PNEUMONIA GUIDELINE MAP (Community-Acquired

Pneumonia)

PNEUMONIA
(CAP)

CAP (Community Acquired LRTI + Ketikpastian

Pneumonia
Kebutuhan Antibiotik

Severity Assesment Diagnostic Tests

LOW

Antibiotics

SvS SvD DvD

Duration

Information :
LRTI : Lower Respiratory Tract Infection
S : Single Antibiotic Therapy
D : Dual Antibiotic therapy
V : Versus/ Or
: Prescribe Antibiotic as indicated by test resuslt
NEUMONIA GUIDELINE MAP (Hospital Presentation)

PNEUMONIA
(HOSPITAL
PRESENTATION)

CAP (Community (HAP) Hospital

Acquired Acquired
Pneumonia Pneumonia
Severity
Assesment

LOW Moderate /high Antibiotics

Antibiotic Antibiotic
s s Timing

SvS SvD DvD SvS SvD DvD SvD SvD DvD

Duration

Glucocorticosteroids
:

Gas Exchange
:

Monitoring
:

Safe discharge
:
 Microbiological tests for patients with community-
acquired pneumonia or hospital-acquired pneumonia

Component Description

Review question In adults with community-acquired pneumonia or hospital-acquired

pneumonia in a hospital setting, what microbiological test or combination of
tests at presentation (including urinary pneumococcal and urinary legionella
antigen, blood culture and sputum culture) is most likely to be clinically and
cost effective?
Objectives The aim of this review is to determine whether targeted treatment is
worthwhile (as opposed to empiric therapy) and, if so, what test is the most
likely to be of value in hospital.
 Targeted therapy is defined as using an antibiotic with as narrow an
antimicrobial spectrum as possible which is active against a bacterium that
is identified as being the likely causative organism.
 Empirical therapy is considered to be antibiotic therapy likely to be active
against the most likely causative bacteria in the absence of a definite known
cause in that case.
Population Adults diagnosed with pneumonia (community- or hospital-acquired):
 adult is defined as aged 18 years or over
 pneumonia diagnosis made on the basis of chest X-ray for those in a
hospital setting
 CAP is defined as pneumonia that is acquired outside hospital.
 HAP is defined as pneumonia that occurs 48 hours or more after hospital
admission and is not incubating at hospital admission.

The review will be stratified by severity status as defined by formal severity

assessment tools (such as PSI, CURB65, ATS) if available:
 low-severity CAP
 moderate- and high-severity CAP.
Subgroups The following factors will be considered for subgroup analysis if
heterogeneity is present:
 with or without antibiotic therapy prior to admission
 timing of microbiological tests.
Intervention Initial empiric treatment followed by targeted (pathogen-directed) antibiotic
treatment strategies.
Index tests Any of the following alone or in combination:
 blood culture
 sputum culture
 urinary pneumococcal antigen
 urinary legionella antigen.

Invasive sampling techniques (e.g. bronchoalveolar lavage and protected

brush sampling) will not be considered as they are only applicable to a small
proportion of the population.
Comparison Empirical (broad-spectrum) antibiotic treatment strategies without index tests
OR
Comparison between any of the index tests.
Outcomes  Change in antibiotic prescription/treatment.
 Single- compared with single-antibiotic
therapy for low-severity community-
acquired pneumonia
Class of antibiotics Tetracycline Beta-lactamase Narrow-spectrum Macrolide
stable penicillin beta-lactam
Cephalosporin  Cephalexin vs  Cefuroxime vs
demeclocycline co-amoxiclav
Table 65, page 187 Table 66, page 189
Respiratory  Levofloxacin vs  Moxifloxacin vs  Moxifloxacin vs
fluoroquinolone co-amoxiclav amoxicillin clarithromycin
 Levofloxacin vs
Table 69, page 195 Table 68, page 193 clarithromycin
Table 70, page 197
Non-respiratory  Ofloxacin vs
fluoroquinolone erythromycin
Table 71 page 199
Macrolide  Erythromycin vs  Clarithromycin vs  Azithromycin vs
doxycycline co-amoxiclav clarithromycin
Table 64, page 185  Erythromycin vs Table 72, page 201
co-amoxiclav
 Azithromycin vs
co-amoxiclav
Table 67, page 191

Single- compared with other single-antibiotic therapy for low-severity community-acquired

pneumonia managed in hospital and/or treated with intravenous antibiotic therapy (click on
hyperlinks or refer to page numbers)

Class of antibiotics Narrow spectrum Beta-lactamase Macrolide Tetracycline

beta-lactam stable penicillin
Cephalosporin  Cefaclor vs  Cefuroxime vs co-
amoxicillin amoxiclav
Table 78, page 213  Cefuroxime vs co-
amoxiclav
Table 77, page 211
Non-respiratory  Ofloxacin vs
fluoroquinolone doxycycline
Table 79, page 215
Macrolide  Azithromycin vs  Clarithromycin vs  Azithromycin vs
benzylpenicillin co-amoxiclav erythromycin
Table 74, page 205 Table 75, page 207 Table 76, page 209
 Summary of studies included in the review of low-severity
community-acquired pneumonia duration of antibiotic therapy

Study Intervention Comparison

Dunbar 2003 65
Levofloxacin 750 mg once daily Levofloxacin 500 mg once daily
Duration: 5 days Duration: 10 days
Route: IV or oral. Route: IV or oral.
Elmoussaoui 2006 67
Amoxicillin 3 days IV (dose Amoxicillin 3 days IV (dose
unspecified), followed by placebo unspecified), followed by 750 mg 3
for 5 days times daily for 5 days
Duration: 3 days Duration: 8 days
Route: IV and oral. Route: IV and oral.
Leophonte 2002 114
Ceftriaxone 1 g 24 hourly, Ceftriaxone 1 g 24 hourly
followed by placebo Duration: 10 days
Duration: 5 days Route: IV 5 days, and IM 5 days.
Route: IV 5 days, and IM placebo
for 5 days.
Siegel 1999182
Cefuroxime 750 mg IV 8 hourly Cefuroxime 750 mg IV 8 hourly
for 2 days, followed by 500 mg bd for 2 days, followed by 500 mg bd
orally for 5 days, and placebo for 3 orally for 8 days
days Duration: 10 days
Duration: 7 days Route: IV 2 days, and orally 8
Route: IV 2 days, and orally 5 days.
days.

Summary of studies on the duration of antibiotic use for low-

severity community-acquired pneumonia managed in the
community

Study Intervention Comparison (N randomised)

(N randomised)
Wiesner 1993 204
Erythromycin 800 mg daily in 2
Macrolide compared with doses. Route of administration:
tetracycline oral Duration: 7 to 14 days. (N
only with CAP = 11).
Higuera 1996 92
Cefuroxime axetil 500 mg twice
Cephalosporin compared with daily
beta-lactamase stable penicillin Route of administration: oral
Duration: 10 days.
Bonvehi 2003 23
Clarithromycin 500 mg immediate-
Macrolide compared with beta- release twice daily.
lactamase stable penicillin Route of administration: oral.
Duration: 7 days.
Doxycycline 100 mg daily plus
identical placebo tablet
Route of administration: oral
Duration: 7 to 14 days. (N only
with CAP = 13).
Co-amoxiclav 500 mg/125 mg 3-
times daily
Route of administration: oral
Duration: 10 days.
Co-amoxiclav 875 mg/125 mg
twice daily
Route of administration: oral
Duration: 7 days or more

Lode 1995 124

Erythromycin 1,000 mg twice Co-amoxiclav 500/125 mg 3-times
Macrolide compared with beta- daily. daily.
lactamase stable penicillin Route of administration: oral. Route of administration: oral.
Duration: 7 to 14 days. Duration: 7 to 14 days.

Paris 2008156
Macrolide compared with beta-
lactamase stable penicillin
Azithromycin 1 g once daily. Co-amoxiclav 875/125 mg twice
Route of administration: oral daily.
Duration: 3 days. Route of administration: oral
Duration: 7 days
Carbon 1999 42
Respiratory fluoroquinolone
compared with beta-lactamase
stable penicillin
Nielsen 1993 146
Non-respiratory fluoroquinolone
compared with macrolide
Summary of studies included on the duration of antibiotic for low severity
community-acquired pneumonia managed in the in hospital and/or treated
with intravenous antibiotic
Study
Bohte 1995-pneumococcal 21
Azithromycin (macrolide)
compared with narrow-spectrum
beta-lactam (class 1)
Genne 1997 85
Macrolide compared with beta-
lactamase stable penicillin
Bohte 1995-non-pneumococcal
Azithromycin (macrolide)
compared with other macrolide
Harazim 1987 91
Non-respiratory fluoroquinolone
compared with tetracycline
Single compared with other single antibiotics for moderate-
to high-severity community-acquired pneumonia
Study
Nicolle 19961 45
Cephalosporin compared with
narrow-spectrum beta-lactam
Roson 2001169
Levofloxacin 500 mg once or twice
daily.
Route of administration: oral.
Duration: 7 to 10 days (mean 8.1
days).
Ofloxacin (400 mg once daily).
Route of administration: oral.
Duration: 7 days.
Intervention
(N randomised)
Azithromycin 500 mg twice on
first day and once daily for the next
4 days
Route of administration: oral
Duration: 5 days.
Clarithromycin lactobionate 500
mg twice daily IV for 3 to 5 days
followed by 500 mg orally twice
daily
Route of administration: IV then
oral
Duration: at least 10 days.
21
Azithromycin 500 mg twice on
first day and once daily for the next
4 days
Route of administration: oral
Duration: 5 days
Ofloxacin 200 or 400 mg twice
daily
Route of administration: oral
Duration: 10 days.
Intervention
Ceftriaxone 1 g IV daily, plus 2
daily infusions of saline. After 4
days an assessment was made to
determine whether to intensify,
maintain or modify to oral therapy
Route of administration: IV to
oral
Duration: 7 days or more (mean:
8.1 days).
Ceftriaxone IV 1 g every 24 hours
Co-amoxiclav 625 mg 3 times
daily.
Route of administration: oral.
Duration: 7 to 10 days (mean 8.1
days).
Erythromycin (500 mg twice
daily).
Route of administration: oral.
Duration: 7 days.
Comparison (N randomised)
Benzylpenicillin 1 x 106 IU 4 times
daily.
Route of administration: IV
Duration: until 5 days after body
temperature had normalised.
Co-amoxiclav 1.2 g IV 4 times
daily for 3 to 5 days followed by
625 mg orally 3-times daily
Route of administration: IV then
oral
Duration: at least 10 days.
Erythromycin 500 mg 4 times daily
Route of administration: oral
Duration: 10 days.
Doxycycline 100 mg twice daily
Route of administration: oral
Duration: 10 days.
Comparison
Ampicillin 1 g IV every 8 hours.
After 4 days an assessment was
made to determine whether to
intensify, maintain or modify to
oral therapy (could be switched to
oral amoxicillin if considered
appropriate)
Route of administration: IV to
oral
Duration: Mean 10.2 days.
Co-amoxiclav IV 2 g/200 mg every
Cephalosporin compared with
beta-lactamase stable penicillin
for at least 72 hour followed by IM
ceftriaxone 1 g every 24 hours
Route of administration: IV then
IM
Duration: Mean 10.1 days.
8 hours for at least 72 hours,
followed by oral co-amoxiclav 1
g/125 mg every 8 hours (after
significant clinical improvement
was achieved)
Route of administration: IV then
oral
Duration: Mean 10.9 days

Summary of studies included in the review of single- compared

with other single-antibiotic therapy for hospital-acquired
pneumonia
Study Intervention
(N randomised)
Hoffken 200794 Moxifloxacin 400 mg IV once
Respiratory fluoroquinolone daily followed by moxifloxacin
compared with cephalosporin 400 mg oral once daily
Route of administration: IV
then oral
Duration: 7 to 14 days.
Schmitt 2006174 Piperacillin-tazobactam 4 g/0.5
Beta-lactamase stable g IV q8h.
penicillin compared with Route of administration: IV
carbapenem Duration: 5 to 21 days.
(N = 110).
Comparison (N randomised)
Ceftriaxone 2 g IV once daily
followed by cefuroxime axetil
500 mg oral twice daily.
Route of administration: IV
then oral
Duration: 7 to 14 days.
Imipenem-cilastatin 1 g/1 g IV
q8h.
Route of administration: IV
Duration: 5 to 21 days.
(N = 111).

Consider a 5- to 10-day course of antibiotic therapy for patients with hospital-acquired

pneumonia

Summary of studies included in the review to

used corticosteroid

Component Comparison/interventions

Confalonieri 2005 54
Antibiotic (according to guidelines) plus
hydrocortisone compared with antibiotic (according to
guidelines) plus placebo.
Antibiotic: Initial choice followed ATS 1993
guidelines
Glucocorticosteroid: hydrocortisone IV as 200 mg
loading bolus followed by an infusion (hydrocortisone
240 mg in 500 cc 0.9% saline) at a rate of 10 mg/hour.
Total glucocorticosteroid duration 7 days.
Placebo: saline administered as for
glucocorticosteroid.
Fernandez-Serrano 2011 76
Cephalosporin plus fluoroquinolone plus
methylprednisolone compared with cephalosporin plus
fluoroquinolone plus to placebo.
Empirical antibiotics: 1 g/day IV ceftriaxone (9
days) and 500 mg/day levofloxacin (5 days then oral
for at least 20 days).
Glucocorticosteroid: Bolus of 200 mg
methylprednisolone 30 minutes before starting
 antibiotic followed by titrated IV dose of 20 mg every
6 hours for 3 days, then 20 mg per 12 hours for 3 days
then 20 mg/day for 3 days.
Placebo: administered as for glucocorticosteroid
Marik 1993 127
Antibiotic (according to guidelines) plus
hydrocortisone compared with antibiotic (according to
guidelines) plus placebo
 Antibiotics: All initially received ceftriaxone 1 g
IV every 6 hours. The first dose was given 30
minutes after study drug. Additional antibiotics
were added according to microbiological results -
amikacin, cloxacillin or erythromycin .
Glucocorticosteroid: Hydrocortisone was given as a
single 10 mg/kg bolus (low dose).
 Placebo: Saline solution administered as for
glucocorticosteroid.
McHardy 1972 129
Beta-lactam (1 g or 2 g) plus prednisolone compared
with beta-lactam (1 g or 2 g).
Antibiotics: Ampicillin 1 g or 2 g (in 4 divided doses)
– oral for at least 7 days plus an additional 7 days if
satisfactory response not achieved
Steroid: Prednisolone 20 mg daily (in 4 divided
doses) – oral for up to 7 days
Control: No placebo used
Meijvis 2011 131
Antibiotic (according to guidelines) plus
dexamethasone compared with antibiotic (according
to guidelines) plus placebo.
Antibiotics: choice, duration and administration were
at the discretion of the medical team and in accordance
with national guidelines. All patients received
antibiotic therapy within 4 hours of hospital admission
and treatment was modified based on outcome of
microbiological tests
Glucocorticosteroid: dexamethasone (5 mg)
intravenously once-daily for 4 days. Initial dose given
within a maximum of 12 hours of admission; all
received antibiotic therapy before the
glucocorticosteroid was given.
Placebo: administered as for glucocorticosteroid
Mikami 2007 139
Antibiotic (according to guidelines) plus prednisolone
compared with antibiotic (according to guidelines)
alone.
Antibiotics: IV within 8 hours of hospital arrival and
modified based on culture results. Selection and
duration of antibiotics was decided by the treating
physician.
Glucocorticosteroid: Prednisolone 40 mg in 100 ml
saline IV for 3 days
Control: no placebo.
Sabry 2011 172
Antibiotic (according to guidelines) plus
hydrocortisone compared with antibiotic (according to
guidelines) plus placebo.
Antibiotics: Maximal conventional therapy
Glucocorticosteroid: Hydrocortisone, loading dose of
200 mg over 30 minutes, followed by 300 mg in 500
ml 0.9% saline at a rate of 12.5 mg/h for 7 days.
Placebo: saline solution administered as for
glucocorticosteroid.