Emergency physicians will most often initiate empiric treatment for patients who have CAP. Four different specialty societies have developed guidelines for the treatment of adults with CAP: the American Thoracic Society (ATS), the British Thoracic Society, the Canadian Infectious Disease Society, and the Infectious Disease Society of America.2 ,26,2Z and 28 Slight differences exist between the guidelines, particularly regarding etiologic diagnosis and antimicrobial therapy. For emergency physicians, the ATS guidelines are most germane because they take into account the low risk of mortality in otherwise healthy patients under the age of 60, emphasize empiric antibiotic selection, and discourage ancillary testing which has little influence on patient management. All four guidelines recognize that although pneumococcal pneumonia is still the single most common cause of CAP, atypical agents are increasingly more common and empiric therapy should include antibiotics that are active against organisms that lack a cell wall (Table. ...5.9.-3.). Recommended agents include doxycycline, a macrolide, or one of the newer fluoroquinolones orally for 7 to 10 days for treatment of bacterial infection, although there is evidence that treatment for up to 21 days is helpful for atypical infections. Doxycycline is an excellent antibiotic because of its tolerance, bioavailability, low price, and easy compliance with twice-a-day dosing. Erythromycin is a very cost-effective agent for CAP, but is associated with GI side affects in about 25 percent of adult patients. Clarithromycin has fewer Gi side effects and the advantage of twice-a-day dosing. Azithromycin has the advantage of once-a-day dosing for only 5 days. Both clarithromycin and azithromycin are many times more expensive than erythromycin or doxycycline. The newer fluoroquinolone agents, including sparfloxacin, levofloxacin, and trofloxacin, have extended coverage that includes both common bacterial agents and atypical agents and the advantage of once-a-day dosing. Because of increasing S. pneumoniae resistance to doxycycline and the macrolides (approaching 30 percent in some areas), some societies are revising their recommendations to use a fluoroquinolone, such as levofloxacin, as the initial agent for empiric treratment of CAP.

The ATS guidelines recommend that patients over age 60 or those with concomitant disease should be treated with extended-spectrum antibiotics, such as a second-generation cephalosporin, a combination of penicillin plus b-lactamase inhibitor, or TMP-SMX. Although such agents are considered to have an "extended spectrum," they do not cover atypical agents. Clinical trials indicate that, even in older patients, the inclusion of an antibiotic that is active against atypical agents leads to lower mortality and morbidity rates. This suggests that emergency physicians should use a newer fluoroquinolone alone or a macrolide agent plus an "extended spectrum" cephalosporin or penicillin in older or compromised patients with CAP.

Emergency physicians play a prominent role in the initiation of treatment for patients being hospitalized with CAP. Recent evidence indicates that early administration of antibiotics, within the first 8 h of presentation, leads to a lower mortality rate and a shorter hospital stay. Although the yield is low, admitting physicians may benefit from the results of the sputum Gram stain, sputum culture, or blood culture obtained in the emergency department. For patients hospitalized with CAP, therapy should be initiated with a second- or third-generation cephalosporin or penicillin plus b-lactamase inhibitor, usually with a macrolide to provide coverage against Legionella or other atypical agents. Coverage can also be provided by a fluoroquinolone alone with the advantage that the newer quinolones such as levofloxacin achieve very high serum levels after oral administration, matching those achieved with intravenous administration. Patients with severe CAP should receive a macrolide plus an extended-spectrum antibiotic with antipseudomonal coverage (ceftazidime, cefoperazone, cefepime, imipenem, meropenem, levofloxacin, or trovafloxacin).

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