UPDATE IN OFFICE MANAGEMENT

Treatment of Community-Acquired Pneumonia in an

Ambulatory Setting
a

Saira Butt, MD, Edwin Swiatlo, MD, PhD

a,b

DepartmentofMedicine,DivisionofInfectiousDiseases,UniversityofMississippiMedicalCenter,Jackson;bVAMedicalCenter,
Jackson,Miss.

ABSTRACT
Communityacquiredpneumoniacontinuestobeasignificantcauseofmorbidityandmortalitydespite
broadspectrum antibiotics and advances in critical care. Frequently, the diagnosis is confounded by
coexisting cardiac or pulmonary conditions. Recognition of patients at risk for complications from
pneumoniaiscriticalwhenmakingthedecisionofhowandwheretotreat.Thisreviewsummarizesthe
diagnosisandtreatmentofcommunityacquiredpneumoniawithoralantibioticsinanoutpatientsetting.
Specificpathogensandclinicalpresentationsincertainatriskpopulationsarehighlighted.Alsopresented
arevalidatedalgorithmsforevaluatingandidentifyingpatientswhomaybeatriskforseriouscomplica
tionsofpneumoniaandrequiretreatmentinaninpatientsetting.
PublishedbyElsevierInc.TheAmericanJournalofMedicine(2011)124,297300
KEYWORDS: Antibiotics;Pneumonia;Vaccines

cough. In contrast,
Communityacquired pneumonia is diagnosed in 3 to 4atypical pathogens such
millionpersonsannuallyandcontinuestobealeadingcause as
Mycoplasma,
ofdeathintheUnitedStates.Onestudyestimatedthatmore Chlamydophila,
and
than900,000casesofcommunityacquiredpneumoniaoccur
viruses

often

present

with
1
each year in persons aged more than 65 years. Approxfever, nonproductive
imately 80% of patients with pneumonia are treated as cough, and constitutional
outpatients. Common risk factors for communityacquired symptoms that develop
pneumonia include age greater than 65 years, smoking, over days. Legionella
alcoholconsumption,chroniclungdiseases,mechanicalob
initially may produce
struction of airways, aspiration of oropharyngeal or gastric
primarily gastrointestinal
2
contents,pulmonaryedema,uremia,andmalnutrition.
symptoms. A careful
history, including travel,
animal

exposure,
CLINICAL PRESENTATION
Typical bacterial pathogens such as Streptococcus pneu incarceration, asplenia,
moniae (pneumococcus), Haemophilus influenzae, and enhuman immunodeficiency
tericgramnegativeorganismsusuallymanifestacutelywith virus, and other
comorbidities, can often
highfever,chills,tachypnea,tachycardia,andproductive
suggest an otherwise
Funding:DepartmentofMedicine,UniversityofMississippiMedical unsuspectedpathogen.
CenterandDepartmentofVeteransAffairs.
Systemic physical
ConflictofInterest:None.
findings in pneumonia are
Authorship:Allauthorshadaccesstothedataandplayedarolein nonspecific and include
writingthismanuscript.
fever/chills,

fatigue,
ReprintrequestsshouldbeaddressedtoEdwinSwiatlo,MD,PhD,
myalgias,

or

headaches.
VA Medical Center Research (151), 1500 Woodrow Wilson Drive,
Pulmonary findings in
Jackson,MS39216.
pneumonia are typically
Emailaddress: Edwin.swiatlo@va.gov.
localizedtoaspecificlung

zoneandmayincluderales,
rhonchi, bronchial breath
sounds,dullness,increased
fremitus, and egophony.
Atypical pneumonia may
have absent or diffuse
findings on lung
examination.

Rapid
progressionofdiseasefrom
mild,

nonspecific
symptoms to respiratory
failure can be seen in
severe pneumococcal,
staphylococcal, or Legio
3,4

nellapneumonia.
The age of the patient
has important implications
in disease presentation.
Older patients often have
humoral or cellular
immunodeficiencies as a
result of underlying dis
eases, immunosuppressive
medications, or the aging
process. Older patients
withpneumoniahavefewer
symptomsthandoyounger
patients,andmental status
changesarecommonlythe

predominant presenting symptom. Delirium may be theonly manifestation of

00029343/$seefront
matterPublishedby

pneumoniainthesepa

ElsevierInc.
06.027
doi:10.1016/j.amjmed.2010.

298

The American Journal of Medicine, Vol 124, No 4, April 2011

Table 1 Pneumonia
tients.Alcoholism,asthma,immunosuppression,andage70 Severity Index

based on 5 easily
measurablefactors(1point
for each) from which its
yearsareriskfactorsforcommunityacquiredpneumoniain
nameisderived: confusion
the elderly. Among nursing home residents, advanced age,
Demographic factors
(basedonaspecificmental
male sex, dysphagia, inability to take oral medications, Age for men
testornewdisorientationto
profounddisability,bedriddenstate,andurinaryincontinence Age for women
person,place,
are risk factors for communityacquired pneumonia. Nursing home resident
ortime);bloodureanitrogen
20
Aspiration pneumonia is underdiagnosed in this group of Coexisting illnesses
rate30breaths/min;bloodpressure(
5
Active neoplastic disease
patients,andtuberculosisalwaysshouldbeconsidered.
ordiastolic60mmHg);andage
Extrapulmonaryphysicalfindingscanprovidecluestothe Chronic liver disease
aCURB65scoreof0to1
CHF
cangenerallybetreatedas
diagnosis. Poor dentition and foulsmelling sputum may Cerebrovascular disease
outpatients, those with a
indicate the presence of a lung abscess with anaerobic Chronic renal disease
score of 2 should be
bacteria. Bullous myringitis can accompany infection with Physical examination
admittedtothehospital,and
Mycoplasma pneumoniae. An absent gag reflex or altered Altered mental status
those with a score of 3 or
sensorium raises the possibility of aspiration and polymi Respiratory rate 30
morearecandidatesforan
crobialinfectionwithanaerobes.Encephalitiscancomplicate Blood pressure 90 mm Hg
pneumonia caused by M. pneumoniae or Legionella Temperature 35C or 40C intensive care unit.10 In
Pulse 125 bpm
pneumophila. Cutaneous manifestations of infection can
additiontomedicalcriteria,
Laboratory and radiographic findings
include erythema multiforme (especially M. pneumoniae), Arterial pH 7.35
residential status also
influences treatment
erythema nodosum (Chlamydophila pneumoniae or Myco BUN 30 mg/dL
decisions. Residents of
bacterium tuberculosis), or ecthyma gangrenosum (Pseu Sodium 130 mmol/L
chronic care facilities,
Glucose 250 mg/dL
domonasaeruginosa).
Hematocrit 30%
homeless persons, and
PaO2 60 mm Hg
incarcerated persons are
LABORATORY DATA
Pleural effusion
more likelyto be admitted
Diagnostic tests such as sputum and blood cultures are
CHF congestive heart failure; BUN
than other patients with
optionalforanetiologicdiagnosisinoutpatientswithcom PaO2 partial pressure of arterial oxygen.
similar severity scores.
munityacquiredpneumonia.Nasopharyngealswabsshouldbe
Outpatient therapy is
collectedforinfluenzaduringtheappropriateseasonorwhen
preferredbecause
influenzaiscirculatinginthecommunity.Patientswithcough
This decision involves 3
formorethan1month,chronicfever,nightsweats,weight
steps: determination of
loss,orasuggestivechestXrayshouldbeevaluatedfor M. diseaseseverity,assessment
tuberculosis. A high level of suspicion is necessary toof any preexisting social
diagnoseinfectionscausedbyagentsofbioterrorism.

conditionsthatcompromise
thesafetyofhomecare,and
clinical judgment. The
RADIOGRAPHY
Pneumonia Severity Index
ThecornerstoneofdiagnosisisthechestXray,whichusually
revealsaninfiltrateatpresentation.However,thisfindingmaybe assesses 20 variables (
absent in dehydrated or neutropenic patients. Also, the Table1)andplacespatients
radiographic manifestations of chronic diseases such as into5riskgroupsthat can
congestiveheartfailure,chronicobstructivepulmonarydisease, helptostratifypatientsfor
7therapeutic and prognostic
and malignancy may obscure the infiltrate of pneumonia.
9
purposes. Patients in
Althoughradiographicpatternsareusuallynonspecific,theycan
groups I and II can be
sometimes suggest a microbiological diagnosis. Focal
treated as outpatients,
consolidation is seen in typical bacterial pneumonia, whereas
patientsingroupIIIcanbe
viruses, Mycoplasma, and Chlamydophila frequently present
treated with a short
with an interstitial pattern. Cavitary lesions may be associated
hospitalization or in
withbacterialabscesses,fungi,or Nocardia.Rapidprogression
observational units, and
with multifocal lung involvement may indicate Legionella, S.
patientsingroupsIVandV
8
pneumoniae,orStaphylococcusaureus.
should be treated as
inpatients.
A more tractable model
MANAGEMENT
for
communityacquired
Choosingthesiteofcareforcommunityacquiredpneumoniais
pneumonia

severity
thesinglemostimportantdecisionmadebyclinicians.
9
assessment is CURB65.
The CURB65 score is

Butt and Swiatlo Community-acquired Pneumonia

Table 2 Recommended Empirical Antibiotics for Outpatient

Therapy of Community-Acquired Pneumonia1
Previously healthy, no recent (within 3 mo) antibiotic therapy:
macrolide OR doxycycline
Previously healthy, antibiotics within past 3 mo: azithromycin or
clarithromycin, PLUS high-dose amoxicillin

(4 g/d) or amoxicillin-clavulanate (4 g/d); OR a respiratory

fluoroquinolone alone
Comorbidities (COPD, diabetes, renal or congestive heart
failure, malignancy), no recent antibiotic therapy:
azithromycin or clarithromycin; OR a
respiratory fluoroquinolone alone
Comorbidities, antibiotics within past 3 mo:
azithromycin or clarithromycin, PLUS high-dose amoxicillin,
amoxicillin/clavulanate, cefpodoxime, cefprozil, or cefuroxime;
OR a respiratory fluoroquinolone
COPD

chronic obstructive pulmonary disease.

thisisassociatedwithfasterreturntonormalactivitiesthan
10
inpatienttreatment.

ANTIBIOTICS
Antimicrobialtherapyisacriticalcomponentoftreatmentof
communityacquired pneumonia in the outpatient setting.
Until better diagnostic tests are available, initial treatment
remains largely empiric. Antibiotics recommended on the
basisofriskfactorsandlikelypathogenshavebeenpublished
1
recently and are summarized in Table 2. Presently,
macrolides remain effective for patients with mild to mod
erately severe communityacquired pneumonia with no risk
factors.
Patientswithchronicobstructivelungdiseasewhohavenot
received antibiotics or oral steroids during the previous 3
monthscanbetreatedinamanneridenticaltothatofpatients
withoutmodifyingfactors,withthecaveatthatonlyanewer
macrolide(azithromycinorclarithromycin)beusedtoensure
adequate coverage of H. influenzae. Patients with chronic
obstructive pulmonary disorder and a history of use of
antibioticsororalsteroidswithinthepast3monthsmayhave
anincreasedriskforinfectionwith H.influenzaeandenteric
gramnegative bacilli, in addition to pneumococcus, C.
pneumoniae, and L. pneumophila, and a respiratory
fluoroquinolone is
recommended. A respiratory
fluoroquinolone is one with predictable activity against
pneumococcus, such as levofloxacin or moxifloxacin.
Fluoroquinolonesalsoarerecommendediffirstlinetherapy
failsinthepatient,thepatienthasconfirmedallergytofirst
lineagents,orwhenhighlyresistantpneumococcus(penicillin
minimuminhibitoryconcentration4g/mL)isprevalent.
Forpatientswhocanbetreatedinthenursinghomesetting
and do not require hospitalization, a respiratory
fluoroquinoloneoramoxicillinclavulanateplusamacrolide
is recommended as the first choice. A secondgeneration

299
cephalosporin plus a
macrolideisanalternative.

Anaerobic coverage should

beconsideredforthosepa
tientswithahistoryofloss
ofconsciousnessorinper
sons with gingival or
esophageal

disease.
Antibioticselectionshould
always consider local
epidemiology

and
susceptibilitypatterns.

FOLLOW-UP
Patients treated in the
outpatient setting must be
monitored carefully to
ensure adherence to the
antibiotic regimen and
clinical improvement.
Followupbytelephoneora
clinicvisitwithin48to72
hoursisstronglysuggested.
Patientswhofailtorespond
despitewhatseemstobean
appropriate choice of
antimicrobial therapy may
have complications of
pneumonia, such as
empyema,

bronchial
obstruction,

ex
trapulmonary spread of
infection, superinfections,
or misdiagnosis of
noninfectious causes (eg,
congestive heart failure,
neoplasm,

vasculitis,
sarcoidosis, drug reaction,
alveolitis, pulmonary
embolism,orhemorrhage).

PREVENTION
Allpersonsagedmorethan6
months should receive inac
tivated influenza vaccine
yearly as recommended by
the Advisory Committee on
Immunization Practices,
Centers for Disease Control
11

and

Prevention.
Pneumococcal

poly
saccharide vaccine is
recommendedforallpersons
agedmorethan65yearsand
anyone aged 2 to 64 years
with a chronic health

problem,suchasheartdisease,lungdisease,sicklecelldisease,
diabetes,alcoholism,andcirrhosis.Allpersonsaged2to64years
whohaveanimmunosuppressivecondition,suchashematologic
malignancy, kidney failure, nephrotic syndrome, human
immunodeficiencyvirusinfection,asplenia,ororgantransplant,
shouldreceivevaccine.Anyoneagedmorethan2yearswholives
in an institutional or group setting is a candidate for
pneumococcal vaccine. A comprehensive discussion of risk
factorsforinvasivepneumococcalinfectionispublishedbythe
CentersforDiseaseControlandPrevention.

12

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1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases 4. Marrie
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