Adult Pneumonia Treatment Algorithm

Outpatient Management

 Fever (≥38°C), cough, purulent sputum, pleural pain, dyspnoea

 New focal chest signs (e.g. crepitation) on examination
 New chest x-ray shadowing for which there is no other
explanation (e.g. not pulmonary oedema).

Pneumonia

Determine severity of pneumonia using clinical scores (CORB or SMART-COP)

along with clinical judgement

Mild pneumonia Moderate pneumonia Severe pneumonia

CORB=0, SMART-COP ≤2 CORB=1, SMART-COP 3-4 CORB ≥2, SMART-COP ≥5

 Old age
 Poor co-morbidities
Yes Consider ICU referral
 Immune suppression
 No caregiver available
 Staying long distance from hospital or
lack of transportations

No
Admit to ward
Outpatient CAP Treatment

Oral amoxicillin/clavulanate Start empirical antibiotic

OR therapy
Oral ampicillin/sulbactam
(see next page)
for 5 days

Consider referral to nearest health

clinic or hospital for follow-up. SMART-COP score

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 Adult Pneumonia Treatment Algorithm
Inpatient Empirical Antibiotics

Clinical features ± chest X-ray suggest pneumonia

Determine severity of pneumonia using clinical scores (CORB or SMART-COP)

along with clinical judgement

Risk of HCAP
 Hospitalization within the last 90 days Yes
 Nursing home resident
 Chronic dialysis
 Home wound care
 Home infusion therapy
( ≥1 risks )

No Risk of MDR pathogens

HCAP: Healthcare associated pneumonia
MDR: Multidrug-resistant No  Immune suppression
CAP: Community acquired pneumonia
CAP treatment  Hospitalization within ≤ 90 days
 Poor functional status
 Antibiotic therapy within ≤ 6 months
( ≥1 risks )

Non-severe pneumonia Severe pneumonia

Yes
(Moderate) CORB ≥2, SMART-COP ≥5

Azithromycin Piperacillin/tazobactam
Azithromycin
PLUS PLUS
PLUS
1. Amoxicillin/clavulanate OR Azithromycin
Amoxicillin/clavulanate OR Ampicillin/sulbactam
Ampicillin/sulbactam +
*Consult ID if suspect MRSA pneumonia
Gentamicin
*If patient had received antibiotics for (if no renal failure)
current illness prior to admission,
consider adding gentamicin or use OR
ceftriaxone as beta-lactam agent. 2. Ceftriaxone
(see Severe pneumonia)
(if renal failure)
OR
3. Ceftazidime
(if at risk of melioidosis)

SMART-COP score
Risk of melioidosis
Occupation in farming, forestry, fishing, army etc
OR
Exposure to contaminated soil or river water
AND
Underlying diabetes mellitus
±
Presence of other foci of infections
(e.g. intra-abdominal abscesses, septic arthritis)

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 Pneumonia Treatment Algorithm
De-escalation Therapy

Reassessment at 48-72hours

 General condition
 Temperature
 Hemodynamic stability
 SpO2 under room air, respiratory rate
 WBC trend, CRP
 Chest X-ray (only if persistent or new
focal chest signs on examination)

Clinical improvement

Yes No

Culture positive Culture negative Culture negative Culture positive

Continue/de-escalate to Look for complications of

Pathogen directed pneumonia
Amoxicillin/clavulanate
therapy with
OR  Empyema
narrowest spectrum
Ampicillin/sulbactam  Lung abscess
antibiotics
 ARDS
PLUS Yes Concordant sensitivity
 Pulmonary embolism
Total antibiotic with initial empirical
Azithromycin
duration 5-7 days antibiotics
Total antibiotic duration Look for other causes
5-7 days  PTB
 Viral pneumonia No
*For HCAP, can consider
complete a course of
 Co-infections
piperacillin/tazobactam  Non-infectious causes

Pathogen directed therapy

with narrowest spectrum
antibiotics
Criteria (>24 hours) for switching IV to
oral antibiotics

 Absence of mental confusion

 Ability to take oral medication
 Temperature lower than 38.3°C Reassess response after
 Hemodynamic stability (heart rate <100 beats/min and 48-72 hours
systolic blood pressure >90 mm Hg)
 Respiratory rate lower than 25 breaths/min
 Sp02 > 90% while breathing in normal room air or return to
baseline oxygen level for patients receiving long-term
oxygen therapy (LTOT)

( must fulfill all criteria )

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 Adult Pneumonia Treatment Algorithm
Supplementary guidelines

Recommended Antibiotic Dosage

1. Amoxycillin/clavulanate 625mg tds PO, 1.2gm tds IV

2. Ampicillin/sulbactam 375mg-750mg bd PO, 1.5gm-3gm tds IV
3. Azithromycin 500mg od PO/IV
4. Ceftriaxone 2gm od IV (1gm bd if serum albumin<25g/L)
5. Ceftazidime 2gm tds IV
6. Piperacillin/tazobactam 4.5gm qid IV
7. Gentamicin 5mg/kg daily IV
• Use adjusted body weight if obese
• No levels required for empiric dosing
• Use only in patients with normal renal function CrCl > 60 ml/min
• Do not use if previous vestibular or auditory toxicity.

Note: The doses recommended above are intended for patients with normal renal function;
the doses must be adjusted in patients with renal insufficiency.

References
1. Antibiotic therapy for community-acquired pneumonia in adults: Information for clinicians. Centre for Healthcare Related Infection
Surveillance and Prevention (CHRISP), Version 4.1, November 2012

2. Therapeutic Guidelines Limited. Therapeutic guidelines: Antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited; 2010

3. Adult Pneumonia Guideline HNEH CPG

4. The British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Adults Update 2009

5. Charles PGP, et al. SMART-COP: A Tool for Predicting the Need for Intensive Respiratory or Vasopressor Support in Community-Acquired
Pneumonia. Clinical Infectious Diseases 2008; 47:375–84.

6. Buising et al. Identifying severe community-acquired pneumonia in the emergency department: A simple clinical prediction tool.
Emergency Medicine Australasia 2007; 19: 418–426.

7. Maruyama et al. A New Strategy for Healthcare-Associated Pneumonia: A 2-Year Prospective Multicenter Cohort Study Using Risk
Factors for Multidrug-Resistant Pathogens to Select Initial Empiric Therapy. CID 2013;57(10):1373–83

8. Lee et al. Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia A Systematic Review. JAMA.
2016;315(6):593-602.

9. Peto et al. The bacterial aetiology of adult community-acquired pneumonia in Asia: a systematic review. Trans R Soc Trop Med Hyg
2014; 108: 326–337

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