تجربة

تجربةنظرة عامةالأدلةالمساهمون

التعليمات

Diagnosis of community acquired pneumonia (CAP) is usually made with a combination of history, physical exam, and findings on chest x-ray, lung US or chest CT scan.
Intended for immunocompetent adults who have not recently traveled internationally.

Confusion

Introduction

Community acquired pneumonia (CAP) is a common condition that presents in the outpatient setting (primary care and emergency care) with a hospitalization rate of approximately 2% in ages ≥ 65 years and is associated with a 30-day mortality rate of 5% in hospitalized patients (Womack & Kropa, 2022). Further, Womack & Kropa highlight that in 11% of patients a bacterial pathogen was identified, 23% of patients a viral pathogen and 62% of patients no organism was identified. (Note: These studies were conducted before the COVID-19 pandemic.) Diagnosis of community acquired pneumonia (CAP) is usually made with a combination of history, physical exam, and findings on chest x-ray, lung US or chest CT scan. Clinicians are encouraged to use both their clinical judgement and a validated clinical prediction rule to determine the need for hospitalization in patients with CAP (Armstrong, 2020). The CURB-65 (confusion, urea level, respiratory rate, blood pressure, and age 65 or older) Score for pneumonia severity is a well-validated risk stratification tool that can assist clinicians in the outpatient setting with determining disposition (inpatient versus outpatient) and does not require laboratory testing.

However, validated clinical prediction rules, like the CURB-65 and Pneumonia Severity Index (PSI), do not effectively determine the level of care required (Armstrong, 2020). The American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) criteria for severe CAP is preferred to predict ICU admission.¹ Low-quality evidence suggests the PSI may outperform CURB-65. Armstrong (2020) reports the PSI can underestimate the severity of illness among younger patients, but it has higher discriminative power in predicting mortality and a lover false-positive rate then the CURB-65.

¹Statement on COVID-19 (Armstrong, 2020): "Editor's Note: This ATS/IDSA guideline was produced before the COVID-19 pandemic, which has altered the diagnosis and management of lower respiratory tract infections. The current version of this guideline limits testing and antiviral treatment in patients with influenza, and we expect testing for and treatment of severe acute respiratory syndrome coronavirus 2 infection to become a long-standing element of standard pneumonia care.

Although the IDSA has published initial guidelines for management of COVID-19, the situation is evolving rapidly (https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management).
Free information on COVID-19 is available from American Family Physician at https://www.aafp.org/journals/afp/explore/COVID-19.html and Essential Evidence Plus at http://www.essentialevidenceplus.com/content/eee/904."

Scoring

The CURB-65 Score (confusion, urea level, respiratory rate, blood pressure, and age 65 or older) for pneumonia severity is a well-validated risk stratification tool that can assist clinicians in the outpatient setting with determining disposition (inpatient versus outpatient) and does not require laboratory testing.

Rule criteria

Criteria	Points
Confusion	1
BUN > 19 mg/dL (>7 mmol/L urea)	1
Respiratory Rate ≥ 30	1
Systolic BP < 90 mmHg or Diastolic BP ≥ 60	1
Age ≥ 65	1

Scoring & Recommendations*

Recommendation	Score (out of 5 points)
Low Risk: Consider outpatient treatment	≤ 1
Moderate Risk: Consider inpatient treatment or outpatient with close follow-up	2
Severe Risk: Consider inpatient treatment with possible intensive care admission	3
Highest Risk: Consider inpatient treatment with possible intensive care admission	≥ 4

*Risk groups and score cut-offs based on the derivation study performed by Lim et al (2003).

Considerations

According to the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) practice guidelines on patients with community acquired pneumonia (CAP)(Armstrong, 2020; Womack & Kropa, 2022):

Clinical judgement is a key component to determine the need for hospitalization.
Validated clinical prediction rules, like the Curb-65 and Pneumonia Severity Index (PSI), do not effectively determine the level of care required.
The ATS/IDSA criteria for severe CAP is preferred to predict ICU admission.¹
Five-day antibiotic treatment courses are recommended for all patients with CAP, with reassessment following treatment.
For outpatients without comorbidities, treatment with amoxicillin, doxycycline or macrolide is recommended.
Routine treatment of CAP with macrolide monotherapy is no longer recommended unless local resistance is low (< 25%).
In outpatients with comorbidities and inpatients with non-severe pneumonia, a combination of a beta-lactam or third-generation cephalosporin plus a macrolide, or monotherapy with a respiratory fluoroquinolone is recommended.
Patients should be treated for methicillin-resistant Staphylococcus aureus or Pseudomonas infection only if they present with risk factors for those pathogens.

Although the IDSA has published initial guidelines for management of COVID-19, the situation is evolving rapidly (https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management).
Free information on COVID-19 is available from American Family Physician at https://www.aafp.org/journals/afp/explore/COVID-19.html and Essential Evidence Plus at http://www.essentialevidenceplus.com/content/eee/904."

جميع الأسئلة والنتائج المحتملة

Guidanceالعنوان غير مرئي

Confusion

Select one option:

BUN > 19 mg/dL (>7 mmol/L urea)

Select one option:

Respiratory Rate ≥ 30

Select one option:

Systolic BP < 90 mmHg or Diastolic BP ≤ 60

Select one option:

Age ≥ 65

Select one option:

النتائج المحتملة

Moderate Risk: Consider inpatient treatment or outpatient with close follow-up

Considerations

Clinical judgement is a key component to determine the need for hospitalization.
Validated clinical prediction rules, like the CURB-65 and Pneumonia Severity Index (PSI), do not effectively determine the level of care required.
The ATS/IDSA criteria for severe CAP is preferred to predict ICU admission.¹
Five-day antibiotic treatment courses are recommended for all patients with CAP, with reassessment following treatment.
For outpatients without comorbidities, treatment with amoxicillin, doxycycline or macrolide is recommended.
Routine treatment of CAP with macrolide monotherapy is no longer recommended unless local resistance is low (< 25%).
In outpatients with comorbidities and inpatients with non-severe pneumonia, a combination of a beta-lactam or third-generation cephalosporin plus a macrolide, or monotherapy with a respiratory fluoroquinolone is recommended.
Patients should be treated for methicillin-resistant Staphylococcus aureus or Pseudomonas infection only if they present with risk factors for those pathogens.

Although the IDSA has published initial guidelines for management of COVID-19, the situation is evolving rapidly (https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management).
Free information on COVID-19 is available from American Family Physician at https://www.aafp.org/journals/afp/explore/COVID-19.html and Essential Evidence Plus at http://www.essentialevidenceplus.com/content/eee/904."

Severe Risk: Consider inpatient treatment with possible intensive care admission

Considerations

Clinical judgement is a key component to determine the need for hospitalization.
Validated clinical prediction rules, like the CURB-65 and Pneumonia Severity Index (PSI), do not effectively determine the level of care required.
The ATS/IDSA criteria for severe CAP is preferred to predict ICU admission.¹
Five-day antibiotic treatment courses are recommended for all patients with CAP, with reassessment following treatment.
For outpatients without comorbidities, treatment with amoxicillin, doxycycline or macrolide is recommended.
Routine treatment of CAP with macrolide monotherapy is no longer recommended unless local resistance is low (< 25%).
In outpatients with comorbidities and inpatients with non-severe pneumonia, a combination of a beta-lactam or third-generation cephalosporin plus a macrolide, or monotherapy with a respiratory fluoroquinolone is recommended.
Patients should be treated for methicillin-resistant Staphylococcus aureus or Pseudomonas infection only if they present with risk factors for those pathogens.

Although the IDSA has published initial guidelines for management of COVID-19, the situation is evolving rapidly (https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management).
Free information on COVID-19 is available from American Family Physician at https://www.aafp.org/journals/afp/explore/COVID-19.html and Essential Evidence Plus at http://www.essentialevidenceplus.com/content/eee/904."

Low Risk: Consider outpatient treatment

Considerations

Clinical judgement is a key component to determine the need for hospitalization.
Validated clinical prediction rules, like the CURB-65 and Pneumonia Severity Index (PSI), do not effectively determine the level of care required.
The ATS/IDSA criteria for severe CAP is preferred to predict ICU admission.¹
Five-day antibiotic treatment courses are recommended for all patients with CAP, with reassessment following treatment.
For outpatients without comorbidities, treatment with amoxicillin, doxycycline or macrolide is recommended.
Routine treatment of CAP with macrolide monotherapy is no longer recommended unless local resistance is low (< 25%).
In outpatients with comorbidities and inpatients with non-severe pneumonia, a combination of a beta-lactam or third-generation cephalosporin plus a macrolide, or monotherapy with a respiratory fluoroquinolone is recommended.
Patients should be treated for methicillin-resistant Staphylococcus aureus or Pseudomonas infection only if they present with risk factors for those pathogens.

Although the IDSA has published initial guidelines for management of COVID-19, the situation is evolving rapidly (https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management).
Free information on COVID-19 is available from American Family Physician at https://www.aafp.org/journals/afp/explore/COVID-19.html and Essential Evidence Plus at http://www.essentialevidenceplus.com/content/eee/904."

Highest Risk: Consider inpatient treatment with possible intensive care admission

Considerations

Clinical judgement is a key component to determine the need for hospitalization.
Validated clinical prediction rules, like the CURB-65 and Pneumonia Severity Index (PSI), do not effectively determine the level of care required.
The ATS/IDSA criteria for severe CAP is preferred to predict ICU admission.¹
Five-day antibiotic treatment courses are recommended for all patients with CAP, with reassessment following treatment.
For outpatients without comorbidities, treatment with amoxicillin, doxycycline or macrolide is recommended.
Routine treatment of CAP with macrolide monotherapy is no longer recommended unless local resistance is low (< 25%).
In outpatients with comorbidities and inpatients with non-severe pneumonia, a combination of a beta-lactam or third-generation cephalosporin plus a macrolide, or monotherapy with a respiratory fluoroquinolone is recommended.
Patients should be treated for methicillin-resistant Staphylococcus aureus or Pseudomonas infection only if they present with risk factors for those pathogens.

Although the IDSA has published initial guidelines for management of COVID-19, the situation is evolving rapidly (https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management).
Free information on COVID-19 is available from American Family Physician at https://www.aafp.org/journals/afp/explore/COVID-19.html and Essential Evidence Plus at http://www.essentialevidenceplus.com/content/eee/904."

الاستشهاد المرجعي

Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, Lewis SA, Macfarlane JT. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May;58(5):377-82.

الأدبيات العلمية

Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May;58(5):377-82.
Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, Lewis SA, Macfarlane JT.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746657/?tool=pmcentrez
Community-Acquired Pneumonia: Updated Recommendations from the ATS and IDSA. Am Fam Physician. 2020;102(2):121-124
Armstrong C.
https://www.aafp.org/pubs/afp/issues/2020/0715/p121.html
Community-Acquired Pneumonia in Adults: Rapid Evidence Review. Am Fam Physician. 2022 Jun 1;105(6):625-630.
Womack J, Kropa J.
https://pubmed.ncbi.nlm.nih.gov/35704808/
Validity of pneumonia severity index and CURB-65 severity scoring systems in community acquired pneumonia in an Indian setting. Indian J Chest Dis Allied Sci. 2010 Jan-Mar;52(1):9-17.
Shah BA, Ahmed W, Dhobi GN, Shah NN, Khursheed SQ, Haq I.
https://pubmed.ncbi.nlm.nih.gov/20364609/
Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med. 2005 Apr;118(4):384-92.
Aujesky D, Auble TE, Yealy DM, Stone RA, Obrosky DS, Meehan TP, Graff LG, Fine JM, Fine MJ.
https://pubmed.ncbi.nlm.nih.gov/15808136/
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. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67.
Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812437/

جميع الأسئلة والنتائج المحتملة

الاستشهاد المرجعي

الأدبيات العلمية

تقييمات ذات صلة

PSI/PORT Score: Pneumonia Severity Index for CAP

mMRC (Modified Medical Research Council) Dyspnea Scale

STOP-BANG Score for Obstructive Sleep Apnea

COPD Assessment Test (CAT)

Global Initiative for Obstructive Lung Disease (GOLD) Criteria for COPD

Assess Asthma Control & Adjust Therapy

Classify Asthma Severity

Identify Current Asthma Treatment Step

Asthma Inhaled Corticosteroid (ICS) Dose Strength Algorithm

أيضًا من EVAL Foundation

Alcohol Use Disorders Identification Test - C (AUDIT-C)

Alcohol Use Disorders Identification Test (AUDIT)

American Shoulder and Elbow Surgeons (ASES) Shoulder Score

Behavioral Activity Rating Scale (BARS)

Drug Abuse Screening Test (DAST-10)

Foot and Ankle Ability Measure (FAAM)

Foot and Ankle Disability Index (FADI)

General Anxiety Disorder (GAD-7)