Community–Acquired Pneumonia (CAP) Guidelines

Introduction

SCHN/Mercy Care Plan Community-Acquired Pneumonia guidelines are adopted from the Infectious Diseases Society of America, the American Thoracic Society, and the Institute for Clinical Systems Improvement.

The purpose of practice guidelines Community-Acquired Pneumonia 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.ⁱ

Community–Acquired 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 fourteen days or more before the onset of symptoms. Several 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 chromic cough, chest discomfort, or the onset of dyspnea. Most patients also have nonspecific symptoms such a fatigue, myalgias, abdominal pain, anorexia, and headache.ⁱⁱ

Pneumonia is the sixth most common cause of death in the United Statesⁱⁱⁱ and overall death rates associated with pneumonia and influenza have increased over 59% since 1979. Annually, 2-3 million cases of CAP result in approximately 10 million physician visits and 500,000 hospitalizations. The incidence of pneumonia increases with age and 90 percent of deaths due to this condition are in the “over 65” age category. Community-Acquired Pneumonia affects approximately 5.6 million patients each year, representing a major economic burden in the United States. The majority of the cost for care for CAP is spent on the minority of patients who require hospitalization. The 1.7 million elderly patients who develop this disease each year account for more that half of the total cost of care reflecting the high rates of comorbidity and hospital admission as well as the longer duration of hospital stay in this group.^iv

People at risk for CAP are age 50 or more years of age, or, have comorbid conditions (including neoplastic disease, congestive heart failure, cerebrovascular disease, renal disease or liver disease). Those at-risk are classified as being at “low”, “moderate”, or “high” risk based on an algorithm to calculate risk scores ranging from 70-90 points (for low risk), 91-130 points (for moderate risk) and 130 or more points (for high risk). Other factors including physical exam findings and laboratory test findings are elements of the algorithm producing the risk score. Respiratory disease in general, and pneumonia/asthma specifically, is 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 member’s quality of life through education, immunization, and appropriate treatment;
2. Collaborate with MCP physicians to improve screening and treatment; and
3. Reduce utilization of medical and pharmacy services by accurate diagnosis and treatment of members in the appropriate setting.

---

ⁱ Trials Assessing Innovative Strategies to Improve Clinical Practice, June 29, 2001
ⁱⁱ Guidelines from the Infectious Diseases Society of America, Community-Acquired Pneumonia in Adults; Guidelines for Management, Clinical Infectious Diseases 1998; 26:811-38
ⁱⁱⁱ Ibid
^iv Community-Acquired Pneumonia-A Hospital Practice Special Report, June 2001 Community-acquired Pneumonia, The need for pathways, Niederman, Michael S. MD.

Other References
Institute for Clinical Systems Improvement Health Care Guideline
Total Resource Utilization for Community-Acquired Pneumonia, Roche
Community-Acquired Pneumonia-A Hospital Practice Special Report, June 2001

Back to Top

Demographics Factors Age Males Females Nursing home resident	Value Ages in yrs Age in yrs -10 Age in yrs +10
Comorbid Illnesses Neoplastic disease Liver disease Congestive heart failure Cerebrovascular disease Renal disease	Value +30 +20 +10 +10 +10
Physical Examination Findings Altered mental status Respiratory rate >= 30/min Systolic BP < 90 mmHg Temperature < 95 ºF (35 ºC) or >= 104 ºF (40 ºC) Pulse >= 125/min	Value +20 +20 +15 +15 +10
Laboratory Findings pH<7.35 BUN >= 30mg/dL (11 mmo/L) Sodium < 130mEq/L Glucose > 250mg/dL (14 mmo/L) Hgb < 9gm (Hematocrit < 30%) PO2 < 60mmHg (O2 sat < 90% * (room air)) Pleural effusion	Value +30 +20 +20 +10 +10 +10 +10

** Patients with these finding may warrant hospitalization despite their risk classification.

Neoplastic disease - any cancer, except basal or squamous cell carcinoma of the skin active at the time of presentation or within one year of presentation.
Liver disease - clinical or histologic cirrhosis or chronic active hepatitis.
CHF - documented with history, physical exam or CSR findings; echo, MUGA; or left ventriculogram.
CVD - clinical diagnosis of stroke or TIA; or documented stroke on CT or MRI.
Renal Disease - chronic renal disease; or abnormal BUN or creatinine.

---

Risk Category Classification

Based On	Risk Class	Risk	Mortality Range %
Algorithm (negative response to patient education or treatment or treatment with macrolide, doxycycline or TMP/SMX.	I	Low	0.1-0.4
<= 70 total points	II	Low	0.6-0.7
71-90 total points	III	Low	0.9-2.8
90-130 total points	IV	Moderate	8.2-9.3
> 130 total points	V	High	27.0-31.1

Back to Top