Therapeutic Agents
Community-Acquired Pneumonia (CAP) in Adults
Annual Impact in the US:
emergency room visits3
1.4M
cause of emergency care & hospitalization1
10
Top
Treatment Considerations
Diagnostic Considerations
Basic Principles
1.4M
Emergency depatment visits annually1
annual deaths2
41,000
cause of infectious mortality2
#1
Antibiotic Duration
Treatment Pathway
Hospitalizations5
740,000
References
Resources
Annually in US
Hospitalizations
740,000
We need to interact with each other. We learn collaboratively.
management practices for CAP across various healthcare settings
We avoid becoming part of the content saturation in the digital world.
41,000
Annually in US
Deaths
Community-Acquired Pneumonia (CAP) in Adults
Individualized Care
Basic Principles:
Antibiotics
Assess Risk Factors
Identify prior susceptibilities, recent antibiotic use, and comorbidities such as underlying lung disease. Patients who are immunocompromised should be approached differently.
Confirm Diagnosis
Review initial imaging and other diagnostic tests.
Aim to reduce bacterial overgrowth, minimizing disruption to the microbiome.
New Perspective
Pneumonia is comparable with a forest infestation— the overgrowth of pathogens in an active lung ecosystem.
Other Treatments
Focus on modulating the immune response (eg, sepsis management, immunomodulation with steroids, macrolides).
Antibiotics & Beyond
Manage complications like sepsis, respiratory failure, and secretions; add immunomodulation, oxygen/ventilation support, vasopressors, early mobilization, glucose control, and corticosteroids as needed.
Assess Clinical Response
Adaptive Care
Recovery & Prevention
Treatment should be tailored to the individual—what works for most may not work for your patient.
Review diagnostic testing and evaluate patient clinical stability to optimize treatment.
Establish clear follow-up plans, and address modifiable risk factors (eg, smoking, vaccinations, cardiac risks, substance abuse, functional status).
Clinical Stability
Allergy Evaluation
Use evidence-based validated risk strategies for evaluating penicillin allergy and cross-reactivity to other β-lactams.4
Community-Acquired Pneumonia (CAP) in Adults
Diagnostic Considerations:
Diagnosis
Microbiologic Testing
Fungi & Mycobacteria 2%
Bacteria + Viral Codetection 7%
Signs and symptoms of pneumonia
Rapid molecular tests +/- Culture-based confirmation
with chest imaging confirmation5
Pathogen Identification Is Difficult7
Bacteria 29%
Virus 62%
Dx Uncertainty
No Pathogen Detected 62%
Pathogen Identified 38%
1/3rd
of initial pneumonia diagnoses change by discharge6
References
Community-Acquired Pneumonia (CAP) in Adults
Antibiotic Treatment Considerations
Agent selection is impacted by a variety of clinical factors:
Allergies/Adverse Events
Comorbidities
Consider allergies to penicillin or β-lactams. Medication side effects profile.
Different pathogens are linked to specific conditions.Consider bronchiectasis, smoking, chronic obstructive lung disease, etc.
Local Epidemiology
Disease Severity
Antimicrobial resistance rates vary by location.
Ward vs ICU vs outpatient (10% to 20% of patients require ICU Care)
CURB-65
SCAP
PSI
Complications
Resistant Pathogens Assessment
Lung abscess, pleural effusion, cardiovascular events, stroke, or coinfections.
Use rapid diagnostic tests and patient microbiologic history to assess risk for resistant organisms.
Community-Acquired Pneumonia (CAP) in Adults
Empiric Treatment Pathway
β-lactam + macrolide
or
β-lactam
Respiratory fluoroquinolone
or
Nonsevere
Tetracycline
No Comorbidities
Add anti-MRSA if prior infection in past year or validated risk factors & positive PCR
or
Macrolide (if resistance <25%)
Add antipseudomonal if prior P. aeruginosa infection in the past year
Disposition
Outpatient
Inpatient
β-lactam + macrolide
β-lactam with β-lactamase inhibitor AND macrolide or tetracycline
or
Respiratory fluoroquinolone
or
Comorbidities
Severe
Respiratory fluoroquinolone
Add anti-MRSA if prior infection in past year or validated risk factors & positive PCR
Add antipseudomonal if prior P. aeruginosa infection in the past year
Community-Acquired Pneumonia (CAP) in Adults
Excessive Antibiotic Duration
Duration
2/3rds
Whether inpatient or outpatient, the duration of antibiotics should be driven by the patient’s comorbidities, clinical response, and stability.
of hospitalized patients receive excessive antibiotic duration5
Inpatient
3-5
Days
>5
Days
Antibiotics can be stopped in select patients who achieve clinical stability
Longer for patients with complications or risk factors for slow recovery
90%
occur after patients leave the hospital9
Risk Factors
Clinical Stability
Outpatient
3-5
Days
Ensure close communication and follow-up
Excess Antibiotic Duration
Related to higher antibiotic-associated adverse events and antibiotic resistance5
Short courses generally safe
References
References:
- Cairns C, Kang K. National Hospital Ambulatory Medical Care Survey: 2021 Emergency Department Summary Tables. Centers for Disease Control and Prevention, National Center for Health Statistics. 2021. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc21-ed-508.pdf
- Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in severe community-acquired pneumonia. N Engl J Med. 2023;388(21):1931-1941.
doi:10.1056/NEJMoa2215145
- Jain S, Self WH, Wunderink RG, et al. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015;373(5):415-427. Preprint. Posted online July 14, 2015. doi: 10.1056/NEJMoa1500245
- Jones BE, Chapman AB, Ying J, et al. Diagnostic discordance, uncertainty, and treatment ambiguity in community-acquired pneumonia : a
national cohort study of 115 U.S. Veterans Affairs hospitals. Ann Intern Med. 2024;177(9):1179-1189. Preprint. Posted online August 6, 2024. doi:10.7326/M23-2505
- 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;200(7):e45-e67.
doi:10.1164/rccm.201908-1581ST
- Mortality Data on CDC WONDER. Centers for Disease Control and Prevention, National Center for Health Statistics. 2018-2022. Accessed November 4, 2024. http://wonder.cdc.gov/ucd-icd10-expanded.html
- Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a
multihospital cohort study. Ann Intern Med. 2019;171(3):153-163. doi:10.7326/M18-3640
Inpatient
Severe
Diagnostic tests:
- Viral tests according to clinical suspicion, local prevalence, and availability
- Blood & respiratory cultures
- Legionella urinary antigen & respiratory culture/nucleic acid assay
- Strep urinary antigen
- MRSA PCR if initiating anti-MRSA therapy or risk factors for MRSA
- Chronic heart, lung, liver, or renal disease
- Diabetes mellitus
- Alcoholism
- Malignancy
- Asplenia
Clinical Stability
- Resolution of vital sign abnormalities:
- Heart rate
- Respiratory rate
- Blood pressure
- Oxygen saturation
- Temperature
- Ability to eat
- Normal mentation
*Utilized in combination with β-lactamic agents for hospitalized patients and as monotherapy if patients do not have comorbidities
Outpatient
No Comorbidities
Diagnostic tests: Viral tests according to clinical suspicion, local prevalence, and availability
Inpatient
Severe Risk Factors
- Prior history of positive cultures for MRSA/pseudomonas
- IV antibiotics
- Less strongly recent hospitalization
Inpatient
Severe Risk Factors
- Prior history of positive cultures for MRSA/pseudomonas
- IV antibiotics
- Less strongly recent hospitalization
Virus
- Human rhinovirus
- Influenza A or B
- Human metapneumovirus
- Respiratory syncytial virus
- Parainfluenza virus
- Coronavirus (**SARS-CoV-2)
- Adenovirus
Clinical Stability
- Resolution of vital sign abnormalities:
- Heart rate
- Respiratory rate
- Blood pressure
- Oxygen saturation
- Temperature
- Ability to eat
- Normal mentation
Inpatient
Severe Risk Factors
- Prior history of positive cultures for MRSA/pseudomonas
- IV antibiotics
- Less strongly recent hospitalization
*Used in combination for atypical coverage.
Inpatient
Severe Risk Factors
- Prior history of positive cultures for MRSA/pseudomonas
- IV antibiotics
- Less strongly recent hospitalization
Outpatient
Comorbidities
- Chronic heart, lung, liver, or renal disease
- Diabetes mellitus
- Alcoholism
- Malignancy
- Asplenia
Diagnostic tests: Viral tests according to clinical suspicion, local prevalence, and availability
Inpatient
Not Severe
Diagnostic tests:
- Viral tests according to clinical suspicion, local prevalence, and availability
- Blood & respiratory culture if risk of MRSA or P. aeruginosa
- Legionella urinary antigen if local outbreak
- MRSA PCR if initiating anti-MRSA therapy or risk factors for MRSA
- Chronic heart, lung, liver, or renal disease
- Diabetes mellitus
- Alcoholism
- Malignancy
- Asplenia
Risk Factors
- Pneumonia complications (e.g., empyema/parapneumonic effusion, abscess/necrotizing process, bacteremia, extrapulmonary infection)
- Organism requiring longer duration (e.g., Staphylococcus aureus, Pseudomonas aeruginosa, suspected Legionella pneumophila or other intracellular microorganisms)
- Radiographic findings (high burden of disease, necrotizing process, dense consolidations)
- Underlying lung disease (e.g., bronchiectasis, post-obstructive pneumonia, chronic hypoxemia)
- Barriers to self assessment, follow-up, or communication to ensure recovery
References:
- McDermott KW, Roemer M. Most Frequent Principal Diagnoses for Inpatient Stays in U.S. Hospitals, 2018. HCUP Statistical Brief #277. Agency for Healthcare Research and Quality. July 2021. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb277-TopReasons-Hospital-Stays-2018.pdf
- Mortality Data on CDC WONDER. Centers for Disease Control and Prevention, National Center for Health Statistics. 2018-2022. Accessed November 4, 2024. http://wonder.cdc.gov/ucd-icd10-expanded.html
- Cairns C, Kang K. National Hospital Ambulatory Medical Care Survey: 2021 Emergency Department Summary Tables. Centers for Disease Control and Prevention, National Center for Health Statistics. 2021. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc21-ed-508.pdf
- Khan DA, Banerji A, Blumenthal KG, et al. Drug allergy: a 2022 practice parameter update. J Allergy Clin Immunol. 2022;150(6):1333-1393. doi: 10.1016/j.jaci.2022.08.028
- 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;200(7):e45-e67. doi:10.1164/rccm.201908-1581ST
- Jones BE, Chapman AB, Ying J, et al. Diagnostic discordance, uncertainty, and treatment ambiguity in community-acquired pneumonia : a national cohort study of 115 U.S. Veterans Affairs hospitals. Ann Intern Med. 2024;177(9):1179-1189. Preprint. Posted online August 6, 2024. doi:10.7326/M23-2505
- Jain S, Self WH, Wunderink RG, et al. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015;373(5):415-427. Preprint. Posted online July 14, 2015. doi: 10.1056/NEJMoa1500245
- Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in severe community-acquired pneumonia. N Engl J Med. 2023;388(21):1931-1941.
doi:10.1056/NEJMoa2215145
- Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a
multihospital cohort study. Ann Intern Med. 2019;171(3):153-163. doi:10.7326/M18-3640
References:
- Cairns C, Kang K. National Hospital Ambulatory Medical Care Survey: 2021 Emergency Department Summary Tables. Centers for Disease Control and Prevention, National Center for Health Statistics. 2021. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc21-ed-508.pdf
- Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in severe community-acquired pneumonia. N Engl J Med. 2023;388(21):1931-1941.
doi:10.1056/NEJMoa2215145
- Jain S, Self WH, Wunderink RG, et al. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015;373(5):415-427. Preprint. Posted online July 14, 2015. doi: 10.1056/NEJMoa1500245
- Jones BE, Chapman AB, Ying J, et al. Diagnostic discordance, uncertainty, and treatment ambiguity in community-acquired pneumonia : a
national cohort study of 115 U.S. Veterans Affairs hospitals. Ann Intern Med. 2024;177(9):1179-1189. Preprint. Posted online August 6, 2024. doi:10.7326/M23-2505
- 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;200(7):e45-e67.
doi:10.1164/rccm.201908-1581ST
- Mortality Data on CDC WONDER. Centers for Disease Control and Prevention, National Center for Health Statistics. 2018-2022. Accessed November 4, 2024. http://wonder.cdc.gov/ucd-icd10-expanded.html
- Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a
multihospital cohort study. Ann Intern Med. 2019;171(3):153-163. doi:10.7326/M18-3640
Bacteria
- Streptococcus pneumoniae
- Mycoplasma pneumoniae
- Staphylococcus aureus
- Legionella pneumophila
- Enterobacteriaceae
- Other
Inpatient
Severe Risk Factors
- Prior history of positive cultures for MRSA/pseudomonas
- IV antibiotics
- Less strongly recent hospitalization
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Transcript
Therapeutic Agents
Community-Acquired Pneumonia (CAP) in Adults
Annual Impact in the US:
emergency room visits3
1.4M
cause of emergency care & hospitalization1
10
Top
Treatment Considerations
Diagnostic Considerations
Basic Principles
1.4M
Emergency depatment visits annually1
annual deaths2
41,000
cause of infectious mortality2
#1
Antibiotic Duration
Treatment Pathway
Hospitalizations5
740,000
References
Resources
Annually in US
Hospitalizations
740,000
We need to interact with each other. We learn collaboratively.
management practices for CAP across various healthcare settings
We avoid becoming part of the content saturation in the digital world.
41,000
Annually in US
Deaths
Community-Acquired Pneumonia (CAP) in Adults
Individualized Care
Basic Principles:
Antibiotics
Assess Risk Factors
Identify prior susceptibilities, recent antibiotic use, and comorbidities such as underlying lung disease. Patients who are immunocompromised should be approached differently.
Confirm Diagnosis
Review initial imaging and other diagnostic tests.
Aim to reduce bacterial overgrowth, minimizing disruption to the microbiome.
New Perspective
Pneumonia is comparable with a forest infestation— the overgrowth of pathogens in an active lung ecosystem.
Other Treatments
Focus on modulating the immune response (eg, sepsis management, immunomodulation with steroids, macrolides).
Antibiotics & Beyond
Manage complications like sepsis, respiratory failure, and secretions; add immunomodulation, oxygen/ventilation support, vasopressors, early mobilization, glucose control, and corticosteroids as needed.
Assess Clinical Response
Adaptive Care
Recovery & Prevention
Treatment should be tailored to the individual—what works for most may not work for your patient.
Review diagnostic testing and evaluate patient clinical stability to optimize treatment.
Establish clear follow-up plans, and address modifiable risk factors (eg, smoking, vaccinations, cardiac risks, substance abuse, functional status).
Clinical Stability
Allergy Evaluation
Use evidence-based validated risk strategies for evaluating penicillin allergy and cross-reactivity to other β-lactams.4
Community-Acquired Pneumonia (CAP) in Adults
Diagnostic Considerations:
Diagnosis
Microbiologic Testing
Fungi & Mycobacteria 2%
Bacteria + Viral Codetection 7%
Signs and symptoms of pneumonia
Rapid molecular tests +/- Culture-based confirmation
with chest imaging confirmation5
Pathogen Identification Is Difficult7
Bacteria 29%
Virus 62%
Dx Uncertainty
No Pathogen Detected 62%
Pathogen Identified 38%
1/3rd
of initial pneumonia diagnoses change by discharge6
References
Community-Acquired Pneumonia (CAP) in Adults
Antibiotic Treatment Considerations
Agent selection is impacted by a variety of clinical factors:
Allergies/Adverse Events
Comorbidities
Consider allergies to penicillin or β-lactams. Medication side effects profile.
Different pathogens are linked to specific conditions.Consider bronchiectasis, smoking, chronic obstructive lung disease, etc.
Local Epidemiology
Disease Severity
Antimicrobial resistance rates vary by location.
Ward vs ICU vs outpatient (10% to 20% of patients require ICU Care)
CURB-65
SCAP
PSI
Complications
Resistant Pathogens Assessment
Lung abscess, pleural effusion, cardiovascular events, stroke, or coinfections.
Use rapid diagnostic tests and patient microbiologic history to assess risk for resistant organisms.
Community-Acquired Pneumonia (CAP) in Adults
Empiric Treatment Pathway
β-lactam + macrolide
or
β-lactam
Respiratory fluoroquinolone
or
Nonsevere
Tetracycline
No Comorbidities
Add anti-MRSA if prior infection in past year or validated risk factors & positive PCR
or
Macrolide (if resistance <25%)
Add antipseudomonal if prior P. aeruginosa infection in the past year
Disposition
Outpatient
Inpatient
β-lactam + macrolide
β-lactam with β-lactamase inhibitor AND macrolide or tetracycline
or
Respiratory fluoroquinolone
or
Comorbidities
Severe
Respiratory fluoroquinolone
Add anti-MRSA if prior infection in past year or validated risk factors & positive PCR
Add antipseudomonal if prior P. aeruginosa infection in the past year
Community-Acquired Pneumonia (CAP) in Adults
Excessive Antibiotic Duration
Duration
2/3rds
Whether inpatient or outpatient, the duration of antibiotics should be driven by the patient’s comorbidities, clinical response, and stability.
of hospitalized patients receive excessive antibiotic duration5
Inpatient
3-5
Days
>5
Days
Antibiotics can be stopped in select patients who achieve clinical stability
Longer for patients with complications or risk factors for slow recovery
90%
occur after patients leave the hospital9
Risk Factors
Clinical Stability
Outpatient
3-5
Days
Ensure close communication and follow-up
Excess Antibiotic Duration
Related to higher antibiotic-associated adverse events and antibiotic resistance5
Short courses generally safe
References
References:
Inpatient
Severe
Diagnostic tests:
Clinical Stability
*Utilized in combination with β-lactamic agents for hospitalized patients and as monotherapy if patients do not have comorbidities
Outpatient
No Comorbidities
Diagnostic tests: Viral tests according to clinical suspicion, local prevalence, and availability
Inpatient
Severe Risk Factors
Inpatient
Severe Risk Factors
Virus
Clinical Stability
Inpatient
Severe Risk Factors
*Used in combination for atypical coverage.
Inpatient
Severe Risk Factors
Outpatient
Comorbidities
Diagnostic tests: Viral tests according to clinical suspicion, local prevalence, and availability
Inpatient
Not Severe
Diagnostic tests:
Risk Factors
References:
References:
Bacteria
Inpatient
Severe Risk Factors