Clinical Policy for the Management and Risk Stratification of
Community-Acquired Pneumonia in Adults in the Emergency Department
March 14, 2001

Inclusion criteria
This clinical policy is intended for patients 18 years of age or older with
clinical and radiologic evidence of pneumonia. Patients arriving at the ED
from nursing homes are included.

Exclusion criteria
Patients excluded from this policy are those who are critically ill or who
require respiratory support in the ED.
Excluded also are patients with hospital-acquired pneumonia, patients with
pneumonia rehospitalized within 30 days of their previous hospitalization,
patients who are pregnant, and patients with HIV or who are otherwise
immunocompromised.

If a patient is younger than 51 years and has no coexisting illnesses or no
abnormal physical examination findings, then risk class=I. OTHERWISE, circle
the following characteristics and add up the score to determine the risk class.

Description of patients in the various risk classes

Class I: young (median age, 35 to 37 years); none have pertinent coexisting
illnesses or abnormalities.

Class II: typically middle-aged (median age, 58 to 59 years); most are
assigned to this group by virtue of age alone.

Class III: typically older (median age, 72 years), and most had at least one
pertinent coexisting illness, one physical examination abnormality, or one
laboratory or radiographic abnormality.

Classes IV and V: somewhat older (median age, 75 years) and never assigned to
the class by virtue of age alone; the majority had abnormalities in 2 (Class
IV) or all 3 (Class V) of the pertinent risk factor categories.

This classification scheme, which is based on the PSI, potentially has utility
to the emergency physician. All Class I patients and many in Classes II and
III are likely candidates for outpatient treatment. The remaining Class II and
III patients may be candidates for a short hospital stay (< 24 hours).

Level A recommendations. Hospitalize patients in PSI Class IV and V.
Level B recommendations. Identify low-risk patients eligible for outpatient
therapy by using the PSI.

BLOOD CULTURES TO DETERMINE CAUSATIVE ORGANISM

The utility of blood cultures to determine the etiologic agent in unselected
patients with CAP is low, ranging from 6% to 11%, with most isolates being
Streptococcus pneumoniae. Furthermore, the presence of a positive blood
culture infrequently changes empiric patient management. However, in those
patients with severe pneumonia and/or associated risk factors, the incidence
of positive blood cultures may approach 30%. Blood cultures may isolate
uncommon etiologic organisms (ie, gram-negative organisms or yield agents)
demonstrating unusual antibiotic resistance patterns. Precise demonstration of
the etiologic agent permits judicious antibiotic use. In the elderly,
obtaining blood cultures within 24 hours of admission was associated with
reduced 30-day mortality.

Blood culture recommendations:
Level C recommendations.
Obtain blood cultures in all hospitalized patients with CAP.

Sputum Gram stain/culture recommendations:

Level C recommendations.
Consider sputum culture and Gram stain on adequate specimens in high-risk
patients who are hospitalized.

Empiric therapy of CAP recommendations:
Level C recommendations.
As one option, consider antibiotic therapy as outlined in the Appendix.

Administration of antibiotics for admitted patient recommendations:
Level B recommendations.
Start antibiotics in all hospitalized patients diagnosed with CAP, and within
8 hours in patients 65 years or older.