Community Acquired Pneumonia
		Signs and Symptoms
		Cough (+/- sputum production), dyspnea, fever (+/- rigors), increased respiratory rate, altered breath sounds, altered chest X-ray, imparied oxygenation, incrased WBC count with left shift, chest pain
		Diagnosis
		Subjective signs and symptoms and blood/sputum cultures
		Epidemiological Conditions Related to Specific Pathogens
		Condition			Likely Pathogen(s)
		Alcoholism			Steptococcus pneumoniae, anaerobes
		COPD and/or smoker			S. pneumoniae, H. influenzae, Moraxella catarrhalis, Legionella species
		Nursing home residency			S. pneumoniae, gram-negative bacilli, H. influenzae, Staph. aureus, anaerobes, Chlamydia pneumoniae
		Poor dental hygiene			Anaerobes
		Exposure to bats or bird droppings			Histoplasma capsulatum
		Esposure to birds			Chlamydia psittaci
		Exposure to rabbits			Francisella tularensis
		Early stage HIV infection			S. pneumoniae, H. influenzae, Mycobacterium tuberculosis
		Late stage HIV infection			S. pneumoniae, H. influenzae, Mycobacterium tuberculosis, P. carinii, Cryptococcus, Histoplasma
		Structural disease of lung			Pseudomonas aeruginosa, Burkholderia cepacia, S. aureus
		Intravenous drug abuse			S. aureus, Anaerobes, M. tuberculosis, S. pneumoniae
		Airway obstruction			Anaerobes, S. pneumoniae, H. influenzae, S. aureus
		Empiric Therapy
		Outpatient therapy (young, otherwise healthy adult patients (< 60 years old))
			1. Doxycycline 100mg bid for 7-14 days
			2. Clarithromycin or Azithromycin for 7-14 days
			3. Select Fluoroquinolones (ex. Cipro or Levaquin)
		Moderately ill patients
			1. Parenteral beta-lactam agent (ex. Ceftriaxone or cefotaxime) plus macrolide (ex. Azithromycin)
			2. Beta-lactam/beta-lactamase inhibitor (ex. Zosyn) plus macrolide (ex. Azithromycin)
			3. Fluoroquinolone monotherapy (ex. Cipro or Levaquin)
		Severely ill (ICU patient)
			1. Parenteral macrolide (ex. Azithromycin) or fluoroquinolone (ex. Levaquin) plus ceftriaxone, cefotaxime - preferred
			2. Beta lactam/beta-lactamase inhibitor (ex. Zosyn)
		Structural lung disease
			Antipseudomonal agent (ex. Imipenem, Gentamicin) plus fluoroquinolone
		Suspected aspiration
			Augmentin, clindamycin, ceftazidime, amikacin, or vancomycin
		Treatment Guidelines Based on Cultures
		Streptococcus pneumonia (penicillin susceptible)
			Preferred therapy: Penicillin-V (oral) or Penicillin-G (parenteral), amoxicillin, or ampicillin
			Secondary therapies (penicillin allergy, etc.): Erythromycin, clarithromycin, azithromycin, tetracycline, doxycycline, gatifloxacin, moxefloxacin, clindamycin, levofloxacin, ceftriaxone, cefuroxime
		Streptococcus pneumonia (intermediate penicillin resistant strains)
			Preferred therapy: Penicillin-G, ampicillin, amoxicillin, ceftriaxone, cefotaxime, second generation fluoroquinolone (levofloxacin)
			Alternative therapy: Clindamycin or doxycycline
		Steptococcus pneumonia (high penicillin resistant strains)
			Preferred therapy: Vancomycin (as per renal function), gram-positive fluoroquinolones (ex. Levofloxacin)
			Alternative therapy: Linezolid or Synercid
		Haemophilus influenzae (beta-lactamase negative)
			Preferred therapy: Ampicillin or amoxicillin
			Alternative therapy: Cephalosporins, doxycycline, fluoroquinolones
		Haemophilus influenzae (beta-lactamase positive)
			Preferred therapy: Mixed or gram negative cephalosporins (ex. Cefotaxime or ceftriaxone), beta-lactamase inhibitor agents (ex. Zosyn), fluoroquinolones, doxycycline
			Alternative therapy: Co-trimoxazole, azithromycin, clarithromycin
		Mycoplasma pneumoniae
		Atypical agent with persistant symptoms - may require up to 21 days of therapy
			Use macrolides, doxycycline, or fluoroquinolones
		Legionella pneumophilia
		Water borne pathogen - high fever and GI symptoms are common
			Erythromycin 1g IV q6h +/- rifampin 600mg daily for 21 days
		Monitoring
			1. Reduction in temperature
			2. Reduction in white blood cell count
			3. Resolution in left shift
			4. Improvement in oxygenation
			5. Improvement of associated signs/symptoms
			6. Routine chest X-rays are not appropriate for patient monitoring
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