During the pandemic, consider all patients with cough and fever or suggestive symptoms to have COVID-19 until proven otherwise. See our topic Coronavirus disease 2019 (COVID-19).
Initial treatment for any patient with pneumonia is guided by the severity of the disease and presence of comorbidities, prior hospitalizations, and resistant bacteria in the community.[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
Patients should be assessed for hydration status, adequacy of gas exchange, and hemodynamic stability. Oxygen and ventilation should be started immediately if needed.
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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
Antibiotic therapy
Atypical bacterial pneumonia pathogens generally do not respond to beta-lactam antibiotics and require treatment with a macrolide, tetracycline, or fluoroquinolone. The current pneumonia treatment guidelines recommend considering empiric use of a macrolide or doxycycline for uncomplicated community-acquired pneumonia to ensure coverage of atypical organisms.[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
[39]Lim WS, Baudouin SV, George RC, et al; Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009 Oct;64 Suppl 3:iii1-55.
https://thorax.bmj.com/content/64/Suppl_3/iii1.long
http://www.ncbi.nlm.nih.gov/pubmed/19783532?tool=bestpractice.com
[43]Eliakim-Raz N, Robenshtok E, Shefet D, et al. Empiric antibiotic coverage of atypical pathogens for community-acquired pneumonia in hospitalized adults. Cochrane Database Syst Rev. 2012 Sep 12;2012(9):CD004418.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004418.pub4/full
http://www.ncbi.nlm.nih.gov/pubmed/22972070?tool=bestpractice.com
[44]Sligl WI, Asadi L, Eurich DT, et al. Macrolides and mortality in critically ill patients with community-acquired pneumonia: a systematic review and meta-analysis. Crit Care Med. 2014 Feb;42(2):420-32.
http://www.ncbi.nlm.nih.gov/pubmed/24158175?tool=bestpractice.com
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In hospitalized adults with community-acquired pneumonia, is there randomized controlled trial evidence to support the use of empiric atypical antibiotic coverage over typical antibiotic coverage?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.306/fullShow me the answer Coverage of atypical organisms is also recommended in more severe disease and patients with comorbidities.[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
[39]Lim WS, Baudouin SV, George RC, et al; Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009 Oct;64 Suppl 3:iii1-55.
https://thorax.bmj.com/content/64/Suppl_3/iii1.long
http://www.ncbi.nlm.nih.gov/pubmed/19783532?tool=bestpractice.com
[45]König R, Cao X, Oswald M, et al. Macrolide combination therapy for hospitalised CAP patients? An individualised approach supported by machine learning. Eur Respir J. 2019 Dec 12;54(6):1900824.
http://www.ncbi.nlm.nih.gov/pubmed/31537702?tool=bestpractice.com
The recommendation to cover atypical pathogens in the empiric antibiotic regimen is debated;[46]Postma DF, van Werkhoven CH, Oosterheert JJ. Community-acquired pneumonia requiring hospitalization: rational decision making and interpretation of guidelines. Curr Opin Pulm Med. 2017 May;23(3):204-10.
http://www.ncbi.nlm.nih.gov/pubmed/28198726?tool=bestpractice.com
[47]Naucler P, Strålin K. Routine atypical antibiotic coverage is not necessary in hospitalised patients with non-severe community-acquired pneumonia. Int J Antimicrob Agents. 2016 Aug;48(2):224-5.
http://www.ncbi.nlm.nih.gov/pubmed/27374746?tool=bestpractice.com
[48]File TM Jr, Marrie TJ. Does empiric therapy for atypical pathogens improve outcomes for patients with CAP? Infect Dis Clin North Am. 2013 Mar;27(1):99-114.
http://www.ncbi.nlm.nih.gov/pubmed/23398868?tool=bestpractice.com
however, the recommendation is supported by current data.[49]File TM Jr, Eckburg PB, Talbot GH, et al. Macrolide therapy for community-acquired pneumonia due to atypical pathogens: outcome assessment at an early time point. Int J Antimicrob Agents. 2017 Aug;50(2):247-51.
http://www.ncbi.nlm.nih.gov/pubmed/28599867?tool=bestpractice.com
[50]Eljaaly K, Alshehri S, Aljabri A, et al. Clinical failure with and without empiric atypical bacteria coverage in hospitalized adults with community-acquired pneumonia: a systematic review and meta-analysis. BMC Infect Dis. 2017 Jun 2;17(1):385.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5457549/
http://www.ncbi.nlm.nih.gov/pubmed/28576117?tool=bestpractice.com
Tetracyclines and fluoroquinolones are generally not recommended in children or pregnant women; however, their use may be considered in these patients when the benefits of using these drugs outweigh the risks, and there are no other suitable treatment options available, especially in cases of macrolide resistance.
When a specific etiology for the pneumonia is found using a reliable method, antimicrobial therapy should be directed at that pathogen.[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
However, in the last few years an increasing frequency (up to 80%) of macrolide-resistant Mycoplasma pneumoniae cases have been reported in Asia,[51]Liu Y, Ye X, Zhang H, et al. Antimicrobial susceptibility of Mycoplasma pneumoniae isolates and molecular analysis of macrolide-resistant strains from Shanghai, China. Antimicrob Agents Chemother. 2009 May;53(5):2160-2.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2681541/
http://www.ncbi.nlm.nih.gov/pubmed/19273684?tool=bestpractice.com
whereas rates are lower in the Middle East (30%),[52]Averbuch D, Hidalgo-Grass C, Moses AE, et al. Macrolide resistance in Mycoplasma pneumoniae, Israel, 2010. Emerg Infect Dis. 2011 Jun; 17(6):1079-82.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3358208/
http://www.ncbi.nlm.nih.gov/pubmed/21749775?tool=bestpractice.com
Europe (10%),[53]Peuchant O, Ménard A, Renaudin H, et al. Increased macrolide resistance of Mycoplasma pneumoniae in France directly detected in clinical specimens by real-time PCR and melting curve analysis. J Antimicrob Chemother. 2009 Jul;64(1):52-8.
https://academic.oup.com/jac/article/64/1/52/758196
http://www.ncbi.nlm.nih.gov/pubmed/19429926?tool=bestpractice.com
[54]Spuesens EB, Meijer A, Bierschenk D, et al. Macrolide resistance determination and molecular typing of Mycoplasma pneumoniae in respiratory specimens collected between 1997 and 2008 in the Netherlands. J Clin Microbiol. 2012 Jun;50(6):1999-2004.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3372106/
http://www.ncbi.nlm.nih.gov/pubmed/22495561?tool=bestpractice.com
[55]Uldum SA, Bangsborg JM, Gahrn-Hansen B, et al. Epidemic of Mycoplasma pneumoniae infection in Denmark, 2010 and 2011. Euro Surveill. 2012 Feb 2;17(5):20073.
https://www.eurosurveillance.org/content/10.2807/ese.17.05.20073-en#html_fulltext
http://www.ncbi.nlm.nih.gov/pubmed/22321137?tool=bestpractice.com
and the US (10%).[56]Wolff BJ, Thacker WL, Schwartz SB, et al. Detection of macrolide resistance in Mycoplasma pneumoniae by real-time PCR and high-resolution melt analysis. Antimicrob Agents Chemother. 2008 Oct;52(10):3542-9.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565909/
http://www.ncbi.nlm.nih.gov/pubmed/18644962?tool=bestpractice.com
This is likely due to overuse of macrolides for the treatment of community-acquired pneumonia. Tetracyclines and fluoroquinolones are highly effective for macrolide-resistant strains of M pneumoniae.[57]Cao B, Qu JX, Yin YD, et al. Overview of antimicrobial options for Mycoplasma pneumoniae pneumonia: focus on macrolide resistance. Clin Respir J. 2017 Jul;11(4):419-29.
https://www.doi.org/10.1111/crj.12379
http://www.ncbi.nlm.nih.gov/pubmed/26365811?tool=bestpractice.com
[58]Waites KB, Xiao L, Liu Y, et al. Mycoplasma pneumoniae from the respiratory tract and beyond. Clin Microbiol Rev. 2017 Jul;30(3):747-809.
https://www.doi.org/10.1128/CMR.00114-16
http://www.ncbi.nlm.nih.gov/pubmed/28539503?tool=bestpractice.com
When Legionella pneumophila is diagnosed, either macrolides or fluoroquinolones should be used without preference to any of the agents.[59]Gershengorn HB, Keene A, Dzierba AL, et al. The association of antibiotic treatment regimen and hospital mortality in patients hospitalized with Legionella pneumonia. Clin Infect Dis. 2015 Jun 1;60(11):e66-79.
https://academic.oup.com/cid/article/60/11/e66/356290
http://www.ncbi.nlm.nih.gov/pubmed/25722195?tool=bestpractice.com
The use of procalcitonin (a biomarker) to guide initiation and duration of antibiotic treatment has been found to result in a lower risk of mortality, lower antibiotic consumption, and lower risk of side effects in patients with acute respiratory infections.[60]Schuetz P, Wirz Y, Sager R, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. 2017 Oct 12;10(10):CD007498.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007498.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/29025194?tool=bestpractice.com
[61]Schuetz P, Wirz Y, Sager R, et al. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. Lancet Infect Dis. 2018 Jan;18(1):95-107.
https://www.doi.org/10.1016/S1473-3099(17)30592-3
http://www.ncbi.nlm.nih.gov/pubmed/29037960?tool=bestpractice.com
However, one review found no difference in short-term mortality in critically ill patients specifically, while another study found that procalcitonin-guided therapy did not result in decreased use of antibiotics in patients with suspected lower respiratory tract infection.[62]Lam SW, Bauer SR, Fowler R, et al. Systematic review and meta-analysis of procalcitonin-guidance versus usual care for antimicrobial management in critically ill patients: focus on subgroups based on antibiotic initiation, cessation, or mixed strategies. Crit Care Med. 2018 May;46(5):684-90.
http://www.ncbi.nlm.nih.gov/pubmed/29293146?tool=bestpractice.com
[63]Huang DT, Yealy DM, Filbin MR, et al. Procalcitonin-guided use of antibiotics for lower respiratory tract infection. N Engl J Med. 2018 Jul 19;379(3):236-49.
https://www.doi.org/10.1056/NEJMoa1802670
http://www.ncbi.nlm.nih.gov/pubmed/29781385?tool=bestpractice.com
Outpatient care or hospitalization
Scoring the severity of illness can help to determine whether the patient can be treated as an outpatient or requires hospitalization or intensive care. It is most commonly determined using the Pneumonia Severity Index (PSI).[64]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.
https://www.nejm.org/doi/full/10.1056/NEJM199701233360402
http://www.ncbi.nlm.nih.gov/pubmed/8995086?tool=bestpractice.com
[
Community-acquired pneumonia severity index (PSI) for adults
] The PSI, also referred to as the Pneumonia Patient Outcomes Research Team Model, has been repurposed as an online tool. Twenty factors are assessed, including age, respiratory rate, pulse, blood pressure, and temperature, and total points are added together. CURB-65 is another severity scoring system developed by the British Thoracic Society.[39]Lim WS, Baudouin SV, George RC, et al; Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009 Oct;64 Suppl 3:iii1-55.
https://thorax.bmj.com/content/64/Suppl_3/iii1.long
http://www.ncbi.nlm.nih.gov/pubmed/19783532?tool=bestpractice.com
[
CURB-65 pneumonia severity score
]
New scoring systems might have some advantage on the PSI and the CURB-65, in identifying patients who need intensive care and hospital admission.[65]Yandiola PP, Capelastegui A, Quintana J, et al. Prospective comparison of severity scores for predicting clinically relevant outcomes for patients hospitalized with community-acquired pneumonia. Chest. 2009 Jun;135(6):1572-9.
https://journal.chestnet.org/article/S0012-3692(09)60363-9/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/19141524?tool=bestpractice.com
[66]España PP, Capelastegui A, Gorordo I, et al. Development and validation of a clinical prediction rule for severe community-acquired pneumonia. Am J Respir Crit Care Med. 2006 Dec 1;174(11):1249-56.
http://www.ncbi.nlm.nih.gov/pubmed/16973986?tool=bestpractice.com
[67]Charles PG, Wolfe R, Whitby M, et al; Australian Community-Acquired Pneumonia Study Collaboration. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis. 2008 Aug 1;47(3):375-84.
https://academic.oup.com/cid/article/47/3/375/315583
http://www.ncbi.nlm.nih.gov/pubmed/18558884?tool=bestpractice.com
[68]Ewig S, Woodhead M, Torres A. Towards a sensible comprehension of severe community-acquired pneumonia. Intensive Care Med. 2011 Feb;37(2):214-23.
http://www.ncbi.nlm.nih.gov/pubmed/21080155?tool=bestpractice.com
Two studies suggest that saturation below 92% is associated with adverse effects and more severe disease, thus requiring admission.[67]Charles PG, Wolfe R, Whitby M, et al; Australian Community-Acquired Pneumonia Study Collaboration. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis. 2008 Aug 1;47(3):375-84.
https://academic.oup.com/cid/article/47/3/375/315583
http://www.ncbi.nlm.nih.gov/pubmed/18558884?tool=bestpractice.com
[69]Majumdar SR, Eurich DT, Gamble JM, et al. Oxygen saturations less than 92% are associated with major adverse events in outpatients with pneumonia: a population-based cohort study. Clin Infect Dis. 2011 Feb 1;52(3):325-31.
https://academic.oup.com/cid/article/52/3/325/305087
http://www.ncbi.nlm.nih.gov/pubmed/21217179?tool=bestpractice.com
Role of corticosteroids
The use of corticosteroids in patients with severe community-acquired pneumonia has been a long-debated issue. Current guidelines generally recommend against the use of corticosteroids in patients with nonsevere or severe community-acquired pneumonia; although; Surviving Sepsis Campaign guidelines acknowledge that they may be considered in patients with refractory septic shock 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 community-acquired pneumonia with respect to mortality or organ failure, and only limited data to support their use in patients with severe community-acquired pneumonia.[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
Meta-analyses of studies of hospitalized adults with community-acquired pneumonia found that the use of corticosteroids was associated with reduced need for mechanical ventilation, reduced hospital stay, lower clinical failure rates, fewer complications (including septic shock), decreased C-reactive protein (CRP) levels, and reduced all-cause mortality. However, it appears that the reduction in mortality applies only to patients with severe community-acquired pneumonia. In patients with nonsevere disease, adjunctive corticosteroids reduce morbidity, but not mortality.[70]Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med. 2015 Oct 6;163(7):519-28.
http://www.ncbi.nlm.nih.gov/pubmed/26258555?tool=bestpractice.com
[71]Bi J, Yang J, Wang Y, et al. Efficacy and safety of adjunctive corticosteroids therapy for severe community-acquired pneumonia in adults: an updated systematic review and meta-analysis. PLoS One. 2016;11(11):e0165942.
https://www.doi.org/10.1371/journal.pone.0165942
http://www.ncbi.nlm.nih.gov/pubmed/27846240?tool=bestpractice.com
[72]Briel M, Spoorenberg SMC, Snijders D, et al. Corticosteroids in patients hospitalized with community-acquired pneumonia: systematic review and individual patient data meta-analysis. Clin Infect Dis. 2018 Jan 18;66(3):346-54.
http://www.ncbi.nlm.nih.gov/pubmed/29020323?tool=bestpractice.com
[73]Stern A, Skalsky K, Avni T, et al. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2017 Dec 13;(12):CD007720.
https://www.doi.org/10.1002/14651858.CD007720.pub3
http://www.ncbi.nlm.nih.gov/pubmed/29236286?tool=bestpractice.com
[74]Wu WF, Fang Q, He GJ. Efficacy of corticosteroid treatment for severe community-acquired pneumonia: A meta-analysis. Am J Emerg Med. 2018 Feb;36(2):179-84.
http://www.ncbi.nlm.nih.gov/pubmed/28756034?tool=bestpractice.com
[75]Huang J, Guo J, Li H, et al. Efficacy and safety of adjunctive corticosteroids therapy for patients with severe community-acquired pneumonia: A systematic review and meta-analysis. Medicine (Baltimore). 2019 Mar;98(13):e14636.
http://www.ncbi.nlm.nih.gov/pubmed/30921179?tool=bestpractice.com
[76]Jiang S, Liu T, Hu Y, et al. Efficacy and safety of glucocorticoids in the treatment of severe community-acquired pneumonia: a meta-analysis. Medicine (Baltimore). 2019 Jun;98(26):e16239.
https://journals.lww.com/md-journal/Fulltext/2019/06280/Efficacy_and_safety_of_glucocorticoids_in_the.96.aspx
http://www.ncbi.nlm.nih.gov/pubmed/31261585?tool=bestpractice.com
A study from Japan suggests that corticosteroids may not offer any advantage in the treatment of M pneumoniae pneumonia.[77]Okubo Y, Michihata N, Morisaki N, et al. Recent trends in practice patterns and impact of corticosteroid use on pediatric Mycoplasma pneumoniae-related respiratory infections. Respir Investig. 2018 Mar;56(2):158-65.
http://www.ncbi.nlm.nih.gov/pubmed/29548654?tool=bestpractice.com
Patients treated with corticosteroids have an increased risk for hyperglycemia.[72]Briel M, Spoorenberg SMC, Snijders D, et al. Corticosteroids in patients hospitalized with community-acquired pneumonia: systematic review and individual patient data meta-analysis. Clin Infect Dis. 2018 Jan 18;66(3):346-54.
http://www.ncbi.nlm.nih.gov/pubmed/29020323?tool=bestpractice.com
[73]Stern A, Skalsky K, Avni T, et al. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2017 Dec 13;(12):CD007720.
https://www.doi.org/10.1002/14651858.CD007720.pub3
http://www.ncbi.nlm.nih.gov/pubmed/29236286?tool=bestpractice.com
Other adverse effects include super infection and upper gastrointestinal bleeding.
Adjunctive corticosteroid therapy has not been studied in pregnant or pediatric populations and cannot currently be recommended.
Safety of fluoroquinolone antibiotics
Consider safety issues before prescribing fluoroquinolones. The Food and Drug Administration has issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[78]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. July 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
[79]Food and Drug Administration. FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients. December 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 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. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid are at a higher risk of tendon damage. Co-administration of a fluoroquinolone and a corticosteroid should be avoided if possible. This review resulted in prescribing restrictions in Europe, limiting the use of fluoroquinolones to severe infections only.[80]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. March 2019 [internet publication].
https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products
Tracheal intubation: animated demonstration
Bag-valve-mask ventilation: animated demonstration