Disposition

An estimated 75 percent of patients with CAP do not require hospitalization. In young adults, the pathogenic organism is frequently viral or atypical and associated with low morbidity and mortality rates. Many factors influence the prognosis and outcome of CAP.29 In general, physicians tend to overestimate the risk of pneumonia mortality. Fine and coworkers have developed a decision tree that can be used to estimate the risk of death from pneumonia and predict the need for hospitalization 30 (Table. . . 59-4, T.a.ble 5.9-5 and Iab!e...5.9:6.). With this decision rule, patients are assigned to one of five risk categories, with the lowest category having a mortality rate of around 0.1 percent. Although not a prominent part of this decision rule, patients who are immunocompromised as a result of AIDS or chronic alcohol use may require hospitalization. In addition, a chest radiograph that demonstrates bilateral effusions, bilateral infiltrates, moderately large pleural effusions, or extensive pulmonary involvement is associated with a higher risk of mortality. Patients should be considered for admission to an intensive care unit if they are markedly tachypneic or have high oxygen requirements, evidence of shock, or very extensive pulmonary involvement (more than 50 percent of the lung). For patients in risk category II, admission may be chosen based on the presence of relative hypoxemia, social factors, and the inability to complete a course of oral antibiotics.

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