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General
Presentation
Diagnosis
Microbiology
Pharmacology
Treatment
References
Links
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Treatment
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Site of Care
- having made the diagnosis of CAP, the 1st step in treatment must assess the severity of illness and a decision made as to whether the patient may be treated as an outpatient or if hospitalization is required
- it is estimated that approximately 75% of patients with CAP may be treated as outpatients
- several studies have attempted to identify risk factors that predict increased mortality; Canadian and ATS guidelines defined severe CAP as those cases that included respiratory failure, respiratory rate > 30/min, sepsis or shock, or the presence of extensive infiltrates 20
- the IDSA guidelines for hospitalization are based on Fine's prediction rule 21 which takes a two-step approach in deciding the appropriate site of care (see IDSA treatment flowchart)
- according to the rule, patients can be stratified into five risk classes (I-V) using a point system based on 19 variables (Table 5)
| TABLE 5. Prediction model scoring system 22 |
| Patient characteristics |
Points assigned * |
Demographic factors
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age: males
age: females
nursing home resident |
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age (in years)
age (in years) - 10
+10 |
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Comorbid illnesses
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neoplastic disease
liver disease
congestive heart failure
cerebrovascular disease
renal disease |
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Physical examination findings
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altered mental status
respiratory rate > 30/min
SBP < 90 mm Hg
temperature < 35 C or > 40 C
pulse > 125/min |
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Laboratory findings
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pH < 7.35
BUN > 10.7 mmol/L
sodium < 130 mEq/L
glucose > 13.9 mmol/L
hematocrit < 30
PO2 < 60 mm Hg**
pleural effusion |
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* the total risk score is obtained by summing the age in years (age - 10 for females) and the points for each applicable characteristic
** oxygen saturation < 90% was also considered abnormal |
- Step 1 attempts to identify patients in Class I by using information obtained from the H&P which is the criteria most commonly available in the primary care setting; this approach is intended to allow a quick assessment of patients who are candidates for outpatient treatment
- the assessment algorithm in Step 1 considers patient age (> 50 years?), comorbid conditions present (neoplastic disease, CHF, cerebrovascular disease, renal or liver disease?) and physical findings (altered mental status, pulse „ 125/min, RR „ 30/min, SBP < 90 mm Hg, temperature < 35ƒ C or „ 40ƒ C?); a "no" response to all of these questions would place the patient in Class I (Table 6); a reply of "yes" to any of the above would place the patient in Classes II-V and further evaluation based on the above scoring system would be used to determine risk class
| TABLE 6. Stratification of risk score 23 |
| Risk |
Risk class |
Based on |
| Low |
I
II
III |
algorithm
< 70 points
71-90 points |
| Moderate |
IV |
91-130 |
| High |
V |
> 131 |
- patients in Risk Classes I-III have a low risk of mortality (0.1-0.4%, 0.6-0.7%, and 0.9-2.8% respectively) and may be candidates for outpatient care
- Step 2 uses the scoring chart (Table 5) to stratify patients into risk classes II-V; hospitalization is recommended for patients in classes IV and V; patients in class III may be treated as outpatients or inpatients depending on clinical judgment
- problems with the prediction model include the possibly time-consuming requirement of calculating a score based on 19 variables and the fact that social factors, which often make outpatient care impractical, are not considered
- the prediction model is intended to be used as an aid in deciding site of care but is not meant to replace clinical judgment
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Footnotes:
20) Mandell LA, Community-acquired pneumonia: etiology, epidemiology, and treatment, Chest, 1995, 108:35S-42S.
21) Fine MJ, et al., A prediction rule to identify low-risk patients with community-acquired pneumonia, NEJM, 1997 Jan 23, 336(4):243-50.
22) Fine MJ, et al., A prediction rule to identify low-risk patients with community-acquired pneumonia, NEJM, 1997 Jan 23, 336(4):243-50.
23) Fine MJ, et al., A prediction rule to identify low-risk patients with community-acquired pneumonia, NEJM, 1997 Jan 23, 336(4):243-50.
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Site of care
medschool.ucsd.edu/curricular_resources/MED/CAP/index.html 3/30/99