6 American Nurse Today Volume 12, Number 12 AmericanNurseToday.com

COMMUNITY-ACQUIRED PNEU-MONIA (CAP) is exactly what itsounds like—a lung infection ac-quired while out and about in theworld. The cause may be a virus,bacteria, or fungus. (See CAP stats.)The estimated cost of treating

CAP in the United States is about$12.2 billion a year. Inpatient treat-ment ranges from $7,500 to $10,227per admission, whereas outpatienttreatment ranges from $150 to $350per patient. This difference demon-strates the need for accurate diag-nosis and appropriate treatment.

Immune responseA patient’s immune response toCAP depends on the type of organ-ism involved. Less noxious organ-isms typically are destroyed bymacro phage engulfment, which re-sults in a moderate immune re-sponse. If the organism is highlyvirulent or is present in great num-bers, a series of immune responsesoccur, including inflammation, cel-lular infiltration, and activation ofthe immune cascade. When the pa-tient can’t clear pulmonary secre-tions, a secondary infection maydevelop. (See Immune response.)In response to physiologic

changes, the patient’s respiratoryrate may increase in an attempt toimprove oxygen levels, but eventu-ally he or she becomes exhaustedfrom the work of tachypnea, andthe respiratory rate decreases, lead-ing to hypoxemia and hypercapnia.In addition, the patient may experi-ence fever, pleuritic chest pain,coughing, dyspnea, and a generalfeeling of being unwell. In olderadults, symptoms may not be as ob-vious; they may have a less produc-

tive cough, anorexia, or confusion.

Risk factorsMany factors contribute to an in-creased chance of developing CAP.(See CAP risk factors.) Antibiotictreatment, chronic steroid use, andmalnutrition increase the risk forCAP, as do comorbidities such aschronic renal failure. In the elderlypopulation, comorbidities as well asthe effects of aging (such as re-duced mucociliary movement andclearance, decreased cough reflex,increased potential for colonizationof gram-negative organisms, anddecreased immune response) in-crease the risk for CAP. Additionalrisk factors include spleen removal,HIV, hypogammaglobulinemia, andsickle cell disease.

Classification and causes CAP is just one classification ofpneumonia. (See CAP vs. HAP.)The criteria for CAP include:• patient hasn’t been hospitalized

within 14 days before symptomonset

• patient’s symptoms begin within4 days of hospital admission

• patient doesn’t live in a long-term care facility.Bacterial pathogens and respira-

tory viruses are common causes ofCAP. Bacterial organisms that aretreatable in the outpatient settinginclude Chlamydophila pneumoni-ae, Haemophilus influenzae, Mo -rax ella catarrhalis, Mycoplasmapneumoniae, and Streptococcuspneumoniae. Respiratory viruses as-sociated with outpatient treatmentof CAP include adenovirus, influen-za A and B, parainfluenza virus,and respiratory syncytial virus. How -ever, any patient infected withthese pathogens who shows severesymptoms may be admitted for in-patient care as well as those infect-ed with anaerobes that are relatedto aspiration and Legionella pneu-mophila.

Patient assessment Begin the patient assessment byidentifying symptoms and their on-set. Note symptom severity, includ-ing characteristics of cough andsputum, descriptions of pain level,factors that relieve or aggravatesymptoms, treatments the patienthas already tried, and how the pa-tient describes illness severity.Negative test results and negative

symptoms can help rule out otherdiagnoses. Ask about abdominalpain, chest pain, hematuria, dys uria,edema, weight gain, and neurologi-cal symptoms. In addition, gatherinformation about the patient’s cur-rent medications (including pre-scription and over-the-counter med-

Community-acquired pneumoniaWith accurate diagnosis, patients can be

appropriately treated in and out of the hospital.

By Shari J. Lynn, MSN, RN

LEARNING OBJECTIVES

1. Identify the causes of and risk fac-tors for community-acquiredpneumonia (CAP).

2. Describe the assessment of thepatient with CAP.

3. Discuss the management of thepatient with CAP.

The author and planners of this CNE activity havedisclosed no relevant financial relationships withany commercial companies pertaining to thisactivity. See the last page of the article to learnhow to earn CNE credit.

CNE1.51 contact

hours

AmericanNurseToday.com December 2017 American Nurse Today 7

ications and herbal remedies); to-bacco, alcohol, and illicit drug use;environmental exposure to possiblelung irritants; and immunizations.Note allergies and past medical

history as well as social and familyhistories. Ask about any comorbidi-ties, such as cancer, autoimmunedisease, and chronic respiratory is-sues. Also note the patient’s resi-dence (for example, home or long-term care facility). Examine all body systems to

determine infection severity, theprobability of CAP, and other ill-nesses that may have contributedto CAP. A head, ears, eyes, nose,and throat exam may reveal an up-per-respiratory infection related tonasal congestion, ocular discharge,mouth breathing, nasal flaring, orotitis media. Dullness and drynessof the lips, eyes, and mucosa maybe signs of dehydration.Pulmonary auscultation and

physical examination may revealdull percussion, chest tenderness,increased tactile fremitus, broncho -ph ony, egophony, and whisperedpectoriloquy. You also may hearwheezes, rhonchi, or crackles, andthe patient may have pleuritic chestpain that’s more severe on deep in-spiration.Cardiovascular effects of CAP in-

clude poor perfusion, prolongedcapillary refill, and tachycardia. Be-cause of dehydration and cyanosiscaused by hypoxia, the patient’sskin may tent, and he or she mayexperience men tal status changes.Changes in mental status, loss ofappetite, and falls (related to confu-sion and dizziness as a result of hy-poxia) also can be factors that arepart of a CAP diagnosis.

Diagnostic toolsDiagnosis of CAP includes a chest x-ray. Viral pneumonia commonlypresents with interstitial infiltrateson x-ray; bacterial infection pres-ents with alve olar infiltrates. Viraland bacterial infections can occursimultaneously.

Many tools (including the pneu-monia severity index, CURB-65 andCRB-65, SMART-COP, and the Amer -i can Thoracic Society criteria) areavailable to help determine if thepatient with CAP can be treatedsuccessfully as an outpatient or ifhospital admission is required.

Pneumonia severity indexThe pneumonia severity index(PSI) was developed to classifypatients suspected of having CAP(goo.gl/Yk5JLH). This tool, whichhas been used in emergency de-partments, nursing homes, andcommunity hospitals, looks at pa-

These statistics reveal the prevalence of community-acquired pneumonia (CAP)and why outpatient treatment is preferred when possible.

• All age groups are susceptible to CAP, but the greatest morbidity and mortalitycan be found in young patients under 6 years old and older patients over 75years old.

• The incidence of CAP increases exponentially in patients over age 50 in indus-trialized countries.

• Even with the discovery of antibiotics, pneumonia is still prevalent on a globallevel and remains an economic burden on the healthcare system.

• According to the World Health Organization, 1.4 million people die every yearfrom pneumonia, and it’s a predominant cause of death in children.

• In the United States, CAP is the eighth leading cause of death and the mostcommon cause of death from an infectious agent.

• The death rate for patients being treated in the outpatient setting is less than 5%.

• The death rate may increase to 10% and go as high as 30% for patients admit-ted to the intensive care unit.

• The most prevalent reasons for death related to CAP are complications, suchas refractory hypoxemia, multi-organ failure, sepsis, and shock.

CAP stats

Immune responseA patient’s immune response to the organism causing community-acquired pneumoniaincludes vasodilation of the pulmonary capillaries, resulting in permeability and leakingof protein-rich exudate into the interstitial space and eventually reaching the alveoli. Asthe alveoli fill with exudate, they stick together and inhibit gas exchange.

The formation of neutrophils, as part of the inflammatory response, may damage thelung tissue and lead to fibrosis or pulmonary edema. The tissue of the alveoli is delicateand can be damaged easily by the normal inflammatory response, which can be exac-erbated if the patient has underlying protective mechanism issues such as overproduc-tion of mucous, immune deficiencies, and diminished ciliary action.

8 American Nurse Today Volume 12, Number 12 AmericanNurseToday.com

tient characteristics such as:• demographics (gender and resi-dence)

• physical assessment findings(mental status, pulse, respiratoryrate, temperature, and systolicblood pressure)

• laboratory results (pH, bloodurea nitrogen [BUN], sodiumglucose, hematocrit, and partialpressure of arterial oxygen)

• comorbidities (liver disease, neo-plasm, stroke, heart disease, andrenal failure)

• radiology results (presence ofpleural effusion).PSI scoring places patients into

one of five categories. The firstthree recommend outpatient treat-ment; the fourth and fifth recom-mend hospitalization.

CURB-65 and CRB-65CURB-65 and CRB-65 are easier touse than the PSI. Although the PSIhas 20 items, CURB-65 has only

five (confusion, BUN > 19 mg/dL,respiratory rate > 30 breaths/minute, systolic blood pressure <90 mmHg or diastolic blood pres-sure < 60 mmHg, and age > 65years) and CRB-65 has only four(the same items as CURB-65, butBUN isn’t necessary if lab resultsaren’t available). (Visit goo.gl/qXJ76f to view the CURB-65 andCRB-65 tools.)Both tools result in a rating that

corresponds to patient care recom-mendations. CURB-65 rates patientswith 0 or 1 as being acceptable foroutpatient treatment; 2 as short in-patient stay or closely supervised

outpatient treatment; and 3, 4, and5 as hospitalization and possibleICU admission. CRB-65 rates patientsas 0 (no need for hospitalization), 1to 2 (consider hospitalization), and 3 to 4 (urgent recommendation forhospitalization).

SMART-COPSMART-COP (goo.gl/bkuDFo) is usedto determine the severity of CAP inadults. The acronym represents theinformation needed to make theproper determination for care, andthe data collected translates to apoint system. Scoring for a patientwho is under 50 years old is:

Several factors place patients at riskfor community-acquired pneumonia(CAP), including comorbidities,lifestyle, and patient characteristics.

Comorbidities

• Altered mental state

• Asthma

• Bronchiectasis

• Chronic obstructive pulmonarydisease

• Cystic fibrosis

• Diabetes

• Heart disease

Lifestyle

• Alcohol or substance misuse

• Homelessness

• Overcrowded living conditions

• Smoking

Patient characteristics

• Extremes of age

• Immunocompromised status

CAP risk factorsThis chart from the Wexner Medical Center of the Ohio State University College ofMedicine differentiates community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP).

CAP HAP

Presentation

Necessary features for diagnosis: Variable clinical features:• Cough • Fever• Fever • Leukocytosis• Chest x-ray infiltrates • Increased respiratory secretions • Chest x-ray infiltrates

Risk factors

• Age extremes • Aspiration risks:• Alcohol misuse • supine positioning• Chronic corticosteroid use • swallowing dysfunction• Cormorbidities: • tracheal intubation • cardiac disease • tracheostomy • liver disease • Elevated gastric pH • pulmonary disease • Intensive care unit admission • renal disease • Immunosuppression• HIV/AIDS • Hyperglycemia/poor glycemic control• Immunosuppression • Mechanical ventilation• Preceding influenza • Oropharyngeal microbial colonization• Tobacco use Most common pathogens

• Chlamydophila pneumoniae • Enteric gram-negative bacilli• Haemophilus influenza • Pseudomonas aeruginosa• Legionella pneumophila • Staphylococcus aureus• Moraxella catarrhalis • Mycoplasma pneumoniae • Respiratory viruses • Streptococcus pneumoniae

CAP vs HAP

AmericanNurseToday.com December 2017 American Nurse Today 9

Systolic blood pressure < 90 mmHg(2 points)

Multilobar chest x-ray involvement(1 point)

Albumin < 35 g/L (1 point)Respiratory rate ≥ 25 breaths/minute (1 point)

Tachycardia ≥ 125 beats/minute (1point)

Confusion—acute (1 point)Oxygen—low arterial oxygen pres-sure (PaO2) ≤ 70 mmHg or oxy-gen saturation ≤ 93% or PaO2/fraction of inspired oxygen(FiO2) < 333 mmHg (2 points)

pH < 7.35 (2 points).For patients over 50, all the fac-

tors are the same except respiratoryrate (> 30 breaths/minute) and oxy-gen level (PaO2 < 60 mmHg or oxy-gen saturation ≤ 90% or PaO2/FiO2< 250 mmHg). The total score determines the

patient’s risk for needing intensiverespiratory vasopressor support.0-2 = low risk3-4 = moderate risk5-6 = high risk7 = very high riskPatients with a score of ≥ 5 are con -

sidered to have an increase risk for CAP.

American Thoracic Society criteriaThe American Thoracic Society has

created criteria for patients withsevere CAP who require ICU ad-mission. Minor criteria include:

• respiratory rate > 30 breaths/minute and PaO2/FiO2 ≤ 250mmHg (A need for noninvasiveventilation can substitute for a res-piratory rate > 30 breaths/minuteor PaO2/FiO2 mmHg < 250.)

• multilobar infiltrates• confusion/disorientation• uremia (BUN level ≥ 20 mg/dL)• leukopenia as a result of the in-fection alone (white blood cellcount < 4,000 cells/mm3)

• thrombocytopenia (platelet count< 100,000 cells/mm3)

• hypothermia (core temperature < 96.8° F [36° C])

• hypotension requiring aggressivefluid resuscitation.Major criteria include:

• invasive mechanical ventilation• septic shock with the need forvasopressors.Other criteria to consider include

hypoglycemia (in patients withoutdiabetes), acute alcoholism or alco-hol withdrawal, hyponatremia, un-explained metabolic acidosis or ele-vated lactate level, cirrhosis, andasplenia.

Nursing interventions andtreatment In the outpatient setting, patientswith CAP are treated with antibi-otics as outlined in guidelines fromthe American Thoracic Society andthe Infectious Diseases Society ofAmerica. (See Treatment options.)With the increase in antibiotic re-sistance, evidence-based prescribingis crucial. To decrease the chanceof antibiotic-resistant micro organ -isms developing and to reduce thechances of adverse effects fromantibiotic treatment, a short (5-day)course of antibiotic treatment isrecommended. Research shows no difference between long- andshort-course antibiotic treatment of CAP, and the short course hasbeen shown to reduce the risk of

CAP HAP

Less common pathogens

• Enteric gram-negative bacilli • Acinetobacter baumannii• Pseudomonas aeruginosa • Candida sp.• Staphylococcus aureus • Hemophilus influenza • Influenza • Legionella pneumophilia • Stenotrophomonas • Streptococcus pneumoniae and other Strep sp.

Diagnosis

• Chest x-ray infiltrate • Bronchoalveolar lavage or protected • Cough specimen brush with quantitative cultures• Fever • Clinical features are unreliable (fever, • Precise role for microbiologic leukocytosis, new chest x-ray infiltrate) cultures is unclear. • Serial chest x-rays or CT scanning • Suctioned/expectorated sputum

Empiric treatments

• Beta-lactams • Aminoglycosides• Macrolides • Antipseudomonal beta-lactams• Respiratory fluoroquinolone • Antipseudomonal fluoroquinolones • Vancomycin or linezolid

Prevention

• Comorbidity treatment • Gastric acidity maintenance• Influenza vaccination • Head of bed elevation• Pneumococcal vaccination • Infection prevention measures• Smoking cessation • Invasive mechanical ventilation avoidance • Oral and pharyngeal decontamination • Subglottic suctioning

Source: The Ohio State University College of Medicine. scribd.com/document/114849137/Community-Acquired-Pneumonia-CAP-Vs

10 American Nurse Today Volume 12, Number 12 AmericanNurseToday.com

Clo stri dium difficile.To qualify for short-course anti -

biotic treatment, patients must bedeemed clinically stable by thehealth care provider. The definitionof clinically stable includes 48 to 72hours without a fever in the last 5days of therapy, systolic blood pres-sure > 90 mmHg, heart rate < 100beats/minute, respiratory rate < 24breaths/minute, oxygen saturation >90%, and normal mental status. Ifno improvement occurs after 5 daysof antibiotic use, treatment shouldcontinue for another 2 days.Recent research provides a better

understanding of CAP patients re-ceiving current treatments as com-pared to health care-associated

pneumonia patients, specifically related to CAP drug-resistant patho -gens (CAP-DRP), including Pseudo -monas aeruginosa, Acinetobacterbaumannii, methicillin-resistantStaphylococcus aureus (MRSA), andextremely resistant Enterobacteri-aceae. The goal of this research is todecrease the overuse of narrow-spectrum antibiotics, which can re-sult in using inappropriate medica-tions and broad-spectrum antibiotics.(Access an algorithm for treatingCAP-DRPs at americannursetoday.com/?p=36506.)Other treatments include aceta-

minophen for pain and fever, earlyambulation, appropriate hydration,and nutritional meals. Systemic

steroids (if reactive airway involvement secondary to CAP ex-ists), bronchodilators, and coughsuppressants may also be ordered.Teach patients the expected

guidelines for recovery, which in-clude:• fever resolved in 1 week• notably decreased chest painand sputum in 4 weeks

• notably decreased cough andbreathlessness in 6 weeks

• resolution of symptoms (al-though fatigue may still be pres-ent) in 3 months

• feeling back to normal in 6months.Patients with underlying comor-

bidities may follow a different orextended course of recovery. Follow-up for outpatient treat-

ment is usually 48 to 72 hours afterthe initial diagnosis, with anotherfollow-up appointment with thehealthcare provider in 2 to 3 weeks.Instruct patients to contact theirprovider if any unexpected compli-cations develop. Patients whosmoke should have additional fol-low-up at the 6- to 12-week markfor a repeat assessment and chestx-ray to rule out underlying pathol-ogy that may have been a factor inthe original CAP diagnosis.

What’s in your toolkit? Using tools to assess whether CAPpatients can be treated in the com-munity reduces care costs andprotects patients with decreased im-munity from being admitted to hos-pitals, where they may acquire oth-er infections. The assessment toolslead to treatment designed to limitthe creation of additional drug-re-sistant patho gens. Research regard-ing CAP is fluid, so stay up-to-datewith the most recent evidence-based practices.

Visit americannursetoday.com/?p=36506 for a

list of selected references.

Shari J. Lynn is an instructor at the Johns HopkinsUniversity School of Nursing in Baltimore, Maryland.

The Infectious Diseases Society of America/American Thoracic Society collaboratedto create these outpatient treatment options for those with community-acquiredpneumonia.

Patient considerations Treatment options

Patient is healthy, with no use of Macrolide (azithromycin, clarithromycin, antimicrobials in the past 3 months erythromycin) OR Doxycycline (Note: macrolide preferred.)

Patient with compromised immune Respiratory fluoroquinolone (moxifloxacin, system or other comorbidities gemifloxacin, levofloxacin [750 mg])(chronic heart, lung, liver, or renal ORdisease; diabetes; asplenia; alcoholism; Beta-lactam (high-dose amoxicillin 1 g malignancy) or use of antimicrobials three times a day or amoxicillin-clavulanate within the previous 3 months 2 g twice a day by mouth* plus macrolide)

Patient in region with high rate (> 25%) Respiratory fluoroquinolone (moxifloxacin,of high-level (MIC ≥ 16 mcg/ml) gemifloxacin, levofloxacin [750 mg])macrolide-resistant Streptococcus ORpneumoniae Beta-lactam (high-dose amoxicillin 1 g three times a day or amoxicillin-clavulanate 2 g twice a day** plus macrolide)

The use of antivirals, when the course of treatment is started early with patients di-agnosed with viral pneumonia or a combination of viral and bacterial pneumonia,has resulted in a decrease in mortality rates.

*Alternative for patients unable to take the medication because of a previous allergic reaction or contraindi-cated medical condition: ceftriaxone, cefpodoxime, and cefuroxime (500 mg two times daily); doxycycline isan alternative to the macrolide. **High dose to cover patients with drug-resistant Staphylococcus pneumoniae (DRSP), patients < 2 or > 65years old who have received beta-lactam therapy within the last 3 months, patients diagnosed with alco-holism, patients with a compromised immune system or other comorbidities, and children exposed in daycare. Source: Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Tho-racic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin In-fect Dis. 2007;44(suppl 2):s27-72.

Treatment options

AmericanNurseToday.com December 2017 American Nurse Today 11

Please mark the correct answer online.

1. The body’s physiologic response to anorganism causing community-acquiredpneumonia (CAP) includes

a. vasoconstriction of pulmonary capillaries.b. vasodilation of pulmonary capillaries.c. leaking of low-protein exudate.d. leaking of low-carbohydrate exudate.

2. A risk factor for CAP is a. increased cough reflex.b. chronic renal failure.c. intermittent steroid use.d. hypergammaglobulinemia.

3. Which statement about mortality from CAPis correct?

a. Older patients over age 75 are at higher riskof mortality.

b. Patients between 20 and 40 years old are athigher risk of mortality.

c. The mortality rate for patients treated in theoutpatient setting is 15%.

d. The mortality rate for patients treated in theintensive care unit is 5%.

4. One of the most common pathogens thatcauses CAP is

a. Haemophilus influenzae.b. Pseudomonas aeruginosa.c. Staphylococcus aureus.d. enteric gram-negative bacilli

5. Which patient most likely has CAP ratherthan hospital-acquired pneumonia?

a. Symptoms began 7 days after admission tothe hospital.

b. The patient was hospitalized 20 days beforesymptoms started.

c. The patient lives in a long-term care facility.d. Symptoms began 3 days after admission to

the hospital.

6. Signs and symptoms of CAP include a. whispered pectoriloquy.b. increased appetite.c. decreased tactile fremitus. d. lack of skin tenting.

7. Which statement about the use of chest x-rays for diagnosing CAP is correct?

a. Viral infection presents with alveolarinfiltrates.

b. Use of computed tomography scans ispreferable over serial chest x-rays.

c. Bacterial infection presents with alveolarinfiltrates.

d. Viral and bacterial infections do not occursimultaneously.

8. Which tool used to assess whether a patientwith CAP can be treated as an outpatientrequires only four parameters?

a. SMART-COPb. Pneumonia severity index c. American Thoracic Society criteriad. CRB-65

9. Which tool uses minor and major criteria toassess whether patients with severe CAP needto be admitted to the intensive care unit?

a. SMART-COPb. Pneumonia severity index c. CURB-65d. American Thoracic Society criteria

10. What is the level of risk for needingintensive respiratory vasopressor support for apatient who scores 3 on the SMART-COP tool?

a. Lowb. Moderatec. High d. Very high

11. The recommended course of antibiotictreatment for CAP in a patient who is clinicallystable is

a. 3 days.b. 5 days. c. 7 days.d. 14 days.

12. A 55-year-old man with CAP is otherwisehealthy and has not used antimicrobials in thepast 3 months. An appropriate treatment choiceis

a. azithromycin.b. amoxicillin. c. levofloxacin.d. gemifloxacin.

13. Which of the following indicates a patientwith CAP is clinically stable and can be treatedwith short-course antibiotic therapy?

a. Oxygen saturation of 85% b. Respiratory rate of 26 breaths/minute c. Systolic blood pressure of 95 mmHgd. Heart rate of 90 beats/minute

14. A 70-year-old woman with CAP lives in aregion that has a 30% rate of high-level (MIC ≥16 mcg/ml) macrolide-resistant Streptococcuspneumoniae. An appropriate single-treatmentchoice is

a. erythromycin.b. doxycycline.c. moxifloxacin. d. clarithromycin.

15. Patients receiving treatment for CAP shouldbe told which of the following is an expectedguideline for recovery?

a. Fever resolves in 2 weeks.b. Chest pain and sputum notably decrease in

6 weeks. c. Cough and breathlessness notably decrease

in 6 weeks.d. Symptoms resolve in 2 months.

POST-TEST • Community Acquired Pneumonia Earn contact hour credit online at americannursetoday.com/article-type/continuing-education/

Provider accreditationThe American Nurses Association’s Center for Continuing Edu-cation and Professional Development is accredited as aprovider of continuing nursing education by the AmericanNurses Credentialing Center’s Commission on Accreditation.ANCC Provider Number 0023.

Contact hours: 1.51

ANA’s Center for Continuing Education and Professional Devel-opment is approved by the California Board of Registered Nurs-ing, Provider Number CEP6178 for 1.81 contact hours.

Post-test passing score is 80%. Expiration: 12/1/20

ANA Center for Continuing Education and Professional Devel-opment’s accredited provider status refers only to CNE activitiesand does not imply that there is real or implied endorsement ofany product, service, or company referred to in this activity norof any company subsidizing costs related to the activity. Theauthor and planners of this CNE activity have disclosed no rele-vant financial relationships with any commercial companiespertaining to this CNE. See the banner at the top of this pageto learn how to earn CNE credit.

CNE: 1.51 contact hours

CNE

AmericanNurseToday.com December 2017 American Nurse Today 12

Drug-resistant pathogen algorithmThis diagnostic and treatment algorithm aids in treating patients at risk for community-acquired pneumonia drug-resistant pathogens.

2 risk factors

3 or morerisk factors

CAP = community-acquired pneumonia, MRSA = methicillin-resistant Staphylococcus aureus

Source: Wunderink RG. Community-acquired pneumonia versus healthcare-associated pneumonia. The returningpendulum. Am J Respir Crit Care Med. 2013;188(8):896-8. Reprinted with permission of the American Thoracic Soci-ety. Copyright 2017 American Thoracic Society.

Assess riskfactors

Broad-spectrumtherapy

Culturepositive

Culturenegative

Specifictherapy

Usual CAPdrugs

0-1 riskfactor

Usual CAPdrugs

AssessMRSA risk

factors

No Yes

Usual CAPdrugs

Usual CAP + MRSA coverage

Culturenegative

Culturepositive

Usual CAPdrugs

Specifictherapy

Aggressivediagnostic

testing

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