Neumonia I
Neumonia I
Neumonia I
Community-acquired pneumonia is a leading cause of death. Risk factors include older age and medical comorbidi-
ties. Diagnosis is suggested by a history of cough, dyspnea, pleuritic pain, or acute functional or cognitive decline,
with abnormal vital signs (e.g., fever, tachycardia) and lung examination findings. Diagnosis should be confirmed
by chest radiography or ultrasonography. Validated prediction scores for pneumonia severity can guide the decision
between outpatient and inpatient therapy. Using procalcitonin as a biomarker for severe infection may further assist
with risk stratification. Most outpatients with community-acquired pneumonia do not require microbiologic testing
of sputum or blood and can be treated empirically with a macrolide, doxycycline, or a respiratory fluoroquinolone.
Patients requiring hospitalization should be treated with a fluoroquinolone or a combination of beta-lactam plus mac-
rolide antibiotics. Patients with severe infection requiring admission to the intensive care unit require dual antibiotic
therapy including a third-generation cephalosporin plus a macrolide
alone or in combination with a fluoroquinolone. Treatment options
for patients with risk factors for Pseudomonas species include admin-
istration of an antipseudomonal antibiotic and an aminoglycoside,
plus azithromycin or a fluoroquinolone. Patients with risk factors for
methicillin-resistant Staphylococcus aureus should be given vanco-
mycin or linezolid, or ceftaroline in resistant cases. Administration
of corticosteroids within 36 hours of hospital admission for patients
with severe community-acquired pneumonia decreases the risk of
T
CME This clinical content ogether, influenza and pneumo- States, annual health care costs associated
conforms to AAFP criteria nia are the eighth leading cause with CAP range from $10.6 to $17 billion
for continuing medical
education (CME). See
of mortality among adults in and are expected to grow as the proportion
CME Quiz Questions on the United States and result of older persons increases.1,2,4 Inpatient care
page 689. in more than 60,000 deaths annually.1-4 accounts for more than 90% of pneumonia-
Author disclosure: No rel- Community-acquired pneumonia (CAP) related health expenditure.2,3,5
evant financial affiliations. disproportionately affects persons who
are very young or very old, with an annual Diagnosis
incidence of 9.2 to 33 per 1,000 person- DIFFERENTIAL DIAGNOSIS
years.1,5 Out of an estimated 878,000 adults Although Streptococcus pneumoniae remains
45 years and older who were hospitalized the most commonly isolated pathogen in
with a primary diagnosis of CAP in 2010, CAP, the relative frequency of other patho-
71% were 65 years or older, and 10% to gens has increased. Clinical suspicion should
20% required admission to the intensive be driven by comorbidities and other risk
care unit (ICU).1,2,6,7 Pneumococcal pneu- factors (Table 1).6,9-11 Commonly used diag-
monia alone was responsible for 866,000 nostic methods may identify a pathogen in
outpatient visits in 2004.8 In the United only 30% to 40% of patients.12
698 American
Downloaded Family
from the Physician
American www.aafp.org/afp
Family Physician website at www.aafp.org/afp.
Copyright © 2016 Volume
American Academy 94, Physicians.
of Family Number 9For the
November 1, 2016
private, noncom-
◆
mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en agosto 17, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Community-Acquired Pneumonia
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
In patients with suspected CAP, chest radiography or lung ultrasonography should be performed to confirm C 6, 13, 17, 18
the diagnosis.
Testing for specific pathogens should be ordered only when it would alter standard empiric therapy, which C 6, 19, 22, 25
is rare in outpatients.
Use of procalcitonin testing can assist in the management of CAP and reduce antibiotic exposure without C 27-29
compromising patient safety.
Validated mortality and pneumonia severity assessment tools should be used to determine the appropriate C 6, 31, 34
level of care for patients with CAP.
Patients with CAP who are admitted to the intensive care unit should be treated with dual antibiotic therapy. B 6, 43
For patients with severe CAP, use of corticosteroids within 36 hours improves outcomes. A 46-48
Influenza vaccination for all patients and pneumococcal vaccination for patients 65 years and older and A 49-51
other high-risk patients are the mainstays of CAP prevention.
Bioterrorism Bacillus anthracis (anthrax), Francisella tularensis (tularemia), Yersinia pestis (plague)
Chronic obstructive pulmonary disease or smoking Chlamydophila pneumoniae, Haemophilus influenzae, Legionella species,9,10
Moraxella catarrhalis, Pseudomonas aeruginosa or other gram-negative rods,
S. pneumoniae
HIV infection (late) Aspergillus and Cryptococcus species, H. capsulatum, H. influenzae, Nocardia
species, nontuberculous mycobacteria, Pneumocystis jiroveci
Influenza active in community H. influenzae, influenza and other respiratory viruses, S. pneumoniae,
Staphylococcus aureus (including MRSA)
Travel to or residence in Southeast Asia and East Asia Avian influenza, severe acute respiratory syndrome
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en agosto 17, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Community-Acquired Pneumonia
WHAT IS NEW ON THIS TOPIC: COMMUNITY- Table 2. Prediction Rule for Community-
ACQUIRED PNEUMONIA Acquired Pneumonia Diagnosis
For patients with severe community-acquired pneumonia,
corticosteroids decrease the risk of adult respiratory distress Add points when present Points
syndrome and modestly reduce intensive care unit and hospital
stays, duration of intravenous antibiotic treatment, and time to Rhinorrhea –2
clinical stability without increasing major adverse events. Sore throat –1
Adults 65 years and older should routinely receive the Night sweats 1
13-valent pneumococcal conjugate vaccine (PCV13; Prevnar Myalgia 1
13) and the 23-valent pneumococcal polysaccharide vaccine Sputum all day 1
(PPSV23; Pneumovax 23), preferably PCV13 first followed by
Respiratory rate > 25 breaths per minute 2
PPSV23 in 12 months.
Temperature ≥ 100°F (37.8°C) 2
Total:
a thorough history is an essential component in the diag- Information from reference 14.
nosis of CAP, no individual symptom can adequately
predict its presence. Across four studies, the most predic-
tive findings were fever greater than 100°F (37.8°C) (pos-
itive likelihood ratio [LR+] is approximately 2.7) and
egophony (LR+ = 5.3).13 Clinical prediction rules that
combine symptoms and examination findings (Table 214)
can be helpful in generating a likelihood ratio that can
be applied to patients with different prior probabilities of
CAP and aid in diagnosis and management.14
Physician judgment has better discriminatory abil-
ity to rule out pneumonia (negative likelihood ratio
[LR–] = 0.25), but ability to clinically diagnose pneumo-
nia is less certain (LR+ = 2.0).13 Patients with no vital
COPYRIGHT © VISUAL DX
sign abnormality and normal lung examination findings
are unlikely to have pneumonia.15 Thus, lung imaging is
helpful for patients presenting with possible CAP who
have any vital sign or examination abnormalities (given
Figure 1. Chest radiograph showing right middle lobe
the absence of asthma).16 infiltrate in a patient with pneumonia.
Guidelines from the Infectious Diseases Society of
America advise diagnosing CAP based on suggestive Lung ultrasonography has the potential to more accu-
examination findings and characteristic infiltrate on rately and efficiently diagnose pneumonia, as well as
chest radiography with or without microbiologic data.6 pleural effusions, pneumothorax, pulmonary embolism,
Caution should be used when diagnosing CAP in older and pulmonary contusions.17 Two recent meta-analyses
patients and those who are immunocompromised using chest computed tomography as the comparative
because they may not exhibit typical symptoms such standard show that lung ultrasonography has a pooled
as a fever greater than 100.4°F (38°C). However, most sensitivity of 0.94 to 0.95 (95% confidence interval [CI],
patients exhibit at least one respiratory symptom; acute 0.92 to 0.97) and a specificity of 0.90 to 0.96 (95% CI,
functional or cognitive decline; or repeat temperatures 0.86 to 0.97), with LR+ = 16.8 (95% CI, 7.7 to 37.0) and
of 99°F (37.2°C) or greater.15 LR– = 0.07 (95% CI, 0.05 to 0.10), compared with chest
radiography (pooled sensitivity = 0.77 [95% CI, 0.73 to
IMAGING 0.80]; specificity = 0.91 [95% CI, 0.87 to 0.94]) for diagno-
Lung imaging with chest radiography has been the sis of pneumonia.17,18 Because lung ultrasonography can
standard method of diagnosing pneumonia6 (Figure 1). be performed at the bedside in an average of 13 minutes
700 American Family Physician www.aafp.org/afp Volume 94, Number 9 ◆ November 1, 2016
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en agosto 17, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Community-Acquired Pneumonia
Table 3. Diagnostic Testing in Patients with Suspected Community-Acquired Pneumonia
Alcohol abuse ✓ ✓ ✓ ✓
Asplenia ✓ ✓
Failure of outpatient ✓ ✓ ✓
antibiotic therapy
Leukopenia ✓ ✓
Positive pneumococcal ✓ ✓
urine antigen test
Severe obstructive or ✓
structural lung disease
AFB = acid-fast bacillus; MRSA = methicillin-resistant Staphylococcus aureus; PCR = polymerase chain reaction; TB = tuberculosis.
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society
consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S40, with additional infor-
mation from reference 19.
and lacks ionizing radiation, it is a promising diagnostic but statistically significant increase in the length of stay,
option in primary care and emergency department set- time to clinical stability, and in-hospital mortality for
tings.18 Physicians should consider use of chest computed bacteremic patients.21 However, an earlier study showed
tomography when concern for alternative or concurrent no change in outcomes and demonstrated the potential
diagnoses remains high (e.g., interstitial lung disease, for false-positive blood cultures to cause prolonged hos-
cavitary lesions, sarcoidosis, malignancy). pitalization and unnecessary vancomycin use.22
Urine antigen testing may be useful in select patients,
DIAGNOSTIC TESTING especially if adequate sputum cannot be obtained or
Pulse oximetry should be assessed in all patients with antibiotics were given, because antigen can be detected
possible CAP. Patients who require supplemental oxy- starting on the first day of illness and for several weeks
gen should receive inpatient treatment. Routine micro- thereafter.6,23 Pneumococcal urine antigen testing has a
biologic testing of outpatients with CAP is unnecessary.6 sensitivity of 60% to 80% and specificity greater than
Testing may be indicated according to patient-specific 90%, whereas Legionella testing has a sensitivity of 70%
risk factors (Table 3).6,19 Testing for human immuno- to 90% and specificity of 99% for serogroup 1, which
deficiency virus infection, tuberculosis, and pneumo- accounts for 80% to 95% of Legionella-associated CAP.6
cystis pneumonia should be considered in those with Testing is most useful in critically ill patients and in the
high-risk sexual exposures or a history of injection drug scenarios listed in Table 3.6,19
use. Blood and sputum cultures should be obtained in The overall rate of pathogen detection among patients
the presence of specific risk factors or with severe CAP with CAP is 30% to 40%.12 Recent developments allow
(Table 4 6,20) when culture results can alter antibiotic use of rapid multiorganism polymerase chain reaction–
selection.6 A study of 833 patients with pneumococcal based testing for pathogen-directed treatment, with bac-
CAP, 47% of whom were bacteremic, showed a marginal terial and viral detection rates as high as 86%.9,19 Such
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en agosto 17, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Community-Acquired Pneumonia
detection can potentially result in earlier de-escalation exposure from eight to four days and lowered the risk
of therapy and decreased reliance on broad-spectrum of treatment failure (19.1% vs. 21.9%) with no impact
antimicrobials.11,24 Additionally, because viral etiolo- on mortality or length of hospitalization, regardless of
gies account for about 25% of all CAP cases, utilization clinical setting.29
of rapid viral respiratory panels can be useful to tailor A systematic review of 14 randomized controlled tri-
treatment and limit antibiotic exposure.6,24-26 als examining use of procalcitonin testing in European
Although more readily available through newer poly- settings found a reduction in antibiotic prescribing in
merase chain reaction–based methods, routine testing low-acuity settings and shorter duration of therapy in
for other atypical pathogens (e.g., Chlamydophila pneu- higher-acuity settings (i.e., emergency department and
moniae, Mycoplasma pneumoniae) in patients with CAP ICU) when results of high-sensitivity (detection limit
is not currently recommended.6,11,19 0.1 ng per mL) procalcitonin assays were used in clinical
To improve patient outcomes and reduce unnecessary decision making.30 Further research is needed to evaluate
antibiotic exposure, procalcitonin is being studied as a the impact of procalcitonin testing among patients with
potential biomarker of severe CAP. With a cost of $25 to acute respiratory illnesses in terms of patient-oriented
$30 per test, the value of procalcitonin testing is depen- outcomes, antibiotic exposure, and cost-effectiveness in
dent on laboratory capability, with a cutoff value of less U.S. populations.
than 0.1 ng per mL having superior prognostic accuracy
for short-term mortality (relative risk = 4.18; 95% CI, Management
3.19 to 5.48), bacteremia, and disease severity.27,28 A 2012 INPATIENT VS. OUTPATIENT CARE
Cochrane meta-analysis found the use of procalcito- The costs of hospitalization and potential for nosoco-
nin testing significantly decreased median antibiotic mial infections and thromboembolic events necessitate
careful consideration of risk factors for severe CAP when
considering appropriate level of care (Table 4).6,20 Deci-
Table 4. Criteria for Severe Community-Acquired sion support tools such as the Pneumonia Severity Index
Pneumonia (http://www.aafp.org/afp/2006/0201/p442.html#a fp
20060201p442-t3) assist in predicting the risk of 30-day
Minor criteria
mortality and severe CAP requiring ICU admission.
Confusion or disorientation
Table 5 summarizes the more widely adopted CURB-
Hypotension requiring aggressive fluid resuscitation
65 and CRB-65 prediction scores,6,31 which have greater
Multilobar infiltrates
ease of use, but weaker predictive power for 30-day mor-
PaO2/FiO2 ratio ≤ 250
tality.24,31,32 Among low-risk patients (Pneumonia Sever-
Respiratory rate ≥ 30 breaths per minute
ity Index class less than 3 or CURB-65 score less than
Urea nitrogen level ≥ 20 mg per dL (7.14 mmol per L)
Minor criteria that have less prognostic value20
2), the LR– for 30-day mortality using the index is 0.08,
Hypothermia (core temperature < 96.8°F [36°C])
and 0.21 using CURB-65.31 Sensitivity for predicting
Leukopenia (white blood cell count < 4,000 per mm3
ICU admission was reported as 74% vs. 39% to 50% for
[4.0 × 10 9 per L]) Pneumonia Severity Index vs. CURB-65, respectively.24,32
Thrombocytopenia (platelet count < 100 × 103 per mm3 Although CURB-65 has a higher false-negative rate
[100 × 109 per L]) (i.e., incorrectly ruling out severe CAP) compared with
Major criteria other instruments, its relatively high specificity allows
Invasive mechanical ventilation physicians to more accurately advance treatment for
Septic shock with need for vasopressors patients with a score of 3 or greater while taking fur-
ther measures to determine risk in patients who score
NOTE: Any major criterion is an absolute indication for admission to an
intensive care unit. One or more minor criteria indicate increased risk low.24,32,33 CRB-65 is more practical for use in the pri-
of death, and admission to an intensive care unit may be appropriate. mary care setting without a significant compromise in
FiO2 = fraction of inspired oxygen; PaO2 = partial arterial oxygen prognostic value.6,31 Patients with a score of 0 or 1 can be
pressure. managed safely as outpatients.6
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, SMART-COP (http://www.aafp.org/afp/2011/0601/
et al. Infectious Diseases Society of America/American Thoracic Soci-
p1299.html#afp20110601p1299-t6), a more recently de‑
ety consensus guidelines on the management of community-acquired
pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S38, with addi- veloped predictive tool, was designed to identify patients
tional information from reference 20. with CAP who are most likely to need mechanical ven-
tilation or vasopressor support (sensitivity = 92%).34
702 American Family Physician www.aafp.org/afp Volume 94, Number 9 ◆ November 1, 2016
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en agosto 17, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Community-Acquired Pneumonia
Other risk factors predictive of severe CAP include especially in North America.6,16 Exposure to antibiotics
male sex and the presence of congestive heart failure or in the preceding three months or presence of comorbid
chronic obstructive pulmonary disease.35 illness necessitates the preferential use of fluoroquino-
lones followed by a beta-lactam antibiotic (e.g., high-
ANTIBIOTIC THERAPY dose amoxicillin, amoxicillin-clavulanate [Augmentin],
Given the relatively low yield of standard culture tech- cefuroxime [Ceftin], cefpodoxime) combined with a
niques, empiric treatment using the 2007 Infectious Dis- macrolide as an alternative. Evidence from randomized
eases Society of America and American Thoracic Society controlled trials shows a modest reduction in treatment
guidelines (Table 6 6,36-40) targets likely pathogens based failure, adverse events, and treatment discontinuation
on epidemiologic risk factors.6 with fluoroquinolones compared with combination
Outpatient. Evidence is lacking on the optimum anti- beta-lactam and macrolide antibiotics.36,37
biotic regimen for treatment of CAP in the outpatient Facility-specific antibiograms should be used when-
setting.41 In the absence of significant comorbidities, ever available to account for variable resistance patterns.
macrolides (e.g., azithromycin [Zithromax]) should Given the risk of pneumococcal resistance, an antibiotic
be used for outpatient therapy of adult CAP, with from a different class should be used when recent anti-
doxycycline as an alternative, because S. pneumoniae biotic exposure is known. A five-day treatment course
and atypical pathogens account for most cases of CAP, for low-severity CAP has been shown to be sufficient in
clinical trials, whereas a seven- to 10-day
course should be provided in patients with
Table 5. CURB-65 and CRB-65 Mortality Prediction Tools moderate- and high-severity CAP (based on
for Patients with Community-Acquired Pneumonia CURB-65 and CRB-65 scores).42
Inpatient, No ICU. Hospitalized patients
Prognostic variables (assign 1 point for each variable) who are not admitted to the ICU should
Confusion (new onset) receive a respiratory fluoroquinolone or
Urea nitrogen level > 20 mg per dL (7.14 mmol per L)* a beta-lactam antibiotic and a macrolide.
Respiratory rate ≥ 30 breaths per minute Observational data suggest lower short-
Blood pressure (systolic < 90 mm Hg or diastolic ≤ 60 mm Hg) term mortality when antibiotic therapy is
Age ≥ 65 years administered within four to eight hours of
30-day mortality for CURB-65 (CRB-65)
hospital arrival in patients with moderate or
severe pneumonia.36 Table 7 provides recom-
Score Sensitivity Specificity LR+ LR– mended criteria for transitioning patients
≥ 1 point 98.6% (94.4%) 26.5% (38.3%) 1.2 (1.3) 0.10 (0.15)
from intravenous to oral antibiotics.36
≥ 2 points 89.1% (72.7%) 52.2% (70.8%) 1.7 (2.4) 0.21 (0.39) Although oral doxycycline is not included
≥ 3 points 62.0% (29.1%) 80.8% (90.9%) 3.1 (4.4) 0.46 (0.72) in existing guidelines, observational studies
≥ 4 points 29.0% 95.3% 5.4 0.73 show that it has similar effectiveness as levo-
floxacin (Levaquin) alone or in combination
30-day observed mortality by score
with ceftriaxone in the inpatient, non-ICU
CURB-65† CRB-65‡ setting, and is associated with fewer Clos-
tridium difficile infections.39,40,43,44 Trials of
Score Observed mortality Score Observed mortality
a new cephalosporin (ceftaroline [Teflaro])
0 to 1 2.0% 0 2.3% show promising results, although treatment
2 8.3% 1 to 2 13.3% should be reserved for patients with highly
3 to 5 22.3% 3 to 4 34.4% resistant gram-positive organisms.38
Inpatient, ICU. Patients with severe CAP
LR+ = positive likelihood ratio; LR– = negative likelihood ratio.
who are admitted to the ICU—about 10%
*—Excluded in CRB-65.
of patients hospitalized with CAP—should
†—Derived from a pooled cohort of 15 studies with 1,136 events in a sample of
13,319 individuals. receive dual antibiotic therapy, which
‡—Derived from a pooled cohort of nine studies with 55,302 events in a sample of has been shown to improve survival6,7,43
395,802 individuals. (Table 6 6,36-40). Anaerobic coverage should
Information from references 6 and 31. be considered if risk factors are present,
including aspiration, stroke with bulbar
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en agosto 17, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Community-Acquired Pneumonia
Table 6. Empiric Therapy for Community-Acquired Pneumonia
Outpatients with comorbidities* or Preferred 36,37: Respiratory fluoroquinolone (levofloxacin [Levaquin], gemifloxacin [Factive],
antibiotic use in past three months† or moxifloxacin [Avelox])
Alternative: Beta-lactam antibiotic (high-dose amoxicillin, amoxicillin/clavulanate
[Augmentin], cefuroxime [Ceftin], or cefpodoxime) plus a macrolide‡
Special considerations
Risk factors for Pseudomonas species Beta-lactam antibiotic (piperacillin/tazobactam [Zosyn], cefepime, imipenem/cilastatin
[Primaxin], meropenem [Merrem IV], or doripenem [Doribax]), plus either ciprofloxacin or
levofloxacin
or
The above beta-lactam antibiotic plus an aminoglycoside and azithromycin
or
The above beta-lactam antibiotic plus an aminoglycoside and an antipneumococcal
respiratory fluoroquinolone
symptoms, alcoholism, and loss of consciousness. Such ratory distress syndrome (relative risk = 0.21; 95% CI,
agents include carbapenems, clindamycin, metronida- 0.08 to 0.59) and modest reductions in lengths of ICU
zole (Flagyl), amoxicillin/clavulanate, and piperacillin/ and hospital stays, duration of intravenous antibiotic
tazobactam (Zosyn).7 Coverage for methicillin-resistant treatment, and time to clinical stability without a corre-
Staphylococcus aureus and Pseudomonas species should sponding increase in major adverse events.46 Additional
be administered depending on risk factors (Tables 16,9-11 observations include reduced need for mechanical ven-
and 36,19). Physicians must be aware that up to one in four tilation (number needed to treat = 20) and 3% reduc-
cases of CAP has a viral etiology, which may account tion in mortality with a typical regimen consisting of
for poor response to antibiotics or atypical features.6,26 methylprednisolone 0.5 mg per kg every 12 hours for
Prompt recognition and antiviral treatment, especially five to seven days, administered within 36 hours of
during influenza season, improve outcomes and reduce admission.47,48
mortality.45
Prevention
ADJUNCTIVE THERAPIES The 2015 Advisory Committee on Immunization Prac-
Meta-analyses of randomized trials of corticosteroids tices recommends that adults 65 years and older receive
for CAP demonstrate a decreased risk of adult respi- both the 13-valent pneumococcal conjugate vaccine
704 American Family Physician www.aafp.org/afp Volume 94, Number 9 ◆ November 1, 2016
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en agosto 17, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Community-Acquired Pneumonia
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en agosto 17, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Community-Acquired Pneumonia
pneumonia:review of the literature and meta-analysis. PLoS One. 2015; 36. Lee JS, Giesler DL, Gellad WF, Fine MJ. Antibiotic therapy for adults
10(6):e0130066. hospitalized with community-acquired pneumonia:a systematic review.
18. Chavez MA, Shams N, Ellington LE, et al. Lung ultrasound for the diag- JAMA. 2016;315(6):593-602.
nosis of pneumonia in adults:a systematic review and meta-analysis. 37. Raz-Pasteur A, Shasha D, Paul M. Fluoroquinolones or macrolides alone
Respir Res. 2014;15:50. versus combined with β-lactams for adults with community-acquired
19. Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of the pneumonia:systematic review and meta-analysis. Int J Antimicrob
microbiology laboratory for diagnosis of infectious diseases:2013 rec- Agents. 2015;4 6(3):242-248.
ommendations by the Infectious Diseases Society of America (IDSA) 38. Taboada M, Melnick D, Iaconis JP, et al. Ceftaroline fosamil versus ceftri-
and the American Society for Microbiology (ASM). Clin Infect Dis. 2013; axone for the treatment of community-acquired pneumonia:individual
57(4):e22-e121. patient data meta-analysis of randomized controlled trials. J Antimicrob
20. Salih W, Schembri S, Chalmers JD. Simplification of the IDSA/ATS cri- Chemother. 2016;71(4):862-870.
teria for severe CAP using meta-analysis and observational data. Eur 39. Mokabberi R, Haftbaradaran A, Ravakhah K. Doxycycline vs. levofloxa-
Respir J. 2014;43(3):8 42-851. cin in the treatment of community-acquired pneumonia. J Clin Pharm
21. Bordon JM, Fernandez-Botran R, Wiemken TL, et al. Bacteremic pneu- Ther. 2010;35(2):195-200.
mococcal pneumonia:clinical outcomes and preliminary results of 4 0. Flanders SA, Dudas V, Kerr K, McCulloch CE, Gonzales R. Effectiveness
inflammatory response. Infection. 2015;43(6):729-738. of ceftriaxone plus doxycycline in the treatment of patients hospitalized
22. Metersky ML, Ma A, Bratzler DW, Houck PM. Predicting bacteremia in with community-acquired pneumonia. J Hosp Med. 2006;1(1):7-12.
patients with community-acquired pneumonia. Am J Respir Crit Care 41. Pakhale S, Mulpuru S, Verheij TJ, Kochen MM, Rohde GG, Bjerre LM.
Med. 2004;169(3):342-347. Antibiotics for community-acquired pneumonia in adult outpatients.
23. Watkins RR, Lemonovich TL. Diagnosis and management of community- Cochrane Database Syst Rev. 2014;(10):CD002109.
acquired pneumonia in adults. Am Fam Physician. 2011;83(11): 42. Lim WS, Smith DL, Wise MP, Welham SA;British Thoracic Society. Brit-
1299-1306. ish Thoracic Society community acquired pneumonia guideline and the
24. Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J NICE pneumonia guideline:how they fit together. Thorax. 2015;70(7):
Med. 2014;371(17):1619-1628. 698-700.
25. van der Eerden MM, Vlaspolder F, de Graaff CS, Groot T, Jansen HM, 43. Garin N, Genné D, Carballo S, et al. β-lactam monotherapy vs β-lactam-
Boersma WG. Value of intensive diagnostic microbiological investiga- macrolide combination treatment in moderately severe community-
tion in low- and high-risk patients with community-acquired pneumo- acquired pneumonia:a randomized noninferiority trial. JAMA Intern
nia. Eur J Clin Microbiol Infect Dis. 2005;24(4):241-249. Med. 2014;174(12):1894-1901.
26. Qu JX, Gu L, Pu ZH, et al.;Beijing Network for Adult Community- 4 4. Doernberg SB, Winston LG, Deck DH, Chambers HF. Does doxycycline
Acquired Pneumonia (BNACAP). Viral etiology of community-acquired protect against development of Clostridium difficile infection? Clin
pneumonia among adolescents and adults with mild or moderate sever- Infect Dis. 2012;55(5):615-620.
ity and its relation to age and severity. BMC Infect Dis. 2015;15:89. 45. Rello J, Pop-Vicas A. Clinical review:primary influenza viral pneumonia.
27. Liu D, Su LX, Guan W, Xiao K, Xie LX. Prognostic value of procalcito- Crit Care. 2009;13(6):235.
nin in pneumonia:a systematic review and meta-analysis. Respirology. 4 6. Wan YD, Sun TW, Liu ZQ, Zhang SG, Wang LX, Kan QC. Efficacy and
2016;21(2):280-288. safety of corticosteroids for community-acquired pneumonia:a system-
28. Müller F, Christ-Crain M, Bregenzer T, et al.;ProHOSP Study Group. atic review and meta-analysis. Chest. 2016;149(1):209-219.
Procalcitonin levels predict bacteremia in patients with community- 47. Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid ther-
acquired pneumonia:a prospective cohort trial. Chest. 2010;138(1): apy for patients hospitalized with community-acquired pneumonia:a
121-129. systematic review and meta-analysis. Ann Intern Med. 2015;163(7):
29. Schuetz P, Müller B, Christ-Crain M, et al. Procalcitonin to initiate or 519-528.
discontinue antibiotics in acute respiratory tract infections. Cochrane 4 8. Torres A, Sibila O, Ferrer M, et al. Effect of corticosteroids on treatment
Database Syst Rev. 2012;( 9):CD007498. failure among hospitalized patients with severe community-acquired
30. Schuetz P, Chiappa V, Briel M, Greenwald JL. Procalcitonin algorithms pneumonia and high inflammatory response:a randomized clinical trial.
for antibiotic therapy decisions:a systematic review of randomized con- JAMA. 2015;313(7):677-686.
trolled trials and recommendations for clinical algorithms. Arch Intern
49. Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13
Med. 2011;171(15):1322-1331.
and PPSV23 vaccines:recommendations of the Advisory Committee on
31. Chalmers JD, Singanayagam A, Akram AR, et al. Severity assessment Immunization Practices (ACIP) [published correction appears in MMWR
tools for predicting mortality in hospitalised patients with community- Morb Mortal Wkly Rep. 2015;6 4(42):1204]. MMWR Morb Mortal Wkly
acquired pneumonia. Systematic review and meta-analysis. Thorax. Rep. 2015;6 4(34):944-947.
2010;65(10):878-883.
50. Centers for Disease Control and Prevention. Use of 13-valent pneumo-
32. Abers MS, Musher DM. Clinical prediction rules in community-acquired coccal conjugate vaccine and 23-valent pneumococcal polysaccharide
pneumonia:lies, damn lies and statistics. QJM. 2014;107(7):595-596. vaccine for adults with immunocompromising conditions:recommen-
33. Aujesky D, Fine MJ. The pneumonia severity index:a decade after
dations of the Advisory Committee on Immunization Practices (ACIP).
the initial derivation and validation. Clin Infect Dis. 2008;47(suppl 3): MMWR Morb Mortal Wkly Rep. 2012;61(40):816-819.
S133-S139. 51. Jefferson T, Rivetti D, Rivetti A, Rudin M, Di Pietrantonj C, Demicheli
34. Charles PG, Wolfe R, Whitby M, et al.;Australian Community-Acquired V. Efficacy and effectiveness of influenza vaccines in elderly people:
Pneumonia Study Collaboration, Grayson ML. SMART-COP:a tool for a systematic review [published correction appears in Lancet. 2006;
predicting the need for intensive respiratory or vasopressor support in 367(9515):986]. Lancet. 2005;366(9492):1165-1174.
community-acquired pneumonia. Clin Infect Dis. 2008;47(3):375-384. 52. Lutfiyya MN, Henley E, Chang LF, Reyburn SW. Diagnosis and treat-
35. Restrepo MI, Mortensen EM, Velez JA, Frei C, Anzueto A. A compara- ment of community-acquired pneumonia. Am Fam Physician. 2006;
tive study of community-acquired pneumonia patients admitted to the 73(3):442-450.
ward and the ICU. Chest. 2008;133(3):610-617.
706 American Family Physician www.aafp.org/afp Volume 94, Number 9 ◆ November 1, 2016
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en agosto 17, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.