What defines pneumonia as moderate risk?

From the Guidelines

Moderate risk pneumonia is defined by a Pneumonia Severity Index (PSI) score in class III or a CURB-65 score of 1-2, indicating a need for hospitalization but not intensive care. This classification is based on the most recent and highest quality study available, which emphasizes the importance of using objective severity-of-illness scores to guide treatment decisions 1. The CURB-65 criteria, which assess Confusion, Urea levels, Respiratory rate, Blood pressure, and age over 65, provide a simple and easily remembered tool for evaluating the severity of pneumonia.

Key Factors in Moderate Risk Pneumonia

• Comorbidities such as heart, lung, liver, or kidney disease, diabetes, alcoholism, malignancy, or immunosuppression
• CURB-65 scores of 1-2
• PSI score in class III
• Need for hospitalization but not intensive care

Treatment Considerations

• Antibiotics such as a respiratory fluoroquinolone (levofloxacin 750 mg daily or moxifloxacin 400 mg daily) or a combination of a beta-lactam (such as ceftriaxone 1-2 g daily or ampicillin-sulbactam 1.5-3 g every 6 hours) plus a macrolide (azithromycin 500 mg daily) for 5-7 days
• Close monitoring for clinical improvement within 48-72 hours, with consideration for changing antibiotics if no improvement occurs

Importance of Objective Admission Criteria

The use of objective admission criteria, such as the PSI or CURB-65 score, can help decrease the number of patients hospitalized with CAP and ensure that those who require hospitalization receive appropriate care 1. These criteria have been validated in multiple studies and provide a reliable means of assessing the severity of pneumonia and guiding treatment decisions.

Clinical Decision-Making

In clinical practice, the decision to hospitalize a patient with pneumonia should be based on a thorough evaluation of the patient's condition, including their medical history, physical examination, and laboratory results. The use of objective severity-of-illness scores, such as the PSI or CURB-65, can help guide this decision and ensure that patients receive the most appropriate level of care. By prioritizing the use of these scores and considering the individual needs of each patient, clinicians can provide high-quality care and improve outcomes for patients with pneumonia 1.

From the FDA Drug Label

Azithromycin should not be used in patients with pneumonia who are judged to be inappropriate for oral therapy because of moderate to severe illness or risk factors such as any of the following: patients with cystic fibrosis, patients with nosocomially acquired infections, patients with known or suspected bacteremia, patients requiring hospitalization, elderly or debilitated patients, or patients with significant underlying health problems that may compromise their ability to respond to their illness (including immunodeficiency or functional asplenia).

The definition of pneumonia as moderate risk is not explicitly stated in the drug label. However, the label does provide criteria for patients who are at higher risk and may not be suitable for oral therapy with azithromycin, including those with:

• Cystic fibrosis
• Nosocomially acquired infections
• Known or suspected bacteremia
• Requirement for hospitalization
• Elderly or debilitated patients
• Significant underlying health problems, such as immunodeficiency or functional asplenia 2.

From the Research

Definition of Pneumonia Moderate Risk

The definition of pneumonia as moderate risk can be understood through various studies that have classified community-acquired pneumonia (CAP) into different risk categories based on severity.

• The study 3 recommends classifying patients with community-acquired pneumonia into four risk categories, with Group 3 being patients admitted to general wards with criteria of moderate severity.
• Another study 4 compares the efficacy and tolerability of different antibiotic treatments for hospitalized patients with moderate to severe community-acquired pneumonia, indicating that moderate risk is associated with patients who require hospitalization but do not have severe symptoms.
• A prospective, randomized, multicenter study 5 compared the clinical and bacteriological outcomes of patients with moderate-to-severe CAP, providing insight into the treatment of moderate risk pneumonia.
• The pneumonia severity index (PSI) and CURB-65 are two assessment systems used to direct appropriate site of care based on 30-day mortality, with PSI classes IV/V being significantly better than CURB-65 score ≥3 for predicting patients who died within 30 days or needed ICU admission 6.
• Emergency department providers often do not rely on the PSI to determine the initial site of treatment for patients with pneumonia, with reasons including the presence of comorbid illnesses, laboratory values, or symptoms that preclude ED discharge 7.

Key Factors in Determining Moderate Risk

Some key factors that determine moderate risk in pneumonia include:

• The presence of comorbid illnesses
• Laboratory values or vital signs that indicate a higher level of severity
• Symptoms that preclude ED discharge
• PSI risk classification of IV or V
• The need for hospitalization but not intensive care unit (ICU) admission.

Treatment of Moderate Risk Pneumonia

The treatment of moderate risk pneumonia typically involves hospitalization and antibiotic therapy, with options including:

• Ceftriaxone plus azithromycin
• Ceftriaxone plus clarithromycin or erythromycin
• Levofloxacin
• Cefuroxime axetil.