What are the admitting orders for a patient with severe community-acquired pneumonia (CAP)?

Admitting Orders for Severe Community-Acquired Pneumonia

For patients with severe community-acquired pneumonia (CAP), immediate implementation of a comprehensive care bundle is essential, including appropriate oxygen therapy, fluid resuscitation, antibiotic administration, and close monitoring of vital signs. 1

Initial Assessment and Monitoring

• Assess oxygen saturation immediately using pulse oximetry and provide appropriate oxygen therapy to maintain PaO2 >8 kPa and SaO2 >92% 1
• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation, and inspired oxygen concentration at least twice daily, with more frequent monitoring for severe pneumonia 1
• For patients with pre-existing COPD complicated by ventilatory failure, guide oxygen therapy with repeated arterial blood gas measurements 1
• Assess for volume depletion and provide intravenous fluid resuscitation with at least 30 ml/kg of isotonic crystalloid solution in the first 3 hours for hypotensive patients 2
• If hypotension persists after adequate fluid resuscitation, administer vasopressors with norepinephrine as the first choice, targeting a mean arterial pressure ≥65 mmHg 2

Diagnostic Studies

• Obtain blood cultures before initiating antibiotic therapy 1
• Request sputum samples for Gram stain and culture 1
• Perform legionella urinary antigen testing, especially when epidemiologically indicated 1
• Test for COVID-19 and influenza when these viruses are common in the community 3
• Obtain baseline laboratory studies including complete blood count, comprehensive metabolic panel, C-reactive protein, and lactate level 1, 2
• Order a chest radiograph to confirm diagnosis and assess extent of disease 1

Antibiotic Therapy

• Administer the first antibiotic dose while still in the emergency department 2, 3
• For severe CAP without risk factors for resistant pathogens, use combination therapy with:
  • A beta-lactam (ceftriaxone, cefotaxime, ampicillin/sulbactam, or piperacillin/tazobactam) plus
  • A macrolide (azithromycin 500 mg IV daily for at least 2 days, then 500 mg orally daily to complete 7-10 days) 4, 3, 5
• If Pseudomonas aeruginosa is suspected (due to COPD, bronchiectasis, or recent antibiotic use), use an anti-pseudomonal beta-lactam (piperacillin/tazobactam, carbapenem, cefepime) plus either an anti-pseudomonal fluoroquinolone or an aminoglycoside 5
• For patients with penicillin allergy, consider a respiratory fluoroquinolone plus clindamycin 5

Respiratory Support

• For patients with hypoxemia or respiratory distress, consider a cautious trial of noninvasive ventilation unless immediate intubation is required 2
• If invasive mechanical ventilation is needed, use low tidal volume ventilation (6 cm³/kg of ideal body weight) for patients with diffuse bilateral pneumonia or ARDS 2
• For moderate-severe ARDS, use higher PEEP, prone positioning for >12 hours per day, and consider deep sedation with muscle relaxation within the first 48 hours of mechanical ventilation 2

ICU Admission Criteria

• Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation 1
• Consider ICU or high-level monitoring unit admission for patients with 3 or more minor criteria for severe CAP 1
• Early ICU admission is associated with improved survival compared to delayed transfer 1

Supportive Care

• Provide nutritional support, especially in prolonged illness 1
• Assess and manage pleuritic pain with appropriate analgesia 1
• Consider systemic corticosteroids within 24 hours of development of severe CAP to potentially reduce 28-day mortality 3

Monitoring Response and Follow-up

• Remeasure CRP level and repeat chest radiograph in patients not progressing satisfactorily 1
• Treat for a minimum of 5 days, ensuring the patient is afebrile for 48-72 hours with no more than one pneumonia-associated sign of clinical instability before discontinuing therapy 2, 6
• Arrange clinical review at around 6 weeks, either with the patient's general practitioner or in a hospital clinic 1
• Consider follow-up chest radiograph for patients with persistent symptoms or physical signs, especially those at higher risk of underlying malignancy (smokers and those over 50 years) 1

Common Pitfalls to Avoid

• Delaying antibiotic administration, which is associated with increased mortality 3
• Underestimating severity of illness, leading to inappropriate management 6
• Failing to recognize the need for ICU admission, resulting in delayed transfer and worse outcomes 1
• Inadequate duration of therapy (less than 5 days) 6
• Overuse of fluoroquinolones as first-line agents, which should be reserved for specific situations 6