CAP Infographic (Mobile)

Top

10

740,000

Hospitalizations

740,000

Hospitalizations5

cause of emergency care & hospitalization1

Resources

#1

cause of infectious mortality2

1.4M

emergency room visits3

41,000

Annually in US

annual deaths2

References

Antibiotic Duration

Treatment Pathway

Therapeutic Agents

Treatment Considerations

Diagnostic Considerations

Basic Principles

Annual Impact in the US:

1.4M

Emergency depatment visits annually1

Annually in US

Community-Acquired Pneumonia (CAP) in Adults

management practices for CAP acoss various healthcare settings

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Community-Acquired Pneumonia (CAP) in Adults

Review diagnostic testing and evaluate patient clinical stability to optimize treatment.

Assess Clinical Response

Pneumonia is comparable with a forest infestation— the overgrowth of pathogens in an active lung ecosystem.

New Perspective

Review initial imaging and other diagnostic tests.

Confirm Diagnosis

Allergy Evaluation

Use evidence-based validated risk strategies for evaluating penicillin allergy and cross-reactivity to other β-lactams.4

Establish clear follow-up plans, and address modifiable risk factors (eg, smoking, vaccinations, cardiac risks, substance abuse, functional status).

Recovery & Prevention

Manage complications like sepsis, respiratory failure, and secretions; add immunomodulation, oxygen/ventilation support, vasopressors, early mobilization, glucose control, and corticosteroids as needed.

Antibiotics & Beyond

Identify prior susceptibilities, recent antibiotic use, and comorbidities such as underlying lung disease. Patients who are immunocompromised should be approached differently.

Assess Risk Factors

Individualized Care

Antibiotics

Aim to reduce bacterial overgrowth, minimizing disruption to the microbiome.

Other Treatments

Focus on modulating the immune response (eg, sepsis management, immunomodulation with steroids, macrolides).

Adaptive Care

Treatment should be tailored to the individual—what works for most may not work for your patient.

Clinical Stability

Basic Principles:

Community-Acquired Pneumonia (CAP) in Adults

References

Bacteria + Viral Codetection 7%

Fungi & Mycobacteria 2%

Bacteria 29%

Virus 62%

Pathogen Identified 38%

Diagnostic Considerations:

Rapid molecular tests +/- Culture-based confirmation

Microbiologic Testing

No Pathogen Detected 62%

Pathogen Identification Is Difficult7

Signs and symptoms of pneumonia

with chest imaging confirmation5

Dx Uncertainty

1/3rd

of initial pneumonia diagnoses change by discharge6

Diagnosis

Community-Acquired Pneumonia (CAP) in Adults

Agent selection is impacted by a variety of clinical factors:

Comorbidities

Different pathogens are linked to specific conditions.Consider bronchiectasis, smoking, chronic obstructive lung disease, etc.

Disease Severity

Ward vs ICU vs outpatient (10% to 20% of patients require ICU Care)

Complications

Lung abscess, pleural effusion, cardiovascular events, stroke, or coinfections.

Resistant Pathogens Assessment

Use rapid diagnostic tests and patient microbiologic history to assess risk for resistant organisms.

Local Epidemiology

Antimicrobial resistance rates vary by location.

Allergies/ Adverse Events

Consider allergies to penicillin or β-lactams. Medication side effects profile.

SCAP

CURB-65

PSI

Antibiotic Treatment Considerations

or

Community-Acquired Pneumonia (CAP) in Adults

β-lactam + macrolide

Add anti-MRSA if prior infection in past year or validated risk factors & positive PCR

or

Add antipseudomonal if prior P. aeruginosa infection in the past year

Respiratory fluoroquinolone

β-lactam + macrolide

β-lactam with β-lactamase inhibitor AND macrolide or tetracycline

Macrolide (if resistance <25%)

β-lactam

Tetracycline

Severe

Nonsevere

No Comorbidities

Comorbidities

Add anti-MRSA if prior infection in past year or validated risk factors & positive PCR

or

or

or

Add antipseudomonal if prior P. aeruginosa infection in the past year

Respiratory fluoroquinolone

Respiratory fluoroquinolone

Inpatient

Outpatient

Disposition

Empiric Treatment Pathway

Days

3-5

Days

>5

Days

3-5

References

Community-Acquired Pneumonia (CAP) in Adults

Excess Antibiotic Duration

Related to higher antibiotic-associated adverse events and antibiotic resistance5

Short courses generally safe

Whether inpatient or outpatient, the duration of antibiotics should be driven by the patient’s comorbidities, clinical response, and stability.

occur after patients leave the hospital9

Longer for patients with complications or risk factors for slow recovery

Antibiotics can be stopped in select patients who achieve clinical stability

90%

Risk Factors

Outpatient

Inpatient

Clinical Stability

Excessive Antibiotic Duration

2/3rds

Ensure close communication and follow-up

of hospitalized patients receive excessive antibiotic duration5

Duration

References:

1. 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
2. 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
3. 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
4. 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
5. 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
6. 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
7. 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

Severe

Inpatient

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

Diagnostic tests: Viral tests according to clinical suspicion, local prevalence, and availability

No Comorbidities

• 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

Inpatient

Severe Risk Factors

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

• Prior history of positive cultures for MRSA/pseudomonas
• IV antibiotics
• Less strongly recent hospitalization

Inpatient

Severe Risk Factors

*Used in combination for atypical coverage.

• Prior history of positive cultures for MRSA/pseudomonas
• IV antibiotics
• Less strongly recent hospitalization

Inpatient

Severe Risk Factors

• Chronic heart, lung, liver, or renal disease
• Diabetes mellitus
• Alcoholism
• Malignancy
• Asplenia

Outpatient

Diagnostic tests: Viral tests according to clinical suspicion, local prevalence, and availability

Comorbidities

Not Severe

Inpatient

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:

1. 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
2. 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
3. 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
4. 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
5. 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
6. 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
7. 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
8. 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
9. 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:

1. 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
2. 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
3. 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
4. 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
5. 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
6. 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
7. 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

• Prior history of positive cultures for MRSA/pseudomonas
• IV antibiotics
• Less strongly recent hospitalization

Inpatient

Severe Risk Factors