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CADTH » Resources » Academic Detailing Templates » Supporting Information - Appendices » Appendix 16c : ADUP CAP Key Messages

Appendix 16c : ADUP CAP Key Messages

ADULT

1. Chest x-ray is the ‘gold standard’ in the diagnosis of community acquired pneumonia

a. PA and lateral x-rays should be performed

b. The presence of a new opacity on x-ray plus symptoms and physical findings is diagnostic

c. If chest x-ray is positive for diagnosis, a patient should be treated with antibiotics (it is difficult to differentiate viral from bacterial)

d. Ensure follow-up of a patient if a diagnosis of CAP is made.

  • It is recommended to see patients within a week of diagnosis
  • A follow-up chest x-ray should be performed at 6 weeks after initial diagnosis in high risk individuals (see TOP Summary for details)

2. Empiric first line treatment for CAP in otherwise healthy adults is a macrolide (azithromycin [Zithromax], clarithromycin [Biaxin], erythromycin) or doxycycline.

e. Antibiotic choice should provide coverage for S. pneumoniae AND atypical organisms

  • Doxycycline and macrolides provide coverage of the atypicals as well as S. pneumoniae. Both doxycycline and the macrolides are generally well tolerated*. (*Erythromycin has a higher incidence of GI intolerance vs. the newer macrolides)

3. Respiratory fluoroquinolones (levofloxacin [Levaquin], gatifloxacin [Tequin] or moxifloxacin [Avalox], NOT ciprofloxacin [Cipro]) should be reserved for patients who have failed or are intolerant of 1st line therapy

f. Failure of therapy = hemodynamic compromise or clinical deterioration after 72 hours antibiotic therapy or no improvement after completion of antibiotic therapy

g. Resistance to fluoroquinolones is increasing. Reserve fluoroquinolones for cases most likely to benefit to preserve their long term effectiveness. (See Rx Files)

h. An alternative for patients who have failed first line therapy is [Amoxicillin-clavulanate OR cefuroxime axetil] + Telithromycin.

i. Failure of first line therapy indicates that the patient may be infected with beta-lactamase producing organisms. Therefore treatment must cover for these pathogens. Amoxicillin without clavulanate does not provide adequate coverage for beta-lactamase producing organisms.

  • Ciprofloxacin does not provide adequate coverage for S. pneumoniae or atypical organisms and should not be used.

j. Elderly patients who are otherwise healthy are candidates for macrolides or doxycycline.

k. Patients with co-morbid conditions may be candidates for a fluoroquinolone depending on their severity of illness.

4. When treating CAP, switch to another class of agent if recent antibiotic therapy (within the past 3 months)

l. Switching class is recommended to cover for potential S. pneumoniae resistance.

m. Ask the patient if they have had recent antibiotics for ANY infection.

n. No comorbidity: [Doxycycline or macrolide] + high dose amoxicillin (1 g TID) should be used (alternatively, a respiratory fluorquinolone may be used)

o. Comorbidity: [Doxycyline, advanced macrolide OR telithromycin] + high dose amoxicillin or amoxicillin-clavulanate should be used (alternatively, a respiratory fluoroquinolone may be used)

p. Amoxicillin is recommended in addition to switching classes to cover for resistant S. pneumoniae. (Amoxicillin-clavulanate is recommended for certain patient populations to cover for beta-lactamase producing organisms)

PEDIATRIC

5. For pediatric community acquired pneumonia (patients aged 3 months to 5 years old), amoxicillin is the first line drug of choice

q. S. pneumoniae is the most common bacterial pathogen

  • Amoxicillin retains the best coverage of all oral beta-lactams against S. pneumoniae (including penicillin intermediate resistant strains)
  • Standard dose of amoxicillin is recommended EXCEPT for children who are attending daycare AND/OR have received an antibiotic in the last 3 months. For these patients, high dose (90mg/kg/day) is recommended.
  • For patients with documented beta-lactam allergy, alternate agents are azithromycin or clarithromycin

6. For pediatric community acquired pneumonia (patients aged 6 to 16 years old), a macrolide is the first line drug of choice

r. Atypical pathogens such as Mycoplasma pneumoniae and Chlamydia pneumoniae are the organisms most responsible for CAP in this age group

  • Newer macrolides have fewer gastrointestinal side effects than erythromycin but are more expensive
  • Doxycycline is an option for patients > 8 years