Provincial Clinical Knowledge Topic

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1 Provincial Clinical Knowledge Topic Pneumonia, Adult Emergency V 1.0 Copyright: 2017, Alberta Health Services. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit Disclaimer: This material is intended for use by clinicians only and is provided on an "as is", "where is" basis. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for the advice of a qualified health professional. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use.

2 Revision History Version Date of Revision Description of Revision Revised By Pneumonia, Adult Emergency V 1.0 Page 2 of 31

3 Important Information Before you Begin The recommendations contained in this knowledge topic have been provincially adjudicated and are based on best practice and available evidence. Clinicians applying these recommendations should, in consultation with the patient, use independent medical judgment in the context of individual clinical circumstances to direct care. This knowledge topic will be reviewed periodically and updated as best practice evidence and practice change. The information in this topic strives to adhere to Institute for Safe Medication Practices (ISMP) safety standards and align with Quality and Safety initiatives and accreditation requirements such as the Required Organizational Practices. Some examples of these initiatives or groups are: Health Quality Council Alberta (HQCA), Choosing Wisely campaign, Safer Healthcare Now campaign etc. Pneumonia, Adult Emergency V 1.0 Page 3 of 31

4 Goals of Management 1. Early diagnosis of pneumonia in the Emergency Department 2. Rapid identification and management of patients with severe pneumonia and septic shock requiring mechanical ventilation, vasopressor support or Intensive Care (ICU) care 3. Early initiation of appropriate antibiotics Clinical Decision Support CURB-65 and the Pneumonia Severity Index (PSI) are severity assessment tools used to stratify patients by mortality rate and facilitate safe disposition. Table 1: CURB-65 1 Characteristics Score C Confusion 1 U Urea GREATER than 7 mmol/l 1 R BP Respiratory Rate GREATER than or equal to 30 breaths/min Systolic Blood Pressure (SBP) LESS than or equal to 90 mmhg OR Diastolic Blood Pressure (DBP) LESS than or equal to 60 mmhg years Age GREATER than 65 years 1 CURB-65 score 30-day Mortality Risk (%) Management 0 to 1 LESS than 3 Outpatient 2 3 to 15 Hospitalization 3 to 5 GREATER than 15 Consider ICU Pneumonia, Adult Emergency V 1.0 Page 4 of 31

5 Table 2: Pneumonia Severity Index (PSI) 2 Demographics Age Sex Nursing home resident Co-morbidities Neoplastic disease Liver disease Congestive heart failure Cerebrovascular disease Renal disease Examination findings Altered mental status Respiratory rate GREATER than 30 per minute Systolic blood pressure (SBP) LESS THAN 90 mmhg Temperature LESS than 35 o C or GREATER than or equal to 40 o C Pulse GREATER than or equal to 125 beats per minute Laboratory findings ph LESS than 7.35 (do ABG only if hypoxic) Blood urea level GREATER than or equal to 10.7 mmol/l Sodium LESS than 130 meq/l Glucose GREATER than or equal 13.9 mmol/l Hematocrit LESS than 0.30 PaO2 LESS than 60 mmhg or SaO2 LESS than 90% Pleural effusion Click here for link to online calculator PSI 30-day Mortality Management Class Risk (%) I, II LESS than 1 Outpatient III 2.8 Consider Hospitalization IV 9.3 Hospitalization V 27 Consider ICU Table 3: Criteria for severe community acquired pneumonia (CAP) 3 Minor criteria: Respiratory rate GREATER than or equal to 30 breaths/min PaO2/FiO2 ratio LESS than or equal to 250 Multilobar infiltrates Confusion/disorientation Uremia (Urea level, GREATER than or equal to 7.14 mmol/l) Leukopenia (WBC count, LESS than or equal to 4000 cells/mm 3 ) Thrombocytopenia (platelet count, LESS than or equal to 100,000 cells/mm 3 ) Hypothermia (core temperature, LESS than or equal to 36 o C) Hypotension requiring aggressive fluid resuscitation Major criteria: Invasive mechanical ventilation Septic shock with the need for vasopressors Pneumonia, Adult Emergency V 1.0 Page 5 of 31

6 Table 4: Antibiotic Agents in Outpatient Treatment of CAP 3,12 Patient Population No comorbid factors Treatment Regimes doxycycline +/- amoxicillin 2 Alternative: macrolide (AZIthromycin, clarithromycin) +/- amoxicillin 3 Comorbid factors 1 macrolide or doxycycline + amoxicillin or amoxicillin-clavulanate or cefuroxime axetil Alternative: levofloxacin 1 Chronic heart disease, lung disease, diabetes mellitus, alcoholism, active cancer, and asplenia 2 Add amoxicillin if lobar pneumonia, recent (within 3 months) antibiotic therapy, or greater than 15% tetracycline resistant Streptococcus pneumoniae (S. pneumoniae) 3 Add amoxicillin if lobar pneumonia, recent (within 3 months) antibiotic therapy, or greater than 25% macrolide resistant S. pneumoniae To view the S. pneumoniae resistance in your area, see the antibiogram from your region: Pneumonia, Adult Emergency V 1.0 Page 6 of 31

7 Table 5: Antibiotic Agents in Inpatient Treatment of CAP 3,12 Patient Population Hospitalized, non-icu patients Treatment Regimes ceftriaxone + macrolide or doxycycline Alternative: levofloxacin Hospitalized, ICU patients ceftriaxone + AZIthromycin or levofloxacin Cephalosporin allergy: levofloxacin + vancomycin or clindamycin Hospitalized, ICU patients, MRSA 1 suspected Hospitalized, ICU patients, Pseudomonas aeruginosa (P. aeruginosa) suspected add vancomycin or linezolid to above regime piperacillin-tazobactam + levofloxacin Pneumonia, Adult Emergency V 1.0 Page 7 of 31

8 Table 6: Antibiotic Agents in Inpatient Treatment of Hospital Acquired Pneumonia (HAP) 6,12 Patient Population Treatment Regimes Early onset (<4 days) HAP See CAP, hospitalized (Table 5) Late Onset (>4 days) HAP Non-ICU, no mechanical ventilation, no broad-spectrum antibiotics Coma, diabetes, head injury, recent influenza, IV drug use history Prior (<3 month) broad spectrum antibiotics, structural lung disease (bronchiectasis/cystic fibrosis), immunosuppression ceftriaxone or levofloxacin +/- gentamicin 1 ceftriaxone or levofloxacin +/- gentamicin 1 + vancomycin or linezolid piperacillin-tazobactam or meropenem + tobramycin +/- vancomycin or linezolid (if MRSA suspected) Penicillin allergy:* vancomycin or linezolid + ciprofloxacin + tobramycin 1Consider adding gentamicin to cover multi-resistant Gram negative organisms until culture results are available * See AHS Beta Lactam Allergy Antimicrobial Stewardship Backgrounder for further details Table 7: Criteria for clinical stability Temperature LESS than or equal to 37.8 o C Heart rate LESS than 100 beats/min Respiratory rate LESS than or equal to 24 breaths/min Systolic blood pressure GREATER than or equal to 90 mmhg or GREATER than or equal to PaO2 60 mmhg on room air Arterial oxygen saturation GREATER than 90% Ability to maintain oral intake Normal mental status Pneumonia, Adult Emergency V 1.0 Page 8 of 31

9 Risk factors for drug-resistant S. pneumoniae 3 : Age LESS than 2 or GREATER than 65 years Antibiotic therapy last 3 months (risk for pneumococcal resistance to the same class of antibiotics used) Alcoholism Medical comorbidities Immunosuppression Exposure to child in daycare Features suggestive of MRSA as a pathogen in CAP 12 : Rapid onset of pneumonia Necrotizing process on chest x-ray (CXR) Post-influenza Intravenous drug use history Colonization / recent infection with MRSA Gram positive cocci in clusters on Gram stain Additional general risk factors for MRSA to consider (uptodate, Spectrum): Recent hospitalization (within 12 months) Residence in long term care facility and supportive living facilities Recent surgery Hemodialysis HIV infection Recent (within 3 months) antibiotic use Incarceration Military service Sharing sports equipment Sharing needles, razors, or other sharp objects Risk factors for P. aeruginosa in pneumonia (uptodate, Bugs and Drugs): Hospital acquired Increased Age (GREATER than 90 years) Increased length of mechanical ventilation Antibiotics at admission Transfer form medical unit or ICU Admission on ward with high incidence of P. aeruginosa Presence of central venous or urinary catheter Community acquired Immunocompromise Recent (within 3 months) antibiotic use Structural lung abnormalities (cystic fibrosis, bronchiectasis) Repeated acute exacerbation of COPD requiring frequent glucocorticoid and/or antibiotic use Pneumonia, Adult Emergency V 1.0 Page 9 of 31

10 Oral (PO) versus Intravenous (IV) antibiotics in treatment of pneumonia (IDSA antimicrobial stewardship; Li et al 2015): Many patients treated in the inpatient setting likely receive intravenous (IV) antibiotics unnecessarily, where oral antibiotics would be equally effective. Risk associated with IV therapy includes increase in subjective patient pain, phlebitis, extravasation injury, thrombosis, infection, and increased length of hospital stay (LOS). Furthermore, early transition to oral from IV antibiotics result in shorter LOS and reduction in healthcare costs, with no increase in adverse patient outcomes. Whenever possible, patients with mild and moderate pneumonia should be treated with oral antibiotics. Potential indications for parenteral (IV) antibiotics: Patient cannot tolerate PO / contraindication to PO medication administration Critical illness Rapidly progressive infections Poor bioavailability of required antimicrobial agent Table 8: Bioavailability of antibiotics commonly used in uncomplicated, low, or moderate severity pneumonia Agent Oral Bioavailability (%) Azithromycin 37 clarithromycin 50 amoxicillin 80 CefUROXime axetil 52 Doxycycline 100 Levofloxacin 99 A note about Macrolide use in Alberta: A significant proportion of S. pneumoniae isolates in Alberta are macrolide resistant, and in general, macrolides have poor coverage against Haemophilus influenzae. Bugs & Drugs recommends against macrolide monotherapy in suspected cases of pneumococcal bacteremia (clinical history of rigors, or positive blood cultures). Furthermore, macrolides are not recommended as first line monotherapy in low risk patients in areas where macrolide resistant S. pneumoniae is GREATER than 25%. It is therefore advisable for primary care clinicians treating pneumonia to understand the local resistance patterns in which they practice (Click here for Alberta Health Services Antibiograms). Pneumonia, Adult Emergency V 1.0 Page 10 of 31

11 Decision Making 1. Obtain a chest radiograph (CXR) to support the diagnosis of pneumonia in patients with appropriate constellation of clinical findings, as elicited on history and physical exam. There are no combinations of history and physical examination findings that can definitively confirm the diagnosis of pneumonia, and there is a large degree of inter-observer variability in these findings. Therefore, when possible, a chest radiograph is recommended to support the diagnosis of CAP 8 Furthermore, a small minority of patients will present with clinical features consistent with pneumonia, but normal initial chest radiographs. Up to 55% of patients with initially normal CXR will develop infiltrates on subsequent studies 5. In these patients, it is reasonable to treat with antibiotics, and repeat imaging in 24 to 48 hours. 2. Assess the severity of pneumonia using an objective measurement tool, where possible (see Table 1 and Table 2). Identify patients with severe CAP and septic shock that require intensive care unit (ICU) care by either of the following: i. Need for intubation / mechanical ventilation or vasopressor support. ii. Patients with more than 3 minor criteria for severe CAP (see Table 3). 3. Initiate appropriate and timely antimicrobial therapy (within 4 hours) based on pneumonia severity, treatment location (inpatient vs. outpatient), and the presence of risk factors indicative of potential multidrug resistant pathogens (see Table 4, Table 5 and Table 6). Obtain blood cultures prior to antibiotics (when possible but not delaying treatment) in patients with moderate to severe CAP. Cultures are not routinely indicated in patients with low severity CAP, as they are frequently negative and do not change management. 4. Choose most appropriate duration of therapy: Patients with uncomplicated CAP should be treated for a minimum of 5 days, should be afebrile for 48 to 72 hours, and should should be clinically stable (see Table 7) before the antibiotics can be safely discontinued. For moderate to severe infections a 7 to 10 day course is recommended. Duration of therapy should be longer for complicated infections (i.e. pneumonia with endocarditis, meningitis), P. aeruginosa and MRSA infections, and cavitary pneumonia. Determine disposition based on pneumonia severity assessment, response to therapy in the emergency department (ED), and clinical judgement of high-risk patient populations that would benefit from admission. Pneumonia, Adult Emergency V 1.0 Page 11 of 31

12 Order Set Components Order Set: Pneumonia Adult Emergency Department Orders Order Set Keywords: Community acquired pneumonia, CAP, hospital acquired pneumonia, HAP Order Set Requirements: Clinical Assessment Tools (see Table 1, Table 2, Table 4 and Table 5) Goals of Care Designation Conversations leading to the ordering of a Goals of Care Designation (GCD), should take place as early as possible in a patient's course of care. The Goals of Care Designation is created, or the previous GCD is affirmed or changed resulting from this conversation with the patient or, where appropriate, the Alternate Decision-Maker. Complete the Goals of Care Designation (GCD) Order Set within your electronic system, or if using paper process, complete the Provincial Goals of Care Designation (GCD) paper form ( Intravenous Fluids Intravenous Cannula Insert: Initiate IV IV Peripheral Saline Flush/Lock: Saline Lock IV Bolus or Rapid infusion 0.9% NaCl infusion ml as fast as possible Maintenance IV Solutions 0.9% NaCl infusion at ml/hour D5W - 0.9% NaCl infusion at ml/hour D5W % NaCl infusion at ml/hour Other: at ml/hour IV Solutions with Potassium KCl 20 mmol/l in 0.9% NaCl infusion at ml/hour; STOP AFTER ONE LITRE KCl 40 mmol/l in 0.9% NaCl infusion at ml/hour; STOP AFTER ONE LITRE KCl 20 mmol/l in D5W % NaCl infusion at ml/hour; STOP AFTER ONE LITRE KCl 40 mmol/l in D5W % NaCl infusion ml/hour; STOP AFTER ONE LITRE Other: (specify fluid) at ml/hour Laboratory Investigations Hematology CBC Chemistry Electrolytes (Na, K, Cl, CO2) C-reactive protein (CRP) Glucose Random Creatinine Urea Pneumonia, Adult Emergency V 1.0 Page 12 of 31

13 ALT Alkaline phosphatase Bilirubin Lipase Microbiology Blood Culture (See Clinical Decision Making section) Nasopharyngeal swab/aspirate for respiratory virus PCR MRSA Nasal Swab Respiratory medicine Blood Gases, Venous Blood Gases, Arterial On current therapy On room air Urine Tests Pregnancy Test, Urine (POCT if available) Other Investigations Electrocardiogram 12 Lead Diagnostic Imaging General Radiology GR Chest, 2 Projections (Chest X-ray PA and Lateral) GR Chest, 1 Projection portable (Chest X-ray Portable) Computed Tomography May be indicated if complicated parapneumonic effusion, or concern for concurrent acute intrathoracic process (i.e. pulmonary embolism [PE]) CT chest, enhanced Medications ED to Outpatient Management The recommended course of antibiotics for CAP patients treated as outpatients is 5 to 7 days. For all antibiotic regimes, reassess response to therapy after 5 days. A) No comorbid factors (see Table 4): Choose ONE: doxycycline 200 mg PO once now AND THEN 100 mg PO BID AZIthromycin 500 mg PO daily x 3 days clarithromycin 500 mg PO BID AND CONSIDER ADDING: (if lobar pneumonia, recent (within 3 months) antibiotic therapy, or GREATER than 15% local tetracycline OR 25% macrolide resistance S. pneumoniae) amoxicillin 1 gram PO TID Pneumonia, Adult Emergency V 1.0 Page 13 of 31

14 OR if PENICILLIN ALLERGY: (See AHS Beta Lactam Allergy Antimicrobial Stewardship Backgrounder for further details) levofloxacin 750 mg PO daily (use as monotherapy if amoxicillin indicated) B) Presence of Comorbidities (see Table 4): Choose ONE: doxycycline 200 mg PO once now AND THEN 100 mg PO BID AZIthromycin 500 mg PO daily x 3 days clarithromycin 500 mg PO BID AND Choose ONE: amoxicillin-clavulanate 875 mg PO BID amoxicillin 1 gram PO TID cefuroxime axetil 500 mg PO BID Or if PENICILLIN ALLERGY: (See AHS Beta Lactam Allergy Antimicrobial Stewardship Backgrounder for further details) levofloxacin 750 mg PO daily (use as monotherapy if comorbidities present and unable to tolerate any beta lactam options above; recommended course 5 to 7 days) ED to Inpatient Management Consider oral (PO) administration whenever possible in mild to moderate severity CAP admitted to hospital. The recommended course of antibiotics for CAP patients admitted to hospital is 5 to 10 days. For all antibiotic regimes, reassess response to therapy after 5 days. A) Non-ICU Patients (see Table 5): Choose: ceftriaxone 1 gram IV daily AND Choose ONE : doxycycline 200 mg PO once now AND THEN 100 mg PO BID AZIthromycin 500 mg PO/IV x 3 days clarithromycin 500 mg PO BID Alternative: levofloxacin 750 mg PO/IV daily B) ICU Patients (see Table 5): Choose: ceftriaxone 1 gram IV daily x 5-10 days AND Choose ONE: AZIthromycin 500 mg PO/IV x 3-5 days levofloxacin 750 mg PO/IV daily x 7-10 days Pneumonia, Adult Emergency V 1.0 Page 14 of 31

15 If MRSA suspected (see Clinical Decision Support section) ADD: Choose ONE: vancomycin 25 mg/kg IV loading dose (no maximum); followed by maintenance dose of 15 mg/kg (maximum 2 grams / dose) Note: Dosing interval is determined by CrCl and desired trough levels; see AHS vancomycin dosing policy for details linezolid 600 mg PO/IV every 12 hours C) If MRSA suspected (see Clinical Decision Support section) ADD: Choose ONE: vancomycin 25 mg/kg IV loading dose (no maximum); followed by maintenance dose of 15 mg/kg (maximum 2 grams / dose) Note: Dosing interval is determined by CrCl and desired trough levels; see AHS vancomycin dosing policy for details linezolid 600 mg PO/IV every 12 hours D) If P. aeruginosa suspected (see Clinical Decision Support section) select: Choose BOTH: piperacillin / tazobactam 4.5 grams IV every 6 hours AND levofloxacin 750 mg PO/IV daily Non-opiate Analgesia Oral ibuprofen 600 mg PO once ibuprofen 200 to 600 mg PO every 6 hours PRN for pain (maximum 3200 mg/day) ibuprofen mg PO Suggest mg for mild to moderate pain, 600 mg for moderate to severe pain acetaminophen tab 975 or 1000 mg PO once acetaminophen tab 325 to 1000 mg PO every 4 hours PRN for pain (maximum 3000 mg/day) acetaminophen tab mg PO Suggest 325 to 650 mg for mild to moderate pain, 975 to 1000 mg for moderate to severe pain Parenteral Recommend restricting ketorolac use to actively vomiting patients and using lowest effective dose ketorolac mg IV / IM once ketorolac mg IV / IM every 6 hours PRN for pain ketorolac mg IV / IM Opiate Analgesia For susceptible patients defined as elderly, frail, low body mass, systemically unwell, or on medications known to cause sedation or lower blood pressure we recommend decreasing narcotic dosing by 50%. Contact physician or nurse practitioner for reassessment if pain not controlled after administration of maximum prescribed dosage. Pneumonia, Adult Emergency V 1.0 Page 15 of 31

16 Oral Maximum dosage of acetaminophen from all sources not to exceed 3000 mg per day acetaminophen 325 mg/caffeine 15 mg/codeine 30 mg 2 tabs PO once acetaminophen 325 mg/caffeine 15 mg/codeine 30 mg 1 to 2 tabs PO every 4 hours PRN for pain acetaminophen 325 mg/caffeine 15 mg/codeine 30 mg tabs PO every hours PRN for pain oxycodone 5 mg/acetaminophen 325 mg 2 tabs PO once oxycodone 5 mg/acetaminophen 325 mg 1 to 2 tabs PO every 4 hours PRN for pain oxycodone 5 mg/acetaminophen 325 mg tabs PO every hours PRN for pain HYDROmorphone 1 mg PO once HYDROmorphone 1 to 2 mg PO every 4 hours PRN for pain HYDROmorphone mg PO every hours PRN for pain Suggest 1 mg for moderate pain and 2 mg for severe pain Parenteral HYDROmorphone 1 mg IV once HYDROmorphone 0.5 to 1 mg IV every 10 minutes PRN for pain (maximum 3 mg total) HYDROmorphone mg IV every minutes PRN for pain Suggest 0.5 mg for moderate pain and 1 mg for severe pain morphine 5 mg IV once morphine 2.5 to 5 mg IV every 10 minutes PRN for pain (maximum 15 mg total) morphine mg IV every minutes PRN for pain Suggest 2.5 mg for moderate pain and 5 mg for severe pain fentanyl 50 mcg IV once fentanyl 25 to 50 mcg IV every 5 minutes PRN for pain (maximum 200 mcg total) fentanyl mcg IV every minutes PRN for pain Suggest 25 mcg for moderate pain and 50 mcg for severe pain Antiemetics Avoid dimenhydrinate in patients 65 years of age or older due to increased risk of side effects including delirium. Suggest 25 mg for mild/moderate nausea, 50 mg for moderate/severe nausea dimenhydrinate 50 mg PO once dimenhydrinate 25 to 50 mg PO every 4 hours PRN for nausea/vomiting dimenhydrinate mg PO every hours PRN for nausea/vomiting dimenhydrinate 50 mg IV once dimenhydrinate 25 to 50 mg IV every 4 hours PRN for nausea/vomiting dimenhydrinate mg IV every hours PRN for nausea/vomiting Oral administration or slow infusion via IVPB are preferred for metoclopramide to reduce the risk of akathisia. Suggest 5 mg for mild/moderate nausea or if CrCl less than 40 ml/min; 10 mg for moderate/severe nausea, and CrCl over 40 ml/min metoclopramide 10 mg PO once Pneumonia, Adult Emergency V 1.0 Page 16 of 31

17 metoclopramide 5 to 10 mg PO every 6 hours PRN for nausea/vomiting metoclopramide mg PO every hours PRN for nausea/vomiting metoclopramide 10 mg IVPB once metoclopramide 5 to 10 mg IVPB every 6 hours PRN for nausea/vomiting metoclopramide mg IVPB every hours PRN for nausea/vomiting 4 mg starting dose recommended for IV ondansetron Avoid ondansetron in patients with prolonged QTc interval ondansetron 4 mg IV once ondansetron 4 mg IV every 8 hours PRN for nausea/vomiting ondansetron mg IV every hours PRN for nausea/vomiting ondansetron tab 8 mg PO every 8 hours PRN for nausea/vomiting ondansetron tab mg PO every hours PRN for nausea/vomiting Due to high cost, recommend reserving ondansetron DISINTEGRATING tab for actively vomiting patients without an IV ondansetron DISINTEGRATING tab 8 mg PO every 8 hours PRN for nausea/vomiting ondansetron DISINTEGRATING tab mg PO every hours PRN for nausea/vomiting Vasopressors norepinephrine infusion 0.05 to 0.5 microgram/kg/min IV; titrate to maintain Mean Arterial Pressure (MAP) of GREATER than 60 mmhg norepinephrine 8 to 12 mcg/min IV continuous; titrate to maintain Mean Arterial Pressure (MAP) GREATER than 60 mmhg dopamine 5 to 20 mcg/kg/min IV continuous; titrate to maintain Mean Arterial Pressure (MAP) GREATER than 60 mmhg Patient Care Orders Isolation Most cases of community acquired pneumonia do not require isolation; those that do require isolation are because of the causative organism, not because of the diagnosis of pneumonia. Other than pulmonary tuberculosis, which requires Airborne isolation, Contact and Droplet isolation would cover all of the organism that can cause pneumonia which do require isolation (refer to Appendix A for more information) Contact Droplet Airborne Respiratory Care If oxygen saturation is already adequate, no supplemental oxygen is required O2 Therapy to maintain saturation GREATER than or equal to 92% for previously healthy patients O2 Therapy to maintain saturation GREATER than or equal to 90% for CO2 retaining / COPD patients Pneumonia, Adult Emergency V 1.0 Page 17 of 31

18 Vital Signs Vital Signs (respiratory rate, pulse, blood pressure, temperature, oxygen saturation) as per provincial guideline (Assessment and Reassessment of Patients guideline, ESCN - HCS ) every hour(s) every minute(s) Bedside Cardiac Monitoring Diet / Nutrition NPO NPO May Have Sips, May Take Meds Clear Fluids Regular Diet Other Diet : Activity: Activity as tolerated Bed rest with bathroom privileges Bed rest with commode Complete bed rest Fall risk assessment Consults Consult: Respiratory Therapy: Indication: Consult: Transition Services: Indication: Consult: Hospitalist: Indication: Consult: Internal medicine: Indication: Consult: ICU: Indication: Consult: Pulmonary medicine: Indication: Consult: Infectious diseases: Indication: Rural Considerations For patients with severe CAP that may require ICU level care, initiate call through RAAPID early for guidance on management as needed, and arranging transport to accepting centre able to provide ICU level care. Pneumonia, Adult Emergency V 1.0 Page 18 of 31

19 Disposition Planning 1. Considerations for Admission Moderate or severe pneumonia: PSI IV, CURB-65 greater than or equal to 2 (see Tables 1&2) Physical condition (such as frailty, mobility issues) Social instability or psychiatric co-morbidity Persistent vomiting 2. Considerations for Admission to ICU Consider with PSI IV or CURB (see Tables 1&2) Septic shock requiring vasopressor support Respiratory failure requiring intubation and mechanical ventilation Three or more minor predictors of severe CAP (see Table 3) 3. Considerations for Discharge/Transfer Low severity CAP (PSI of I-III, CURB ), (see Tables 1&2) Adequate oxygenation Patient able to safely manage symptoms at home and reliable / able to return if deterioration Initiate appropriate antibiotics at discharge (5 to 7 days in total duration) Influenza vaccine, 0.5 ml if not vaccinated this influenza season (September through April) Pneumococcal polysaccharide vaccine, 0.5 ml IM or SQ, prior to discharge if not vaccinated in previous 5 years for adults greater than 65 years of age, patients with asplenia, and immunocompromised patients Assessment of functional status 4. Outpatient follow-up Failure of symptom improvement in 3 days after initiation of antibiotic therapy should prompt reassessment. To follow up with family physician in the next 5 to 7 days to ensure clinical resolution Follow up with family physician in 4 to 6 weeks to ensure radiographic resolution in patients at risk for lung cancer (i.e. smokers) 5. Patient and Family education/discharge instructions If questions or concerns call Health Link Smoking cessation information offered to all patients who smoke: Government of Canada - Quit Smoking Alberta Quits Patient Care Handout: Pneumonia Patient Care Handout: Sepsis Pneumonia, Adult Emergency V 1.0 Page 19 of 31

20 Analytics Outcome Measure#1 Name of Measure Definition Rationale Notes for Interpretation # of times order set/protocol Pneumonia Adult Emergency Department Orders used (Number [%] of ED patients with ICD-10 discharge diagnosis code of pneumonia, and frequency this order set is applied) Number of times order set Pneumonia Adult Emergency Department Orders is used. Overall, by zone, by sites, by domain (ED, Inpatient, etc.), and by units. Will be required on an ongoing basis with the ability to filter by location, time period, domain, etc. Intended to measure if the order set cited in the knowledge topic is being used and what % of time for the indicated disease or condition. May indicate areas with adoption issues or gaps in topic Health record must have coding for disease/condition, consider timing of roll out of provincial CIS vs paper order sets. Pneumonia, Adult Emergency V 1.0 Page 20 of 31

21 Outcome Measure#2 Name of Measure Reduction in time to MD assessment for moderate to severe pneumonia Definition Requires: ED time markers (triage to physician, physician to consult and then to admission or physician to discharge) and outcome markers (identified as clinical decision unit patient [CDU], consulted for admission, admitted to ICU or ward, died) ED diagnoses for pneumonia using ICD-10 Outcome Measure#3 Name of Measure Reduced rates of unplanned return to ED within 72 hours of discharge with diagnosis of pneumonia Definition Requires: Number (%) of ED pneumonia patients (by site/zone/hospital type or location [e.g. inner city]) admitted from the ED to ward / ICU Length of stay for admitted and discharged patients with pneumonia 72-hour unplanned ED return visits for pneumonia / respiratory illness / cough / shortness of breath Outcome Measure#4 Name of Measure Mean / median time to antibiotic administration Definition Requires: ED time markers (triage to physician, physician to consult and then to admission or physician to discharge) and outcome markers (identified as clinical decision unit patient [CDU], consulted for admission, admitted to ICU or ward, died) ED diagnoses for pneumonia using ICD-10 Time to antibiotic use, dosage, duration Appropriateness of antibiotic therapy Pneumonia, Adult Emergency V 1.0 Page 21 of 31

22 Outcome Measure#5 Name of Measure Increased blood cultures before antibiotics in cases of moderate to severe pneumonia Definition Rationale Requires: ED time markers (triage to physician, physician to consult and then to admission or physician to discharge) and outcome markers (identified as clinical decision unit patient [CDU], consulted for admission, admitted to ICU or ward, died) ED diagnoses for pneumonia using ICD-10 Number (%) of ED pneumonia patients (by site/zone/hospital type or location [e.g. inner city]) for whom blood and / or sputum culture studies were completed Time to antibiotic use, dosage, duration Pretreatment blood cultures are recommended for moderate to high severity CAP patients, or admitted with the following conditions: cavitary infiltrates, leukopenia, active alcohol abuse, chronic severe liver disease, asplenia, positive test for pneumococcal urinary antigen, pleural effusion, or those admitted to ICU. Outcome Measure#6 Name of Measure Definition Rationale Reduction in total duration of antimicrobial therapy Requires: ED time markers (triage to physician, physician to consult and then to admission or physician to discharge) and outcome markers (identified as clinical decision unit patient [CDU], consulted for admission, admitted to ICU or ward, died) ED diagnoses for pneumonia using ICD-10 Time to antibiotic use, dosage, duration Patients with uncomplicated CAP should be treated for a minimum of 5 days, should be afebrile, for 48 to 72 hours, and should have no CAP associated signs of clinical instability before the antibiotics can be safely discontinued. For moderate to severe infections a 7-10 day course is recommended. Duration of therapy should be longer for complicated infections (i.e. endocarditis, meningitis), pseudomonal and S. aureus infections, and cavitary pneumonia. Pneumonia, Adult Emergency V 1.0 Page 22 of 31

23 Outcome Measure#7 Name of Measure Reduced rates of IV antibiotics in patients appropriate for oral therapy Definition ED diagnoses for pneumonia using ICD-10 Time to antibiotic use, dosage, duration Number (%) of ED pneumonia patients (by site/zone/hospital type or location [e.g. inner city]) treated with IV antibiotics Number (%) of ED pneumonia patients (by site/zone/hospital type or location [e.g. inner city]) treated with PO antibiotics Pneumonia, Adult Emergency V 1.0 Page 23 of 31

24 Clinical Questions Clinical Question #1: Which clinical factors should be used to guide the safe disposition of community-acquired pneumonia (CAP) patients to be treated in the outpatient, inpatient, or intensive care unit settings? Clinical Statement #1: Severity assessment tools, such as CURB-65 (see Table 1) or PSI (see Table 2), can be used to identify patients that may be treated as outpatients versus those that require admission to hospital. However, these objective scoring systems should always be considered in the context of subjective factors identified by the physician as important (i.e. supports in the community, ability to tolerate oral medications). Quality of Evidence: High Strength of Recommendation: Strong References: 1. 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):S National Institute for health and Care Excellence (NICE). Pneumonia diagnosis and management of community and hospital acquired pneumonia in adults. Published December Accessed June Clinical Question #2: What is the most accurate and cost effective pneumonia severity assessment tool? Clinical Statement #2: Amongst pneumonia severity assessment tools, the CURB-65 score (see Table 1) is the most accurate and cost effective in determining whether patients are at low, intermediate, or high risk of death and thus requiring admission to hospital or safe discharge home. Quality of Evidence: Low Strength of Recommendation: Weak References: 1. National Institute for health and Care Excellence (NICE). Pneumonia diagnosis and management of community and hospital acquired pneumonia in adults. Published December Accessed June Clinical Question #3: Are routine blood cultures indicated for patients admitted with CAP? Clinical Statement #3: Routine blood cultures are not indicated for patients with low severity CAP, as they are often not positive, and infrequently lead to a change in management. Pretreatment blood cultures are recommended for moderate to high severity CAP patients, or admitted with the following conditions: cavitary infiltrates, leukopenia, active alcohol abuse, chronic severe liver disease, asplenia, positive test for pneumococcal urinary antigen, pleural effusion, or those admitted to ICU. Pneumonia, Adult Emergency V 1.0 Page 24 of 31

25 Quality of Evidence: Moderate Strength of Recommendation: Strong References: 1. 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):S Nazarian DJ, Eddy OL, Lukens TW, et al. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia. Ann Emerg Med. 2009;54: National Institute for health and Care Excellence (NICE). Pneumonia diagnosis and management of community and hospital acquired pneumonia in adults. Published December Accessed June Clinical Question #4: What is the optimal time from initial ED presentation to initiation of antimicrobial therapy in CAP? Clinical Statement #4: In general, the evidence is conflicting regarding optimal time to antibiotics in CAP. Certainly in critically ill, hemodynamically unstable patients antibiotic therapy should be initiated as soon as possible. The focus should be on correctly diagnosing CAP and initiating antibiotics within 4 hours of ED presentation. Quality of Evidence: Low to very low Strength of Recommendation: Weak References: 1. National Institute for health and Care Excellence (NICE). Pneumonia diagnosis and management of community and hospital acquired pneumonia in adults. Published December Accessed June Clinical Question #5: In patients with CAP being treated in the outpatient setting, what are appropriate empiric treatment regimens? Clinical Statement #5: Use the following table to guide appropriate outpatient therapy (see Table 4) Quality of Evidence: High Strength of Recommendation: Strong References: 1. 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):S Blondel-Hill E and Fryters S. Bugs & Drugs. Pneumonia, Adult Emergency V 1.0 Page 25 of 31

26 Clinical Question #6: In patients with CAP being treated in the inpatient setting, what are appropriate empiric treatment regimes? Clinical Statement #6: Use the following table to guide appropriate inpatient therapy (see Table 5) Quality of Evidence: High Strength of Recommendation: Strong References: 1. 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):S Blondel-Hill E and Fryters S. Bugs & Drugs. Clinical Question #7: What is the appropriate therapy for patients being treated for hospital acquired pneumonia? Clinical Statement #7: Hospital acquired pneumonia (HAP) is pneumonia that occurs 48 hours after admission and did not appear to be incubating at the time of admission. Empiric treatment is based on the presence or absence or risk of resistant organism, patient factors, and wherever possible, local antibiotic resistance patterns. Use the following table to guide appropriate therapy (see Table 6) Quality of Evidence: Moderate Strength of Recommendation: Strong References: 1. Blondel-Hill E and Fryters S. Bugs & Drugs Rotstein C, Evans G, Born A, et al. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol. 2008;19(1):19-53 Clinical Question #8: What is the optimal duration of antimicrobial therapy in patients with CAP? Clinical Statement #8: Patients with uncomplicated CAP should be treated for a minimum of 5 days, should be afebrile, for 48 to 72 hours, and should have no CAP associated signs of clinical instability (see Table 7) before the antibiotics can be safely discontinued. For moderate to severe infections a 7-10 day course is recommended. Duration of therapy should be longer for complicated infections (i.e. endocarditis, meningitis), pseudomonal and S. aureus infections, and cavitary pneumonia. Quality of Evidence: Moderate to High Strength of Recommendation: Strong References: 1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Pneumonia, Adult Emergency V 1.0 Page 26 of 31

27 Community-Acquired Pneumonia in Adults. Clin Infect Dis. 2007;44(Suppl 2):S Nazarian DJ, Eddy OL, Lukens TW, et al. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia. Ann Emerg Med. 2009;54: National Institute for health and Care Excellence (NICE). Pneumonia diagnosis and management of community and hospital acquired pneumonia in adults. Published December Accessed June Pneumonia, Adult Emergency V 1.0 Page 27 of 31

28 References 1. Lim WS, van der Eerden MH, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5): Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community acquired pneumonia. N Engl J Med. 1997;336(4): 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):S Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clin Infect Dis. 2007;44: Hagaman J, Rouan GW, Shipley RT, et al. Admission chest radiograph lack sensitivity in the diagnosis of community acquired pneumonia. Am J Med Sci. 2009;337: Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61-e Li HK, Agweyu A, English M, et al. An Unsupported Preference for Intravenous Antibiotics PLoS Med. 2015;12(5): e Metlay JP, Kapoor WN, Fine MJ. Does this patient have community acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278: National Institute for health and Care Excellence (NICE). Pneumonia diagnosis and management of community and hospital acquired pneumonia in adults. Published December Accessed June Nazarian DJ, Eddy OL, Lukens TW, et al. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia. Ann Emerg Med. 2009;54: Rotstein C, Evans G, Born A, et al. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol. 2008;19(1): Blondel-Hill E and Fryters S. Bugs & Drugs. Pneumonia, Adult Emergency V 1.0 Page 28 of 31

29 Appendix A Bacteria Group A Streptococcus (invasive illness only) Neisseria meningitidis (invasive illness only) MRSA Mycobacterium tuberculosis Mycoplasma pneumoniae Pseudomonas aeruginosa (multi-drug resistant only) Contact and Droplet Droplet Contact and Droplet Airborne Droplet Contact Viruses Adenovirus Coronavirus (SARS, MERS CoV, non-sars, non-mers CoV) Enterovirus/Rhinovirus Influenza Metapneumovirus Parainfluenza virus Respiratory Syncytial Virus Contact and Droplet Contact and Droplet Contact and Droplet Contact and Droplet Contact and Droplet Contact and Droplet Contact and Droplet Pneumonia, Adult Emergency V 1.0 Page 29 of 31

30 Acknowledgements We would like to acknowledge the contributions of the clinicians who participated in the development of this topic. Your expertise and time spent are appreciated. Name Title Zone Knowledge Lead Chris Hall Physician, Emergency Medicine Provincial Topic Lead Jennifer Nicol Physician, Emergency Medicine Calgary Zone Working Group Members Shawn Dowling Physician, Emergency Medicine Calgary Zone Simon Ward Physician, Emergency Medicine Central Zone Michael Bullard Physician, Emergency Medicine Edmonton Zone Dan Banmann Physician, Emergency Medicine South Zone Vincent DiNinno Physician, Emergency Medicine South Zone Jennifer Evangelista Registered Nurse, Clinical Nurse Educator Calgary Zone Sarah Halverson Registered Nurse, Clinical Nurse Educator Central Zone Matthew Douma Registered Nurse, Clinical Nurse Educator Edmonton Zone Jean Harsch Registered Nurse, Clinical Nurse Educator Edmonton Zone Dawn Peta Registered Nurse, Clinical Nurse Educator South Zone Kristen Mackenzie Registered Nurse, Clinical Nurse Educator North Zone Clinical Support Services Steven Freriks James Wesenberg Pharmacy Information Management Governance Committee (PIM-GC) on behalf of Pharmacy Services on behalf of Laboratory Services - Provincial Networks Provincial Provincial Bill Anderson on behalf of Diagnostic Imaging Services Provincial Carlota Basualdo-Hammond & Marlis Atkins on behalf of Nutrition & Food Services Provincial Pneumonia, Adult Emergency V 1.0 Page 30 of 31

31 SCN or Provincial Committee Emergency Strategic Clinical Network Core Committee Provincial Clinical Informatics Lead Sarah Searle Registered Nurse Provincial Additional Contributors Thank you to the following clinicians who participated in the colleague review process. Your time spent reviewing the knowledge topics and providing valuable feedback is appreciated. Charles Wong, Leanne Dekker, Brian Holroyd, Shelley O'Neill, Margaret Gray, Bruce Dalton, Margaret Dymond, Mary Gunther, Kelsey Isfan, Shelane Leroux, Susan Fryters, Shelley Scorgie, Bre Hutchinson, Brenda Ashman, Brian Dufresne, Brian Rowe, Janet Wallace, Teresa Thurber Pneumonia, Adult Emergency V 1.0 Page 31 of 31