Community-acquired pneumonia (non Covid-19)
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
outpatient
Outpatient treatment is recommended in patients with Pneumonia Severity Index (PSI) risk class I or II with a PSI score ≤70 (low risk), or a CURB-65 score of 0-1 (low severity).[87]Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50. http://www.nejm.org/doi/full/10.1056/NEJM199701233360402#t=article http://www.ncbi.nlm.nih.gov/pubmed/8995086?tool=bestpractice.com [88]Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May;58(5):377-82. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746657 http://www.ncbi.nlm.nih.gov/pubmed/12728155?tool=bestpractice.com PSI is preferred over CURB-65.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [90]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com
Empiric oral antibiotics are recommended: amoxicillin, doxycycline, or a macrolide (e.g., azithromycin or clarithromycin). Only use a macrolide in areas with pneumococcal resistance to macrolides <25% and when there are contraindications to alternative therapies.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Treat for a minimum of 5 days. Duration of treatment should be guided by a validated measure of clinical stability (e.g., resolution of vital sign abnormalities, normal cognitive function, ability to eat).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [116]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com [117]Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Ann Intern Med. 2021 Jun;174(6):822-7. https://www.doi.org/10.7326/M20-7355 http://www.ncbi.nlm.nih.gov/pubmed/33819054?tool=bestpractice.com Consider discontinuing treatment when the patient has been afebrile for 48-72 hours and there are no signs of complications (endocarditis, meningitis).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [116]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Reassess patients at 48 hours. Symptoms should improve within this time with appropriate treatment. Consider hospital admission in patients who fail to improve within 48 hours.
Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.
Primary options
amoxicillin: 1000 mg orally three times daily
OR
doxycycline: 100 mg orally twice daily
Secondary options
azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily thereafter
OR
clarithromycin: 500 mg orally (immediate-release) twice daily; 1000 mg orally (extended-release) once daily
Treatment recommended for ALL patients in selected patient group
Advise patients not to smoke, to rest, and to stay well hydrated.
Treatment recommended for SOME patients in selected patient group
Consider antiviral therapy (e.g., oseltamivir) in outpatients who test positive for influenza virus.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
Outpatient treatment is recommended in patients with Pneumonia Severity Index (PSI) risk class I or II with a PSI score ≤70 (low risk), or a CURB-65 score of 0-1 (low severity).[87]Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50. http://www.nejm.org/doi/full/10.1056/NEJM199701233360402#t=article http://www.ncbi.nlm.nih.gov/pubmed/8995086?tool=bestpractice.com [88]Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May;58(5):377-82. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746657 http://www.ncbi.nlm.nih.gov/pubmed/12728155?tool=bestpractice.com PSI is preferred over CURB-65.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [90]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com
Comorbidities include: chronic heart, lung, liver, or renal disease; diabetes mellitus; alcohol abuse; malignancy; asplenia. Broader-spectrum antibiotic regimens are required in these patients as many will have risk factors for drug-resistant pathogens (e.g., recent hospitalization and administration of parenteral antibiotics in the past 90 days), and they are more vulnerable to poor outcomes if the empiric regimen is inadequate.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Empiric oral antibiotics are recommended: combination therapy with amoxicillin/clavulanate or a cephalosporin (e.g., cefpodoxime, cefuroxime) plus a macrolide or doxycycline; or monotherapy with a respiratory fluoroquinolone (e.g., levofloxacin, moxifloxacin). These regimens should effectively cover drug-resistant pathogens.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider safety issues before prescribing fluoroquinolones. The Food and Drug Administration (FDA) has warned about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects.[112]Food and Drug Administration. FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes. Jul 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-reinforces-safety-information-about-serious-low-blood-sugar-levels-and-mental-health-side [113]Food and Drug Administration. FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients. Dec 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics The European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with fluoroquinolones in 2018. These adverse effects included tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[114]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. Mar 2019 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products Despite these concerns, American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines still recommend fluoroquinolones as an option in patients with low-severity CAP who have comorbidities and are managed in the outpatient setting.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Treat for a minimum of 5 days. Duration of treatment should be guided by a validated measure of clinical stability (e.g., resolution of vital sign abnormalities, normal cognitive function, ability to eat).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [116]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com [117]Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Ann Intern Med. 2021 Jun;174(6):822-7. https://www.doi.org/10.7326/M20-7355 http://www.ncbi.nlm.nih.gov/pubmed/33819054?tool=bestpractice.com Consider discontinuing treatment when the patient has been afebrile for 48-72 hours and there are no signs of complications (endocarditis, meningitis).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [116]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Reassess patients at 48 hours. Symptoms should improve within this time with appropriate treatment. Consider hospital admission in patients who fail to improve within 48 hours.
Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.
Primary options
amoxicillin/clavulanate: 500 mg orally (immediate-release) three times daily; 875 mg orally (immediate-release) twice daily; 2000 mg orally (extended-release) twice daily
More amoxicillin/clavulanateDose refers to amoxicillin component.
or
cefpodoxime proxetil: 200 mg orally twice daily
or
cefuroxime axetil: 500 mg orally twice daily
-- AND --
azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily thereafter
or
clarithromycin: 500 mg orally (immediate-release) twice daily; 1000 mg orally (extended-release) once daily
or
doxycycline: 100 mg orally twice daily
OR
levofloxacin: 750 mg orally once daily
OR
moxifloxacin: 400 mg orally once daily
Treatment recommended for ALL patients in selected patient group
Advise patients not to smoke, to rest, and to stay well hydrated.
Treatment recommended for SOME patients in selected patient group
Consider antiviral therapy (e.g., oseltamivir) in outpatients who test positive for influenza virus.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
inpatient
Hospital admission is recommended in patients with a Pneumonia Severity Index (PSI) risk class III (these patients may benefit from a brief period of hospitalization), PSI risk class IV or V, or a CURB-65 score of 3.[87]Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50. http://www.nejm.org/doi/full/10.1056/NEJM199701233360402#t=article http://www.ncbi.nlm.nih.gov/pubmed/8995086?tool=bestpractice.com [88]Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May;58(5):377-82. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746657 http://www.ncbi.nlm.nih.gov/pubmed/12728155?tool=bestpractice.com PSI is preferred over CURB-65.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [90]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com
Empiric intravenous antibiotics are recommended: combination therapy with a beta-lactam (e.g., ampicillin/sulbactam, cefotaxime, ceftriaxone, ceftaroline) plus a macrolide (e.g., azithromycin, clarithromycin); or monotherapy with a respiratory fluoroquinolone (e.g., levofloxacin, moxifloxacin). Consider combination therapy with a beta-lactam plus doxycycline in patients who have contraindications to both macrolides and fluoroquinolones. Note that clarithromycin is only available as an oral formulation in the US, and so can only be used if the oral route is feasible.
Consider safety issues before prescribing fluoroquinolones. The Food and Drug Administration (FDA) has warned about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects.[112]Food and Drug Administration. FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes. Jul 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-reinforces-safety-information-about-serious-low-blood-sugar-levels-and-mental-health-side [113]Food and Drug Administration. FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients. Dec 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics The European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with fluoroquinolones in 2018. These adverse effects included tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[114]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. Mar 2019 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products
Treat for a minimum of 5 days. Duration of treatment should be guided by a validated measure of clinical stability (e.g., resolution of vital sign abnormalities, normal cognitive function, ability to eat).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [116]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com [117]Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Ann Intern Med. 2021 Jun;174(6):822-7. https://www.doi.org/10.7326/M20-7355 http://www.ncbi.nlm.nih.gov/pubmed/33819054?tool=bestpractice.com Consider discontinuing treatment when the patient has been afebrile for 48-72 hours and there are no signs of complications (endocarditis, meningitis).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [116]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Evaluate whether the patient can be switched to oral therapy on a daily basis; the switch should be made as soon as possible. Switch to an oral formulation of the same drug or an oral formulation of a drug within the same drug class.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.
Primary options
ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours
More ampicillin/sulbactamDose consists of 1 g of ampicillin plus 0.5 g sulbactam (1.5 g) or 2 g of ampicillin plus 1 g sulbactam (3 g).
or
cefotaxime: 1-2 g intravenously every 8 hours
or
ceftriaxone: 1-2 g intravenously every 24 hours
or
ceftaroline fosamil: 600 mg intravenously every 12 hours
-- AND --
azithromycin: 500 mg intravenously every 24 hours
or
clarithromycin: 500 mg orally (immediate-release) twice daily
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
moxifloxacin: 400 mg intravenously every 24 hours
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for methicillin-resistant Staphylococcus aureus (MRSA) if locally validated risk factors are present.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
If the patient has a prior history of respiratory isolation of MRSA: add vancomycin or linezolid and obtain cultures (or nasal polymerase chain reaction [PCR] if available) to guide de-escalation or to confirm the need to continue additional cover.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
If the patient has had a recent hospitalization and parenteral antibiotics in the past 90 days, and has been locally validated for risk factors for MRSA: obtain cultures and nasal PCR. If PCR or cultures are negative, withhold additional cover. If PCR or cultures are positive, start additional cover.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course of 7 days is recommended in patients with MRSA.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours; adjust dose based on serum vancomycin levels
OR
linezolid: 600 mg intravenously every 12 hours
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for Pseudomonas aeruginosa if locally validated risk factors are present.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
If the patient has a prior history of respiratory isolation of P aeruginosa: add piperacillin/tazobactam, cefepime, ceftazidime, aztreonam, meropenem, or imipenem/cilastatin, and obtain cultures to guide de-escalation or to confirm the need to continue additional cover.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
If the patient has had a recent hospitalization and parenteral antibiotics in the past 90 days, and has been locally validated for risk factors for P aeruginosa: obtain cultures but only initiate cover for P aeruginosa if cultures are positive.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course of 7 days is recommended in patients with P aeruginosa.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Take the initial empiric regimen into account adding Pseudomonas cover so that two antibiotics from the same class are not used together.
Primary options
piperacillin/tazobactam: 4.5 g intravenously every 6 hours
More piperacillin/tazobactamDose consists of 4 g of piperacillin plus 0.5 g tazobactam.
OR
cefepime: 2 g intravenously every 8 hours
OR
ceftazidime sodium: 2 g intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component.
OR
meropenem: 1 g intravenously every 8 hours
OR
aztreonam: 2 g intravenously every 8 hours
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for extended-spectrum beta-lactamase-producing Enterobacteriaceae. Consult an infectious disease specialist for guidance on an appropriate antibiotic regimen.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course is recommended in patients in cases of pneumonia due to less common pathogens.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Treatment recommended for SOME patients in selected patient group
Add antiviral treatment (e.g., oseltamivir) to antimicrobial treatment in patients with CAP who test positive for influenza in the inpatient setting, independent of duration of illness before diagnosis.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary. Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO₂ above 92%. High concentrations of oxygen can safely be given in uncomplicated pneumonia.
[ 
]
What are the effects of noninvasive positive pressure ventilation with supplemental oxygen, when compared with Venturi mask oxygen delivery, in adults with pneumonia?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.73/fullShow me the answer Patients with respiratory failure, despite appropriate oxygen therapy, require urgent airway management and possible intubation. Treatment of patients with COPD complicated by ventilatory failure oxygen therapy should be guided by repeated arterial blood gas measurements.[106]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017;4(1):e000170.
https://www.doi.org/10.1136/bmjresp-2016-000170
http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com
Assess patients for volume depletion. Administer intravenous fluids if needed according to local protocols, and give nutritional support in prolonged illness.
Monitor temperature, respiratory rate, pulse, blood pressure, and mental status at least twice daily and more frequently in those with severe pneumonia or requiring regular oxygen therapy. Monitor C-reactive protein (CRP) levels regularly as they are a sensitive marker of progress in pneumonia. Repeat chest x-rays in patients who are not progressing satisfactorily. Routine follow-up chest imaging is not recommended if symptoms resolve within 5-7 days.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Admit patients with hypotension requiring vasopressor therapy or respiratory failure requiring mechanical ventilation to the intensive care unit (ICU). In patients who do not require vasopressor therapy or mechanical ventilation, use the American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) criteria for defining severe CAP (see Diagnostic criteria section) and clinical judgment to guide the need for higher levels of treatment intensity.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [90]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com Admit patients with severe CAP (defined as one major criterion or three or more minor criteria) to the ICU.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Start antibiotic therapy promptly as a delay in administration has been associated with an increased risk in mortality.[115]Garnacho-Montero J, Barrero-García I, Gómez-Prieto MG, et al. Severe community-acquired pneumonia: current management and future therapeutic alternatives. Expert Rev Anti Infect Ther. 2018 Sep;16(9):667-77. http://www.ncbi.nlm.nih.gov/pubmed/30118377?tool=bestpractice.com
Empiric intravenous antibiotics are recommended: combination therapy with a beta-lactam (e.g., ampicillin/sulbactam, cefotaxime, ceftriaxone, ceftaroline) plus a macrolide (e.g., azithromycin, clarithromycin); or combination therapy with a beta-lactam plus a respiratory fluoroquinolone (e.g., levofloxacin, moxifloxacin). There is stronger evidence for beta-lactam plus macrolide combination.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com Although ATS/IDSA recommend clarithromycin in these patients, it is only available as an oral formulation in the US so is unlikely to be useful in this setting.
Consider safety issues before prescribing fluoroquinolones. The Food and Drug Administration (FDA) has warned about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects.[112]Food and Drug Administration. FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes. Jul 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-reinforces-safety-information-about-serious-low-blood-sugar-levels-and-mental-health-side [113]Food and Drug Administration. FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients. Dec 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics The European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with fluoroquinolones in 2018. These adverse effects included tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[114]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. Mar 2019 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products
Treat for a minimum of 5 days. Duration of treatment should be guided by a validated measure of clinical stability (e.g., resolution of vital sign abnormalities, normal cognitive function, ability to eat).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [116]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com [117]Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Ann Intern Med. 2021 Jun;174(6):822-7. https://www.doi.org/10.7326/M20-7355 http://www.ncbi.nlm.nih.gov/pubmed/33819054?tool=bestpractice.com Consider discontinuing treatment when the patient has been afebrile for 48-72 hours and there are no signs of complications (endocarditis, meningitis).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [116]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Evaluate whether the patient can be switched to oral therapy on a daily basis; the switch should be made as soon as possible. Switch to an oral formulation of the same drug or an oral formulation of a drug within the same drug class.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.
Primary options
ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours
More ampicillin/sulbactamDose consists of 1 g of ampicillin plus 0.5 g sulbactam (1.5 g) or 2 g of ampicillin plus 1 g sulbactam (3 g).
or
cefotaxime: 1-2 g intravenously every 8 hours
or
ceftriaxone: 1-2 g intravenously every 24 hours
or
ceftaroline fosamil: 600 mg intravenously every 12 hours
-- AND --
azithromycin: 500 mg intravenously every 24 hours
Secondary options
ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours
More ampicillin/sulbactamDose consists of 1 g of ampicillin plus 0.5 g sulbactam (1.5 g) or 2 g of ampicillin plus 1 g sulbactam (3 g).
or
cefotaxime: 1-2 g intravenously every 8 hours
or
ceftriaxone: 1-2 g intravenously every 24 hours
or
ceftaroline fosamil: 600 mg intravenously every 12 hours
-- AND --
levofloxacin: 750 mg intravenously every 24 hours
or
moxifloxacin: 400 mg intravenously every 24 hours
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for methicillin-resistant Staphylococcus aureus (MRSA) if locally validated risk factors are present.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Add appropriate additional antibiotic cover and obtain cultures (or nasal polymerase chain reaction if available) to guide de-escalation of therapy or confirm the need to continue therapy.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course of 7 days is recommended in patients with MRSA.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours; adjust dose based on serum vancomycin levels
OR
linezolid: 600 mg intravenously every 12 hours
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for Pseudomonas aeruginosa if locally validated risk factors are present.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Add appropriate additional antibiotic cover and obtain cultures to guide de-escalation of therapy or confirm the need to continue therapy.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course of 7 days is recommended in patients with P aeruginosa.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Take the initial empiric regimen into account adding Pseudomonas cover so that two antibiotics from the same class are not used together.
Primary options
piperacillin/tazobactam: 4.5 g intravenously every 6 hours
More piperacillin/tazobactamDose consists of 4 g of piperacillin plus 0.5 g tazobactam.
OR
cefepime: 2 g intravenously every 8 hours
OR
ceftazidime sodium: 2 g intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component.
OR
meropenem: 1 g intravenously every 8 hours
OR
aztreonam: 2 g intravenously every 8 hours
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for extended-spectrum beta-lactamase-producing Enterobacteriaceae. Consult an infectious disease specialist for guidance on an appropriate antibiotic regimen.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course is recommended in patients in cases of pneumonia due to less common pathogens.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Treatment recommended for SOME patients in selected patient group
Add antiviral treatment (e.g., oseltamivir) to antimicrobial treatment in patients with CAP who test positive for influenza in the inpatient setting, independent of duration of illness before diagnosis.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
Treatment recommended for SOME patients in selected patient group
The use of corticosteroids in patients with severe CAP has been a long-debated issue.
Current American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines generally recommend against the use of corticosteroids in patients with nonsevere or severe CAP, although acknowledge that they may be considered in patients with refractory septic shock according to Surviving Sepsis Campaign guidelines, and can be used as clinically appropriate for comorbid conditions (e.g., COPD, asthma, autoimmune diseases). This recommendation is based on the fact that there are no data suggesting benefit in patients with nonsevere CAP with respect to mortality or organ failure, and only limited data to support their use in patients with severe CAP.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary. Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO₂ above 92%. High concentrations of oxygen can safely be given in uncomplicated pneumonia.
[ ]
What are the effects of noninvasive positive pressure ventilation with supplemental oxygen, when compared with Venturi mask oxygen delivery, in adults with pneumonia?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.73/fullShow me the answer Patients with respiratory failure, despite appropriate oxygen therapy, require urgent airway management and possible intubation. Treatment of patients with COPD complicated by ventilatory failure oxygen therapy should be guided by repeated arterial blood gas measurements.[106]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017;4(1):e000170.
https://www.doi.org/10.1136/bmjresp-2016-000170
http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com
Assess patients for volume depletion. Administer intravenous fluids if needed according to local protocols, and give nutritional support in prolonged illness.
Monitor temperature, respiratory rate, pulse, blood pressure, and mental status at least twice daily and more frequently in those with severe pneumonia or requiring regular oxygen therapy. Monitor C-reactive protein (CRP) levels regularly as they are a sensitive marker of progress in pneumonia. Repeat chest x-rays in patients who are not progressing satisfactorily. Routine follow-up chest imaging is not recommended if symptoms resolve within 5-7 days.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
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