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■ Outpatient empiric therapy

■ Healthy adults: Macrolide (azithromycin or clarithromycin) or doxy-

cycline.

■ Adults with comorbidity (or recent antibiotic use): Antipneumococcal

fluoroquinolone orcombination of macrolide (azithromycin or clar-

ithromycin) + a β-lactam against S. pneumoniae(high-dose amoxicillin

or amoxicillin-clavulanate or cefpodoxime or cefuroxime).

■ Inpatient empiric therapy not admitted to the ICU

■ Ceftriaxone or cefotaxime IV + azithromycin or antipneumococcal

fluoroquinolone

■ Inpatient empiric therapy admitted to the ICU

■ Patients are more likely to have risk factors for resistant pathogens,

including community-associated MRSA and Legionellaspp, therefore

intravenous combination therapy with a potent antipneumococcal

β-lactam (ceftriaxone or cefotaxime) + either azithromycin or a respira-

tory fluoroquinolone (levofloxacin or moxifloxacin).

■ Special considerations

■ SuspectedPseudomonas: Add combination therapy with both an anti-

pseudomonalβ-lactam antibiotic andfluoroquinolone such as piperacillin-

tazobactam, imipenem, meropenem, cefepime, ceftazidime + ciprofloxacin,

or levofloxacin. For β-lactam allergic patients, options include: aztreonam +

levofloxacin or moxifloxacinplusan aminoglycoside.

■ SuspectedLegionellaspp: Add fluoroquinolone or azithromycin.

■ Suspected MRSA: Add vancomycin or linezolid.

■ Suspected aspiration pneumonia: Add piperacillin-tazobactam or

clindamycin.

Fungal Pneumonia

Fungal pneumonia occurs when disruption of contaminated soil results in

inhalation of fungal spores.

HISTOLASMOSIS

The fungus Histoplasma capsulatum is endemic in the moist soil of the Mis-

sissippi andOhio River valleys. It can be found in bat and bird droppings.

Severe or disseminated infection is more common in immunocompromised

patients.

THORACIC AND RESPIRATORY

DISORDERS

TABLE 10.11. Risk Stratification Based on PORT Score

MORTALITY AT

NUMBER OFPOINTS RISKCLASS 30 DAYS(%) RECOMMENDEDSITE OFCARE

Absence of predictors I 0.1–0.4 Outpatient

≤ 70 II 0.6–0.7 Outpatient

71–90 III 0.9–2.8 Outpatient or brief inpatient

91–130 IV 8.2–9.3 Inpatient

≥ 130 V 27.0–31.1 Inpatient

(Data from Fine MJ et al. “A prediction rule to identify low-risk patients with community-acquired

pneumonia.” NEJM. 1997(336):243.)