| | | |
RECOMMENDATIONS | | |
| | | |
Recommendation Hospital admission decision. |
| Imperative: | Severity-of-illness scores, such as the CURB-65 criteria (confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater), or prognostic models, such as the Pneumonia Severity Index (PSI), can be used to identify patients with CAP who may be candidates for outpatient treatment. | | | | | IF | | | | | Inclusion Criterion: | | | | Exclusion Criterion: | | | THEN | | | | | Use Severity-of-illness scores, such as the CURB-65 criteria to identify patients with CAP who may be candidates for out- patient treatment. | | Evidence Quality: | Level 1 | Strength of Recommendation: | Strong | Reason: | | Logic: | | Cost: | | | |
|
|
| Imperative: | Objective criteria or scores should always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. | | | | | IF | | | | | Inclusion Criterion: | | | | Exclusion Criterion: | | | THEN | | | | | Supplement objective criteria or scores with physician determination of subjective factors, including ability to safely and reliably take oral medication and availability of outpatient support resources | | Evidence Quality: | level II evidence | Strength of Recommendation: | Strong recommendation | Reason: | | Logic: | | Cost: | | | |
|
|
| Conditional: | For patients with CURB-65 scores ≥2, more-intensive treatment that is, hospitalization or, where appropriate and available, intensive in-home health care services is usually warranted. | | | | | | | IF | | | | patients with CURB-65 scores ≥2 | | | | THEN | | | | more-intensive treatment that is, hospitalization | | | | where appropriate and available, intensive in-home health care services | |
|
Evidence Quality: | level III evidence. | Strength of Recommendation: | Moderate recommendation | Reason: | | Logic: | If patients with CURB-65 scores ≥2 Then more-intensive treatment that is, hospitalization OR where appropriate and available, intensive in-home health care services | | |
|
| | | |
Recommendation ICU admission decision. |
| Conditional: | Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respi- ratory failure requiring intubation and mechanical ven- tilation. | | | | | | | IF | | | | septic shock requiring vasopressors | | | | acute respiratory failure requiring intubation and mechanical ventilation. | | | | THEN | | | | Direct admission to an ICU is required | |
|
Evidence Quality: | level II evidence. | Strength of Recommendation: | Strong recommendation; | Reason: | | Logic: | | | |
|
| Conditional: | Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed in table 4 | | | | | | | IF | | | | patients with 3 of the minor criteria for severe CAP | | | | | Value: Resp rate .GE.30; PaO2/FiO2 .LE. 250; multilobar infiltrates; confusion/disorientation; uremia; leukopenia (WBC .LT.4000; thrombocytopenia <100,000; hypothermia .LT. 36; hypotension requiring aggressive fluid resuscitation | |
| | | THEN | | | | Direct admission to an ICU or high-level monitoring unit | |
|
Evidence Quality: | | Strength of Recommendation: | | Reason: | | Logic: | | | |
|
| | | |
Recommendation Diagnostic Testing |
| Imperative: | In addition to a constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting mi- crobiological data, is required for the diagnosis of pneumonia. | | | | | IF | | | | | Inclusion Criterion: | | | | Exclusion Criterion: | | | THEN | | | | | a constellation of suggestive clinical features is required for the diagnosis of pneumonia | | | | a demonstrable infiltrate by chest radiograph or other imaging technique is required for the diagnosis of pneumonia | | Evidence Quality: | level III evidence. | Strength of Recommendation: | Moderate recommendation; | Reason: | | Logic: | If Then a constellation of suggestive clinical features is required for the diagnosis of pneumonia. AND a demonstrable infiltrate by chest radiograph or other imaging technique is required for the diagnosis of pneumonia. | Cost: | | | |
|
|
| | | |
Recommendation Recommended diagnostic tests for etiology. |
| Conditional: | Patients with CAP should be investigated for specific pathogens that would significantly alter standard (empirical) management decisions, when the presence of such pathogens is suspected on the basis of clinical and epidemiologic clues. | | | | | | | IF | | | | when the presence of pathogens that would significantly alter standard empirical management decisions is suspected on the basis of clinical and epidemiologic clues | | | | THEN | | | | Patients with CAP should be investigated for specific pathogens | |
|
Evidence Quality: | level II evidence. | Strength of Recommendation: | Strong recommendation; | Reason: | | Logic: | | | |
|
| Imperative: | Routine diagnostic tests to identify an etiologic diagnosis are optional for outpatients with CAP | | | | | IF | | | | | Inclusion Criterion: | | | | Exclusion Criterion: | | | THEN | | | | | Routine diagnostic tests to identify an etiologic diagnosis are optional for outpatients with CAP. | | Evidence Quality: | level III evidence. | Strength of Recommendation: | Moderate recommendation; | Reason: | | Logic: | | Cost: | | | |
|
|