISK FACTORS#

(4 to 6mg/kg IV daily) [adjust dose for age & renal function]

PLUS

gentamicin

meropenem
(1g IV 8 hourly)

Patients in tropical regions are at increased risk of infection with Burkholderia pseudomallei (melioidosis) and Acinetobacter baumannii. Additional risk factors include diabetes, alcoholism, chronic renal failure and chronic lung disease.

CURB-65 assessment guideline references: Thorax 2001, 56 (Suppl IV); Thorax 2003, 58 (377-382) Antibiotic management adapted from Therapeutic Guidelines: Antibiotic Version 12, 2003 pages 165-175. Guidelines developed and approved by the Western Australian Therapeutic Advisory Group (WATAG), 2005.

Designed by Medical Illustration Department, Royal Perth Hospital, 04060405