Spectrum: Local Antimicrobial Stewardship, for Prisma Health-Midlands

ED/Ambulatory Setting Pneumonia

Notes

Clinical Criteria

  • Radiographic infiltrate, AND

  • 2 of 3 clinical features:

    • Fever (>38ºC or >100.5ºF)
    • Leukocytosis or leukopenia
    • Purulent sputum

Type of Pneumonia

  • CAP: Symptom onset occurring in the community setting or <48hrs after hospital admission

  • HCAP: Use of this term is no longer recommended by clinical guidelines due to poor predictive performance for drug resistance

Diagnostics to Consider

  • CXR

  • Vitals

  • ABG/O₂ sat

  • CBC

  • Respiratory GS and culture

  • Blood culture x 2 sites

  • S. pneumoniae and Legionella urinary antigens

  • MRSA nasal swab for PCR

  • Influenza A & B PCR

Empiric Treatment Notes

  • All dosages provided assume normal renal and hepatic function.

  • Use of clinical judgment is encouraged when selecting empiric therapy for a patient, including consideration of severity of illness, prior microbiology, and prior antimicrobial history.

  • Revise antimicrobial regimen based on microorganism identification (e.g. culture, PCR) and antimicrobial susceptibility testing results.

Common Pathogens

Select All That Apply

Defined by one of the following:

  • Abbreviated Mental Test Score <8, OR

  • New disorientation in person, place, or time

Additional Information

Beta-Lactam Allergy

Empiric Levofloxacin Use

  • Given the importance of fluoroquinolones in the management of serious infections and their relative toxicity (e.g. dysglycemias, CNS side effects, muscle injury, tendonitis) compared to alternative agents, it is recommended to reserve fluoroquinolones for select patient cases where the benefit outweighs the risk (e.g. severe beta-lactam allergy, oral antipseudomonal coverage)

  • Avoid levfloxacin for gram-negative bacterial coverage if patient had prior fluoroquinolones use particularly within the past 3 months

    • Risk of infections due to fluoroquinolone-resistant bacteria may persist for up to 12 months from fluoroquinolone use

  • If antipseudomonal or other gram-negative bacterial coverage is warranted and an oral fluoroquinolone is not reliable empiric coverage, the patient may require hospital admission for further work-up and consultation with an infectious diseases specialist or PHASST to determine optimal empirical therapy

MRSA Nasal Swab PCR

  • This test demonstrates a negative predictive value of >95% for ruling out MRSA as a causative pathogen for pneumonia

  • This is a useful diagnostic in patients at increased risk of MRSA pneumonia at baseline (e.g. residence in a long-term care facility, wound care in the last 30 days, prior MRSA infection/colonization within 90 days)

Respiratory Viral PCR Panel

  • This test, which is designed for upper respiratory tract infections, includes both viral and atypical bacterial targets for community-acquired pneumonia

  • If the patient is unlikely to have a secondary bacterial pneumonia, consider streamlining to appropriate viral pneumonia management (e.g. oseltamivir for influenza A or B virus, supportive care for rhinovirus) or atypical bacterial pneumonia management (e.g. azithromycin)