Community-Acquired Pneumonia in Adults

8/10/23, 21:48 Community-Acquired Pneumonia in Adults - ClinicalKey
CLINICAL OVERVIEW
Community-Acquired Pneumonia in Adults

Elsevier Point of Care (ver detalles)
Actualizado October 31, 2022. Copyright Elsevier BV. All rights reserved.
Synopsis
Urgent Action
In patients being admitted, initiate empiric antibiotic therapy as soon as possible in the emergency department 5
Admit patients presenting with acute respiratory failure and septic shock directly to the ICU 6
Key Points
Community-acquired pneumonia is an acute infection of the pulmonary parenchyma that is not acquired in a hospital or
other health care facility (patient neither hospitalized nor residing in a long-term care facility for at least 14 days before the
onset of symptoms)
History and physical examination suggest diagnosis, which is confirmed with chest radiography
Testing for the causative agent (eg, blood and sputum cultures) is not necessary for patients able to be treated as outpatients
unless it is likely that treatment or isolation procedures would change based on a suspected unusual pathogen
When infection with SARS-CoV-2 is suspected or probable, confirm the diagnosis. CDC and WHO recommend polymerase
chain reaction as the standard for diagnosis; antigen testing is also widely available
Select site of care decisions (eg, outpatient, general hospital ward, ICU) on pneumonia severity level, Pneumonia Severity
Index score, and CURB-65 1 score. Do not allow these scoring systems to supersede clinical judgment
Select empiric antibiotic therapy based on the site of care and likely pathogen. Initiate treatment promptly once diagnosis of
pneumonia appears likely
Patients able to be treated as outpatients with no significant risk of drug-resistant Streptococcus pneumoniae should receive
first line therapy with a macrolide or second line therapy with doxycycline
Treat hospitalized (general ward) patients with no significant risk of drug-resistant Streptococcus pneumoniae empirically
with respiratory quinolone monotherapy; alternatives include a β-lactam plus a macrolide or a β-lactam plus doxycycline
First line treatment for patients in ICU is usually a combination therapy of β-lactam plus either azithromycin or a respiratory
quinolone
Additional coverage is required in patients with suspected community-acquired MRSA or Pseudomonas species infections
Treat all hospitalized patients who test positive for influenza with oseltamivir, regardless of the duration of illness
Treatment of COVID-19 pneumonia includes infection control measures, routine supportive care, and medications that
include antiviral, monoclonal antibody, immunomodulator, and corticosteroid drugs
Pneumococcal vaccination is indicated in patients aged 65 years or older and aged 19 to 64 years with certain underlying
medical conditions or other risk factors; 2 influenza vaccination is recommended for all persons aged 6 months or older 3
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CDC recommends vaccination against COVID-19 for all persons 5 years and older 4
Pitfalls
Lack of response to initial therapy may suggest unusual pathogens (eg, Legionella species, fungi, viruses), nosocomial
infection, or an infectious complication (eg, empyema, postobstructive pneumonia, abscess)
False-negative chest radiograph findings may occur, especially in a dehydrated patient; the diagnosis should then primarily
depend on history and physical examination findings
False-negative respiratory sample cultures can occur if obtained after antibiotic therapy has been started 7
Terminology
Clinical Clarification
Community-acquired pneumonia in adults is acute infection of the pulmonary parenchyma that is not acquired in a hospital
or other health care facility (patient neither hospitalized nor residing in a long-term care facility for at least 14 days before the
onset of symptoms) 5
Classification
By cause 8
Typical
Classically caused by Streptococcus pneumoniae, but other pyogenic organisms may cause a similar presentation
Characterized both by cough that produces purulent sputum and by lobar consolidation
Atypical
Caused by Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella species, and respiratory viruses
Characterized by dry cough and patchy infiltrates
By severity level (and site of care) 6
Determined by severity of illness scores in combination with clinical judgment and an assessment of the patient’s social
support
Pneumonia that can be managed in an outpatient setting
Pneumonia that should be managed with inpatient admission (general ward)
Pneumonia that is severe and should be managed in the ICU
Severe community-acquired pneumonia (either major criteria or 3 or more minor criteria) 6
Major criteria
Need for mechanical ventilation
Septic shock with need for vasopressors
Minor criteria
Respiratory rate of 30 breaths per minute or more
Ratio of arterial partial pressure of oxygen (PaO₂) to fraction of inspired oxygen (FiO₂) 250 or less
Multilobar disease
Leukopenia (leukocyte count less than 4000 cells/μL)
Uremia (BUN level of 20 mg/dL or higher)
Confusion or disorientation
Hypothermia (core temperature lower than 36 °C)
Thrombocytopenia (platelet count less than 100,000 cells/μL)
Hypotension requiring aggressive fluid resuscitation
Diagnosis
Clinical Presentation
History
Fever may be reported
Chills, sweating, and/or shivering
Chest pain with inspiration and coughing
Cough (productive or nonproductive)

Dyspnea
Fatigue
Myalgia
Physical examination
General
Altered mental status may occur with severe pneumonia, especially in older patients
Fever (typically over 38.1 °C)
In COVID-19 pneumonia, while fever is typical, it may be low-grade or absent, even in hospitalized patients (especially if
vaccinated) 9
Signs of respiratory distress
Cyanosis, if hypoxemic
Tachypnea is a suggestive sign
Clinicians should be aware of the COVID-19–related phenomenon of silent (or "happy") hypoxemia: absence of signs of
respiratory distress may be misleading
Tachycardia occurs with fever and with severe disease
Other symptoms that may suggest COVID-19 infection:

Upper respiratory tract symptoms (eg, rhinorrhea, sneezing, sore throat) may be present in up to 20% of symptomatic
infections 10
Alteration in smell and/or taste is less common but highly suggestive 11
Gastrointestinal symptoms (eg, abdominal pain, nausea, vomiting, diarrhea) are present in 10% to 20% of symptomatic
infections 9 10
Pulmonary
Respiratory splinting
Palpable fremitus
Dullness to percussion
Bronchial breath sounds or rales 6
Egophony
Whispered pectoriloquy
Causes and Risk Factors
Causes
Common pathogens 12 13
Streptococcus pneumoniae (pneumococcus)
Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydia pneumoniae
Staphylococcus aureus
Legionella species
Gram-negative bacilli
MRSA
Pseudomonas aeruginosa
Respiratory viruses
SARS-CoV-2 14 15
Influenza A and B viruses
Parainfluenza virus
Respiratory syncytial virus
Adenoviruses
Rhinovirus
Risk factors and/or associations
Other risk factors/associations

Hospitalization and treatment with parenteral antibiotics in the preceding 90 days
MRSA, Pseudomonas aeruginosa, resistant gram-negative bacilli
Documented history of infection with these organisms
Previously regarded as health care–associated pneumonia, infection due to these bacteria is now considered within the
spectrum of community-acquired pneumonia 6
Chronic obstructive pulmonary disease
Streptococcus pneumoniae
Moraxella (Branhamella) catarrhalis
Legionella species
Bronchiectasis
Burkholderia cepacia
Cystic fibrosis
Most common organism in adults
Diabetes
Gram-negative organisms
Renal disease
Early-stage HIV
Mycobacterium tuberculosis
Late-stage HIV
Pneumocystis jiroveci
Cryptococcus species
Histoplasma species
Medical conditions that result in aspiration of nasopharyngeal secretions, food, liquids, or gastric contents
Alcohol use disorder
Klebsiella pneumoniae
Anaerobic bacteria
Asplenia
Encapsulated organisms
Sickle cell disease
Streptococcus pneumonia
Poor dental hygiene

Anaerobic bacteria
Smoking
Streptococcus pneumonia
Moraxella (Branhamella) catarrhalis
Legionella species
Travel history
Travel to area of known outbreak within 2 weeks before illness
Legionella species
Travel to the southwestern United States within 1 month before illness
Coccidioides species
Exposure to animals
Exposure to bats or soil enriched with bird droppings
Histoplasma capsulatum
Exposure to birds
Chlamydia psittaci
Exposure to rabbits
Francisella tularensis
Exposure to farm animals or parturient cats
Coxiella burnetii
Specific comorbid conditions that have been associated with increased risk for severe COVID-19 infection include the
following (based on systematic review or meta-analysis): 16
Chronic kidney disease
Chronic liver disease

Chronic lung disease
Tuberculosis
Diabetes mellitus, type 1 and type 2
Malignancy
Pregnancy and recent pregnancy
Obesity (BMI of 30 kg/m² or higher)
Serious cardiac conditions (eg, heart failure, coronary artery disease, cardiomyopathy)
Smoking, current and former
Cerebrovascular disease
Mental health disorders (mood disorders and schizophrenia spectrum disorders)
Diagnostic Procedures
Primary diagnostic tools

History and physical examination alone may be sufficient to suggest the diagnosis 13
Chest radiography or other chest imaging demonstrating an infiltrate confirms the

diagnosis 13
Testing to identify a causative agent is not routine for outpatients, except in certain
circumstances 13 Chest radiograph in a patient with
community-acquired pneumonia. -
Testing to identify a causative agent (eg, polymerase chain reaction, blood cultures, Chest radiograph of right middle
sputum testing, pleural fluid testing, antigen testing, and/or cultures for fungi and lobe infiltrate in a patient with
community-acquired pneumonia.
tuberculosis, depending on history and clinical findings) is indicated if: 13
Infection with SARS-CoV-2 is suspected or probable
CDC and WHO recommend polymerase chain reaction as the standard for
diagnosis; antigen testing is also widely available in the United States 17 18
Severe pneumonia
Pleural effusion and/or a cavitary infiltrate
Specific comorbidities (eg, alcohol use disorder, liver disease, leukopenia, chronic
lung disease, asplenia)
Identification of a suspected pathogen would significantly alter antibiotic choice
Failure of outpatient treatment
Epidemiologic considerations (eg, outbreaks of public health importance)
Pulse oximetry assesses hypoxemia 13
Other laboratory tests—including blood gases, CBC, C-reactive protein, and blood
chemistries (including lactate)—may be useful in both determining degree of severity at
presentation and managing hospitalized patients 13
Serum procalcitonin has been used to discriminate between infectious and

noninfectious causes of pneumonia and between bacterial and viral causes. However,
current guidelines do not recommend its use either to determine need for antibacterial
therapy or to determine when to discontinue antibiotics 6 19
Laboratory
Imaging
Procedures
Differential Diagnosis
Most common
Bronchitis (Related: Acute Bronchitis)
Presents with fever, malaise, productive cough, hoarseness, chest pain, and muscle pain
Differentiated by chest radiography and physical examination

No radiographic evidence of pulmonary pathology
Signs of consolidation (eg, rales, egophony, fremitus) indicative of pneumonia will be absent
Seasonal influenza (Related: Influenza)
Sudden onset of high fever with chills, myalgia, or malaise

Dry cough, sneezing, sore throat, nasal discharge, and substernal soreness
History of contact with an infected person
Viral infection present in the winter season
Differentiated by history and laboratory testing
Antigen detection test using nasopharyngeal secretion will help in detecting type A and type B viral antigens
Asthma (Related: Asthma in Adults)
Patient may present with recurrent attacks of dyspnea with wheezing or accessory muscle use
Differentiated by history (absence of fever), chest radiography, spirometry/pulmonary function testing, and response to
bronchodilators
Chronic obstructive pulmonary disease (Related: Stable Chronic Obstructive Pulmonary Disease)
Patients present with dyspnea, pursed lip breathing, or use of accessory muscles for breathing
Other features include chronic productive cough, cyanosis, tachycardia, and tachypnea
Differentiated by history, chest radiography, and spirometry/pulmonary function testing
Spirometry shows abnormal diffusing capacity, fixed reduction in FEV1, and increased total lung capacity and/or
residual volume in patients with chronic obstructive pulmonary disease
Chest radiography shows hyperinflation with flattened diaphragm, tenting of the diaphragm at the rib, and increased
retrosternal chest space in patients with chronic obstructive pulmonary disease
Congestive heart failure (Related: Heart Failure)
Characterized by:
Dyspnea
Fatigue
Exercise intolerance
Fluid retention
Differentiated by:
Chest radiography showing:
Pulmonary edema
Pleural effusion
Pulmonary venous congestion
Chamber dilation
Kerley B lines
Cardiomegaly
Echocardiography showing abnormalities with cardiac structure and function
Pneumothorax
Sudden onset of breathlessness and chest pain
Differentiated by history, physical examination, and chest radiography
Chest radiography will reveal air in the pleural space
Pulmonary embolism (Related: Pulmonary Embolism)
Blocking of pulmonary artery by thrombus
Patients present with dyspnea and pleuritic chest pain but usually do not have a fever or cough productive of purulent
sputum
Calf tenderness and swelling may be present if embolism was caused by deep venous thrombosis
Differentiated by history, physical examination, and imaging
Chest CT shows filling defects in the pulmonary arteries
Tuberculosis
Patients present with weight loss, night sweats, and cough
Travel to or residence in a tuberculosis-infected endemic area or advanced age (born early 20th century during worldwide
endemicity)
Differentiated by history, laboratory testing, and imaging
Positive tuberculin test result
Chest radiography findings of reactivation disease (usually in older patients) showing upper-lobe predominance or
cavity, and/or granuloma formation
Chest radiography of primary tuberculous pneumonia (usually in in younger patients) showing hilar adenopathy, and/or
pleural effusion (sometimes massive)
Treatment
Goals
Eradicate infection
Relieve symptoms and provide supportive care as needed
Prevent disease progression and complications
Disposition
Admission criteria
Use severity of illness scores in combination with clinical judgment to determine if the patient can be safely managed as an
outpatient or should be managed as an inpatient. The 2019 guidelines recommend Pneumonia Severity Index preferentially over
the CURB-65 criteria 6
Pneumonia Severity Index 33
Uses a point system of several variables including patient age, vital signs, mental status, and the presence of comorbid
conditions (eg, neoplastic disease, liver disease, chronic heart failure, cerebrovascular disease, renal disease)
Classifies patients into a mortality risk level
Class I and II patients (fewer than 70 points) may be treated as outpatients
Class III patients should be treated in an observation unit or briefly hospitalized (71-90 points)
Class IV (91-130 points) and V (greater than 130 points) should be treated as inpatients
CURB-65 criteria 1
Patients receive 1 point for each of the following indicators:
Confusion (compared to baseline)
BUN greater than 20 mg/dL
Respiratory rate greater than or equal to 30 breaths per minute
Systolic blood pressure less than 90 mm Hg or diastolic blood pressure of 60 mm Hg or less
Age 65 years or older

Inpatient admission is recommended for patients with a score of 2 or more
Most patients with a score of 1 can be managed as outpatients; consider overnight observation for some patients
Studies of specific biomarkers used to identify high-risk patients have not proven more accurate than these scoring systems
34
For COVID-19 pneumonia:
Nonsevere pneumonia: admission criteria include radiographic evidence of pneumonia, progressive clinical illness, risk
factors for severe disease, and inadequate care at home. CDC provides further guidance 35
More severe/critical respiratory tract disease requires ICU admission 36
Implement standard, contact, and (at least) droplet precautions as soon as the diagnosis is suspected; airborne precautions are
recommended 37
Consider inpatient admission for patients otherwise meeting criteria for outpatient treatment but who are unable to safely and
reliably take medication orally or who have insufficient personal support 25
Criteria for ICU admission

Recommended with either major criteria or 3 or more minor criteria (severe community-acquired pneumonia) 6
Major criteria
Need for mechanical ventilation
Septic shock with need for vasopressors

Minor criteria
Respiratory rate of 30 breaths per minute or more
Ratio of arterial PaO₂ to fraction of inspired oxygen (FiO₂) of 250 or less
Multilobar disease
Leukopenia (leukocyte count less than 4000 cells/μL)
Uremia (BUN level of 20 mg/dL or higher)
Confusion or disorientation
Hypothermia (core temperature lower than 36 °C)
Thrombocytopenia (platelet count fewer than 100,000 cells/μL)
Hypotension requiring aggressive fluid resuscitation
Pneumonia prognostic prediction tools have also been used in practice to determine level of in-hospital care; ICU is
appropriate in the following patients: 29
Pneumonia severity index: class V (greater than 130 points)
CURB-65 1 score of 4 or 5
For severe COVID-19 pneumonia
Admit patients with severe/critical respiratory tract disease to an intensive care environment 36
Tachypnea (respiratory rate greater than 30 breaths or less than 10 breaths per minute), severe respiratory distress,
inadequate oxygenation (eg, SpO₂ less than 92%)
Presence of severe complications (eg, septic shock, acute respiratory distress syndrome)
Recommendations for specialist referral

Refer to pulmonologist for:
Respiratory failure requiring noninvasive and positive pressure ventilation or intubation and mechanical ventilation
Worsening hypoxemia
Pleural effusion requiring chest tube drainage
Nonresolving pneumonia (characterized by persistent fever and absence of clinical improvement)
Bronchoscopic sampling, if necessary
Refer to infectious disease specialist for assistance with identification of causative agent and antibiotic management of severe
pneumonia or pneumonia that does not respond to empiric antibiotics
Treatment Options
Determine the optimal care setting using severity of illness scores and clinical judgment 6
For COVID-19 pneumonia:
Until a diagnosis of COVID-19 is confirmed by polymerase chain reaction or antigen test, administer appropriate
antimicrobial therapy for other viral pathogens (eg, influenza virus) or bacterial pathogens in accordance with the severity of
clinical disease, site of acquisition (hospital or community), epidemiologic risk factors, and local antimicrobial susceptibility
patterns 18
WHO 18 , NIH 38 , and Surviving Sepsis Campaign 39 provide specific guidance for oxygenation, ventilation, and fluid
management in COVID-19
Current standard treatment options include infection control measures, routine supportive care, and medications including
antiviral, monoclonal antibody, immunomodulator, and corticosteroid drugs (Related: Coronavirus: Novel Coronavirus
(COVID-19) Infection)
Antivirals and monoclonal antibodies directed at viral components are most effective when used early in the course of
infection (to prevent cell entry and viral replication); antiinflammatory drugs (eg, dexamethasone) and immunomodulators
are of most benefit during the hyperinflammatory response in later phases of severe disease
At present, in the absence of a standard indication for it, published guidelines do not recommend therapeutic anticoagulation
but do suggest or recommend use of usual prophylactic regimens in any hospitalized patient with COVID-19, including
pregnant patients 18 38 39 40 41 42
For non-COVID-19 pneumonias: begin empiric therapy based on treatment setting; in patients admitted to the hospital, give
first antimicrobial dose before patient leaves emergency department
Outpatient treatment
First line therapy for patients without comorbidities or risk factors for antibiotic-resistant pathogens includes amoxicillin
or doxycycline or a macrolide (only in areas with pneumococcal resistance to macrolides less than 25%) 6
For outpatient adults with the following comorbidities, antibiotic options include combination therapy or monotherapy 6
Comorbidities include: 6
Chronic heart, lung, liver, or renal disease
Diabetes mellitus
Alcohol use disorder
Active malignancy
Asplenia
Combination therapy 6
Amoxicillin-clavulanate or a cephalosporin (eg, cefpodoxime, cefuroxime), and
Macrolide or doxycycline
Monotherapy 6
Respiratory fluoroquinolone
Consider administering treatment (eg, oseltamivir) to patients with positive test results for influenza, independent of
duration of illness before diagnosis 6
General ward inpatient treatment (nonsevere community-acquired pneumonia without risk factors for MRSA, Pseudomonas
aeruginosa, or resistant gram-negative bacilli) 6
Monotherapy with an appropriate respiratory fluoroquinolone, or 6 43
A β-lactam plus a macrolide may be used 6 43
Doxycycline may be used in place of a macrolide 6
A systematic review showed either monotherapy with a respiratory quinolone or combination therapy with a β-lactam plus
a macrolide to be superior to β-lactam monotherapy in patients requiring hospitalization 44
Administer treatment (eg, oseltamivir) to patients with positive test results for influenza, independent of duration of illness
before diagnosis; because patients with influenza often have concurrent bacterial infection, administer recommended
antibacterial antibiotics, pending culture results 6
2019 guidelines recommend clinicians only cover empirically for MRSA or Pseudomonas aeruginosa in adults with
community-acquired pneumonia if locally validated risk factors for either pathogen are present. Infectious Diseases Society
of America guidelines do not recommend empiric coverage (pending culture results) for these organisms based on
individual risk factors in patients with nonsevere pneumonia 6
Empiric treatment options for MRSA include vancomycin or linezolid 6
Empiric treatment options for Pseudomonas aeruginosa include piperacillin-tazobactam, cefepime, ceftazidime,
aztreonam, meropenem, or imipenem 6
ICU inpatient treatment (severe community-acquired pneumonia without risk factors for MRSA or Pseudomonas aeruginosa)
6
β-lactam plus a macrolide 6
Alternatively, a β-lactam plus a respiratory fluoroquinolone may be used 6
Administer treatment (eg, oseltamivir) to patients with positive test results for influenza, independent of duration of illness
before diagnosis; because concurrent bacterial infection is common with influenza, administer recommended antibacterial
antibiotics, pending culture results 6
2019 American Thoracic Society and Infectious Diseases Society of America guidelines recommend clinicians only cover
empirically for MRSA or Pseudomonas aeruginosa in adults with community-acquired pneumonia if locally validated risk
factors for either pathogen are present. In the absence of these, clinicians may treat patients with severe pneumonia
empirically for these pathogens when there is a history of recent (90 days) hospitalization and parenteral antibiotic
treatment or documented past infection with these pathogens. De-escalate antibiotics if indicated by culture results 6
Empiric treatment options for MRSA include vancomycin or linezolid 6
Empiric treatment options for Pseudomonas aeruginosa include: 6
Piperacillin-tazobactam
Cefepime
Ceftazidime
Aztreonam
Meropenem
Imipenem
General considerations
2019 guidelines recommend that duration of antibiotic therapy be guided by a validated measure of clinical stability.
Continue antibiotic therapy until the patient achieves stability and for no fewer than a total of 5 days 6
Indicators of clinical stability: 45
Temperature of 37.8 °C or lower
Heart rate of 100 beats per minute or fewer
Respiratory rate of 24 breaths per minute or fewer
Systolic blood pressure of 90 mm Hg or higher
Arterial oxygen saturation of 90% or higher or PO₂ of 60 mm Hg or higher on room air
Ability to maintain oral intake
Normal mental status
Most patients will achieve clinical stability within the first 48 to 72 hours; thus, a total duration of therapy of 5 days should be
appropriate for most patients 6
2019 guidelines suggest duration of therapy for community-acquired pneumonia due to suspected or proven MRSA
or Pseudomonas aeruginosa should be 7 days 6
Other pathogens or clinical circumstances may require a longer duration:
Initial therapy is not effective against identified pathogen 6
Staphylococcus aureus lobar pneumonia (2 weeks) 29
Staphylococcus aureus bacteremia (4 weeks, IV) 29
Mycoplasma pneumoniae or Chlamydia pneumoniae (10-14 days) 29
Legionella (14-21 days) 29

Complications caused by extrapulmonary infections (eg, meningitis, endocarditis) 6
If there is no improvement within 72 hours of initiation of the empiric treatment, there may be drug resistance, an
unsuspected pathogen, or unrecognized complications (eg, endobronchial obstruction, empyema)
When culture and antibiotic susceptibility results are available, adjust antibiotics to specific, narrow-spectrum therapy 6
Treatment can be switched from IV to oral once hemodynamic stability and clinical improvement are seen 6
Use of adjunctive corticosteroids remains controversial and clinical studies have produced conflicting reports. They may be
considered in some cases of severe pneumonia, particularly with septic shock 6 29 43
2019 Infectious Diseases Society of America guidelines recommend not routinely using corticosteroids in adults with
nonsevere community-acquired pneumonia and suggest not routinely using corticosteroids in adults with
severe community-acquired pneumonia or severe influenza pneumonia 6
2019 Infectious Diseases Society of America guidelines endorse the Surviving Sepsis Campaign recommendations 46 on the
use of steroids in patients with septic shock refractory to adequate fluid resuscitation and vasopressor support 6
Drug therapy
Antibiotics 12
Macrolides
First line therapy for outpatient treatment; used in combination with other antibiotics in the inpatient setting
Azithromycin
Azithromycin Oral tablet; Outpatient Adults: 500 mg PO on day 1, followed by 250 mg PO once daily for at least 5 days.
Azithromycin Oral tablet; Hospitalized Adults: 500 mg PO once daily for at least 5 days.
Azithromycin Solution for injection; Adults: 500 mg IV once daily for at least 5 days.
Clarithromycin
Clarithromycin Oral tablet; Adults: 500 mg PO every 12 hours for at least 5 days.
Tetracyclines
Acceptable alternative to macrolides
Doxycycline
Doxycycline Hyclate Oral tablet; Adults: 100 mg PO every 12 hours for at least 5 days.
Doxycycline Hyclate Solution for injection; Adults: 100 mg IV every 12 hours for at least 5 days.
Quinolones
Respiratory quinolones (ie, gemifloxacin, moxifloxacin, levofloxacin, delafloxacin) are first line outpatient therapy for
patients with community-acquired pneumonia who are at risk for multidrug-resistant Streptococcus pneumoniae
Gemifloxacin
Gemifloxacin Oral tablet; Adults: 320 mg PO once daily for at least 5 days.
Moxifloxacin
Moxifloxacin Hydrochloride Oral tablet; Adults: 400 mg PO once daily for at least 5 days.
Moxifloxacin Hydrochloride Solution for injection; Adults: 400 mg IV once daily for at least 5 days.
Levofloxacin
Levofloxacin Oral tablet; Adults: 750 mg PO every 24 hours for at least 5 days.
Levofloxacin Solution for injection; Adults: 750 mg IV every 24 hours for at least 5 days.
Delafloxacin
Delafloxacin Oral tablet; Adults: 450 mg PO every 12 hours for 5 to 10 days.
Delafloxacin Solution for injection; Adults: 300 mg IV every 12 hours for 5 to 10 days.
Penicillins
Frequently used in combination regimens in both outpatient and inpatient settings
Amoxicillin
Amoxicillin Trihydrate Oral tablet; Adults: 1 g PO every 8 hours for at least 5 days.
Amoxicillin-clavulanate
Amoxicillin Trihydrate, Clavulanate Potassium Oral tablet; Adults: 875 mg amoxicillin with 125 mg clavulanate PO
every 12 hours or 500 mg amoxicillin with 125 mg clavulanate PO every 8 hours for at least 5 days.
Amoxicillin Trihydrate, Clavulanate Potassium Oral tablet, extended-release; Adults: 2,000 mg amoxicillin with 125
mg clavulanate PO every 12 hours for at least 5 days.
Ampicillin-sulbactam
Ampicillin Sodium, Sulbactam Sodium Solution for injection; Adults: 1.5 g (1 g ampicillin and 0.5 g sulbactam) or 3 g
(2 g ampicillin and 1 g sulbactam) IV every 6 hours for at least 5 days.
Piperacillin-tazobactam
Piperacillin Sodium, Tazobactam Sodium Solution for injection; Adults: 4.5 g (4 g piperacillin and 0.5 g tazobactam) IV
every 6 hours for at least 7 days.
Cephalosporins
Frequently used in combination regimens in both outpatient and inpatient settings
Cefuroxime
Cefuroxime Axetil Oral tablet; Adults: 500 mg PO every 12 hours for at least 5 days.
Cefpodoxime
Cefpodoxime Proxetil Oral tablet; Adults: 200 mg PO every 12 hours for at least 5 days.
Ceftriaxone
Ceftriaxone Sodium Solution for injection; Adults: 1 to 2 g IV every 24 hours for at least 5 days.
Cefotaxime
Cefotaxime Sodium Solution for injection; Adults: 1 to 2 g IV every 8 hours for at least 5 days.
Ceftaroline
Ceftaroline fosamil Solution for injection; Adults: 600 mg IV every 12 hours for at least 5 days.
Cefepime
Cefepime Hydrochloride Solution for injection; Adults: 2 g IV every 8 hours for at least 7 days.
Ceftazidime
Ceftazidime Sodium Solution for injection; Adults: 2 g IV every 8 hours for at least 7 days.
Carbapenems
Used in combination regimens in the inpatient and ICU settings to manage seriously ill patients with community-
acquired pneumonia; imipenem-cilastatin and meropenem also provide coverage for suspected Pseudomonas infection
Imipenem-cilastatin
Imipenem, Cilastatin Sodium Solution for injection; Adults: 500 mg IV every 6 hours for at least 7 days.
Meropenem
Meropenem Solution for injection; Adults: 1 g IV every 8 hours for at least 7 days.
Monobactams
Used in combination regimens in the inpatient and ICU settings to manage seriously ill patients with community-
acquired pneumonia who are allergic to penicillin
Aztreonam
Aztreonam Solution for injection; Adults: 2 g IV every 8 hours for at least 7 days.
Glycopeptides
Used for the treatment of MRSA and penicillin-resistant pneumococci
Vancomycin
Vancomycin Hydrochloride Solution for injection; Adults: 20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose,
followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for at least 7 days; adjust dose based on target PK/PD
parameter. Consider loading dose in critically ill patients.
Oxazolidinones
Used for the treatment of infections due to aerobic gram-positive bacteria, including MRSA and penicillin-resistant
pneumococci
Linezolid
Linezolid Oral tablet; Adults: 600 mg PO every 12 hours for at least 7 days.
Linezolid Solution for injection; Adults: 600 mg IV every 12 hours for at least 7 days.
Pleuromutilin
Lefamulin 47
First-in-class antibiotic approved to treat community-acquired pneumonia
Lefamulin Oral tablet; Adults: 600 mg PO every 12 hours for 5 days.
Lefamulin Solution for injection; Adults: 150 mg IV every 12 hours for 5 to 7 days.
Antiviral agents 12 48
Antiviral agents are recommended for patients with confirmed or suspected influenza who have severe, complicated, or
progressive illness; who are hospitalized; or who are at high risk for complications, regardless of the time since symptom
onset. Can be considered for previously healthy, symptomatic outpatients not at high risk for influenza complications if
initiated within 48 hours of onset of symptoms
Neuraminidase inhibitors
Oseltamivir
Oseltamivir Phosphate Oral capsule; Adults: 75 mg PO twice daily for 5 days.
Zanamivir
Zanamivir Inhalation powder; Adults: 10 mg by oral inhalation every 12 hours for 5 days.
Peramivir
Peramivir Solution for injection; Adults: 600 mg IV as a single dose.
Polymerase acidic endonuclease inhibitor

Baloxavir 49
Baloxavir Marboxil Oral tablet; Adults weighing less than 80 kg: 40 mg PO as a single dose.
Baloxavir Marboxil Oral tablet; Adults weighing 80 kg or more: 80 mg PO as a single dose.
Nondrug and supportive care

Supplemental oxygen or mechanical ventilation 50
May be required in patients with severe pneumonia or underlying cardiopulmonary disease
Maintain oxygen saturation within 94% to 98% in patients with hypoxemia 43
Respiratory therapy
Postural drainage facilitated by chest percussion may be helpful in patients who have difficulty mobilizing respiratory
secretions
Breathing exercises
Strengthen the chest wall muscles; beneficial particularly to sedentary patients
Help patients mobilize secretions to improve expectoration
Venous thromboembolism prophylaxis 43
Low-molecular-weight heparin is recommended in patients at high risk
Early ambulation is recommended
Smoking cessation 51
Advise patients to quit smoking, using counseling and pharmacologic approaches recommended in tobacco cessation
guidelines and reviews (Related: Tobacco Use Disorder and Smoking Cessation) 51 52
Procedures
Therapeutic thoracentesis
General explanation
Drainage of pleural fluid for therapeutic (versus diagnostic) purposes
Relieves dyspnea caused by a large parapneumonic effusion
Evacuation of purulent fluid is essential for treatment of empyema
Indication
Parapneumonic pleural effusion 13
Fluid more than 5 cm high on the lateral view of an upright chest radiograph or more than 10 mm of fluid on a lateral
decubitus view
Pleural fluid drainage by chest tube is recommended in cases of empyema 53
Pleural fluid pH is less than 7.28
Pleural fluid glucose level is less than 40 mg/dL
Ratio of pleural fluid to serum glucose is less than 0.5
Pleural fluid lactate dehydrogenase level is greater than 1000 units/L
Contraindications
No absolute contraindications
Relative
Uncorrected coagulopathy
Mechanically ventilated patient
Perform bilateral thoracentesis only after ensuring absence of pneumothorax in the first side
Complications 31
Pain at puncture site
Bleeding (eg, hematoma, hemothorax, hemoperitoneum)
Pneumothorax
Re-expansion pulmonary edema
Infection (eg, empyema, soft tissue infection)
Spleen or liver puncture
Vasovagal events
Retained intrapleural catheter fragments
Comorbidities
Patients with comorbid disorders such as neoplastic disease, liver disease, congestive heart failure, cerebrovascular disease, or
renal disease are likely to require hospital admission and IV antibiotics, at least initially
Immunocompromised patients
Prone to multiorganism pneumonia, including unusual pathogens such as cytomegalovirus, Pneumocystis jiroveci, and
fungal infection
Microbiologic diagnosis may require bronchoscopy with biopsy, immunohistology, and quantitative molecular assays
Begin empiric therapy as soon as possible based on epidemiologic history, sputum Gram stain, previous courses of
antimicrobial agents, and historical microbiologic data
Pneumonia caused by SARS-CoV-2 is a prominent feature of COVID-19; clinicians must consider whether treatment for
additional potential causes of community-acquired pneumonia is appropriate 15
Special populations
Older patients
Classic signs and symptoms may be absent or altered in older patients
Presentation may include nonspecific symptoms such as confusion 25
May recover more slowly compared with younger patients
Aspiration is an important risk factor for community-acquired pneumonia in older patients
Pregnant patients
Prone to preterm labor and delivery
Prone to pulmonary edema
Acidosis and hypoxic state are poorly tolerated by the fetus
High risk for severe influenza
Treat with pregnancy-safe antibiotics

Azithromycin or erythromycin with or without ceftriaxone, depending on severity of illness; antiviral neuraminidase
inhibitor for influenza
Antibiotics to be avoided in pregnancy include doxycycline, fluoroquinolones, and clarithromycin
Lefamulin may cause fetal harm when administered during pregnancy; effective contraception use is recommended for
patients of reproductive potential
Monitoring
2019 guidelines recommend against routinely obtaining follow-up chest imaging in adults with community-acquired
pneumonia whose symptoms have resolved within 5 to 7 days 6
In hospitalized patients with confirmed COVID-19, repeated testing may be done to document clearance of virus, defined as 2
consecutive negative results on polymerase chain reaction at least 24 hours apart 37
Complications and Prognosis
Complications
Reduction in breathing capacity requiring mechanical ventilation
Empyema or lung abscess secondary to inadequately treated pleural effusion
Systemic complications (eg, sepsis, meningitis, bacteremia, endocarditis)
Pneumonia may recur in recently treated patients, particularly in high-risk groups (eg, older patients, patients who smoke,
patients who have alcohol use disorder, immunosuppressed patients, patients with bronchopulmonary anatomic
abnormalities)
Prognosis
Outcomes are improved through early diagnosis and timely administration of antibiotics 7 54
Treatment within 4 to 6 hours of hospital arrival reduces mortality
Patients with a CURB-65 1 score of 0 to 1 or a Pneumonia Severity Index risk class of I and II are at low risk of mortality.
Mortality rate is higher in patients with higher scores or risk class
Infections due to Staphylococcus aureus or gram-negative bacilli and aspiration pneumonia are associated with high
mortality rates for all populations
Incorrect diagnosis, comorbidities, inappropriate medication dose or route of administration, presence of an unusual or
unanticipated pathogen, adverse drug reactions, or complications negatively impact prognosis
With COVID-19 pneumonia, patients who require hospital admission often require prolonged inpatient stay (more than 20
days) and experience significant deconditioning. Infection fatality ratio (proportion of deaths among all who are infected,
including confirmed cases, undiagnosed cases, and unreported cases) varies across global locations but has been estimated as
0.15% 9 10 55
Screening and Prevention
Prevention
Tobacco use
Smoking cessation is important for preventing pneumonia, especially in older patients (Related: Tobacco Use Disorder and
Smoking Cessation) 56
Immunization (Related: Immunizations in Adults)
Pneumococcal vaccine
In the United States, 2 formulations have historically been available: PCV13 and PPSV23; in 2021, 20-valent
pneumococcal conjugate vaccine (PCV20) and 15-valent pneumococcal conjugate vaccine (PCV15) were licensed by the
FDA for adults aged 18 years or older 2
Advisory Committee on Immunization Practices recommends PCV15 or PCV20 for adults who have not received
pneumococcal conjugate vaccine, are aged 65 years or older, or are aged 19 to 64 years with certain underlying conditions
2
Adults aged 65 years or older who have not previously received pneumococcal conjugate vaccine or whose earlier
vaccination history is unknown should receive 1 dose of pneumococcal conjugate vaccine (either PCV20 or PCV15) 2
Adults aged 19 to 64 years with certain underlying medical conditions or other risk factors who have not previously
received pneumococcal conjugate vaccine or whose earlier vaccination history is unknown should receive 1 dose of
pneumococcal conjugate vaccine (either PCV20 or PCV15) 2
For both age groups, if PCV15 is used, it should be followed by a dose of PPSV23 at least 1 year later (a minimum
interval of 8 weeks can be considered for adults who have an immunocompromising condition, cochlear implant, or
cerebrospinal fluid leak) 2
For adults who have previously received only PPSV23, pneumococcal conjugate vaccine (either PCV20 or PCV15) may be
administered at least 1 year after their last PPSV23 dose 2
When PCV15 is used in those with a history of receiving PPSV23, it does not need to be followed by another dose of
PPSV23 2
Benefits of providing PCV15 or PCV20 to adults who have received PCV13 only or both PCV13 and PPSV23 have not
been evaluated; in such cases, the previously recommended PPSV23 series should be completed 2
Advisory Committee on Immunization Practices considers the following to be underlying medical conditions or risk
factors for adults in the 19- to 64-year age group: 2
Alcoholism; chronic heart, liver, or lung disease; chronic renal failure; cigarette smoking; cochlear implant; congenital
or acquired asplenia; cerebrospinal fluid leak; diabetes mellitus; generalized malignancy; HIV; Hodgkin disease;
immunodeficiency; iatrogenic immunosuppression; leukemia, lymphoma, or multiple myeloma; nephrotic
syndrome; solid organ transplant; sickle cell disease; or other hemoglobinopathies 2
Yearly influenza vaccination is recommended for all persons 6 months of age and older 3
CDC recommends vaccination against COVID-19 for all persons 5 years of age and older 4
Dental hygiene
Lack of good dental hygiene is a risk factor for community-acquired pneumonia; periodic dental hygiene checks are
recommended
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8/10/23, 21:48 Community-Acquired Pneumonia in Adults - ClinicalKey

Characterized by dry cough and patchy infiltrates

By severity level (and site of care) 6

Pneumonia that can be managed in an outpatient setting

Pneumonia that should be managed with inpatient admission (general ward)

Pneumonia that is severe and should be managed in the ICU

Severe community-acquired pneumonia (either major criteria or 3 or more minor criteria) 6

Need for mechanical ventilation

Septic shock with need for vasopressors

Leukopenia (leukocyte count less than 4000 cells/μL)

Uremia (BUN level of 20 mg/dL or higher)

Hypothermia (core temperature lower than 36 °C)

Thrombocytopenia (platelet count less than 100,000 cells/μL)

Hypotension requiring aggressive fluid resuscitation

Chills, sweating, and/or shivering

Chest pain with inspiration and coughing

Cough (productive or nonproductive)

Fever (typically over 38.1 °C)

Signs of respiratory distress

Tachypnea is a suggestive sign

Tachycardia occurs with fever and with severe disease

Other symptoms that may suggest COVID-19 infection:

Bronchial breath sounds or rales 6

Causes and Risk Factors

Streptococcus pneumoniae (pneumococcus)

Influenza A and B viruses

Respiratory syncytial virus

Risk factors and/or associations

Other risk factors/associations

MRSA, Pseudomonas aeruginosa, resistant gram-negative bacilli

Documented history of infection with these organisms

Chronic obstructive pulmonary disease

Moraxella (Branhamella) catarrhalis

Alcohol use disorder

Poor dental hygiene

Moraxella (Branhamella) catarrhalis

Travel to area of known outbreak within 2 weeks before illness

Exposure to bats or soil enriched with bird droppings

Exposure to farm animals or parturient cats

Chronic kidney disease

Chronic liver disease

Diabetes mellitus, type 1 and type 2

Pregnancy and recent pregnancy

Obesity (BMI of 30 kg/m² or higher)

Smoking, current and former

Mental health disorders (mood disorders and schizophrenia spectrum disorders)

Primary diagnostic tools

Chest radiography or other chest imaging demonstrating an infiltrate confirms the

Pleural effusion and/or a cavitary infiltrate

Identification of a suspected pathogen would significantly alter antibiotic choice

Failure of outpatient treatment

Epidemiologic considerations (eg, outbreaks of public health importance)

Pulse oximetry assesses hypoxemia 13

Serum procalcitonin has been used to discriminate between infectious and

Differentiated by chest radiography and physical examination

Seasonal influenza (Related: Influenza)

Sudden onset of high fever with chills, myalgia, or malaise

History of contact with an infected person

Viral infection present in the winter season