Ambulatory acquired pneumonia--risk assessment, empirical and targeted therapy

Abstract

The management of patients with community-acquired pneumonia confronts the practicing physician with the requirement to make two principal decisions. The first decision is on the site of treatment of this infection. The options are to either treat the patient as an outpatient or to hospitalize the patient. The second decision concerns the selection of an appropriate antimicrobial agent. Over the course of the last five years, a prediction rule was developed and validated in the U.S., which allows to accurately identify those patients that carry a low risk for the development of complications of their infections. Hence, these patients can safely be managed as outpatients. On the other hand, patients with high scores (risk classes III-V) should be hospitalized and at least initially managed as inpatients. The calculation of this score requires the collection of a substantial number of parameters. However, good clinical practice requires the evaluation of most of this parameters. Therefore, the additional work resulting from the calculation of this score is moderate and certainly justifiable. Details of the prediction rule according to Fine et al. are presented in this article. Several guidelines exist for the empiric antibiotic treatment of patients with community-acquired pneumonia. Some key recommendations are influenced by the aggravating problem of antibiotic resistance in the U.S. The situation in Switzerland differs from the American situation and therefore recommendations in this article reflect this difference. In daily clinical practice it is somewhat rare to know the microbiological etiology of the individual episode of community-acquired pneumonia with certainty. Therefore, antibiotic treatment is started empirically and also continued empirically in most cases.