Community-acquired pneumonia in adults (non Covid-19)

Обзор 
Теория 
Диагноз 
Лечение 
Последующее наблюдение 
Источники 

Пожалуйста, обратите внимание, что состав/способ введения и дозировка могут отличаться для различных названий и брендов препаратов, форм выпуска или места изготовления. Рекомендации относительно лечения для определенных групп пациентов: смотрите заявление об отказе от ответственности

Острый

outpatient

without comorbidities or risk factors for drug-resistant pathogens

1-я линия – oral amoxicillin, doxycycline, or a macrolide

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1-я линия –

oral amoxicillin, doxycycline, or a macrolide

Use a validated clinical prediction rule for prognosis, preferably the Pneumonia Severity Index (PSI) over CURB-65, in addition to clinical judgment, to determine whether the patient should be treated as an outpatient.[81] Outpatient treatment is recommended in patients with PSI risk class I or II with a PSI score ≤70 (low risk), or a CURB-65 score of 0-1 (low severity).[90][91] PSI is preferred over CURB-65.[18][81]

Be aware of the limitations of severity scores and consider other factors when assessing a patient's suitability for outpatient management (e.g., contraindications to outpatient therapy such as inability to maintain oral intake, history of substance abuse, severe comorbid illnesses, cognitive impairment, and impaired functional status, or availability of outpatient support resources). Do not routinely use biomarkers to increase the performance of clinical decision rules when assessing whether to treat the patient as an outpatient.[81]

Empiric oral antibiotics are recommended: amoxicillin, doxycycline, or a macrolide (e.g., azithromycin or clarithromycin). Only use a macrolide in areas with pneumococcal resistance to macrolides <25% and when there are contraindications to alternative therapies.[18]

Treat for a minimum of 5 days. Duration of treatment should be guided by a validated measure of clinical stability (e.g., resolution of vital sign abnormalities, normal cognitive function, ability to eat).[18][118][119] Consider discontinuing treatment when the patient has been afebrile for 48-72 hours and there are no signs of complications (endocarditis, meningitis).[18][118]

Reassess patients at 48 hours. Symptoms should improve within this time with appropriate treatment. Consider hospital admission in patients who fail to improve within 48 hours.

Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.

Первая линия терапии

amoxicillin: 1000 mg orally three times daily

ИЛИ

doxycycline: 100 mg orally twice daily

Вторая линия терапии

azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily thereafter

ИЛИ

clarithromycin: 500 mg orally (immediate-release) twice daily; 1000 mg orally (extended-release) once daily

плюс – supportive care

Рассмотреть – influenza antiviral cover

with comorbidities or risk factors for drug-resistant pathogens

1-я линия – oral combination antibiotic therapy or fluoroquinolone monotherapy

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1-я линия –

oral combination antibiotic therapy or fluoroquinolone monotherapy

Broader-spectrum antibiotic regimens are required in patients with comorbidities such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcohol abuse; malignancy; or asplenia. Many of these patients have risk factors for drug-resistant pathogens (e.g., recent hospitalization and administration of parenteral antibiotics in the past 90 days), and they are more vulnerable to poor outcomes if the empiric regimen is inadequate.[18]

Empiric oral antibiotics are recommended: combination therapy with amoxicillin/clavulanate or a cephalosporin (e.g., cefpodoxime, cefuroxime) plus a macrolide or doxycycline; or monotherapy with a respiratory fluoroquinolone (e.g., levofloxacin, moxifloxacin). These regimens should effectively cover drug-resistant pathogens.[18]

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[116] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Despite these concerns, American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines still recommend fluoroquinolones as an option in patients with low-severity CAP who have comorbidities and are managed in the outpatient setting.[18]

Reassess patients at 48 hours. Symptoms should improve within this time with appropriate treatment. Consider hospital admission in patients who fail to improve within 48 hours.

Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.

Opções primárias

amoxicillin/clavulanate: 500 mg orally (immediate-release) three times daily; 875 mg orally (immediate-release) twice daily; 2000 mg orally (extended-release) twice daily

Mais

cefpodoxime proxetil: 200 mg orally twice daily

cefuroxime axetil: 500 mg orally twice daily

--E--

azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily thereafter

clarithromycin: 500 mg orally (immediate-release) twice daily; 1000 mg orally (extended-release) once daily

doxycycline: 100 mg orally twice daily

levofloxacin: 750 mg orally once daily

moxifloxacin: 400 mg orally once daily

associado a – supportive care

Considerar – influenza antiviral cover

inpatient

not in intensive care unit (nonsevere)

1ª linha – intravenous combination antibiotic therapy or fluoroquinolone monotherapy

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1ª linha –

intravenous combination antibiotic therapy or fluoroquinolone monotherapy

Use a validated clinical prediction rule for prognosis, preferably the Pneumonia Severity Index (PSI) over CURB-65, in addition to clinical judgment to determine whether the patient should be treated as an inpatient. Hospital admission is recommended in patients with a PSI risk class III (these patients may benefit from a brief period of hospitalization), PSI risk class IV or V, or a CURB-65 score of 3.[90][91] PSI is preferred over CURB-65.[18][81]

Empiric intravenous antibiotics are recommended: combination therapy with a beta-lactam (e.g., ampicillin/sulbactam, cefotaxime, ceftriaxone, ceftaroline) plus a macrolide (e.g., azithromycin, clarithromycin); or monotherapy with a respiratory fluoroquinolone (e.g., levofloxacin, moxifloxacin). Consider combination therapy with a beta-lactam plus doxycycline in patients who have contraindications to both macrolides and fluoroquinolones. Note that clarithromycin is only available as an oral formulation in the US, and so can only be used if the oral route is feasible.

Evaluate whether the patient can be switched to oral therapy on a daily basis; the switch should be made as soon as possible. Switch to an oral formulation of the same drug or an oral formulation of a drug within the same drug class.[18]

Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.

Opções primárias

ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours

Mais

cefotaxime: 1-2 g intravenously every 8 hours

ceftriaxone: 1-2 g intravenously every 24 hours

ceftaroline fosamil: 600 mg intravenously every 12 hours

--E--

azithromycin: 500 mg intravenously every 24 hours

clarithromycin: 500 mg orally (immediate-release) twice daily

levofloxacin: 750 mg intravenously every 24 hours

moxifloxacin: 400 mg intravenously every 24 hours

Considerar – MRSA antibiotic cover

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Considerar –

MRSA antibiotic cover

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Additional empiric antibiotic cover is required in patients with risk factors for methicillin-resistant Staphylococcus aureus (MRSA) if locally validated risk factors are present.[18]

If the patient has a prior history of respiratory isolation of MRSA: add vancomycin or linezolid and obtain cultures (or nasal polymerase chain reaction [PCR] if available) to guide de-escalation or to confirm the need to continue additional cover.[18]

If the patient has had a recent hospitalization and parenteral antibiotics in the past 90 days, and has been locally validated for risk factors for MRSA: obtain cultures and nasal PCR. If PCR or cultures are negative, withhold additional cover. If PCR or cultures are positive, start additional cover.[18]

Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]

A longer treatment course of 7 days is recommended in patients with MRSA.[18]

Opções primárias

vancomycin: 15 mg/kg intravenously every 12 hours; adjust dose based on serum vancomycin levels

linezolid: 600 mg intravenously every 12 hours

Considerar – Pseudomonas antibiotic cover

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Considerar –

Pseudomonas antibiotic cover

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Additional empiric antibiotic cover is required in patients with risk factors for Pseudomonas aeruginosa if locally validated risk factors are present.[18]

If the patient has a prior history of respiratory isolation of P aeruginosa: add piperacillin/tazobactam, cefepime, ceftazidime, aztreonam, meropenem, or imipenem/cilastatin, and obtain cultures to guide de-escalation or to confirm the need to continue additional cover.[18]

If the patient has had a recent hospitalization and parenteral antibiotics in the past 90 days, and has been locally validated for risk factors for P aeruginosa: obtain cultures but only initiate cover for P aeruginosa if cultures are positive.[18]

Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]

A longer treatment course of 7 days is recommended in patients with P aeruginosa.[18]

Take the initial empiric regimen into account adding Pseudomonas cover so that two antibiotics from the same class are not used together.

Primary options

piperacillin/tazobactam: 4.5 g intravenously every 6 hours

cefepime: 2 g intravenously every 8 hours

ceftazidime sodium: 2 g intravenously every 8 hours

imipenem/cilastatin: 500 mg intravenously every 6 hours

meropenem: 1 g intravenously every 8 hours

aztreonam: 2 g intravenously every 8 hours

Consider – Enterobacteriaceae antibiotic cover

Consider – influenza antiviral cover

Plus – supportive care

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Administer oxygen therapy as necessary. [ ] Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO₂ above 92%. High concentrations of oxygen can safely be given in uncomplicated pneumonia. Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. Oxygen therapy for patients with COPD complicated by ventilatory failure is guided by repeated arterial blood gas measurements.[110]

Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids as needed, and give nutritional support in prolonged illness.

Monitor temperature, respiratory rate, pulse, blood pressure, and mental status at least twice daily and more frequently in those with severe pneumonia or requiring regular oxygen therapy.

Monitor C-reactive protein (CRP) levels regularly as they are a sensitive marker of progress in pneumonia. Repeat chest x-rays in patients who are not progressing satisfactorily. Routine follow-up chest imaging is not recommended if symptoms resolve within 5-7 days.[18]

in intensive care unit (severe)

1st line – intravenous combination antibiotic therapy

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1st line –

intravenous combination antibiotic therapy

Admit patients with hypotension requiring vasopressor therapy or respiratory failure requiring mechanical ventilation to the intensive care unit (ICU). In patients who do not require vasopressor therapy or mechanical ventilation, use the American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) criteria for defining severe CAP (see Diagnostic criteria) and clinical judgment to guide the need for higher levels of treatment intensity.[18][81] Admit patients with severe CAP (defined as one major criterion or three or more minor criteria) to the ICU.[18]

Start antibiotic therapy promptly as a delay in administration has been associated with an increased risk in mortality.[117]

Empiric intravenous antibiotics are recommended: combination therapy with a beta-lactam (e.g., ampicillin/sulbactam, cefotaxime, ceftriaxone, ceftaroline) plus a macrolide (e.g., azithromycin, clarithromycin); or combination therapy with a beta-lactam plus a respiratory fluoroquinolone (e.g., levofloxacin, moxifloxacin). There is stronger evidence for beta-lactam plus macrolide combination.[18] Although ATS/IDSA recommend clarithromycin in these patients, it is only available as an oral formulation in the US so is unlikely to be useful in this setting.

Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.

Primary options

ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours

cefotaxime: 1-2 g intravenously every 8 hours

ceftriaxone: 1-2 g intravenously every 24 hours

ceftaroline fosamil: 600 mg intravenously every 12 hours

-- AND --

azithromycin: 500 mg intravenously every 24 hours

Secondary options

ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours

cefotaxime: 1-2 g intravenously every 8 hours

ceftriaxone: 1-2 g intravenously every 24 hours

ceftaroline fosamil: 600 mg intravenously every 12 hours

-- AND --

levofloxacin: 750 mg intravenously every 24 hours

moxifloxacin: 400 mg intravenously every 24 hours

Consider – MRSA antibiotic cover

Back

Consider –

MRSA antibiotic cover

Treatment recommended for SOME patients in selected patient group

Additional empiric antibiotic cover is required in patients with risk factors for methicillin-resistant Staphylococcus aureus (MRSA) if locally validated risk factors are present.[18]

Add appropriate additional antibiotic cover and obtain cultures (or nasal polymerase chain reaction if available) to guide de-escalation of therapy or confirm the need to continue therapy.[18]

Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]

A longer treatment course of 7 days is recommended in patients with MRSA.[18]

Primary options

vancomycin: 15 mg/kg intravenously every 12 hours; adjust dose based on serum vancomycin levels

linezolid: 600 mg intravenously every 12 hours

Consider – Pseudomonas antibiotic cover

Back

Consider –

Pseudomonas antibiotic cover

Treatment recommended for SOME patients in selected patient group

Additional empiric antibiotic cover is required in patients with risk factors for Pseudomonas aeruginosa if locally validated risk factors are present.[18]

Add appropriate additional antibiotic cover and obtain cultures to guide de-escalation of therapy or confirm the need to continue therapy.[18]

Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]

A longer treatment course of 7 days is recommended in patients with P aeruginosa.[18]

Take the initial empiric regimen into account adding Pseudomonas cover so that two antibiotics from the same class are not used together.

Primary options

piperacillin/tazobactam: 4.5 g intravenously every 6 hours

cefepime: 2 g intravenously every 8 hours

ceftazidime sodium: 2 g intravenously every 8 hours

imipenem/cilastatin: 500 mg intravenously every 6 hours

meropenem: 1 g intravenously every 8 hours

aztreonam: 2 g intravenously every 8 hours

Consider – Enterobacteriaceae antibiotic cover

Considerar – influenza antiviral cover

Considerar – corticosteroid

associado a – supportive care

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associado a –

supportive care

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids as needed, and give nutritional support in prolonged illness.

Monitor temperature, respiratory rate, pulse, blood pressure, and mental status at least twice daily and more frequently in those with severe pneumonia or requiring regular oxygen therapy.

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Community-acquired pneumonia in adults (non Covid-19)

Алгоритм лечения

outpatient

without comorbidities or risk factors for drug-resistant pathogens

oral amoxicillin, doxycycline, or a macrolide

Первая линия терапии

Вторая линия терапии

These drug options and doses relate to a patient with no comorbidities.

Первая линия терапии

Вторая линия терапии

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Первая линия терапии

Вторая линия терапии

supportive care

influenza antiviral cover

Первая линия терапии

These drug options and doses relate to a patient with no comorbidities.

Первая линия терапии

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Первая линия терапии

with comorbidities or risk factors for drug-resistant pathogens

oral combination antibiotic therapy or fluoroquinolone monotherapy

Opções primárias

These drug options and doses relate to a patient with no comorbidities.

Opções primárias

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Opções primárias

supportive care

influenza antiviral cover

Opções primárias

These drug options and doses relate to a patient with no comorbidities.

Opções primárias

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Opções primárias

inpatient

not in intensive care unit (nonsevere)

intravenous combination antibiotic therapy or fluoroquinolone monotherapy

Opções primárias

These drug options and doses relate to a patient with no comorbidities.

Opções primárias

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Opções primárias

MRSA antibiotic cover

Opções primárias

These drug options and doses relate to a patient with no comorbidities.

Opções primárias

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Opções primárias

Pseudomonas antibiotic cover

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Enterobacteriaceae antibiotic cover

influenza antiviral cover

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

supportive care

in intensive care unit (severe)

intravenous combination antibiotic therapy

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

MRSA antibiotic cover

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Pseudomonas antibiotic cover

Primary options