CommunityAcquired Pneumonia (CAP) Guidelines

Introduction
SCHN/Mercy Care Plan Community-Acquired Pneumonia guidelines are adopted
from the Infectious Diseases Society of America1, the American College of Chest
Physicians Clinical Position Statement2, and the Institute for Clinical Systems
Improvement3.
The purpose of Community-Acquired Pneumonia Practice Guidelines is to
develop an integrated approach to the outpatient management of Community
Acquired Pneumonia (CAP) with emphasis on prevention, early detection and
patient education supported by evidence-based standards and practices.
Evidence-based clinical practice guidelines, as defined by the Institute of
Medicine, are systematically developed statements to assist practitioner and
patient decisions about appropriate health care for specific clinical
circumstances. The guideline development process typically includes a
verifiable, systematic literature search and review of existing evidence published
in peer-reviewed journals to identify proven therapies and define their appropriate
utilization. Guidelines must be applied based on individual patient needs using
professional judgment. 1
CommunityAcquired Pneumonia (CAP) is commonly defined as an acute
infection of the pulmonary parenchyma that is associated with at least some
symptoms of acute infection and is accompanied by the presence of an acute
infiltrate on a chest radiograph or auscultatory findings consistent with
pneumonia (such as altered breath sounds and/or localized rales) and occurs in
a patient who is not hospitalized or residing in a long-term-care facility for 14
days or more before the onset of symptoms. Symptoms of acute lower
respiratory tract infection may be present, including fever or hypothermia, rigors,
sweats, new cough with or without sputum production, or change in the color of
respiratory secretions in a patient with chronic cough, chest discomfort, or the
onset of dyspnea. Most patients have nonspecific symptoms such as fatigue,
myalgias, abdominal pain, anorexia, and headache.2
Pneumonia is the most common cause of death from infectious disease in the
United States and the sixth most common cause of death overall. Annually, 2-3
million cases of CAP result in approximately 10 million physician visits and
500,000 hospitalizations and 45,000 deaths.3
People at increased risk for CAP are over 50 years of age and may have
coexisting conditions such as congestive heart failure or neoplastic disease.
Risks are classified as being at low, moderate, or high based on an
algorithm. Risk scores range from 70-90 points (for low risk), 91-130 points (for

moderate risk) and 130 or more points (for high risk), and are calculated using
physical exam findings and laboratory test findings.2
Respiratory diseases, and pneumonia/asthma specifically, are among the top
diagnoses in the SCHN/Mercy Care Plan population. The objectives of adopting
the Community-Acquired Pneumonia Practice Guidelines are to:
1. Improve our members quality of life through education, immunization, and
proper treatment;
2. Collaborate with MCP physicians to facilitate screening and management
3. Optimal utilization of medical and pharmacy services by timely diagnosis
and care in the appropriate setting.

1- Update of practice guidelines for the management of community-acquired

pneumonia in immunocompetent adults. Mandell LA, Bartlett JG, Dowell SF, File
TM Jr, Musher DM, Whitney C. Update of practice guidelines for the
management of community-acquired pneumonia in immunocompetent adults.
Clin Infect Dis 2003 Dec 1;37(11):1405-33. [235 references]
http://www.journals.uchicago.edu/CID/journal/issues/v37n11/32441/32441.html
2- Management of Community-Acquired Pneumonia in the Home An American
College of Chest Physicians Clinical Position Statement.
Joe Ramsdell, MD, FCCP; Georgia L. Narsavage, PhD, RN, CS; James B. Fink,
MS, RRT; for the American College of Chest Physicians Home Care Network
Working Group Chest. 2005;127:1752-1763 [51 references]
http://www.chestjournal.org/cgi/content/full/127/5/1752

3- Institute for Clinical Systems Improvement. Community Acquired Pneumonia

in Adults: Institute for Clinical Systems Improvement (ICSI); 2005 May 40p
[29 references]
http://www.guidelines.gov/summary/summary.aspx?doc_id=7424&nbr=004383&
string=pneumonia

Pneumonia Severity Index (PSI)

Score = total points accumulated below
Demographics Factors

Value

Age (In years)

Males
Females
Nursing home resident

Age in yrs
Age in yrs -10
Age in yrs +10

Comorbid Illnesses

Value

Neoplastic disease
Liver disease
Congestive heart failure
Cerebrovascular disease
Renal disease

+30
+20
+10
+10
+10

Physical Examination Findings

Value

Altered mental status

Respiratory rate >= 30/min
Systolic BP < 90 mmHg
Temperature < 95 F (35 C) or >= 104 F (40 C)
Pulse >= 125/min
Laboratory Findings

+20
+20
+15
+15
+10
Value

pH<7.35
BUN >= 30mg/dL (11 mmol/L)
Sodium < 130mEq/L
Glucose > 250mg/dL (14 mmol/L)
Hematocrit < 30%
pO2 < 60mmHg or O2 sat < 90%
Pleural effusion

+30
+20
+20
+10
+10
+10
+10

Risk Category Classification

Based On

Risk Class

Recommended site of
Treatment

Mortality Range
%

None

outpatient

0.1

<= 70 total points

II

outpatient

0.6

71-90 total points

III

outpatient

0.9-2.8

90-130 total points

IV

Inpatient

8.2-9.3

> 130 total points

Inpatient

27.0-29.2

Management of Community-Acquired Pneumonia in the Home An American College of Chest Physicians Clinical Position
Statement.Joe Ramsdell, MD, FCCP; Georgia L. Narsavage, PhD, RN, CS; James B. Fink, MS, RRT; for the American College
of Chest Physicians Home Care Network Working Group Chest. 2005;127:1752-1763