Adult Outpatient With Comorbid Conditions

The comorbid conditions that can impact therapy and outcomes in patients with CAP include diabetes mellitus, COPD, chronic heart, liver, or renal disease, alcoholism, malignancy, asplenia, and immunosuppressive condition or use of immunosuppress-ive drugs. 8 If the patient did not receive antibiotics in the last 3 months then either a respiratory fluoroquinolone alone or a combination of an oral ^-lactam agent plus a macrolide or azalide is recommended. If the patient received an antibiotic in the last 3 months the recommendation is to use an agent from a different class. Doxycycline is an acceptable alternative to a macrolide or azalide. The P-lactam agents recommended are high-dose (3 g daily) amoxicillin or high-dose (4 g daily) amoxicillin-clavulanate. Alternative P-lactams are second- and third-generation cephalosporins such as cefur-oxime, cefpodoxime, or ceftriaxone.

Telithromycin, a ketolide antibiotic approved for the treatment of mild to moderate CAP, is not included in the recommendations because of safety issues related to hep-atotoxicity, loss of consciousness, and visual disturbances still pending resolution with the FDA. Telithromycin is similar in spectrum of activity to clarithromycin and azithromycin in that it covers primarily the respiratory pathogens and not gram-negative bacilli.

Adult Inpatient Not in the ICU

For patients admitted to the hospital with CAP, the severity of a illness is generally increased (caused either by the organism itself or underlying comorbidities in the patient) and the pathogens are essentially the same as in the outpatient setting. Recommendations are to use either a respiratory fluoroquinolone alone or a combination of an IV ^-lactam agent plus an advanced macrolide/azalide (clarithromycin/azithromycin) or doxycycline. The recommended ^-lactams include cefotaxime, ceftriaxone,

ampicillin-sulbactam, or ertapenem. Therapy should be initiated in the emergency room; however, due to the controversy with a first antibiotic dose time of less than 4 or 8 hours, no recommendations were made regarding time to the first antibiotic dose. Conversion to oral therapy should occur when the patient is hemodynamically stable, improving clinically, and able to take oral medications, which often is within 48 to 72 hours for most patients. Discharge from the hospital should be as soon as the patient is stable and without other medical complications. The need to observe the patient in the hospital on their oral antibiotic is not necessary.28

Table 71-3 Summary of CAP Treatment

Adult ontpatie ni otherwise healthy

Empirical coverage ¿gains! i pneumoniae, M. pneumoniae, C. pneumoniae, jnd H. rtftjAtQH

A&vil Odi(Wfi(nr rprMrEiitAilrfS

impirkakcivorjgedgjiiin i [mtiirnnrtiae, M. fwwfoflifti, CpwviftQfiiot:. and ft. itJbwxte

Adult inpatient fnan-KM)

tmpiriiaUcwr.ii)i»aq.iiiNi i pneurrximae, H. HtamaQ M. pneumoniae, and C pneumoniae

Adult inpatient Kli(noPwudomonos)

Empfcteal (overage atjinsl S.pneunxmicui, J. pnfunMpkfAi. H. influenzae, enlerk ONE, and £. aureus

Advti iiipot'M KV il>i*ud0rW6iff r> «nrtYrtJ

lmpirkiikQ™Tjgiid(jiHiil P. aeriflfrxna,™fiw<Meh

Advil inpaOtt» not^icy Or Klf (CA-*«?SjI it Qtwxtml

F mpirical coverage aga ns1 ifmerjuncMCi i. pncunxpJvJo, H inBitffiTQC. erteftc iiNH. .11*1 S (Mirnyf Ou(njrA)i'';rtrii]( IflOfl flpdinlric oiriprJifni fmfHrlcalco'.-iT.vjeagairrtl S. pneumoniae, M. pnetimor\iae, jrkd C.pnewHJniie

Pftfiairii iupcjititt (hen 'KVI

Empirical coverage arpinst S. pneumoniae, H. .nlk>er>zaet M, pfMWisxmiic. JIKI C jirtfufisoijii1

Pediatric inpatient iiu inipiritjIiOvtrjgO^jMifil i [^iftirrtejtitw, ¿j)rtiurrjypii..,(j. H .■■ifi.wi'ue, (Mmprlt ilhfl, and tautens


Ajiltiioni)*: In, cLuMhiomycrv erythnooiyc in, do&ycyc line CCimtirKiriflrtfJ^rdpy

High-tow januxklilliri, h)gti-d0SSimeafldlllliVClivitnMe tiUmulivL"! ilS1 (ffptXMJtitVie, Oi C^furiiifiri^. oi (Kf(t UMCtfti) iJilhn^Tiytirt. en clarithromycin or, doaycycfn** Monotherapy

Gemiflraiafin, levAfkn,* in, moslfkMacIn Combination therapy feliraaxiiw, ra frfiitiiKW. (* ampifi In-iLlhsriim. ot edaprnem pHn afJthiotnydn. or cijiM hiornyc.^ of doiycytllne AfitASrJu-Tdpy

GermftMarln, lovofkMUi in, tTKHlfloMacIn Combination therapy

QMsmlineorcefti mciw piui ,irn hionifr in, or levofkwacin, or mmilloixaf in

COrrt&irwJtii&ii IhtrOpy

Cefeplme, or ceftazidime, 01 pifwraciHin ij^otuiUni, 01 imp.-in.=rn, or meftipeneni flVrfOt cipioiiJiWCinQr lenofKMCln c* jn .jmiftoglyiCJiidie If an arrniuglycosJiff! f: chosen, then add arilhiomycln or Kwoftoocacin or moAudi faJd vancamjiciri or linciolhd 1o1he re^mens Ikied above


Hlqh dose amoxicillin, or high-dote jmcrtlcillin clavLikiruile.of Intramuicula col trux**.'. or Jjil Imjinyi in. or cbiilltiomyC in

COrwihrnffrSm ItKrOpy

IV c^urowme.or cefotaxime, or ceftriaxone, ci aropkillin-ujlbdctam plus i vil IniCVlyC in. Of < LiitlhiCrrlyt m

Combination iheiapy

CefajKifrw. C* ceftriinooe plus AflhiiSTttyti^ix tUiitfucmytifi

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