This document provides guidelines for diagnosing and treating pneumonia. It discusses determining whether a patient requires inpatient or outpatient care based on severity scores like CURB-65. For inpatients, it provides criteria for admission to the ICU versus the general ward. It also covers physical exams, diagnostic tests, antibiotic treatment duration, and signs of clinical instability.

1. Areej Abu Hanieh
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2. *Pneumonia usually developed with the patients who
has no contact to a medical facility.

3. *First , we should determine if patient should be treated
outpatient or inpatient .
*Outpatient care: able to take oral medications and
have adequate outpatient care
*º Inpatient care: based on severity-of-illness scores
(eg, CURB-65 criteria [confusion, uremia, respiratory
rate, low blood pressure, 65 years or older]) or
*prognostic models (eg, Pneumonia Severity Index
[PSI]) and professional judgment

4. *
Confusion
Uremia: BUN>7mmolL (20mgdl)
Respiratory rate: greater than or equal to 30/min
Low blood pressure: systolic <90 mm Hg;
or diastolic ≤60 mm Hg
Age 65 years or older
CURB-65 vs CRB-65

5. *
*PSI prognostic model:
* Assess 20 variables and assign points to each variable, this
model classifies patients to 5 classes;
*Risk class 1
*Risk class 2: <70
*Risk class 3: 71-90
*Risk class 4: 91-130
*Risk class 5:>130
*The PSI is less practical in a busy emergency-room setting
because of the need to assess 20 variables.

6. *If CURB-65 is from 0-1 , can be treated outpatient .
*Patients with CURB-65 score ≥2 require hospitalization or
aggressive outpatient care.
*If inpatient treatment required, determine if patient should
be admitted to ICU or general ward
*º ICU admission recommended: 1 major criteria or 3 minor
criteria are present , and CURB-65 of 3 and more .
*Patient who are admitted to ICU usually require:
* vasopressors for septic shock necessitating
* or if he has acute respiratory failure requiring intubation
and mechanical ventilation.

7. *
Hypothermia (<36°C)
• PaO2/FiO2 ratio ≤250
• Leukopenia (WBC <4000
cells/mm³)
• Multilobar infiltrates
• Confusion/disorientation
• Respiratory rate ≥30
breaths/min
• Uremia (BUN ≥20mg/dL)
• Thrombocytopenia (platelets
<100000 cells/mm³)
• Hypotension requiring
aggressive fluid resuscitation
• Other
considerations: hypoglycemia, acute
alcoholism/alcoholic withdrawal,
hyponatremia, unexplained metabolic
acidosis, elevated lactate, cirrhosis,
asplenia

8. *
• Invasive mechanical ventilation
• Septic shock requiring vasopressors

9. *
*Physical exam:
*º Crackles or rales, bronchial breath sounds, hypoxemia,
tachypnic
*º Signs/symptoms of cough, fever, sputum production,
pleuritic chest pain
*• Chest radiograph:
*º Hospitalized for suspected pneumonia but negative chest
radiograph: may receive empiric antibiotics with repeat
chest radiograph 24−48hrs later

10. *
* Lab tests:
*º Pretreatment blood culture and/or expectorated sputum
samples for culture and gram stain should be taken if:
* ICU admission, outpatient antibiotic therapy failure,
cavitary infiltrates, leukopenia, active alcohol abuse,
chronic severe liver and lung disease, asplenia,
positive Legionella or pneumococcal UAT result, pleural
effusion; optional for other indications
*º Tests mentioned above are optional in patients without
these conditions
*Severe CAP: should obtain blood culture, expectorated
sputum culture, urinary antigen tests for Legionella
pneumophila and S. pneumoniae; endotracheal aspirate
sample for intubated patients.

11. *

15. *
*Duration: minimum 5 days of treatment, should be afebrile
48−72hrs, and no more than 1 CAP associated sign of
clinical instability before discontinuing therapy.
*• Longer duration of therapy may be warranted in certain
circumstances (eg, initial therapy did not target identified
pathogen, extrapulmonary infections such as meningitis or
endocarditis)

16. *
*Temp ≤37.8°C
*º Heart rate ≤100 beats per min
*º Respiratory rate ≤24 breaths per min
*º Systolic blood pressure ≥90mmHg
*º Arterial 02 saturation ≥90% or pO2 ≥60mmHg
*º Maintain oral intake and normal mental status
*So signs of instability are the opposites of the signs (eg.
< , > )

17. *

18. *