Fluoroquinolones in the Management of Community-acquired Pneumonia in Primary Care

Brian Wispelwey; Katherine R Schafer

Disclosures

Expert Rev Anti Infect Ther. 2010;8(11):1259-1271. 

In This Article

Site-of-care Decision for Patients with CAP

The decision as to where a patient will be treated – outpatient versus hospital admission and ICU versus general ward – is based upon the severity of CAP.[1,33] This initial decision is critical – although less than 20% of all CAP patients are admitted to hospital, their care accounts for more than 90% of the total cost of care for CAP.[3,33] Clinical assessment and judgment are the foundation upon which these decisions are made; however, prognostic scoring systems are valuable for their ability to identify patients who require more or less aggressive care. Two of the more important scoring systems are the Pneumonia Severity Index (PSI) and the CURB-65 rule. CURB-65 stands for confusion, blood urea greater than 7 mmol/l, elevated respiratory rate (>30/min), low systolic or diastolic blood pressure, and age 65 years or older.[34] The PSI has been developed as a way to identify mild severity pneumonia and low mortality risk patients and includes five risk classes,[33,35] while the CURB-65 method focuses on identifying high mortality-risk patients with severe illness due to CAP. These two systems are best at identifying patients at opposite ends of the disease spectrum.[33] CRB-65 is a simpler version of CURB-65 that can be used when blood urea nitrogen (BUN) is not available, as is often the case in outpatients.[33] The Acute Physiology and Chronic Health Evaluation II (APACHE II) can be used as a prognostic tool in patients with severe CAP, particularly those admitted to the ICU. The odds ratio of death, occurring during an ICU stay, increases by 1.12 for each APACHE II point.[36]

In patients with a CURB-65 score of 0–1 and/or a PSI class of I–III, outpatient treatment is preferable. Hospital admission is advisable for patients with a CURB-65 score of 2 or more or for PSI classes IV and V, taken in conjunction with the physician's determination of subjective factors.[1,33] Direct admission to the ICU is required in patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation.[1] Direct admission to the ICU is recommended in patients with three of the criteria for severe CAP: respiratory rate 30 breaths/min or more, PaO2/FiO2 ratio 250 or less, multilobar infiltrates, confusion/disorientation, uremia (BUN ≥20 mg/dl), leukopenia, thrombocytopenia, hypothermia (core temperature <97°F) or hypotension requiring aggressive fluid resuscitation.[1]

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