Antibiotic Therapy in Community-Acquired Pneumonia: Switch and Step Down Therapy

Hugh A. Cassiere, MD, Winthrop University Hospital

Disclosures

Medscape General Medicine. 1998;1(3) 

In This Article

Tables

Table I - Factors Associated with Increased Morbidity and Mortality

  • Post-splenectomy state

  • Chronic alcohol abuse

  • Altered mental status

  • Vital sign abnormalities:

    • respiratory rate > 30

    • systolic BP < 90

    • diastolic BP < 60

    • temperature >101deg.F

  • PaO2 < 60 mmHg

  • PaCO2 > 50 mmHg

  • Need for mechanical ventilation

  • Metastatic (extrapulmonary) infection

    • WBC < 4,000 or > 30,000/mm3

    • Renal dysfunction, ie, BUN > 20mg/dL

    • Unfavorable chest radiographic pattern:

      • multilobar infiltrates

      • effusions

      • rapidly progressive infiltrates

      • cavitation

  • Evidence of severe infection:

    • metabolic acidosis

    • DIC

    • Severe sepsis or septic shock

    • ARDS

Table II - Factors that Can Slow Pneumonia Resolution

  • Increased age

  • Alcohol abuse

  • Significant coexisting medical disease

  • Severe pneumonia

  • Multilobar disease

  • Infection with a virulent pathogen, ie, Legionella pneumophilia, S aureus, and gram-negative bacilli

  • History of smoking

  • Persistent leucocytosis and fever

  • Bacteremic infection

Table III - Criteria Used in Identifying Step Down Therapy Candidates

  • Improving cough

  • Improving respiratory distress

  • Absence of fever for > 24 hours

  • Absence of high risk or resistant pathogens, ie, S aureus

  • Absence of unstable coexisting medical disease

  • Absence of complications, ie, congestive heart failure

  • Intact gastrointestinal absorption

  • Improving leucocytosis

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