Adapted from American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia. Am J Respir Crit Care Med 2001;163:1730–1754.
Group III. Inpatients who are not in the intensive care unit and have cardiopulmonary or modifying factors. Drugs for these patients include intravenous ﬂuoroquinolone monotherapy or a combination of an intravenous beta-lactam agent plus either intravenous or oral administration of an advanced macrolide or doxycycline. For the small group of inpatients who do not have cardiopulmonary diseases or modifying factors, intravenous azithromycin alone can be used. Alternatives include doxycycline plus a beta-lactam agent (if macrolide allergy or intolerance is present) or monotherapy with an antipneumococcal ﬂuoroquinolone.
Group IV. Inpatients in the intensive care unit. These patients usually have the most severe pneumonia, and all antibiotics are given intravenously. Immediate consultation with an internist, hospitalist, or infectious disease specialist is recommended.
Oxygen therapy and hydration should be initiated in addition to antibiotic therapy. Most patients will have an adequate clinical response within 3 days of treatment. Oral antibiotics may be given when patients meet the following criteria: ability to eat and drink, improvement in cough and dyspnea, afebrile (<100◦F) on two occasions 8 hours apart, and a decreasing white blood cell count. If other clinical features are favorable, patients may be switched to oral antibiotics even if febrile. They may be discharged on the same day that oral antibiotics are started if other medical and social factors are favorable.
Vaccination The pneumococcal vaccine should be given to people at high risk for pneumonia, which includes adults 65 years or older and people with special health problems, such as heart or lung disease, alcoholism, kidney failure, diabetes, HIV infection, or certain types of cancer. Repeat vaccination is recommended 5 years after the first dose is given. The vaccine is active against 23 types of pneumococcal strains, and most individuals develop protection within 2 to 3 weeks of inoculations.
The inﬂuenza vaccine should be given every fall to high-risk groups: individuals 50 years of age or older; anyone with serious long-term health problems such as heart disease, lung disease, kidney disease, diabetes, and weak immune systems as with HIV and AIDS;
Table 9.2 Major Risk Factors for Coronary Artery Disease
Family history of cardiovascular disease (men <55 y; women <65 y)
Adapted from Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). JAMA 2003;289:2560–2572.
individuals on long-term steroids or receiving cancer treatment; women who are pregnant during the ﬂu season (November through April); and anyone coming in close contact with people at risk of serious inﬂuenza like physicians, nurses, and family members. Vaccination is best given from October to mid-November. Antiviral agents should not be used as a substitute for vaccination but may be a useful adjunct. The four agents approved for use in the United States are amantadine, rimantadine, zanamivir, and oseltamivir. These drugs should be given within 2 days of the onset of symptoms to shorten the duration of uncomplicated illness caused by inﬂuenza (11–13).