A 67-year-old woman with mild Alzheimer's disease who has a 2-day history of productive cough, fever, and increased confusion is transferred from a nursing home to the emergency department. According to the transfer records, she has had no recent hospitalizations or recent use of antibiotic agents. Her temperature is 38.4 degrees C (101 degrees F), the blood pressure is 145/85 mm Hg, the respiratory rate is 30 breaths per minute, the heart rate is 120 beats per minute, and the oxygen saturation is 91% while she is breathing ambient air. Crackles are heard in both lower lung fields. She is oriented to person only. The white-cell count is 4000 per cubic millimeter, the serum sodium level is 130 mmol per liter, and the blood urea nitrogen is 25 mg per deciliter (9.0 mmol per liter). A radiograph of the chest shows infiltrates in both lower lobes. How and where should this patient be treated? Community-Acquired Pneumonia Community-acquired pneumonia remains a leading cause of death in the United States and around the world. Although the diagnosis of community-acquired pneumonia is straightforward in most cases, underlying cardiopulmonary disease and atypical presentation in elderly persons can delay recognition. The majority of hospitalized patients with community-acquired pneumonia can be treated with either a respiratory fluoroquinolone or a combination of cephalosporin and a macrolide. Alternative antibiotic treatment should be based on the presence of multiple risk factors for health care-associated pneumonia, specific risks (e.g., structural lung disease), or uniquely characteristic syndromes (e.g., the toxin-mediated, community-acquired, methicillin-resistant Staphylococcus aureus syndrome). The current criteria for health care-associated pneumonia result in excessive use of broad-spectrum antibiotic agents. The presence of multiple pneumonia-specific alternative risk factors may allow focused diagnostic testing and treatment. Patients with three or more minor criteria for severe community-acquired pneumonia (e.g., elevated blood urea nitrogen, confusion, and a high respiratory rate) should receive extensive intervention in the emergency department and be considered for admission to the intensive care unit.
