Lectura 4 Nac Dynamed

30/3/2017 DynaMedPlus:Communityacquiredpneumoniainadults
Communityacquiredpneumoniainadults
OverviewandRecommendations
Background
Communityacquiredpneumonia(CAP)isalowerrespiratoryinfectionduetooneormorepathogens
acquiredoutsideofahealthcaresetting,incontrasttopneumoniasacquiredwithinhealthcaresettings,
includinghospitalacquiredpneumoniaandventilatorassociatedpneumonia
Pneumoniaisaleadingcauseofmorbidityandmortalityworldwide.MortalityassociatedwithCAP
rangesfrom4%to12%andvarieswithageandseverityofillness.
TheincidenceofCAPincreaseswithage.
Inpatients<65yearsold,theincidenceis11casesper1,000personyears.
Inpatients>80yearsold,theincidenceincreasesto82casesper1,000personyears.
RiskfactorsforCAPinclude
Chroniccomorbiditiessuchaschroniclung,renal,heartorliverdisease,anddiabetesmellitus,
ortreatmentwithprotonpumpinhibitors.
Behavioralfactorssuchassmokingorhighalcoholconsumption.
Factorsassociatedwithincreasedriskofdrugresistantorganismsincludesevereillness,recent
antibiotictreatmentorhospitalization,poorfunctionalstatus,andimmunosuppression.
CommonpathogensassociatedwithCAPinclude
Streptococcuspneumoniae(seeStreptococcuspneumoniaepneumoniafordetailsspecificto
infectionwiththisorganism).
Atypicalbacteria,includingMycoplasmapneumoniae,Chlamydophilapneumoniae,and
Legionellaspecies(seeLegionellainfectionsfordetailsspecifictoinfectionwiththisorganism).
Viruses,suchasinfluenza,respiratorysyncytialvirus,parainfluenza,andadenovirus.
KeypreventivemeasuresincludevaccinationforinfluenzaandS.pneumoniaeandsmokingcessation
(Strongrecommendation).
Evaluation
Clinicalfeaturesassociatedwithcommunityacquiredpneumonia(CAP)include:
feverandchills,andleukocytosis
cough,increasedsputumproduction,chestpain,anddyspnea
leukocytosisoncompletebloodcount
Assessfordecreasedbreathsounds,crackles,egophony,andtactilefremitusoverlyingareaof
consolidation.
Beawarethatfindingsmaybemoresubtleinsomepatients,suchastheelderly,whomaypresentwith
mentalstatuschangesandminimalrespiratorysymptoms.
Chestimagingshowinginfiltrates,inadditiontosuggestiveclinicalfeatures,isrequiredfordiagnosis
(Strongrecommendation).
Differentialdiagnosisincludeupperrespiratorytractinfections,influenza,bronchitisaspiration
pneumonitisandbronchiectasis,pulmonaryfibrosis,asthmaorCOPDexacerbationsmostare
distinguishedfromCAPbyhistory,physicalexamination,andchestradiograph.
Bloodcultureandsputumculturesarerecommendedforhospitalizedpatientswith,oratriskfor,
severediseaseandcomplicationsculturesshouldbecollectedbeforethestartofantibiotics(Strong
recommendation).
UrinaryantigentestsforStreptococcuspneumoniaeandLegionellapneumophilaserogroup1are
recommendedforpatientswithsevereCAP(Strongrecommendation).
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Additionaltestingforspecificpathogensbasedonclinicalandepidemiologiccluesisrecommendedif
apositiveresultwouldchangemanagementofCAP(Strongrecommendation),suchastestingfor
influenza.
Scoringsystemsandguidelinecriteriahavebeendevelopedtohelppredictshorttermmortalityand
theneedforhospitalorintensivecareunit(ICU)admission.
Thepneumoniaseverityindex(PSI)andCURB65arethemostwellvalidatedandbothare
commonlyused.
PSIhasgreatersensitivity(about90%),butCURB65issimplertouseandhasslightlybetter
specificityforpredicting30daymortality(53%vs.79%).
Management
Recommendationsforantibiotictherapyvarywiththetreatmentsetting,theriskfactorsforsevere
disease,andthelikelihoodofinfectionwithadrugresistantorganism.
Firstlineoptionsforoutpatients:
Ifpatientisotherwisehealthyandwithoutriskfactorsfordrugresistantorganisms
(particularlynohistoryofantibioticuseinprevious3months),eitherof:
amacrolide(Strongrecommendation),suchasazithromycin500mgorallyonce
followedby250mgorallyfordurationoftherapy
doxycycline(Weakrecommendation)100mgorallytwicedaily
Iftherearechroniccomorbidities(suchasdiabetesmellitus,orheart,lung,liver,orrenal
disease),antibioticuseinprevious3months,orinareaswithhighratesofmacrolide
resistantStreptococcuspneumoniae,eitherof:
arespiratoryfluoroquinolone(Strongrecommendation)suchaslevofloxacin750
mgorallyoncedailyormoxifloxacin400mgorallyoncedaily
bothabetalactamandamacrolide(Strongrecommendation)suchasamoxicillin1
gorally3timesdailyplusazithromycin
Firstlineoptionsforinpatients:
Formostinpatients:
arespiratoryfluoroquinolone(Strongrecommendation)suchaslevofloxacin750
mgorallyoncedailyormoxifloxacin400mgorallyoncedaily
bothabetalactamandamacrolide(Strongrecommendation)suchasceftriaxone1
g/dayIVplusazithromycin500mg/day
ForthesuspicionofPseudomonasinfection,considertheuseofanantipneumococcal,
antipseudomonalbetalactamsuchascefepimeorpiperacillintazobactamplusa
quinolonesuchaslevofloxacinorciprofloxacin(Strongrecommendation).
ForthesuspicionofmethicillinresistantStaphylococcusaureus(MRSA),considerthe
additionofvancomycinorlinezolid(Strongrecommendation).
Forthesuspicionofinfluenzainpatientsatriskforadverseoutcomes,considerthe
additionofoseltamivir.
Treatpatientsforaminimumof5days(Strongrecommendation)oruntiltheyareclinically
stableandafebrilefor4872hours(Strongrecommendation).
Longercourses(typically2weeks)areneededforinfectionswithMRSAorPseudomonasorin
patientswithcomplicationssuchasbacteremia(Weakrecommendation).
Antiviralsmaybeappropriateinpatientswithconfirmedorsuspectedinfluenza,particularlyin
patientswhohavesevere,complicated,orprogressiveillness,orotherwiserequirehospitalization.
Mechanicalventilationmayberequiredinpatientswithseverecommunityacquiredpneumoniaor
respiratoryfailure
Beawareofcomplicationssuchasparapneumoniceffusionorempyema,sepsis,andcardiac
complicationssuchasheartfailure,cardiacarrhythmiasandmyocardialinfarction.Fordetailson
managingsuchcomplications,pleasesee
Parapneumoniceffusionandempyemainadults
SepsisinadultsandSepsistreatmentinadults
RelatedSummaries
Pneumonia(listoftopics)
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Pneumoniaseverityassessment
Antibioticsforadultoutpatientswithcommunityacquiredpneumonia
Antibioticsforadultinpatientswithcommunityacquiredpneumonia
Streptococcuspneumoniaepneumonia
Hospitalacquiredpneumonia
Ventilatorassociatedpneumonia
Aspirationpneumonia
Coccidioidomycosis
GeneralInformation
Description
lunginfectionduetoapathogenacquiredoutsideofahealthcaresetting(4)
Epidemiology
Incidence/Prevalence
in2012,lowerrespiratorytractinfectionsestimatedtoaccountfor3.1milliondeathsglobally
amongtop3causesofdeathworldwide
mostcommoninfectiouscauseofdeathworldwide
ReferenceWorldHealthOrganizationFactSheet
incidencepeaksinwintermonths(4)
UnitedStates
in20092010,pneumoniaintheUnitedStatesaccountedfor
2,250,000primarycarephysicianofficevisits
0.4%ofallambulatorycarevisits
1.128millionhospitaldischargesintheUnitedStatesin2010(36.6per10,000
population)
ReferenceCentersforDiseaseControlandPreventionFastStatsonPneumoniaand
PhysicianVisits,NationalHospitalDischargeSurvey2010PDF,NationalAmbulatory
MedicalCareSurveyPDF
24.8per10,000personsannualincidenceofcommunityacquiredpneumoniarequiring
hospitalizationamongadultsintheUnitedStates,withincreasedincidenceamongadults
aged65years
basedonpopulationbasedsurveillance
5hospitalsinChicagoandNashvilleweremonitoredforhospitalizationofadults18
yearsoldfromJanuary2010toJune2012
2,320casesofcommunityacquiredpneumoniarequiringhospitalizationwereassessed
exclusioncriteriaincludedrecenthospitalization(<28daysinpatientswithout
immunosuppression,<90daysinpatientswithimmunosuppression),residenceinlong
termcarefacility,orcomorbidimmunosuppressivedisorders
annualincidenceofcommunityacquiredpneumonia
24.8casesper10,000personsoverall
63casesper10,000personsaged6579yearsold
164.3casesper10,000personsaged80years
ReferenceEPICstudy(NEnglJMed2015Jul30373(5):415)
10.6per1,000personyearsincidenceofcommunityacquiredpneumoniaamongworking
ageadultsintheUnitedStates
basedonretrospectivecohortstudy
insurancerecordsof12,502,017adults64yearsoldwerereviewed
allpatientswereparticipantsinemployerprovidedhealthinsuranceprograms
overallincidenceofcommunityacquiredpneumoniawas10.6per1,000personyears
19.5%treatedasinpatients
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ReferenceAmHealthDrugBenefits2013Sep6(8):494EBSCOhostFullTextfulltext
44.82per1,000personyearsincidenceofcommunityacquiredpneumoniaamongadult
participantsinMedicareintheUnitedStatesin20072008
65,804casesofcommunityacquiredpneumoniawereidentifiedinanalysisof20072008
MedicareStandardAnalyticFiles(nationallyrepresentativerandomsampleofthe
approximately35.2millionMedicareenrollees)
overallincidenceofcommunityacquiredpneumoniawas44.82per1,000personyears
39%treatedasinpatients
ReferenceJAmGeriatrSoc2012Nov60(11):2137EBSCOhostFullText
hospitalizationandcasefatalityratesfrompneumoniavariedaccordingtoinfectious
organisminUnitedStatesfrom2002to2011
dischargedataforpatients18yearsoldwithprincipaldiagnosisofpneumoniabetween
2002and2011inUnitedStateswereevaluatedfortemporaltrendsinhospitalizationand
casefatalityratesbasedoncausalagent
hospitalizationratesper100,000population
19.2forStaphylococcusaureus
12.6forpneumococcus
11forPseudomonasspecies
9forinfluenzavirus
3.6forKlebsiellaspecies
2.7forHaemophilusinfluenzae
casefatalityratesper100cases
15.6forS.aureus
14.3Klebsiellaspecies
12.1Pseudomonasspecies
6.6forpneumococcus
4.9forH.influenzae
3.5influenzavirus
from2002to2011
hospitalizationratesincreasedsignificantlyforinfluenzavirus(by123%),
Klebsiellaspecies(by35%),Pseudomonasspecies(by23%),andS.aureus(by
23%)anddecreasedsignificantlyforH.influenzae(by42%)andpneumococcus(by
23%)
casefatalityratesincreasedsignificantlyforinfluenzavirus(by67%)and
decreasedsignificantlyforS.aureus(by32%)andpneumococcus(by18%)
ReferenceEmergInfectDis2016Sep22(9):1624EBSCOhostFullTextfulltext
pneumoniahospitalizationratesincreasedwithageamongUnitedStateselderlyin2000
2002
basedonanalysisofNationalHospitalDischargeSurvey
ratesper1,000populationforfirstlisteddiagnosisofpneumonia
12atage6574years(95%CI1113)
51atage85yearsandolder(95%CI4655)
ratesper1,000populationforanylisteddiagnosisofpneumonia
82atage85yearsandolder(95%CI7588)
20002002ratesincreasedsince19881990
ReferenceJAMA2005Dec7294(21):2712EBSCOhostFullText,editorialcanbefound
inJAMA2005Dec7294(21):2760EBSCOhostFullText,commentarycanbefoundin
JAMA2006May10295(18):2137EBSCOhostFullText
hospitalizationsforallcausepneumoniaappeartohavedecreasedintheelderlysince
introductionof7valentpneumococcalvaccineinUnitedStates
NationwideInpatientSampledatabaseinUnitedStateswasassessedforhospitalizations
duetofirstlistedallcausepneumoniadiagnosispriorto7valentpneumococcalconjugate
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vaccine(PCV7,19971999)vs.10yearsfollowingintroductionofPCV7vaccine(2007
2009)
comparingannualhospitalizationrateforallcausepneumoniabeforevs.afterPCV7
vaccine
1,293vs.1,208per100,000patientsaged6574years(6.6%decrease,95%CI
0.5%to13%)
2,758vs.2,398per100,000patientsaged7584years(13%decrease,95%CI7%
to19%)
5,697vs.4,396per100,000patientsaged85years(23%decrease,95%CI17%
to28%)
ReferenceNEnglJMed2013Jul11369(2):155
Europe
256.3per100,000populationannualincidenceofhospitalizationforpneumoniain
northeastItalyfrom2004to2012
110,927hospitalizationsforpneumoniawerereviewed
overallannualincidenceofhospitalizationforpneumonia256.3per100,000population
amongchildrenaged04years,incidencedeclinedfrom617.3per100,000in2004to
451.8per100,000in2012(annualadjustedpercentagechange2.5%,95%CI4.5to
0.5)
overallpneumoniarelatedmortality10.7%
ReferenceBMCInfectDis2014Sep514(1):485EBSCOhostFullTextfulltext
Riskfactors
Riskfactorsfordevelopmentofpneumonia
smoking,alcoholconsumption,householdsize,andcomorbiditiesinfluenceriskofcommunity
acquiredpneumoniainadults
basedonsystematicreview
systematicreviewof60observationalstudiesevaluatingincidenceofandriskfactorsfor
communityacquiredpneumoniainEurope
annualincidencerangedfrom1.07to1.2per1,000personyears(14per1,000personyearsin
adultsaged65years)
lifestylefactorsassociatedwithcommunityacquiredpneumoniain12casecontrolstudies
factorsassociatedwithincreasedrisk
currentorformersmoking
consumptionof>80gramsalcohol/day,orhistoryofalcoholabuse
underweight
householdsize>10individuals
regularcontactwithchildren
frequentvisitstogeneralpractitioner
factorsassociatedwithdecreasedrisk
recentdentalcare
overweight
consumptionof40galcohol/day
frequencyofcomorbidconditionsinadultswithcommunityacquiredpneumonia
previouspneumoniain3.2%33.8%of10cohorts
chronicrespiratorydiseasein9.7%68%of25cohorts
chronicobstructivepulmonarydisorderin9.4%62%of21cohorts
asthmain3%50%of9cohorts
chronicheartdiseasein10%47.2%of23cohorts
heartfailurein1%46%of27cohorts
diabetesmellitusin4.9%33%of48cohorts
cerebrovasculardiseaseorstrokein3.2%33%of26cohorts
dementiain1.1%33.6%of12cohorts
cancerin4.3%18%of33cohorts
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chronicliverdiseasein0.3%20%of36cohorts
chronicrenaldiseasein0.5%26.7%of39cohorts
ReferenceThorax2013Nov68(11):1057fulltext
inconsistentevidenceforgastricacidsuppressivetherapyandriskofcommunityacquiredpneumonia
incidenceofCAPmaybehigherinpatientstakingPPIsthaninpatientsnottakingPPIs,
butincreasedriskofCAPinthesepatientsappearstopredatestartofPPItreatment
basedoncohortstudy
160,000adultpatientsstartingprotonpumpinhibitor(PPI)treatmentwerematchedto
160,000personswithoutPPIexposure
mediandurationofPPItreatment28days
communityacquiredpneumonia(CAP)broadlydefinedbyReadcodesforchestinfection
andlowerrespiratorytractinfection
PPIexposureassociatedwithincreasedincidenceofCAPcomparedtonoexposure
(adjustedhazardratio[HR]1.67,95%CI1.551.70)
indexdatewasdateoffirstPPIexposurewithmatchingdateforunexposedpersons
CAPincidencecomparingexposedpatientsvs.unexposedpatients
beforePPIprescription6%vs.2.7%(HR2.26,95%CI2.182.35)
afterPPIprescription5.45%vs.2.8%(HR2.06,95%CI1.982.14)
patientswithPPIexposurehadhigherratesofsmokingandalcoholuse,higherratesof
corticosteroidandopioidprescriptions,andmorecomorbidities
ReferenceBMJ2016Nov16355:i5813fulltext
shortdurationprotonpumpinhibitorsassociatedwithhigherriskofcommunityacquired
pneumonia
basedonsystematicreviewofcasecontrolstudies
systematicreviewof6nestedcasecontrolstudiesevaluatingassociationbetween
outpatientprotonpumpinhibitor(PPI)useandriskofcommunityacquiredpneumoniain
972,827adults
PPIassociatedwithincreasedriskofcommunityacquiredpneumonia(oddsratio[OR]
1.36,95%CI1.121.65)inanalysisof6studies
insubgroupanalysis
shortdurationPPIuseassociatedwithincreasedriskofcommunityacquired
pneumonia(OR1.92,95%CI1.402.63)inanalysisof5studies
chronicPPIusenotassociatedwithincreasedriskofcommunityacquired
pneumonia(OR1.11,95%CI0.91.38)inanalysisof5trials
ReferenceAlimentPharmacolTher2010Jun31(11):1165EBSCOhostFullText
PPIuseassociatedwithincreasedriskofhospitalizationforpneumonia
185,533Australianveterans65yearsoldwithhistoryof1medicationprescriptionin
previous6monthswerereviewed
inmultivariateanalysis,PPIexposureassociatedwith
increasedriskofhospitalizationforpneumonia(rateratio[RR]1.16,95%CI1.11
1.22)
increasedriskofantibioticprescriptions(RR1.23,95%CI1.211.24)
PPInotassociatedwithincreasedriskofhospitalizationforbacterialpneumonia
ReferenceMedJAust2009Feb2190(3):114
Riskfactorsforinfectionwithlesscommonorpotentiallymultidrugresistant(MDR)organisms
riskfactorsforinfectionwithMDRorganismsinclude(1,2)
severeillness
recenttreatmentwithantibiotics
recenthospitalization
poorfunctionalstatus
immunosuppression
riskfactorsforinfectionwithPseudomonasaeruginosainclude(1,2)
structurallungdisease,suchaschronicobstructivepulmonarydisorder
alcoholism
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historyofmultiplecoursesofantibiotictreatment
longtermtreatmentwithoralsteroids
riskfactorsforinfectionwithmethicillinresistantStaphylococcusaureusinclude
contactwithinfectedindividuals
cirrhosis
residenceinnursingorlongtermcarefacility
longtermdialysis(2)
riskfactorsforhealthcareassociatedpneumonia(HCAP),whichincludescommunityacquired
pneumoniainindividualswithrecentorsignificantcontactwithhealthcareorlongtermcare
environment
morethan2riskfactorsincludingsevereillness,recentantibiotictreatment,recent
hospitalization,poorfunctionalstatus,andimmunosuppressionassociatedwithincreased
ratesofMDRinfectioninpatientswithHCAP(level2[midlevel]evidence)
basedonprospectivecohortstudy
445patientswithpneumoniawereassessedandtreatedusingatherapeuticalgorithm
basedonpresenceofriskfactorsforMDRpathogens
124patientshadcommunityacquiredpneumoniaand321patientshadhealthcare
associatedpneumonia(HCAP)
highriskpatientsdefinedasHCAPpatientswith2MDRpathogenriskfactors
diseaseseverity,basedonneedformechanicalventilationorintensivecareunit
(ICU)admission
recentantibiotictreatment
recenthospitalization
poorfunctionalstatus
immunosuppression
MDRpathogensidentifiedin27.1%HCAPpatientswith2riskfactorsvs.2%ofHCAP
patientswith01riskfactor(p<0.001)
ReferenceClinInfectDis2013Nov57(10):1373EBSCOhostFullText
healthcareassociatedpneumoniadefinitionmayprovidepoorpredictionofpatientsinfected
withpotentiallyresistantmicroorganisms(ClinInfectDis2014Feb58(3):330EBSCOhostFull
Textfulltext,commentarycanbefoundinClinInfectDis2014Apr58(8):1196EBSCOhost
FullText)
historyofPseudomonasaeruginosainfectionorcolonization,residenceinnursinghome,and
historyofantibioticuseorhospitalizationassociatedwithincreasedriskofpneumoniadueto
multidrugresistantorganisms
521patientswithcommunityonsetpneumoniabetween2010and2011werereviewed,
including263patientswithcommunityacquiredpneumoniaand258patientshealthcare
associatedpneumonia
3.8%prevalenceofinfectionwithmultidrugresistant(MDR)organisms
factorsassociatedwithincreasedriskofMDRorganismsinfectioninmultivariateanalysis
previouscolonizationorinfectionwithP.aeruginosa(oddsratio[OR]7.43,95%CI2.24
24.61)
admissionfromnursinghome(OR4.19,95%CI1.5511.31)
antibioticuseinprior90dayperiod(OR2.9,95%CI1.137.45)
longerdurationofhospitalizationinprevious90dayperiod(OR1.06,95%CI1.011.1)
longerdurationofhospitalizationinprevious180dayperiod(OR1.04,95%CI1.02
1.07)
patientsmeetingdefinitionofhealthcareassociatedpneumoniawerenotatincreasedriskof
infectionwithMDRorganismsinmultivariateanalysis
ReferenceAntimicrobAgentsChemother2014Sep58(9):5262
cirrhosis,historyofmethicillinresistantStaphylococcusaureus(MRSA)infection,closecontact
withindividualswithskininfections,andadmissiontonursinghomeorlongtermcare
associatedwithincreasedriskofMRSAcommunityacquiredpneumonia
627patientshospitalizedwithcommunityacquiredpneumoniain20062007wereassessed
14patients(2.4%)hadcommunityacquiredpneumoniaduetoMRSAinfection
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factorsassociatedwithMRSAetiologyofcommunityacquiredpneumonia
underlyingcirrhosis(relativerisk[RR]8.1,95%CI2.126)
historyofMRSAinfection(RR7.6,95%CI1.927)
closecontactwithanindividualhavingaskininfectionwithinpreviousmonth(RR5.1,
95%CI1.318)
admissiontonursinghomeorlongtermcarewithinpreviousyear(RR5,95%CI1.516)
ReferenceClinInfectDis2012Apr54(8):1126EBSCOhostFullText,editorialcanbefoundin
ClinInfectDis2012Apr54(8):1134EBSCOhostFullText
Pathogensassociatedwithspecificcomorbiditiesorexposures
ComorbiditiesRelatedtoSpecificPathogensinCommunityacquiredPneumonia(2):
ComorbidCondition AssociatedMicrobialPathogens
Streptococcuspneumoniae
Oralanaerobes
Alcoholism Klebsiellapneumoniae
Acinetobacterspecies
Mycobacteriumtuberculosis
Haemophilusinfluenzae
Pseudomonasaeruginosa
Chronicobstructivepulmonarydiseaseand/or Legionellaspecies
smoking S.pneumoniae
Moraxellacatarrhalis
Chlamydophilapneumoniae
Gramnegativeentericpathogens
Aspiration
Oralanaerobes
Communityacquiredmethicillinresistant
Staphylococcusaureus
Oralanaerobes
Lungabscess
Endemicfungalpneumonia
M.tuberculosis
Atypicalmycobacteria
S.pneumoniae
HIVinfection(early) H.influenzae
M.tuberculosis
S.pneumoniae
H.influenzae
M.tuberculosis
Pneumocystisjiroveci
Cryptococcusspecies
HIVinfection(late)
Histoplasmaspecies
Aspergillusspecies
Atypicalmycobacteria(especially
Mycobacteriumkansasii)
P.aeruginosa
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ComorbidCondition AssociatedMicrobialPathogens
Anaerobes
S.pneumoniae
Endobronchialobstruction
H.influenzae
S.aureus
P.aeruginosa
Structurallungdisease(forexample,bronchiectasis) Burkholderiacepacia
S.aureus
S.aureus
Anaerobes
Injectiondruguse
M.tuberculosis
S.pneumoniae
ExposuresRelatedtoSpecificPathogensinCommunityacquiredPneumonia(2):
Exposures AssociatedMicrobialPathogens
Batorbirddroppings Histoplasmacapsulatum
Chlamydophilapsittaci
Birds
Ifpoultry:avianinfluenza
Rabbits Francisellatularensis
Farmanimalsorparturientcats Coxiellaburnetii(Qfever)
Hotelorcruiseshipstayinprevious2weeks Legionellaspecies
Coccidioidesspecies
TraveltoorresidenceinsouthwesternUnitedStates
Hantavirus
Burkholderiapseudomallei
TraveltoorresidenceinSoutheastandEastAsia Avianinfluenza
Severeacuterespiratorysyndrome(SARS)
Influenza
Influenzaactiveincommunity
seeStreptococcuspneumoniaepneumoniafordetailsonriskfactorsassociatedwiththatpathogen
seeLegionellainfectionsfordetailsonriskfactorsassociatedwiththatpathogen
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EtiologyandPathogenesis
Pathogen
Commonpathogens
mostcommoncausesofcommunityacquiredpneumonia(2)
respiratoryviruses(influenzaAandB,rhinovirus,humanmetapneumovirus,respiratory
syncytialvirus,parainfluenza,andadenovirus)
Mycoplasmapneumoniae
Chlamydiapneumoniae
Legionellaspecies
gramnegativebacilli
respiratoryvirusesmostfrequentlydetectedpathogensamongUnitedStatesadultshospitalized
withcommunityacquiredpneumonia
2,259patientswithcommunityacquiredpneumoniaat5hospitalsinChicagoandNashville
fromJanuary2010toJune2012
966pathogenswereidentifiedin853(38%)ofpatients,including
singleviralpathogenin22%
singlebacterialpathogenin11%
bacterialviralpathogensincombinationin3%
2viralpathogensin2%
fungalormycobacterialinfectionin1%
organismsidentifiedincluded
humanrhinovirusin194patients(8.9%)
influenzaAorBin132patients(5.8%)
Streptococcuspneumoniaein115patients(5.1%)
humanmetapneumovirusin88patients(3.9%)
respiratorysyncytialvirusin68patients(3%)
parainfluenzavirusin67patients(3%)
coronavirusin53patients(2.3%)
Mycoplasmapneumoniaein43patients(1.9%)
Staphylococcusaureusin37patients(1.6%)
adenovirusin32patients(1.4%)
Legionellapneumophilain32patients(1.4%)
Enterobacteriaceaein31patients(1.4%)
otherorganismsin74patients(3.2%)
ReferenceEPICstudy(NEnglJMed2015Jul30373(5):415)
S.pneumoniaeandrespiratoryvirusesmostfrequentlydetectedpathogensinpatientswith
communityacquiredpneumonia
184patientshospitalizedforcommunityacquiredpneumoniain20042005inSwedenwere
assessed
patientsamplesevaluatedusingculture,polymerasechainreaction(PCR),serology,andurine
antigenassays
definiteorprobableetiologyidentifiedin124patients(67%)
bacterialetiologyin58%
S.pneumoniaein38%
M.pneumoniaein8.2%
H.influenzaein4.9%
Moraxellacatarrhalisin3.8%
viraletiologyin29%
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influenzavirusin7.6%
rhinovirusin6.5%
respiratorysyncytialvirusin3.8%
parainfluenzavirusin3.8%
coronavirusin2.2%(membersincludesevereacuterespiratorysyndrome(SARS)and
MiddleEastrespiratorysyndromecoronavirus(MERSCoV))
metapneumovirusin2.2%
ReferenceClinInfectDis2010Jan1550(2):202EBSCOhostFullTextfulltext
Bacterialpathogens
S.pneumoniaestimatedtocauseabout27%ofcasesofcommunityacquiredpneumonia
worldwide
basedonasystematicreviewof35studiesinmostlydevelopedcountrieswithdatato
assessburdenofpneumococcaldisease
27.3%ofcommunityacquiredpneumoniacasesattributedtopneumococcus
75%ofpneumococcalpneumoniacasesestimatedtobenonbacteremic
ReferencePLoSOne20138(4):e60273EBSCOhostFullTextfulltext
forfurtherdetail,seeincidence/prevalenceorpathogeninS.pneumoniaepneumonia
Staphylococcusaureusidentifiedin1.6%ofpatientswithcommunityacquiredpneumonia,
including0.7%withmethicillinresistantS.aureus
2,259adultshospitalizedwithcommunityacquiredpneumoniafromJanuary2010toJune
2012inEPICstudywereassessed
37patients(1.6%)hadcommunityacquiredpneumoniaduetoS.aureus
15patients(0.7%)hadcommunityacquiredpneumoniaduetomethicillinresistant
S.aureus
22patients(1%)hadcommunityacquiredpneumoniaduetomethicillinsensitiveS.
aureus
29.8%ofallpatientshadantiMRSAantibiotics(vancomycinorlinezolid)withinfirst3
daysofhospitalization
MRSAinfectionassociatedwithlongerhospitalstayandhigherinhospitalmortality
comparedtomethicillinsusceptibleS.aureus(MSSA)infectionornonS.aureus
infection(nopvaluesreported)
ReferenceClinInfectDis2016Aug163(3):300
atypicalpathogens
atypicalpathogensaccountfor25%28%ofcommunityacquiredpneumoniaworldwide
4,337patientswithcommunityacquiredpneumoniawerereviewed
28%ofcommunityacquiredpneumoniacasesinEuropeand20%22%inNorthAmerica,
LatinAmerica,Asia,andAfricawereduetoatypicalpathogens
12%duetoMycoplasmapneumoniae
7%duetoChlamydiapneumoniae
5%duetoLegionellapneumophila
ReferenceAmJRespirCritCareMed2007May15175(10):1086
Legionellaspecies
accountfor2%7%ofcommunityacquiredpneumoniaworldwide
reportedincidenceofLegionellainfectionsisrising,butunclearifduetobetterdiagnostic
assays,increasedtesting,agingpopulation,orotherwise
forfurtherdetail,seeincidence/prevalenceorpathogeninLegionellainfections
gramnegativebacilliidentifiedin11%hospitalizedpatientswithcommunityacquired
pneumonia
559consecutivepatientsadmittedtoteachinghospitalwithcommunityacquiredpneumonia
wereassessed
11/58
60(11%)hadgramnegativebacilli(GNB)including39withPseudomonasaeruginosa
GNBassociatedwith3.4timeshighermortality
factorsassociatedwithincreasedriskofinfectionwithGNBinmultivariateanalysis
probableaspiration(oddsratio[OR]2.3,95%CI1.025.2)
previoushospitaladmission(OR3.5,95%CI1.77.1)
previousantibiotics(OR1.9,95%CI1.013.7)
pulmonarycomorbidity(OR2.8,95%CI1.55.5)
factorsassociatedwithP.aeruginosainfectioninsubgroupanalysis
pulmonarycomorbidity(OR5.8,95%CI2.215.3)
previoushospitaladmission(OR3.8,95%CI1.88.3)
ReferenceArchInternMed2002Sep9162(16):1849EBSCOhostFullText
Viralpathogens
viralrespiratorypathogensidentifiedinapproximately22%ofadultpatientswithcommunity
acquiredpneumonia
systematicreviewof23studieswith6,404patientswithcommunityacquiredpneumonia
reportingincidenceofviralpathogens
methodsfordetectingviralpathogensincludedpolymerasechainreaction(PCR),realtime
PCR,culture,immunofluorescenceassays,andserology
specimenstestedincludedswabs(nasopharyngeal,oropharyngeal,andthroat),aspirates
(tracheobronchialandnasopharyngeal),washes(nasopharyngealandthroat),serum,sputum,
bronchialalveolarlavagefluid,andprotectedspecimenbrushsamples
viralinfectionsdetectedin22%ofpatients(95%CI19%26%),including12%withcoinfection
ofviralandotherpathogens(95%CI10%15%),resultslimitedbyheterogeneity
incidenceofviralpathogensrangedacrossgeographicareas,from16.6%(95%CI10.5%22.8%)
inSoutheastAsiato32.4%(95%CI27.1%37.6%)intheMiddleEast,resultslimitedby
heterogeneity
estimatedincidenceofcommonrespiratoryviruses,allresultslimitedbyheterogeneity
influenzavirusidentifiedin8.9%(95%CI7.1%10.6%)
rhinovirusidentifiedin6%(95%CI4.3%7.7%)
coronavirusidentifiedin4.7%(95%CI2.9%6.6%)
parainfluenzavirusidentifiedin2.4%(95%CI1.4%3.4%)
respiratorysyncitialvirusidentifiedin2%(95%CI1.3%2.7%)
metapneumovirusidentifiedin1.9%(95%CI1%2.8%)
adenovirusidentifiedin1.6%(95%CI0.9%2.4%)
ReferenceRespiration201589(4):343
DynaMedcommentarymoleculardetectionofaviralpathogeninpatientsampledoesnot
provecausationofCAP
viralpathogensaccountfor18%20%ofcommunityacquiredpneumoniainadults
virusesidentifiedin28%ofpneumoniacasesamong300adultsinNewZealand,including
rhinovirusin10%
influenzaAin8%
influenzaBin2%
respiratorysyncytialvirus(RSV)in4%
adenovirusin4%
coronavirusin2%
parainfluenzain1%
morethan1virusfoundinsomepatients
virusesidentifiedin18%ofpneumoniacasesamong338adultsinSpain,including
influenzaAin44%
parainfluenzain18%
influenzaBin16%
RSVin8.2%
adenovirusin8.2%
ReferenceJBrasPneumol2009Sep35(9):899EBSCOhostFullText
12/58
viralpathogensaccountfor39%ofpathogensidentifiedinpatientswithcommunityacquired
pneumonia
193adultswithcommunityacquiredpneumoniainCanadabetween2004and2006evaluated
bloodculture,sputumspecimens,nasopharyngealswabs,andserumsampleswerecollected
fromallpatients
among75patientswithidentifiedrespiratorypathogen
39%hadviralinfection
51%hadbacterialinfection
11%hadmixedviralandbacterialinfection
among29patientswithviralinfection,organismsincluded
influenzaAin10.3%
influenzaBin13.8%
humanmetapneumovirusin24.1%
RSVin17.2%
coronavirusin13.8%
rhinovirusin13.8%
parainfluenzain10.3%
adenovirusin6.9%
prevalenceofviralinfectionwasgreatestinwinter,withallbut1infectionoccurringbetween
OctoberandMay
ReferenceChest2008Dec134(6):1141fulltext
Pathogenesis
specificpathogenesisvariesbyinfectingorganism
exposureofthesterilelowerrespiratorytracttopathogensiscommonrouteofinfectionthrough
either
aspirationoforalflora(aswithaspirationpneumonia)
inhalationofpathogencontainingdropletsoraerosols(suchasinStreptococcus
pneumoniaepneumoniaorLegionellainfectionsorinfluenzavirus)
failureofnormalimmunemechanismstoclearthepathogen,and/or
presenceofvirulencefactorsinpathogenswhichovercomeimmuneresponse
ReferenceInfectDisClinNorthAm2004Dec18(4):743
reviewofmolecularmechanismsinthepathogenesisofacutebacterialinfectionsofthelower
respiratorytractcanbefoundinNEnglJMed2008Feb14358(7):716,commentarycanbe
foundinNEnglJMed2008May29358(22):2413
HistoryandPhysical
Clinicalpresentation
Classicpresentationofcommunityacquiredpneumonia
clinicalpresentationofcommunityacquiredpneumoniamayinclude(1)
systemicsigns
fever
chills
leukocytosis
respiratorysignsandsymptoms
cough
increasedsputumproduction
abnormalpulmonaryexamination
shortnessofbreath
chestpain
chestimagingwithneworchangedinfiltrates
13/58
presentingsymptomsmaybemoresubtleinpatientswith(1)
chronicinfiltrativelungdisease,suchaslungcancerorpulmonaryfibrosis
heartfailure
advancedage
elderlypatientsmaypresentwith(4)
weakness
functionaldecline
cognitiveimpairmentorchangeinmentalstatus
Pathogenspecificsignsandsymptomsofcommunityacquiredpneumonia
classicpresentationofStreptococcuspneumoniaepneumonia
suddenonsetofchills(maybeduetoassociatedbacteremia)
pleuriticchestpain
feverandcoughproductiveofrustcoloredsputum
seealsoStreptococcuspneumoniaepneumonia
clinicalfeatureswhichmayraisesuspicionofLegionellapneumoniainclude
confusionorencephalopathy
gastrointestinaldisorders,usuallywaterydiarrhea
relativebradycardia
laboratoryabnormalitiesincluding
elevatedhepatictransaminases
hyponatremia
hypophosphatemia
elevatedcreatinineorcreatinephosphokinaselevels
seealsoLegionellainfections
presentationofcommunityacquiredmethicillinresistantStaphylococcusaureus(MRSA)pneumonia
mayinclude(1)
cavitaryinfiltrateornecrosis
rapidlyincreasingpleuraleffusion
grosshemoptysis
concurrentinfluenza
neutropenia
erythematousrash
skinpustules
young,previouslyhealthypatient
severepneumoniaduringsummermonths
History
patienthistoryshouldfocusonidentificationofpotentialforimmunecompromiseorpathogen
exposures(4)
askabout(1,2,4)
occupation
animalexposures
travelhistory
tobaccoandalcoholuse
immunesuppressivedrugs,includingsteroidsandbiologics
malignancy
chroniclungdisease
Physical
Generalphysical
14/58
findingsonphysicalexaminationmayinclude(4)
fever
tachycardia
tachypnea
Lungs
findingsonlungexaminationmayinclude(4)
dullnesstopercussion
egophony
asymmetricbreathsounds
pleuralrub
increasedfremitus
rales
bronchialbreathsounds
traditionalchestphysicalexammaynotbesufficienttoconfirmorexcludediagnosisof
pneumonia(level2[midlevel]evidence)
basedonprospectivecohortstudywithunrepresentativestudypopulation
52men(meanage62years)presentingtoemergencydepartmentofUnitedStatesVeterans
Affairsmedicalcenterwithsymptomsoflowerrespiratorytractinfection(coughandchangein
sputum)wereexaminedby3physicianswhowereblindtoclinicalhistory,laboratoryfindings,
andxrayresults
referencestandardwaschestxray
prevalenceofpneumonia46%byreferencestandard
degreeofinterobserveragreementhighlyvariablefordifferentphysicalexaminationfindings
relativelyhighagreementamongexaminersoccurredforralesinlateraldecubituspositionand
forwheezes
clinicaldiagnosisofpneumoniabyphysicalexaminationhad
sensitivity47%69%
specificity58%75%
ReferenceArchInternMed1999May24159(10):1082EBSCOhostFullText
DynaMedcommentarysensitivityandspecificitylikelyhigherinclinicalpracticewhere
patienthistoryalsotakenintoconsiderationresultsmaynotbeextrapolatabletoyounger,
healthypatientswithfewercomorbiditiesanddifferingpretestprobability
Diagnosis
Makingthediagnosis
InfectiousDiseasesSocietyofAmerica/AmericanThoracicSociety(IDSA/ATS)recommendationsfor
diagnosisofcommunityacquiredpneumonia(IDSA/ATSModeraterecommendation,LevelIII)(2)
diagnosissuggestedbyclinicalfeatures,suchas
cough
fever
sputumproduction
pleuriticchestpain
ralesorbronchialbreathsoundsonlungexamination
infiltrateonchestxrayorotherimagingrequiredfordiagnosis
15/58
Pneumoniaonchestxray:Rightlowerlobeinfiltrate.
Rightupperlobepneumoniaonchestxray:Lobarpneumoniainvolvingtherightupperlobe.
Differentialdiagnosis
differentialdiagnosisofcommunityacquiredpneumonia(1)
inpatientswithabnormalchestradiograph
heartfailurewithassociatedviralsyndrome
aspirationpneumonitis
pulmonaryinfarction
acuteexacerbationofpulmonaryfibrosis
acuteexacerbationofbronchiectasis
16/58
acuteeosinophilicpneumonia
hypersensitivitypneumonitis
pulmonaryvasculitis
cocaineinducedlunginjury
inpatientswithnormalchestradiograph
acuteexacerbationofchronicobstructivepulmonarydisease(COPD)
influenza
acutebronchitis
pertussis
asthmawithassociatedviralsyndrome
Testingoverview
diagnosisofcommunityacquiredpneumonia(2)
chestimaging,eitherxrayorcomputedtomography(CT)scan
bloodcultures
optionalformostpatients
recommendedforhospitalizedpatientswithoratriskforseverediseaseandcomplications
shouldbecollectedpriortostartofantibioticswhenperformed
sputumGramstainandcultureforsamepopulationasabovewhenproductivecoughpresent
urinaryantigentestsforStreptococcuspneumoniaeandLegionellapneumophilaserogroup1for
patientswithseverecommunityacquiredpneumonia
additionaltestingforspecificpathogensbasedonclinicalandepidemiologicclues,ifpositive
resultwouldchangemanagement(suchasforinfluenza)
seeInfluenzainadultsforadditionalinformationondiagnostictests
Bloodtests
Routinebloodtests
completebloodcellcount(1,2)
whitebloodcellcount
leukocytosiscommon
leukopeniaassociatedwithincreasedmortalityandriskforacuterespiratorydistress
syndrome(ARDS)
plateletcount<100,000cells/mm3associatedwithworseprognosis
Bloodcultures
InfectiousDiseasesSocietyofAmerica/AmericanThoracicSociety(IDSA/ATS)guidelinesonthe
managementofcommunityacquiredpneumoniainadultsstatethatbloodculturescollectedpriorto
initiationofantibiotictherapyare(2)
optionalformostpatients
recommendedforhospitalizedpatientswithanyof(IDSA/ATSModeraterecommendation,
LevelI)(2)
intensivecareunitadmission
cavitaryinfiltrates
pleuraleffusion
leukopenia
positiveurinetestingforpneumococcus
activealcoholabuse
chronicsevereliverdisease
asplenia
17/58
clinicaldecisionrulemayhelpidentifyadultsforwhombloodcultureiswarranted(level2[mid
level]evidence)
basedonsystematicreviewwithlimitedevidence
systematicreviewof35studiesevaluatingclinicalandlaboratoryfindingsforpredicting
bacteremiainadultpatients
7%pretestprobabilityofbacteremiainpatientswithcommunityacquiredpneumonia,basedon
1studywith13,043patients
individualfindingsthatperformpoorly(inisolation)forpredictingorrulingoutbacteremia
elevatedtemperature
chills
whitebloodcellcount
tachycardia
hypotension
clinicaldecisionrulemayhelppredictbacteremiainemergencydepartmentpatientswith
suspectedbacteremia
bloodcultureindicatedif1majoror2minorfindingsarepresent
majorfindings
suspicionofendocarditis
temperature>39.4degreesC(102.9degreesF)
indwellingvascularcatheter
minorfindings
temperature38.339.3degreesC(100.9102.7degreesF)
age>65years
chills
vomiting
systolicbloodpressure<90mmHg
whitebloodcellcount>18,000/mm3
bands>5%
platelets<150,000/mm3
creatinine>2mg/dL(177mmol/L)
neutrophils>80%
predictiveperformanceofclinicaldecisionrule
basedoncohortof3,730consecutiveadultemergencydepartmentpatientswhohad
bloodcultures,randomlydividedintoderivationandvalidationcohorts
derivationcohortincluded2,466patients,ofwhom204(8.3%)hadbacteremia
validationcohortincluded1,264patients,ofwhom101(8%)hadbacteremia
Results:
DerivationCohort ValidationCohort
Sensitivity 98% 97%
Specificity 29% 28.8%
Positivepredictivevalue 11.1% 10.6%
Negativepredictivevalue 99.4% 99.1%
Positivelikelihoodratio 1.4 1.4
Negativelikelihoodratio 0.07 0.1
derivationandvalidationofclinicaldecisionrulecanbefoundinJEmergMed2008
Oct35(3):255
ReferenceJAMA2012Aug1308(5):502EBSCOhostFullText,correctioncanbefoundin
JAMA2013Jan23309(4):343
bloodculturesmayidentifycausativepathogenin<6%ofpatientshospitalizedforcommunity
acquiredpneumonia
760adultshospitalizedwithsuspecteddiagnosisofcommunityacquiredpneumoniahadblood
culturesperformed
44organismsisolatedfrom43patients(5.7%)
68.1%Streptococcuspneumoniae
18/58
15.9%Enterobacteriaceae,including11.4%Escherichiacoli
11.4%Staphylococcusaureus
2.3%Haemophilusinfluenzae
ReferenceChest2003Apr123(4):1142EBSCOhostFullText,commentarycanbefoundinJ
FamPract2003Aug52(8):599EBSCOhostFullText,AmFamPhysician2003Aug
1568(4):721
Biomarkers
neitherCRPnorprocalcitoninareassociatedwithsufficientdiagnosticaccuracytodiagnose
communityacquiredpneumonia(level2[midlevel]evidence)
basedondiagnosticcohortstudywithoutvalidation
plasmasamplesfrom200adultswithclinicallysuspectedcommunityacquiredpneumonia
(CAP)weretestedforCRPandprocalcitoninlevels
referencediagnosisofdefinite,probable,possible,orexcludedCAPwasmadebyadjudication
committeeonday28basedonavailabledata
prevalenceofdefiniteCAP49%
fordistinguishingdefiniteCAPfromexcludedCAP
CRP>50mg/Lhad
sensitivity84.7%
specificity63.4%
positivepredictivevalue76.1%
negativepredictivevalue75%
procalcitonin>0.25mcg/Lhad
sensitivity50%
specificity64.7%
positivepredictivevalue74.6%
negativepredictivevalue48.4%
ReferenceCritCare2015Oct1619(1):366EBSCOhostFullTextfulltext
CRPlevelsdonotappearsensitiveorspecificenoughtodiagnosepneumonia(level2[midlevel]
evidence)
basedonsystematicreviewlimitedbyclinicalheterogeneity
systematicreviewof8crosssectionalorcohortstudiesevaluatingdiagnosticusefulnessofCRP
againstchestxrayreferencestandardin2,194patientswithsymptomsconsistentwith
criteriafordefiningcommunityacquiredpneumoniavariedbetweenstudies
medianprevalenceofcommunityacquiredpneumonia14.6%
CRPcutpoint20mg/Lhad
pooledpositivelikelihoodratio2.1(95%CI1.82.4)
poolednegativelikelihoodratio0.33(95%CI0.250.43)
CRPcutpoint50mg/Lhad
resultslimitedbysignificantheterogeneity
CRPcutpoint>100mg/Lhad
resultslimitedbysignificantheterogeneity
ReferenceFamPract2009Feb26(1):10EBSCOhostFullTextfulltext
serumprocalcitonin0.1ng/mLmayhelpdiagnosepneumoniainpatientswithdyspnea
presentingtotheemergencydepartment(level2[midlevel]evidence)
basedondiagnosticcohortstudywithoutindependentvalidation
453patients(meanage67years)withdyspneainemergencydepartmentwereassessedfor
serumprocalcitoninlevelsandfollowedfor1year
19/58
referencestandardwasclinicaldiagnosisbasedonmedicalrecordsandverificationwithclinical
practiceguidelines
6.6%hadpneumoniaalone,6.6%hadbothpneumoniaandheartfailure,and47%hadheart
failurewithoutpneumonia
1yearmortality17.7%
overallperformanceofserumprocalcitoninwithoptimalcutoff0.1ng/mLfordiagnosisof
pneumonia
sensitivity78%
specificity80%
positivepredictivevalue39%
negativepredictivevalue96%
insubgroupanalysesaccordingtoclinicians'estimateofheartfailurerisk
lowersensitivity(70%)buthigherspecificity(85%)in244patientsatlowrisk(<25%)
highersensitivity(95%)butlowerspecificity(57%)in139patientsathighrisk(>75%)
predictivevaluesconsistentwithoverallresultsin70patientsatuncertainrisk(25%75%)
elevatedserumprocalcitoninassociatedwithincreased1yearmortality(hazardratio1.8,95%
CI1.42.3)
ReferenceAmJMed2016Jan129(1):96
serumCRPlevel48mg/mLmayhelpdifferentiatecommunityacquiredpneumoniafrom
exacerbationofasthmaorchronicobstructivepulmonarydisease(level2[midlevel]evidence)
basedondiagnosticcasecontrolstudy
62adultpatientswithcommunityacquiredpneumonia,96withexacerbationofasthma,and161
withexacerbationofchronicobstructivepulmonarydisease(COPD)wereassessedforserum
CRPandprocalcitoninlevels
medianCRPandprocalcitoninlevels
191mg/Land1.27ng/mLinpatientswithcommunityacquiredpneumonia
9mg/Land0.03ng/mLinpatientswithexacerbationofasthma
16mg/Land0.05ng/mLinpatientswithexacerbationofCOPD
diagnosticperformanceforcommunityacquiredpneumoniausingoptimumcutpoints
CRP>48mg/L
sensitivity91%
specificity93%
procalcitonin>0.08ng/mL
sensitivity89%
specificity78%
ReferenceChest2011Jun139(6):1410fulltext
Urinestudies
UrinaryantigentestingforStreptococcuspneumoniae
InfectiousDiseasesSocietyofAmerica/AmericanThoracicSociety(IDSA/ATS)recommendurinary
antigentestforStreptococcuspneumoniaeinpatientswithseverecommunityacquiredpneumonia
(IDSA/ATSModeraterecommendation,LevelII)(2)
S.pneumoniaeurinaryantigentesting(2)
rapidlydetectssolubleantigenproducedbyS.pneumoniae(resultsavailableinapproximately
15minutes)
candetectantigenevenafterinitiationofantibiotictherapy
diagnosticyieldappearsincreasedinpatientswithsevereillness
sensitivityrangesfrom50%to80%,withspecificity>90%
falsepositiveresultsmaybeseeninselectedpatientpopulations,including
childrenwithchronicrespiratorydiseaseandS.pneumoniaecolonization
patientswithanepisodeofcommunityacquiredpneumoniaintheprevious3months
recentlyvaccinatedadults
seeStreptococcuspneumoniaepneumoniafordetailsonstreptococcalurinaryantigentesting
20/58
UrinaryantigentestingforLegionellapneumophila
InfectiousDiseasesSocietyofAmerica/AmericanThoracicSociety(IDSA/ATS)recommendurinary
antigentestforLegionellapneumophilainpatientswithseverecommunityacquiredpneumonia
(IDSA/ATSModeraterecommendation,LevelII)(2)
L.pneumophilaurinaryantigentesting(2)
rapidlydetectssolubleantigenproducedbyserogroup1strainsofL.pneumophila(results
availablewithin15minutes)
sensitivityrangesfrom70%to100%,withspecificityabout99%
antigenisdetectableearlyinthecourseofinfectionandpersistsforseveralweeks
seeLegionellainfectionsfordetailsonLegionellaurinaryantigentesting
Imagingstudies
Chestxray
InfectiousDiseasesSocietyofAmerica/AmericanThoracicSociety(IDSA/ATS)requirepresenceof
infiltrateonchestxrayorotherimaging(inadditiontosuggestiveclinicalfeatures)fordiagnosisof
pneumonia(IDSA/ATSModeraterecommendation,LevelIII)(2)
findingsmayinclude
lobarconsolidation
cavitarylesions
pleuraleffusion
diffuseparenchymalinvolvement(maybemorecommonwithviralorpneumonia)
ReferenceAmFamPhysician2011Jun183(11):1299EBSCOhostFullTextfulltext
worseningradiographicfindingsmaybeseenonchestxrayafterfluidadministration
125inpatientadultswithdiagnosisofpneumoniaatdischargehadadmissionandfollowup
chestxrayscomparedtoevaluateradiographicprogressionafterfluidadministration
42patientsshowedradiographicprogression
comparingpatientswithradiographicprogressionvs.thosewithout
meanadmissionbloodureanitrogenlevels34mg/dLvs.24mg/dL(p=0.022)
mean48hourfluidintake5,824mLvs.4,764mL(p=0.044)
meanage59yearsvs.66years(p=0.053)
ReferenceJFamPract2000Sep49(9):833EBSCOhostFullText
interobserverreliabilityfairtogoodforidentificationofinfiltratesonxraysfrompatientswith
suspectedcommunityacquiredpneumonia,butpoorforpatternofinfiltrates
initialchestxraysfrom282adultswithsuspectedcommunityacquiredpneumoniaand
documentedpulmonaryradiographicinfiltratewerefurtherreviewedby2radiologists
interobserverreliability
79.4%agreementonpresenceofinfiltrateand6%agreementoninfiltrateabsence(kappa
=0.37,95%CI0.220.52)
41.5%agreementthatinfiltratewasunilobarand33.9%agreementthatinfiltratewas
multilobar(kappa=0.51,95%CI0.280.62)
10.7%agreementonpresenceofpleuraleffusionand73.2%agreementonabsenceof
pleuraleffusion(kappa=0.46,95%CI0.330.5)
ReferenceChest1996Aug110(2):343
radiographicfeaturesmaynotdistinguishamongcausesofcommunityacquiredpneumonia
(level2[midlevel]evidence)
basedon2retrospectivecohortstudieswithoutdiagnosticuncertainty
196patientswithcommunityacquiredpneumoniaofknownetiologyhadxraystaken
patientswerediagnosedwith1of
pneumococcalpneumonia(91patients)
Legionnairesdisease(49patients)
21/58
mycoplasmapneumonia(46patients)
psittacosis(10patients)
radiographicfindingsincluded
homogenousshadowing
multilobarinvolvement
pleuralfluid
pulmonarycollapse
lymphadenopathy
lungcavitation
swollenlobescausingbulgingfissures
nodistinctivepatternsofradiographicfindingswereidentifiedforanygroupofpatients
ReferenceThorax1984Jan39(1):28PDF
45patientswithserologicevidenceofChlamydophilapneumoniaeand/orStreptococcus
pneumoniaeinfectionwerereviewed
comparing24patientswithC.pneumoniaealonevs.13patientswithS.pneumoniaealone
bronchopneumoniain88%vs.77%group(notsignificant)
lobarorsublobar(airspace)pneumoniaseenin29%vs.54%(notsignificant)
ReferenceArchInternMed1996Sep9156(16):1851
Computedtomography
indicationsforcomputedtomography(CT)
complicatedcasesofsevere,unresolvingpneumoniawhereinterventionisconsidered
patientswithnormalornonspecificchestradiographicfindingsand
febrileneutropenia
HIVinfection
highclinicalsuspicionofsevereacuterespiratorysyndrome(SARS)orpandemic(H1N1)
2009
suspectedanthrax
ReferenceAmericanCollegeofRadiology(ACR)AppropriatenessCriteriaforacute
respiratoryillness(NationalGuidelineClearinghouse2011Jul27:32622)
computedtomographymayincreaseappropriateclassificationofCAPdiagnosisinpatientswith
clinicalsuspicionofCAPbutwithoutinfiltrateonchestradiograph(level2[midlevel]evidence)
basedondiagnosticcohortstudywithoutvalidation
319adultpatientswithclinicallysuspectedcommunityacquiredpneumonia(CAP)were
assessedwithchestxrayandmultidetectorchestCTwithin4hoursofpresentationto
emergencydepartment
referencediagnosiswasclassificationofCAPasdefinite,probable,possible,orexcludedby
blindedpanelofinfectiousdiseases,pulmonology,andradiologyspecialistsonday28
parenchymalinfiltrateinchestxrayin58.9%(188patients)
CTscanmodifiedclassificationin58.6%ofpatients,including
identificationofparenchymalinfiltratein40of121patientswithoutinfiltrateonxray
(33%)
nopneumoniain56of188patientswithinfiltrateonxray(29.8%)
80%ofmodificationsduetoCTscanresultswereinagreementwithreferencediagnosis
treatmentmodificationsduetoCTscanresultsincluded
initiationofantibioticsin51patients(16%)
discontinuationofantibioticsin29patients(9%)
hospitalizationdecisionin22patients
dischargedecisionin23patients
CTscanuseassociatedwithappropriatereclassificationofCAPdiagnosisbyemergency
departmentphysicianinpatientswithoutparenchymainfiltrateonchestradiographin
multivariateanalysis(oddsratio2.97,95%CI1.65.5)
ReferenceAmJRespirCritCareMed2015Oct15192(8):974EBSCOhostFullText
DynaMedcommentarygivensmallstudysize,riskofradiation,andsubjectivecomponentof
referencestandard,resultsmaynotbegeneralizable
22/58
Ultrasound
lungultrasoundmayhelpdiagnosepneumoniainadults(level2[midlevel]evidence)
basedonsystematicreviewofdiagnosticcohortstudieswithinappropriateexclusionofpatients
forwhomtestingwouldbeappropriate
systematicreviewof10diagnosticstudiesevaluatinglungultrasoundin1,172adultsfor
diagnosisofpneumonia
studiesincludedpatientswhowerecriticallyill,hospitalized,orpresentingtoemergency
department(meanagerange3969years)
exclusioncriteriaforindividualstudiesincludedheartfailure,interstitiallungdisease,
suspicionofaspirationpneumonia,severeimmunosuppression,orpregnancy
referencestandardsincludedclinicaldiagnosisorchestimagingwithxrayorcomputed
tomography(CT)scan
allstudiesincludedphysicianswhowereexpertsorexperiencedwithultrasound,except2
studiesthatevaluatedinexperiencedphysicianswhoweregivenashorttrainingsession
analyseslimitedbyclinicalheterogeneityinlungultrasoundprotocolsanddiagnosticcriteria
pooleddiagnosticperformanceoflungultrasoundfordetectionofpneumoniainanalysisofall
studies(bothresultsassociatedwithsignificantheterogeneity)
sensitivity94%(95%CI92%96%)
specificity96%(95%CI94%97%)
consistentresultsinsensitivityanalyseswithreferencestandardascombinationofchestimaging
andclinicaldiagnosis(5studies),chestimagingalone(5studies),andchestCTalone(3studies)
ReferenceRespirRes2014Apr2315(1):50EBSCOhostFullText
lungultrasoundmayhelpdiagnosecommunityacquiredpneumoniainadults(level2
[midlevel]evidence)
basedondiagnosticcohortstudywithoutindependentreferencestandard
362adults(medianage63.8years)withsuspectedcommunityacquiredpneumoniahad
lungultrasoundandchestxrayplusclinicalexamandlabtesting
referencestandardwaschestxrayin2planesorlowdoseCTscanincaseof
inconclusiveornegativexraybutpositivelungultrasound
prevalenceofcommunityacquiredpneumoniawas63%
6patients(1.7%)excludedfromanalysisduetoequivocalultrasoundresults
fordetectionofcommunityacquiredpneumonia,lungultrasoundhad
sensitivity93.4%
specificity97.7%
positivelikelihoodratio40.5
negativelikelihoodratio0.07
ReferenceChest2012Oct142(4):965,commentarycanbefoundinChest2013
Mar143(3):877
Evaluationofhemoptysis
AmericanCollegeofRadiology(ACR)AppropriatenessCriteriaforhemoptysiscanbefoundatACR
2014PDForatNationalGuidelineClearinghouse2014Sep15:48289
SputumGramstainandculture
sputumstainandculture(2)
pretreatmentexpectoratedsputumsampleforGramstainandculture(inpatientswitha
productivecough)optionalformostpatientsbutrecommendedforhospitalizedpatientswith
anyof(IDSA/ATSModeraterecommendation,LevelI)
intensivecareunitadmission
failureofoutpatientantibiotictherapy
pleuraleffusion
severeobstructiveorstructurallungdisease
cavitaryinfiltrates
23/58
activealcoholabuse
positiveurinetestingforStreptococcuspneumoniaeorLegionella(specialmedianeeded
forLegionella)
performpretreatmentGramstainandcultureofexpectoratedsputumwhen(IDSA/ATS
Moderaterecommendation,LevelII)
agoodqualityspecimencanbeobtained,and
qualityperformancemeasuresforcollection,transport,andprocessingofsamplescanbe
met
endotrachealaspiratesamplerecommendedforintubatedpatients(IDSA/ATSModerate
recommendation,LevelII)
fungalandtuberculosisculturesrecommendedifcavitaryinfiltratespresent
thoracentesisandpleuralfluidculturesrecommendedifpleuraleffusionpresent
sensitivityofsputumGramstainandcultureisdependentonqualityofsputumsample
basedoncohortstudy
1,669patientsaged15101yearswithcommunityacquiredpneumoniawererequestedto
providesputumforculturebeforeantibioticsgiven
goodqualitysampledefinedasbothof
<10squamousepithelialcellsperlowpowerfield
>25polymorphonuclearcellsperlowpowerfield
983(59%)producedsputumsample
532samples(54%,or32%oftotalcohort)hadgoodquality
240goodqualitysamples(45%,or14.4%oftotalcohort)haddominantorganismofa
singlemorphology
cultureyieldedmicroorganismin86%ofsampleswithapredominantmorphotypeandin19.5%
goodqualitysampleswithoutapredominantmorphotype(or15.8%totalcohort)
grampositivediplococcihad60%sensitivity,97.6%specificity,91%positivepredictivevalue,
and85%negativepredictivevalueforStreptococcuspneumoniaeonsputumculture
ReferenceArchInternMed2004Sep13164(16):1807,editorialcanbefoundinArchIntern
Med2004Sep13164(16):1725,commentarycanbefoundinArchInternMed2005Feb
28165(4):470EBSCOhostFullText
sensitivityofsputumGramstainvarieswithinfectingorganismbutdetectionoforganismsby
GramStainmaypermitpathogentargetedtreatmentandsubsequentreductioninantibiotic
associatedadverseeventsinpatientswithcommunityacquiredorhealthcareassociated
basedonprospectivecohortstudywithvariablereferencestandards
670patientswithpneumoniawereprospectivelyassessed,including328patientswith
communityacquiredpneumoniaand342patientswithhealthcareassociatedpneumonia
highqualitysputumsampleswereobtainedfrom478patients
diagnosticperformanceofsputumGramstain(comparedtovariablemethodsused)variedby
infectingorganism
forStreptococcuspneumoniae,sensitivitywas62.5%andspecificitywas91.5%
forHaemophilusinfluenzae,sensitivitywas60.9%andspecificitywas96.1%
forMoraxellacatarrhalis,sensitivitywas68.2%andspecificitywas95.1%
forKIebsiellapneumoniae,sensitivitywas39.5%andspecificitywas98.2%
forPseudomonasaeruginosa,sensitivitywas22.2%andspecificitywas99.8%
forStaphylococcusaureus,sensitivitywas9.1%andspecificitywas100%
174patientsreceivedpathogendirectedantibioticregimenbasedonresultsofGramstain
comparingpatientsreceivingpathogendirectedvs.empiricantibioticregimen
adverseeventsin2.9%vs.7%(p=0.0492)
admissiontointensivecareunitin7%vs.19.9%(p=0.017)
mediandurationofintravenoustreatment8daysvs.9days(p<0.001)
medianlengthofhospitalstay9daysvs.11days(p<0.001)
inhospitalmortality8.1%vs.9%(notsignificant)
ReferenceBMCInfectDis2014Oct1814(1):534
24/58
presenceofgrampositivediplococcionsputumGramstainappearshighlyspecificfor
pneumococcusinpatientsabletoproducegoodqualitysputum
533immunocompetentadultsadmittedtoaBarcelonahospitalforcommunityacquired
pneumoniaaskedtogivesputumsamplebeforeantibioticsstarted
samplesdefinedasgoodqualityifeachlowpowerfieldcontained<10squamouscellsand>25
leukocytes
343(64%)patientsgavesputumsampleand210(39%)wereconsideredgoodquality
175(33%)weregoodqualityandhadpredominantmorphotype
Gramstaintestcharacteristics
57%sensitivityand97%specificityin135patientswithdefiniteorprobable
pneumococcalpneumonia
82%sensitivityand99%specificityin34patientswithHaemophilusinfluenzae
pneumonia
ReferenceClinInfectDis2000Oct31(4):869EBSCOhostFullTextfulltext
sensitivityofsputumGramstainandculturemaybeincreasedifspecimeniscollectedpriorto
initiationofantibiotictherapy
basedonretrospectivecohortstudywithoutdiagnosticuncertainty
105patientswithbacteremicpneumococcalpneumoniawerereviewed
adequatespecimensdefinedasanywithareascontaining10whitebloodcellsper1epithelial
cellatmagnificationof400x
sputumGramstainandculture
31%and44%sensitivityoverall
57%and79%sensitivityin58patientswithadequatespecimens
80%and93%sensitivityinpatientswithadequatespecimensbeforereceivingantibiotics
ReferenceClinInfectDis2004Jul1539(2):165EBSCOhostFullTextfulltext
Moleculardiagnostics
multiplexrealtimePCRassayofsputumorendotrachealaspiratedetectsgreaternumberof
organismsinpatientswithcommunityacquiredpneumoniacomparedtostandardculture
basedoncohortstudy
sputumsampleorendotrachealaspiratefrom323adultshospitalizedwithcommunityacquired
pneumonia(CAP)wereassessedwithstandardcultureandmultiplexrealtimePCR(RTPCR)
assay
diagnosisofCAPrequiredbothclinicalsymptomsandradiographicfindingsconsistentwith
pneumonia
multiplexRTPCRassaydetects26respiratorybacteriaandviruses
84.8%ofpatientshadreceivedantimicrobialsinthe72hourperiodprecedingsamplecollection
comparingresultsofculturevs.multiplexRTPCR
1organismidentifiedin39%vs.87%(nopvaluereported)
1organismidentifiedin32.1%vs.77.6%of268patientswhohadreceived
antimicrobialsinprior72hours(p<0.001)
inanalysisofantimicrobialregimensandmoleculartestingresults,moleculartestingresults
couldhaveenabledearlydeescalationtopathogendirectedtherapyin77%ofpatients
ReferenceClinInfectDis2016Apr162(7):817fulltext,editorialscanbefoundinClinInfect
Dis2016Apr162(7):826andClinInfectDis2016Apr162(7):824
DynaMedcommentarywhilethismultiplexPCRassaydetectsagreaternumberoforganisms
inrespiratorysamplesofpatientswithCAP,thespecificityofthisassayremainsuncertain
detectedorganismsmayrepresentcontaminant,colonizers,priorinfectingorganismsinaddition
tocausativeorganism
Additionaltesting
additionaltestingforspecificpathogensbasedonclinicalandepidemiologicclues,ifpositiveresult
wouldchangemanagement(IDSA/ATSStrongrecommendation,LevelII)
considertestingforinfluenzaduringannualfluseasonoroutbreakperiods(2)
25/58
reversetranscriptasepolymerasechainreaction(RTPCR)reportedtobemostsensitiveand
specifictestforinfluenzaandrecommendedastestofchoicebyInfectiousDiseasesSocietyof
America(IDSA)
rapidantigendetectiontestshavemoderatesensitivityandhighspecificityforinfluenza
viralculturemayhavelimitedutilityforclinicaldiagnosis,butisessentialtopublichealth
efforts
seeInfluenzainadultsforadditionalinformationondiagnostictests
Treatment
Treatmentoverview
scoringsystemsandguidelinecriteriahavebeendevelopedtohelppredictshorttermmortalityand
needforhospitalorintensivecareunit(ICU)admission
interactivePneumoniaSeverityIndexCalculatoravailableviatheAgencyforHealthcare
ResearchandQuality(AHRQ)isbasedonthePORTstudy(level1[likelyreliable]evidence)
andiswellvalidated
CURB65,asimplerscoringsystem,alsoperformswell
InfectiousDiseaseSocietyofAmericaandAmericanThoracicSociety(IDSA/ATS)have
suggestedcriteriaforICUadmission
seePneumoniaseverityassessmentforfurtherdetail
IDSA/ATSrecommendationsforantibiotictherapyvarywithtreatmentsetting,riskfactorsforsevere
diseaseandlikelihoodofinfectionwithdrugresistantorganism
firstlineoptionsforoutpatients
ifotherwisehealthyandwithoutriskfactorsfordrugresistantorganisms(includingno
useofantibioticswithinprevious3months),eitherof
amacrolide,suchasazithromycin500mgorallyoncefollowedby250mgorally
fordurationoftherapy
doxycycline100mgorallytwicedaily
Ifchroniccomorbidities(suchasdiabetesmellitus,orheart,lung,liver,orrenaldisease,
orimmunocompromise),recentantibioticuse(withinprevious3months)orinareaswith
highratesofmacrolideresistantStreptococcuspneumoniae,eitherof
arespiratoryfluoroquinolone,suchaslevofloxacin750mgorallyoncedailyor
moxifloxacin400mgorallyoncedaily
abetalactamPLUSamacrolide,suchasamoxicillin1gorally3timesdailyplus
azithromycin
firstlineoptionsforinpatients
formost
arespiratoryfluoroquinolone,suchaslevofloxacin750mgorallyoncedailyor
moxifloxacin400mgorallyoncedaily
abetalactamplusamacrolide,suchasceftriaxone1gIVoncedailyplus
azithromycin
forsuspicionofPseudomonasinfection,consideruseofanantipneumococcal,
antipseudomonalagentsuchascefepimeorpiperacillintazobactamplusaquinolonesuch
aslevofloxacin
forsuspicionofmethicillinresistantStaphylococcusaureus(MRSA),consideradditionof
vancomycinorlinezolid
forsuspicionofinfluenzainpatientsatriskforadverseoutcomes,consideradditionof
oseltamavir
treatforaminimumof5daysoruntilclinicallystableandafebrileforatleast4872hours
longerdurationoftherapymaybeneededforpatientswithcomplicationssuchasbacteremia,or
pathogenssuchasMRSAorPseudomonas
additionalconsiderationsforpatientswithseverecommunityacquiredpneumoniaorrespiratory
failureinclude
arterialoxygensaturation90%suggestedformeasurementofclinicalstability
conductcautioustrialofnoninvasiveventilationinpatientswithhypoxemiaorrespiratory
distress,unlessimmediateintubationisrequired
26/58
immediateintubationrequiredinpatientswithseverehypoxemia(PaO2/FiO2ratio<150despite
receivingpositiveendexpiratorypressure[PEEP]of5fromcontinuousorbilevelpositive
airwaypressure[CPAPorBIPAP])andbilateralalveolarinfiltrates
uselowtidalvolumeventilation(6cm3/kgidealbodyweight)inpatientswithdiffusebilateral
pneumoniaoracuterespiratorydistresssyndromehavingventilation
inpatientswithhypotensionafterfluidresuscitation,screenforoccultadrenalinsufficiency
seeSepsistreatmentinadultsforadditionalinformation
adjunctivecorticosteroidsnotpartofstandardCAPmanagementbutseveralrecenttrialsand
systematicreviewssuggestmortalitybenefitinpatientswithsevereCAP
adjunctivecorticosteroidsmayreducemortalityandneedformechanicalventilationinadults
withseverecommunityacquiredpneumonia(level2[midlevel]evidence)
corticosteroidsmayreducetreatmentfailureat3daysinhospitalizedpatientswithsevere
communityacquiredpneumoniaandhighinflammatoryresponse(level2[midlevel]evidence)
managementofasthmaexacerbationsinpatientswithCAP,includingcorticosteroiduse,is
similartomanagementofpatientswithoutconcurrentpneumoniaseeAsthmaexacerbationin
adultsandadolescentsfordetail
adherencetoIDSAguidelinesforcommunityacquiredpneumoniamayreducemortalityandhospital
stayinnonintensivecarepatients(level2[midlevel]evidence)
rapiddeliveryofappropriateantibioticsassociatedwithlowermortalityandshorterlengthofhospital
stay(level2[midlevel]evidence)
oralantibioticsmaybeaseffectiveasIVantibioticsininpatientswithnonseverepneumonia(level2
[midlevel]evidence)
earlymobilizationmayreducelengthofstayinhospitalizedpatients(level2[midlevel]evidence)
clinicalimprovementgenerallyprecedesresolutiononchestradiographs(level2[midlevel]evidence)
Treatmentsetting
InfectiousDiseasesSocietyofAmerica/AmericanThoracicSociety(IDSA/ATS)
recommendationsforhospitalizationinadultswithcommunityacquiredpneumonia
directadmissiontointensivecareunitifanymajorcriteria(IDSA/ATSStrongrecommendation,
LevelII)
septicshockrequiringvasopressors
respiratoryfailurerequiringmechanicalventilation
directadmissiontointensivecareunitorhighlevelmonitoringif3minorcriteria(IDSA/ATS
Moderaterecommendation,LevelII)
respiratoryrate30breaths/minute(orneedfornoninvasiveventilation)
PaO2/FiO2ratio250(orneedfornoninvasiveventilation)
multilobarinfiltrates
confusion/disorientation
bloodureanitrogen20mg/dL(14.28mmol/L)
whitebloodcellcount<4,000cells/mm3
plateletcount<100,000/mm3
coretemperature<36degreesC(96.8degreesF)
hypotensionrequiringfluidresuscitation
useseverityofillnessscores(suchasCURB65)orprognosticmodels(suchastheinteractive
PneumoniaSeverityIndexCalculatoravailableviatheAgencyforHealthcareResearchand
Quality[AHRQ])toidentifypatientswhomaybecandidatesforoutpatienttreatment
(IDSA/ATSStrongrecommendation,LevelI)
supplementobjectivecriteriaorscoreswithphysiciandeterminationofsubjectivefactors
(IDSA/ATSStrongrecommendation,LevelII)
patientswithCURB65scores2usuallywarranthospitalizationorintensiveinhome
healthcareservices(IDSA/ATSModeraterecommendation,LevelIII)
seePneumoniaseverityassessmentfordetails
ReferenceClinInfectDis2007Mar144Suppl2:S27EBSCOhostFullTextfulltext
27/58
pneumoniaseverityassessmentisusedtodeterminemortalityriskandinformtreatmentsetting
decisions
predictionalgorithmsderivemortalityriskinpatientswithpneumoniabasedonclinicaland
laboratoryvalues
CURB65predictsmortalityinpatientshospitalizedwithpneumoniawith77%sensitivityand
69%specificity
assigns1pointforeachof
confusion
bloodureanitrogen>19mg/dL
respiratoryrate>30breaths/minute
systolicbloodpressure<90/60mmHg
age65years
mortalitybyriskclass
1.5%inpatientswith1point
11%inpatientswith23points
37%inpatientswith45points
PORT,orpneumoniaseverityindex(PSI),predictsmortalitywith75%sensitivityand48%
specificity
morecomplexalgorithmcomparedtoCURB65
ResearchandQuality(AHRQ)
30daymortalitybasedonriskclass
I0%0.4%
II0.4%0.9%
III0%0.28%
IV8.2%12.5%
V0.6%10.6%
otherpredictionmodelsincludeseverecommunityacquiredpneumonia(SCAP)andAPACHE
seePneumoniaseverityassessmentformoredetailsonscoringsystems
delayedtransfertointensivecareunitassociatedwithincreasedriskof28daymortalityin
patientswithseverecommunityacquiredpneumonia(level2[midlevel]evidence)
basedoncohortstudy
453communitydwellingadultsadmittedtointensivecareunit(138delayedtransferand315
directtransferpatients)within3daysofemergencydepartmentpresentationevaluated
comparingdelayedtransfervs.immediatetransfer
28daymortality23.4%vs.11.7%(p=0.002)
meanhospitalstay13daysvs.7days(p<0.001)
similarresultsfoundafterexcluding150patientswithobviousindicationforimmediatetransfer
ReferenceCritCareMed2009Nov37(11):2867
outpatientmanagementmaybesafeinuncomplicatedpatients(level2[midlevel]evidence)
basedonrandomizedtrialwithinadequatestatisticalpower
224immunocompetentadultsinriskclassIIorIII(PneumoniaSeverityIndexscores90
points)diagnosedwithcommunityacquiredpneumoniainemergencydepartmentof2tertiary
carehospitalsandwithnocomplicationswererandomizedtooutpatientcarewithoral
levofloxacinvs.hospitalizationwithsequentialIVthenorallevofloxacin
successfuloveralloutcomedefinedassurvivalat30days,cureofpneumonia,lackof
complications,nochangeininitialtreatment,andnofurthermedicalvisits
comparingoutpatientcarevs.hospitalization
successfuloveralloutcomein83.6%vs.80.7%(notsignificant)
overallmortality0.9%vs.0%(notsignificant)
satisfactionwithoverallcarein91.2%vs.79.1%(p<0.05)
ReferenceAnnInternMed2005Feb1142(3):165EBSCOhostFullText,editorialcanbefound
inAnnInternMed2005Feb1142(3):215EBSCOhostFullText,commentarycanbefoundinJ
FamPract2005May54(5):406,AmFamPhysician2005Nov172(9):1885
DynaMedcommentarysmallsamplesizelimitspowertodetectdifferenceinmortalityrate
Activity
28/58
earlymobilizationmayreducelengthofstayinhospitalizedadultswithcommunityacquired
basedonrandomizedtrialwithoutblindingandwithlowadherencerates
458patients18yearsoldadmittedto17generalmedicalunitsin3hospitalsrandomizedby
grouptoearlymobilization(sittingoutofbedorambulatingforatleast20minuteswithin24
hours,thenprogressivemobilizationeachday)vs.usualcare
meanhospitallengthofstay5.8dayswithearlymobilizationvs.6.9dayswithusualcare
nosignificantdifferencesinadverseevents
ReferenceChest2003Sep124(3):883EBSCOhostFullTextfulltext,editorialcanbefoundin
Chest2003Sep124(3):777EBSCOhostFullText,commentarycanbefoundinAmFam
Physician2004Jan1569(2):394,Chest2004May125(5):1959EBSCOhostFullText,AmFam
Physician2004May169(9):2198
inpatientexercisebasedrehabilitationprogrammayimprovefunctionaloutcomescomparedto
standardrespiratoryphysiotherapyinpatientswithcommunityacquiredpneumonia(level2
[midlevel]evidence)
basedonsmallrandomizedtrial
51patients(meanage55years)withcommunityacquiredpneumoniawererandomizedto
inpatientexercisebasedrehabilitationprogramvs.standardrespiratoryphysiotherapyfor8days
rehabilitationprogramincludeddaily50minutesessionsofwarmup,stretching,
peripheralmusclestrengthtraining,andcontrolledspeedwalkingfor15minutes
standardrespiratoryphysiotherapyincludeddaily50minutesessionsofpercussion,
vibrocompression,respiratoryexercises,andfreewalking
primaryoutcomewasGlittreActivitiesofDailyLivingtestassessingtimetocompletesetof
functionaltasksincludingrisingfromachair,walking,stairs,lifting,andbending
80%completed10dayfollowup,96%includedinanalysis
physicaltrainingprogramassociatedwithsignificantimprovementin
primaryoutcome(meandifference39seconds,95%CI2059seconds)
distancewalkedbasedonIncrementalShuttleWalkTest(meandifference130meters,
95%CI77182meters)
dyspneaandperipheralmusclestrength
physicalfunctioningsubscale,butnotothersubscalesofShortForm36questionnaire
nosignificantdifferencesinlungfunction,hospitallengthofstay,orCreactiveproteinlevels
ReferenceJPhysiother2016Apr62(2):96fulltext
Medications
Antibiotics
Antibioticsforadultoutpatients
empirictreatmentofcommunityacquiredpneumoniainadults
forpreviouslyhealthypersonswithnoantimicrobialusewithinpast3months
macrolides(erythromycin,clarithromycin,azithromycin)asfirstlinetreatment
(IDSA/ATSStrongrecommendation,LevelI)
doxycyclineassecondtreatmentoption(IDSA/ATSWeakrecommendation,LevelIII)
forpatientswithcomorbidities*,highriskofdrugresistantStreptococcuspneumoniae(local
prevalenceofmacrolideresistance>25%),orantibioticusewithinpast3months
respiratoryfluoroquinolonemoxifloxacin,gemifloxacin,orlevofloxacin(IDSA/ATS
Strongrecommendation,LevelI)
macrolide(IDSA/ATSStrongrecommendation,LevelI)(ordoxycycline[IDSA/ATS
Strongrecommendation,LevelII])plusbetalactamasalternativefirstlinetreatment
preferredbetalactamishighdoseamoxicillin1g3timesdailyoramoxicillin
clavulanate2gtwicedaily
alternativebetalactamsincludeceftriaxone,cefpodoxime,andcefuroxime(500mg
twicedaily)
29/58
*comorbiditiesincludeheartdisease,diabetes,lungdisease,liverdisease,alcoholism,
malignancies,asplenia,immunosuppression
giveantibioticsforminimumof5days,oruntilclinicallystableandafebrileforatleast4872
hours
durationof37daysforsomeantibiotics(generallyazithromycin)maybeaseffectiveaslonger
antibioticcoursesforadultswithmildtomoderatecommunityacquiredpneumonia(level2[mid
level]evidence)
dosinginformationforfirstlineantibioticsinadults,assumingnormalrenalfunction
AntibioticDosingforAdultswithCommunityacquiredPneumonia:
Drug Dose*
Respiratoryfluoroquinolones
Levofloxacin 750mgIVororallyevery24hours
Moxifloxacin 400mgIVororallyevery24hours
Macrolides
500mgorallyonce,then250mgorally
Azithromycin every24hoursthereafter,OR
Extendedrelease,2gorallyonce
250500mgorallytwicedaily,OR
Clarithromycin
Extendedrelease,1gorallyevery24hours
Tetracyclines
Doxycycline 100mgorallytwicedaily
Betalactams
Cefuroxime 500mgorallytwicedaily
Amoxicillin 1gorallythreetimesdaily
Amoxicillinclavulanate 2gorallytwicedaily
*Alldosinginformationassumesnormalrenalfunction.Dosagesmayrequireadjustmentinpatients
withimpairedrenalfunction.
ReferencesGilbertD,ChambersH,EliopoulosG,SaagM.TheSanfordGuidetoAntimicrobial
Therapy.44thed.Sperryville,VA:AntimicrobialTherapy,Inc.2014,ClinInfectDis2007Mar144
Suppl2:S27fulltext.
seeAntibioticsforadultoutpatientswithcommunityacquiredpneumoniafordetails
Antibioticsforadultinpatients
empirictreatmentofcommunityacquiredpneumoniainhospitalizedadults
forpatientsnotinintensivecareunit(ICU)
respiratoryfluoroquinolonemoxifloxacin,gemifloxacin,orlevofloxacin(IDSA/ATS
Strongrecommendation,LevelI)
betalactam(cefotaxime,ceftriaxone,ampicillin,or[forselectedpatients]ertapenem,plus
1of
macrolide(IDSA/ATSStrongrecommendation,LevelI)
doxycycline(IDSA/ATSStrongrecommendation,LevelIII)
forICUpatients
betalactam(cefotaxime,ceftriaxone,orampicillinsulbactam)plus1of
azithromycin(IDSA/ATSStrongrecommendation,LevelII)
fluoroquinolone(IDSA/ATSStrongrecommendation,LevelI)
forpenicillinallergicpatientsuserespiratoryfluoroquinoloneplusaztreonam
forPseudomonasinfection
30/58
antipneumococcal,antipseudomonalbetalactam(piperacillin/tazobactam,cefepime,
imipenem,ormeropenem)plus1ofthefollowing(IDSA/ATSModeraterecommendation,
LevelIII)
ciprofloxacin
levofloxacin(750mgdose)
aminoglycosideplusazithromycin
aminoglycosideplusantipneumococcalfluoroquinolone(moxifloxacinor
gemifloxacin)
DynaMedcommentarywhilerecommended,additionofathirdantipneumococcal
agentisrarelyused.
forpenicillinallergicpatients,substituteaztreonamforantipneumococcal,
antipseudomonalbetalactam
forcommunityacquiredmethicillinresistantStaphylococcusaureus(MRSA),addvancomycin,
linezolid,or(ifsusceptible)clindamycin(IDSA/ATSModeraterecommendation,LevelIII)
uponidentificationofcausativeorganism,targetantibiotictreatmenttothespecificpathogen
(IDSA/ATSModeraterecommendation,LevelIII)
adherencetoIDSA/ATSguidelinesforcommunityacquiredpneumoniamayreducemortalityand
hospitalstayinnonintensivecarepatients(level2[midlevel]evidence)
recommendedfirstlineregimensaredesignedtotargetthemostcommoncausesofpneumonia,
Streptococcuspneumoniaandatypicalorganisms(Legionella,Mycoplasma,andChlamydia)
changestofirstlineregimensshouldbebasedonseverityofillness,patientriskfactorsfor
infectionwithpotentiallymultidrugresistant(MDR)organisms,orexposurestolesscommon
pathogens
norecommendedantibioticregimenhasbeenclearlyshowntoimproveoutcomesoveranother
timingofantibioticdelivery
forpatientsadmittedthroughemergencydepartment,administerfirstdoseofantibioticswhile
patientisstillinemergencydepartment(IDSA/ATSModeraterecommendation,LevelIII)
rapiddeliveryofappropriateantibioticsassociatedwithlowermortalityandshorterlengthof
hospitalstay(level2[midlevel]evidence)
shortdurationofantibiotics(35days)maybeadequateinresponsivepatients
durationof37daysforsomeantibiotics(generallyazithromycin)maybeaseffectiveaslonger
antibioticcoursesforadultswithmildtomoderatecommunityacquiredpneumonia(level2
[midlevel]evidence)
levofloxacin750mg/dayfor5daysappearsaseffectiveas500mg/dayfor10days(level2
[midlevel]evidence)
routeofantibioticdelivery
oralantibioticsmaybeaseffectiveasIVantibioticsininpatientswithnonseverepneumonia
(level2[midlevel]evidence)
earlyswitchfromintravenoustooraltherapyforpatientswithseverepneumoniaappearssafe
andshortenshospitalstay(level2[midlevel]evidence)
seealsoPN6qualitymeasureforacceptableregimensaccordingtoMedicare/JointCommission
NationalHospitalInpatientQualityMeasures
dosinginformationforfirstlineantibioticsinadults,assumingnormalrenalfunction
AntibioticDosingforAdultswithCommunityacquiredPneumonia:
Drug Dose*
Respiratoryfluoroquinolones
Levofloxacin 750mgIVororallyevery24hours
Moxifloxacin 400mgIVororallyevery24hours
Macrolides
0.5gorallyonce,then0.25gorallyevery
24hoursthereafter,OR
Azithromycin Extendedrelease,2gorallyonceOR
500mgIVoncedailyfor2daysthen500
mg/dayorallytocompletecourse
31/58
Drug Dose*
250500mgorallytwicedaily,OR
Clarithromycin
Extendedrelease,1gorallyevery24hours
Tetracyclines
Doxycycline 100mgorallytwicedaily
Betalactams
Cefotaxime 12gIVevery912hours
Ceftriaxone 1gIVevery24hours
Ampicillinsulbactam 1.53gIVevery6hours
Amoxicillin 5001gorallythreetimesdaily
Ertapenem 1gIVevery24hours
Antipneumococcal,antipseudomonalbetalactams
3.375gIVevery4hours,OR4.5gIVevery6
Piperacillintazobactam hours,OR4.5gIVinfusedover4hours,given
every8hours(highdoseforPseudomonas)
Cefepime 2gIVevery12hours
Imipenemcilastatin 500mgIVevery6hours
Meropenem 1gIVevery8hours
Aztreonam 2gIVevery6hours
*Alldosinginformationassumesnormalrenalfunction.Dosagesmayrequireadjustmentinpatients
withimpairedrenalfunction.
ReferenceGilbertD,ChambersH,EliopoulosG,SaagM.TheSanfordGuidetoAntimicrobial
Therapy.44thed.Sperryville,VA:AntimicrobialTherapy,Inc.2014.
seeAntibioticsforadultinpatientswithcommunityacquiredpneumoniafordetails
Antibioticselectionconsiderations
increaseinuseofbroadspectrumantibioticsfrom2006to2010associatedwithincreasedusein
patientsbothwithandwithoutpathogensrequiringbroadspectrumantibiotictreatment
95,511patients18yearsoldhospitalizedforpneumoniaatVeteransAffairsmedicalcenters
from2006to2010wereassessedforreceiptofantibioticsandcausativepathogens
comparinguseofantibioticsin2006vs.2010
vancomycinin16%vs.31%(p<0.001)
piperacillintazobactamin16%vs.27%(p<0.001)
ceftriaxonein39%vs.33%(p<0.001)
macrolidesin39.5%vs.36%(p<0.001)
doubleantipseudomonalcoveragein5%vs.11%(p<0.001)
inanalysisofcaseswithdocumentationof1culturefrombloodorrespiratoryspecimen
collectedwithin2daysofadmission
antibioticswithactivityagainstmethicillinresistantStaphylococcusaureusgivenin
46%ofpatientswithMRSAinfectionin2006vs.65%in2010(p<0.001)
15%ofpatientswithoutMRSAinfectionin2006vs.30.6%in2010(p<0.001)
antibioticswithactivityagainstPseudomonasaeruginosagivenin
54%ofpatientswithP.aeruginosainfectionin2006vs.63%in2010(p<0.001)
21%ofpatientswithoutP.aeruginosainfectionin2010vs.33.6%in2010(p<
0.001)
nosignificantincreaseinratesofMRSAorMDRP.aeruginosaidentifiedoverallduringthis
timeperiod
32/58
ReferenceClinInfectDis2015Nov161(9):1403EBSCOhostFullText
Procalcitoninguidedantibioticstrategy
procalcitoninisaquantitativebiomarkerusedtohelppredictthelikelihoodofbacterialinfection
clinicalresearchhasfocusedonuseofprocalcitonininantibioticdecisionmaking
optimalcutoffvaluesandfrequencyofmonitoringnotyetestablished
useremainsinvestigationalinmanytypesofinfections
resultsshouldbeinterpretedcarefullyinclinicalcontext
seeProcalcitoninguidedantibiotictherapyfordetails
procalcitoninguidedstrategyreducesantibioticusewithoutincreasingmortalityorother
adverseoutcomesinpatientspresentingtotheemergencydepartmentwithlowerrespiratory
tractinfections(level1[likelyreliable]evidence)
basedonrandomizedtrial
1,381patientspresentingtoemergencydepartmentwithmostlyseverelowerrespiratory
infections(LRTI)randomizedtotreatmentaccordingtoserumprocalcitoninwithpredefined
cutoffrangesforinitiatingorstoppingantibioticsvs.usualcare
procalcitonincutoffranges
<0.1mcg/Lantibioticsstronglydiscouraged
0.10.25mcg/Lantibioticsdiscouraged
0.250.5mcg/Lantibioticsrecommended
>0.5mcg/Lantibioticsstronglyrecommended
procalcitoninlevelsinhospitalizedpatientsrechecked
after624hoursifantibioticswithheld
atdays3,5,7,andatdischarge
22(1.6%)patientsexcludedfromintentiontotreatanalysisduetoconsentwithdrawal
comparingtreatmentbyprocalcitoninbasedvs.standardguidelines
diseaserecurrence/rehospitalizationin3.7%vs.6.5%(NNT36,95%CI20250)
antibioticassociatedadverseeffectsin19.8%vs.28.1%(NNT13,95%CI827)
nosignificantdifferencesinadverseoutcomes,mortality,intensivecareunit(ICU)
admission,ordiseasespecificcomplications
antibioticprescriptionscomparingprocalcitoninbasedvs.standardguidelines
inallpatients75%vs.87.7%(p<0.05,NNT9,95%CI713)
inpatientswithchronicobstructivepulmonarydisease(COPD)exacerbation48.7%vs.
69.9%(p<0.05,NNT5,95%CI312)
inpatientswithacutebronchitis23.2%vs.50%(p<0.05,NNT4,95%CI39)
inpatientswithcommunityacquiredpneumonia90.7%vs.99.1%(p<0.05,NNT12,
95%CI918)
inpatientswithotherdiagnoses17%vs.22%(notsignificant)
meandurationofantibioticsexposure5.7daysvs.8.7days(p<0.05)
ReferenceProHOSPtrial(JAMA2009Sep9302(10):1059EBSCOhostFullText),editorial
canbefoundinJAMA2009Sep9302(10):1115EBSCOhostFullText,commentarycanbe
foundinJAMA2010Feb3303(5):418EBSCOhostFullText
procalcitoninlevelssafelyreduceantibioticuseinelderlywithcommunityacquiredpneumonia
(level1[likelyreliable]evidence)
basedonrandomizedtrial
302adults(meanage70years)presentingtoemergencydepartmentwithcommunityacquired
pneumoniawererandomizedtoprocalcitoninguidancevs.usualcare
antibioticswereprescribedatphysiciandiscretioninbothgroups
algorithmfromtheProHOSPtrialusedtoguidetherapy
only2patientslosttofollowup
comparingprocalcitoninvs.usualcaregroup
antibioticsprescribedatadmissionin85%vs.99%(p<0.001)
mediandurationofantibioticuse5daysvs.12days(p<0.001)
hospitalizationin97%vs.97%(notsignificant)
33/58
complicationsin13%vs.14%(notsignificant)
mortality12%vs.13%(notsignificant)
curedat6weeks85%vs.85%(notsignificant)
ReferenceAmJRespirCritCareMed2006Jul1174(1):84
Antivirals
CentersforDiseaseControlandPrevention(CDC)20152016recommendationsfortreatmentof
influenza
unchangedfrom2011to2012recommendations
antiviraltreatmentrecommendedassoonaspossibleforpatientswithconfirmedorsuspected
influenzawho
havesevere,complicated,orprogressiveillness
requirehospitalization
whoareathigherriskforinfluenzacomplications
antiviraltreatmentmaybeconsideredforanyoutpatientwithconfirmedorsuspectedinfluenza
iftreatmentcanbestartedwithin48hoursofillnessonset
inseverelyillpatients
treatmentupto5daysafteronsetofillnesshasbeenassociatedwithreducedmorbidity
andmortalityinobservationalstudies,butgreaterbenefitassociatedwithtreatmentwithin
2daysfromillnessonset
treatmentshouldnotbedelayedwhileawaitingconfirmatorydiagnostictests
recommendedantiviralsforadultpatientsincludeoseltamivir,zanamivir,andperamivir
basedonrecentviralsurveillanceandresistancedataindicating>99%circulating
influenzavirusstrainsaresensitive
amantadineandrimantadinenotrecommendedduetohighlevelsofresistance
recommendedantiviralsforpregnantwomen
oseltamivirpreferred
zanamivirmightbeappropriatebuthasriskforrespiratorycomplicationsduetoinhaled
route
monitorlocal,state,andnationalrecommendationsduringinfluenzaseason
ReferenceMMWRRecommRep2011Jan2160(1):1EBSCOhostFullTextfulltext
seeInfluenzaantiviraltreatmentandprophylaxisforadditionalinformation
Corticosteroids
useofadjunctivesystemiccorticosteroidsisnotstandardpracticeinthemanagementofcommunity
acquiredpneumoniabutseveralrecenttrialsandsystematicreviewssuggestcorticosteroids
mightreducemortalityinpatientswithseverecommunityacquiredpneumonia(CAP)butthis
effectisnotshowninallcomerswithCAP
mayreducetimetostabilizationofvitalsignsandlengthofhospitalstayinpatientswithnon
severeCAP
areassociatedwithinhospitalhyperglycemia
corticosteroiduseinpatientswithseverepneumonia
adjunctivecorticosteroidsmayreducemortalityandneedformechanicalventilationin
adultswithseverecommunityacquiredpneumonia(level2[midlevel]evidence)
basedonsystematicreviewlimitedbyclinicalheterogeneityandlimitationson
generalizabilityoffindings
systematicreviewof13randomizedtrialscomparingadjunctivecorticosteroidtherapyvs.
placeboin2,005adultswithcommunityacquiredpneumonia
trialslimitedtopatientswithchronicobstructivepulmonarydiseaseandtrials
includingpatientswithventilatorassociatedpneumonia,aspirationpneumonia,or
Pneumocystisjirovecipneumoniawereexcluded
indicatorsofpneumoniaseverityvariedacrosstrialsandincludedPneumonia
SeverityIndexscoreofIVorV,CURB65score2,1majoror3minorcriteria
fromIDSA/ATS2007consensusguideline,BritishThoracicSocietycriteriascore
34/58
3,1majoror2minorcriteriafrom2001ATSrule,and1criterionfrom1993ATS
rule
corticosteroidregimenandpatientcomorbiditiesvariedacrosstrials
6trialsclassifiedasevaluatingseverepneumonia(70%ofpatientsfulfilledsevere
pneumoniacriteriaormortality15%incontrolgroup)
intrialsevaluatingseverepneumonia,adjunctivecorticosteroidsassociatedwith
reducedmortalityinanalysisof6trialswith388patients
riskratio(RR)0.39(95%CI0.20.77)
NNT620withmortality22%incontrolgroups
reducedriskofmechanicalventilationinanalysisof3trialswith230patients
RR0.54(95%CI0.50.58)
NNT1113withmechanicalventilationin19%incontrolgroups
reducedriskofacuterespiratorydistresssyndromeinanalysisof3trialswith160
patients
RR0.23(95%CI0.050.98)
NNT7308withacuterespiratorydistressin16%incontrolgroup
nonsignificantreductionindurationofhospitalization(meandifference5.03days,
95%CI10.78to0.72)inanalysisof4trialswith280patients
nosignificantdifferencesin
hyperglycemiainanalysisof2trialswith200patients
gastrointestinalhemorrhageinanalysisof4trialswith280patients
timetoclinicalstabilityin1trialwith120patients
severeneuropsychiatriccomplicationsin1trialwith120patients
ReferenceAnnInternMed2015Oct6163(7):519EBSCOhostFullText,editorialcanbe
foundinAnnInternMed2015Oct6163(7):560EBSCOhostFullText,earlierCochrane
reviewwithsameinclusioncriteriaandwith4trialsalsoincludedinthisreviewcanbe
foundinCochraneDatabaseSystRev2011Mar16(3):CD007720
DynaMedcommentaryexclusioncriteriaandlackofsignificantnumbersofsubsetsof
patientswhomayincurharmfromuseofcorticosteroids,suchasthosewithinfluenza,
maylimitgeneralizabilityofthesefindingsfurther,clinicalstabilityisacomposite
outcomeandtimetoimprovementofthisoutcomemaybeartificiallyreduceddueto
corticosteroideffectonfeverthereductioninlengthofstaymayalsobeasimilarartifact
andnotreflectiveofclinicalwellness
adjunctivecorticosteroidsmightnotdecreasemortalityinpatientswithseverecommunity
acquiredpneumonia(level2[midlevel]evidence)
systematicreviewof9randomizedtrialsand6cohortstudiesevaluatingcorticosteroiduse
in5,762adultswithcommunityacquiredpneumonia
meancorticosteroiddosewas30mg/daymethylprednisoloneequivalentsformean
durationof7daysinrandomizedtrials
4trialsevaluatedpatientswithseverepneumonia,definedastrialswith>50%of
patientswithPneumoniaSeverityIndexscoreofIVVormeanAPACHEIIscore
15and1trialincludedsubgroupanalysisofpatientswithseverepneumonia
allcohortstudiesincludedpatientswithseverepneumoniawithvaried
corticosteroiddosages(meanduration7days)
comparingadjunctivecorticosteroidtherapyvs.placeboinstudiesevaluatingsevere
pneumonia,
adjunctivecorticosteroidsassociatedwithnonsignificantreductioninmortality(risk
ratio0.64,95%CI0.321.29)inanalysisof5trialswith347patients
nosignificantdifferenceinmortalityinanalysisof6cohortstudieswith2,546
patients
nosignificantdifferencesinmortalityinanalysisofall9randomizedtrialsevaluatingany
severitypneumoniawith1,667patients
ReferenceChest2016Jan149(1):209
selectedtrialincludedinabovesystematicreviews
corticosteroidsmayreducetreatmentfailureat3daysinhospitalizedpatientswith
severecommunityacquiredpneumoniaandhighinflammatoryresponse(level2
[midlevel]evidence)
35/58
basedonrandomizedtrialwithbaselinedifferences
120adults(meanage65years)hospitalizedwithseverecommunityacquired
pneumoniawererandomizedtomethylprednisolone0.5mg/kgper12hoursIV
bolusvs.placebofor5daysstartingwithin36hoursofhospitalizationinadditionto
guidelinerecommendedantibiotics
allpatientsmetmodifiedAmericanThoracicSocietycriteriaforseverepneumonia
orwereclassifiedasriskclassVbythePneumoniaSeverityIndexclassVandhad
highinflammatoryresponseatadmission(definedasCreactiveproteinlevel>150
mg/L)
17%inmethylprednisolonegroupand31%inplacebogrouphadsepticshockat
baseline(nopvaluereported)
compositeoutcomeofearlytreatmentfailuredefinedasshock,newneedfor
invasivemechanicalventilation,ordeathwithin3days
compositeoutcomeoflatetreatmentfailuredefinedasradiographicprogression,
persistentsevererespiratoryfailure,shock,newneedforinvasivemechanical
ventilation,ordeathbetween3and5days
comparingmethylprednisolonevs.placebo
earlytreatmentfailurein10%vs.10%(notsignificant)
latetreatmentfailurein3%vs.25%(p=0.001,NNT5)
radiographicprogressionin2%vs.15%(p=0.007,NNT8)
latesepticshockin0%vs.7%(p=0.06)
inhospitalmortality10%vs.15%(notsignificant)
nosignificantdifferencesinlengthofhospitalorintensivecareunitstay,timeto
clinicalstability,hyperglycemia,orrateofadverseevents
ReferenceJAMA2015Feb17313(7):677EBSCOhostFullText,editorialcanbe
foundinJAMA2015Feb17313(7):673EBSCOhostFullText
useinpatientswithnonseverepneumonia
adjunctivecorticosteroidsmightreduceneedformechanicalventilationandtimeto
clinicalstabilityinadultswithnonseverecommunityacquiredpneumonia(level2[mid
level]evidence)
basedonsystematicreviewlimitedbyclinicalheterogeneityandlimitationson
generalizabilityoffindings
systematicreviewof13randomizedtrialscomparingadjunctivecorticosteroidtherapyvs.
placeboin2,005adultswithcommunityacquiredpneumonia
trialslimitedtopatientswithchronicobstructivepulmonarydiseaseandtrials
includingpatientswithventilatorassociatedpneumonia,aspirationpneumonia,or
Pneumocystisjirovecipneumoniawereexcluded
indicatorsofpneumoniaseverityvariedacrosstrialsandincludedPneumonia
SeverityIndexscoreofIVorV,CURB65score2,1majoror3minorcriteria
fromIDSA/ATS2007consensusguideline,BritishThoracicSocietycriteriascore
3,1majoror2minorcriteriafrom2001ATSrule,and1criterionfrom1993ATS
rule
corticosteroidregimenandpatientcomorbiditiesvariedacrosstrials
7trialsclassifiedasevaluatinglessseverepneumonia(<70%ofpatientsfulfilledsevere
pneumoniacriteriaormortality<15%incontrolgroup)
intrialsevaluatinglessseverepneumonia,adjuctivecorticosteroidsassociatedwith
reducedriskofmechanicalventilationinanalysisof2trialswith830patients
riskratio(RR)0.18(95%CI0.080.43)
NNT4167withmechanicalventilationin2.7%incontrolgroup
reducedtimetoclinicalstability(meandifference1.41days,95%CI0.272.55
days)inanalysisof4trialswith1,060patients
increasedriskofhyperglycemiainanalysisof4trialswith1,334patients
RR1.78(95%CI1.42.26)
NNH1033withhyperglycemiain7.5%incontrolgroup
nonsignificantreductioninintensivecareunitadmission(RR0.69,95%CI0.46
1.03)inanalysisof3trialswith950patients
nosignificantdifferencein
mortalityinanalysisof6trialswith1,586patients
36/58
durationofhospitalizationinanalysisof5trialswith1,364patients
gasterointestinalhemorrhageinanalysisof3trialswith943patients
severeneuropsychiatriccomplicationsinanalysisof3trialswith1,097patients
rehospitalizationafterdischargeinanalysisof2trialswith1,089patients
acuterespiratorydistresssyndromein1trialwith785patients
ReferenceAnnInternMed2015Oct6163(7):519EBSCOhostFullText,editorialcanbe
foundinAnnInternMed2015Oct6163(7):560EBSCOhostFullText,earlierCochrane
reviewwithsameinclusioncriteriaandwith4trialsalsoincludedinthisreviewcanbe
foundinCochraneDatabaseSystRev2011Mar16(3):CD007720
useofcorticosteroidsinallcomerswithCAP
corticosteroidsmayreducelengthofhospitalstaybutnotmortalityinadultswith
systematicreviewof8randomizedtrialscomparingcorticosteroidsvs.placeboin875
patientswithcommunityacquiredpneumonia
corticosteroidregimen,patientcomorbidities,andseverityofillnessvariedacrosstrials
corticosteroidsassociatedwithreductionin
hospitalstay(meandifference1.21days,95%CI0.292.12days)inanalysisof5
trials
delayedshock(relativerisk0.12,95%CI0.030.41)inanalysisof2trials
persistenceofchestxrayabnormalitiesbyday8(relativerisk0.13,95%CI0.06
0.27)inanalysisof2trials
nosignificantdifferencesin
inhospitalmortalityinanalysisofalltrials
intensivecareunitadmission(2trials)orstay(4trials)
ReferenceJHospMed2013Feb8(2):68EBSCOhostFullText,editorialcanbefoundin
JHospMed2013Feb8(2):59EBSCOhostFullText
corticosteroidsmayreducetimetostabilizationofvitalsignsandlengthofhospitalstayin
patientshospitalizedwithcommunityacquiredpneumonia(level2[midlevel]evidence)
basedonrandomizedtrialwithoutreportofratesofunstablevitalsignsatbaseline
802adults(medianage74years,62%male)hospitalizedwithcommunityacquired
pneumonia(23%withantibioticpretreatment)wererandomizedwithin24hoursof
presentationtoprednisone50mgdailyvs.placebofor7daysinadditiontoguideline
recommendedantibiotics
mostcommoncomorbiditiesincludedrenalinsufficiencyin32%,diabetesmellitus
in20%,heartfailurein18%,chronicobstructivepulmonarydiseasein17%,and
coinfectionin12%
nosignificantdifferencesinbaselinepneumoniaseveritybetweengroups
(PneumoniaSeverityIndexclassIVVin48%)
17patients(2.1%)wereexcludedafterrandomizationfornotmeetingeligibilitycriteria
timetoclinicalstabilitydefinedastimeuntilstablevitalsignsfor24hours
comparingprednisonevs.placebo
mediantimetoclinicalstability3daysvs.4.4days(p<0.0001)
medianlengthofhospitalstay6daysvs.7days(p=0.012)
recurrentpneumoniain6%vs.5%(notsignificant)
readmissiontohospitalin9%vs.8%(notsignificant)
anypneumoniaassociatedcomplicationsat30daysin3%vs.6%(p=0.056)
30daypneumoniaassociatedmortality1%vs.2%(notsignificant)
inhospitalhyperglycemiain19%vs.11%(p=0.001)
consistentresultsinsubgroupanalysesbyage,medianCreactiveproteinconcentration,
historyofchronicobstructivepulmonarydisease,severityofpneumonia,orbloodculture
positivity
nosignificantdifferencesinpneumoniaseverityatdays5or30orinothercorticosteroid
relatedadverseeventsat30days
ReferenceLancet2015Apr18385(9977):1511,editorialcanbefoundinLancet2015
Apr18385(9977):1484
DynaMedcommentarybaselineandposttreatmentratesoftheindividualvitalsigns
comprisingthecompositeoutcomeofclinicalstabilitywerenotreported.Thisleavesopen
37/58
thepossibilitythatcorticosteroidsfunctionedasanantipyretic,reducingtimetofever
reductionandsubsequentlycomposite"clinicalstability"andlengthofstay,potentially
threateningthevalidityofthesefindings
prednisonemaynotreducetimetoclinicalstabilityinpatientswithpneumococcal
basedonprespecifiedsecondaryanalysisofrandomizedtrialabovewithout
intentiontotreatanalysis
726hospitalizedpatients(medianage70years,38.7%withfever)withCAPwho
receivedperprotocoltreatmentwithprednisonevs.placebowereassessed
36.6%ofpatientshadmicrobiologicallydiagnosedpneumonia
47%pneumococcalpneumonia
26%otherbacteria
11%influenzaviruses
23%respiratoryvirusesotherthaninfluenza
prednisonegrouphadsignificantlygreaterpneumoniaseverityandratesofheart
failure
mediantimetoclinicalstabilitywas3.4dayswithprednisonevs.3.6dayswith
placebo(notsignificant)insubgroupofpatientswithpneumococcalpneumonia
prednisoneassociatedwithreducedtimetoclinicalstabilityinsubgroupsofpatients
withotherbacteriaandinfluenzaviruses,butnotwithrespiratoryvirusesotherthan
influenza
nosignificantdifferenceindurationofantibioticsoradverseeventsinoverall
analysis
ReferenceEurRespirJ2016Oct48(4):1150
notethatmanagementofasthmaexacerbationsinpatientswithCAP,includingcorticosteroiduse,is
similartoofpatientswithoutconcurrentpneumoniaseeAsthmaexacerbationinadultsand
adolescentsfordetail
Othermedications
insufficientevidencetoevaluatebenefitofnonprescriptioncoughmedicationsforcoughin
adultsandchildrenwithpneumonia
basedonCochranereview
systematicreviewof4randomizedtrialsevaluatingnonprescriptioncoughmedicationtotreat
coughduetoacutepneumoniain224patientstakingantibiotics
1trialwasinchildrenonly,3trialsincludedadolescentsoradults
nosignificantdifferencesinprimaryoutcomeof"notcuredornotimproved"
mucolyticsassociatedwithimprovementinsecondaryoutcome("notcured")inchildren(p<
0.05,NNT5)andadults(p<0.05,NNT5)atday10
ReferenceCochraneDatabaseSystRev2014Mar10(3):CD006088
vitaminCmightreduceseverityordurationofillnessinadultswithpneumonia(level2[mid
level]evidence)
basedonCochranereviewwithlimitedevidence
systematicreviewof6randomizedorcontrolledclinicaltrialsevaluatingvitaminCfor
pneumoniatreatmentorprophylaxisin2,569persons
2trialsevaluatedvitaminCfortreatmentofcommunityacquiredpneumoniain197adults
comparingvitaminC(0.2g/day)vs.placebofor4weeksafterhospitalizationin1trialwith57
adults(meanage81years)withacutebronchitisorpneumonia
vitaminCsignificantlyimprovedrespiratoryscoresat4weeksinsubgroupofseverelyill
patients,buthadnosignificanteffectinsubgroupoflessillpatients
mortality3.6%vs.17.2%(nopvaluereported)
meandurationofpneumonia15dayswithhighdosevitaminC(0.51.6g/day)vs.19dayswith
lowdosevitaminC(0.250.8g/day)(p<0.001)in1lowqualitytrialwith70menwithacute
pneumonia
ReferenceCochraneDatabaseSystRev2013Aug8(8):CD005532
38/58
granulocytecolonystimulatingfactormaynotreducemortalityinhospitalizedadultswith
basedonCochranereviewwithwideconfidenceintervals
systematicreviewof6randomizedtrialsevaluatingadjunctivegranulocytecolonystimulating
factor(GCSF)in2,018hospitalizedadultswithpneumonia(communityacquiredorhospital
acquired)
nosignificantdifferencein28daymortality(oddsratio0.81,95%CI0.521.27)orincidenceof
seriousadverseevents(oddsratio0.91,95%CI0.731.14)
ReferenceCochraneDatabaseSystRev2007Apr18(2):CD004400(reviewupdated2009
Aug6)
tifacogin(recombinanttissuefactorpathwayinhibitor)maynotreducemortalityinpatients
withseverecommunityacquiredpneumonia(level2[midlevel]evidence)
basedonrandomizedtrialwithallocationconcealmentnotstated
2,138patients18yearsoldwithseverecommunityacquiredpneumoniawererandomizedto
tifacogin(0.025vs.0.075mg/kg/hour)vs.placebofor96hours
tifacogin0.075mgarmwasdiscontinuedforlackofefficacyatprespecifiedinterimanalysis
28daymortality18%withtifacogin0.025mg/kg/hourvs.17.9%withplacebo(notsignificant)
ReferenceAmJRespirCritCareMed2011Jun1183(11):1561,editorialcanbefoundinAm
JRespirCritCareMed2011Jun1183(11):1449
Othermanagement
Clinicalcarepathways
3stepcriticalpathwayinterventionassociatedwithshorterdurationofhospitalstayandIV
antibioticuseinadultshospitalizedforcommunityacquiredpneumonia(level2[midlevel]
evidence)
basedonrandomizedtrialwithoutblindingofoutcomeassessors
401adultshospitalizedforcommunityacquiredpneumoniarandomizedto3stepcritical
pathwayinterventionvs.usualcare
3stepcriticalpathwayinterventionwasdesignedtoreducedurationofcareandconsistedof
earlymobilizationwithuprightpositionforatleast20minutesduringfirst24hoursof
hospitalization
useofobjectivecriteriaforswitchfromIVtooralantibiotics,including
clinicalimprovement
abilitytomaintainoralintake
stablevitalsigns
absenceofexacerbatedmajorcomorbiditiesormetastaticextensionofinfection
useofpredefinedcriteriaforhospitaldischarge,including
meetingallofabovecriteria
baselinementalstatus
adequateoxygenationwithoutsupplementation(PaO260mmHgorpulse
oximetry90%)
comparing3stepcriticalpathwayvs.usualcare
medianhospitalstay3.9daysvs.6days(p<0.001)
mediandurationofIVantibiotics2daysvs.4days(p<0.001)
adversedrugreactionsin4.5%vs.15.9%(p<0.001,NNT9),mainlyphlebitisin4%vs.
10.4%(p=0.02,NNT16)
hospitalreadmissionwithin30daysin9.1%vs.7.5%(notsignificant)
mortality2%vs.1%(notsignificant)
patientsatisfactionwithcarein94.6%vs.94.3%(notsignificant)
ReferenceArchInternMed2012Jun25172(12):922EBSCOhostFullText,editorialcanbe
foundinArchInternMed2012Jun25172(12):928EBSCOhostFullText
Chestphysicaltherapy
39/58
additionofchestphysiotherapytoroutinetreatmentdoesnotappeartoreducemortalityor
improvecurerateinadultswithpneumonia(level2[midlevel]evidence)
basedonCochranereviewoftrialswithmethodologiclimitations
systematicreviewof6randomizedtrialscomparingchestphysiotherapyvs.controlfor
treatmentofpneumoniain434adultpatients
alltrialshad1methodologiclimitation,including
methodofrandomizationnotstated
selectivereportingofoutcomes
physiotherapymethodsincluded
conventionalchestphysiotherapy(posturaldrainage,percussion,vibration,andcoughing)
osteopathicmanipulation(paraspinalinhibition,ribraising,andmyofascialrelease)
activecycleofbreathingtechniques
positiveexpositorypressure
nosignificantdifferencesinmortalityorcureratescomparing
conventionalchestphysiotherapyvs.controlinanalysisof2trialswith225patients
osteopathicmanipulationvs.controlin2trialswith79patients
osteopathicmanipulationassociatedwith(inanalysisof2trialswith79patients)
reducedhospitalstay(meandifference2days,p=0.006)
reduceddurationoftotalantibiotictherapy(meandifference1.9days,p=00015)
ReferenceCochraneDatabaseSystRev2013Feb28(2):CD006338
Additionalconsiderationsforpatientswithseverecommunityacquiredpneumoniaor
respiratoryfailure
useofventilationinpatientswithcommunityacquiredpneumonia(2)
arterialoxygensaturation90%suggestedformeasurementofclinicalstability
conductcautioustrialofnoninvasiveventilationinpatientswithhypoxemiaorrespiratory
distress,unlessimmediateintubationisrequired(IDSA/ATSModeraterecommendation,Level
I)
immediateintubationrequiredinpatientswithseverehypoxemia(PaO2/FiO2ratio<150)and
bilateralalveolarinfiltrates(IDSA/ATSModeraterecommendation,LevelI)
uselowtidalvolumeventilation(6cm3/kgidealbodyweight)inpatientswithdiffusebilateral
pneumoniaoracuterespiratorydistresssyndromehavingventilation(IDSA/ATSStrong
recommendation,LevelI)
inpatientswithhypotensionafterfluidresuscitation,screenforoccultadrenalinsufficiency
(IDSAModeraterecommendation,LevelII)
noninvasiveventilationmayreduceneedforintubationandlengthofintensivecareunitstay
comparedtooxygendeliverybyVenturimaskinadultswithcommunityacquiredpneumonia
complicatedbyrespiratoryfailurenotrequiringimmediateintubation(level2[midlevel]
evidence)
basedonCochranereviewoftrialswithblindingunclearornotstated
systematicreviewof3randomizedtrialsevaluatingoxygentherapyin151adultswith
communityacquiredpneumoniacomplicatedbyrespiratoryfailure
comparingnoninvasiveventilation(NIPPV)tooxygendeliverybyVenturimask
NIPPVassociatedwithdecreased
intubationrate(oddsratio[OR]0.26,95%CI0.110.61)inanalysisof2trialswith
108adults
durationofintensivecareunitstay(meandifference3.28days,95%CI5.41to
1.16days)inanalysisof2trialswith108adults,resultslimitedbyheterogeneity
mortalityinimmunosuppressedpatients(OR0.24,95%CI0.112.68)inanalysisof
1trialwith52patients
nosignificantdifferenceindurationofmechanicalventilationinanalysisof2trialswith
108adults
ReferenceCochraneDatabaseSystRev2012Mar14(3):CD006607
40/58
delayinassessmentofoxygenrequirementinemergencydepartmentmaybeassociatedwith
increasedmortalityinpatientsadmittedtointensivecareunitwithseverecommunityacquired
basedonsecondaryanalysisfromprospectiveobservationalstudy
529patientswithcommunityacquiredpneumoniaadmittedtointensivecareunitin33hospitals
hadrecordsreviewedfortimingofinitialassessmentofoxygenationstatus
delayinoxygenationassessmentof>1hourassociatedwith
increaseintimetofirstantibioticdoseof6.13hours(95%CI3.428.83hours,p<0.001)
increasedriskofdeath(relativerisk2.24,95%CI1.174.3)
delayedoxygenationassessment>3hourswasindependentriskfactorfordeath(hazardratio
2.06,95%CI1.223.5)
ReferenceCritCareMed2007Nov35(11):2509
Followup
chestxrayclearing
clinicalimprovementmayprecederesolutiononchestradiographsinhospitalizedpatients
withseverecommunityacquiredpneumonia
basedoncaseseries
288adultshospitalizedforseverecommunityacquiredpneumoniahadchestradiographs
atbaseline,day7,andday28
outcomesanalyzedin228patientsatday7and195patientsatday28
clinicalimprovementin56%atday7and78%atday28
resolutionofchestradiographabnormalitiesin25%atday7and53%atday28
nosignificantdifferencesatday28betweenpatientswithandpatientswithout
deteriorationofchestradiographfindings(p>0.09)
delayedresolutionofradiographabnormalitiesassociatedwith
multilobardisease(p<0.01)
dullnesstopercussionatphysicalexamination(p<0.01)
highCreactiveproteinlevel(>200mg/L)(p<0.01)
highrespiratoryrateatadmission(>25breaths/minute)(p<0.03)
ReferenceClinInfectDis2007Oct1545(8):983EBSCOhostFullText
radiographicclearancemaytake12weeksinelderly
basedoncaseseries
74patients>70yearsoldadmittedtohospitalforcommunityacquiredbacterial
pneumoniahadchestxraysdoneevery3weeksfor12weeksoruntilradiographic
clearance(resolutionorreturntobaseline)
64patients(86%)completedthestudy
rateofradiographicclearancewas35%at3weeks,60%at6weeks,and84%at12weeks
independentriskfactorsfordelayedradiographicclearancewerecomorbidityindexand
multilobardisease
ReferenceJAmGeriatrSoc2004Feb52(2):224EBSCOhostFullText,summarycanbe
foundinAmFamPhysician2004Oct170(7):1388
incidenceoflungcanceronxrayappearstobelowfollowingpneumonia
basedoncaseseries
3,398patients(meanage58years,52%men)whohadfollowupradiographyafter
hospitalizationforpneumoniawerefollowedforupto5years
17%werecurrentsmokersand18%hadchronicobstructivepulmonarydiseaseattimeof
pneumonia
incidenceoflungcancer
1.1%at90days
1.7%at1year
2.1%at2years
2.3%overentirefollowup
increasedriskoflungcancerassociatedwithage50yearsattimeofpneumoniaand
malesex
ReferenceArchInternMed2011Jul11171(13):1193EBSCOhostFullText
41/58
ComplicationsandPrognosis
Complications
Pulmonarycomplications
Parapneumoniceffusionandempyema
parapneumoniceffusioncomplicatesabout20%57%ofcasesofpneumonia
asmanyas40%ofparapneumoniceffusionsmaybecomeinfectedordevelopintoempyema
lungabscessespeciallywithaspirationpneumonia
Systemiccomplications
bacteremia,particularlyasacomplicationofStreptococcuspneumoniaepneumonia
sepsis,seeSepsisinadultsorSepsisinchildrenforadditionalinformation
Cardiaccomplications
predictionrulemayhelppredictriskofcardiaccomplicationsinpatientshospitalizedfor
basedonprognosticcohortstudywithindependentderivationandvalidationcohorts
derivationcohortincluded1,343patientshospitalizedforcommunityacquiredpneumoniaand
validationcohortincluded608similarpatients
cardiaccomplications(neworworseningheartfailure,neworworseningcardiacarrhythmia,or
acutemyocardialinfarction)in27%ofderivationcohortand21%ofvalidationcohort
predictionrulederivedusingfactorssignificantlyassociatedwithshorttermriskofcardiac
complicationsinpatientshospitalizedwithcommunityacquiredpneumonia(totalscore171
points)
age
comorbiditiesincludingheartfailure,coronaryarterydisease,andcardiacarrhythmias
pulserateandbloodpressure
7laboratoryfindings
bilateralinfiltratesonchestxray
seeonlinecalculatorfordetails
patientsassignedtoriskclassbasedonpredictionrule
riskclassI=77points
riskclassII=78134points
riskclassIII=135170points
riskclassIV=171points
predictedandobservedriskofcardiaccomplicationbyriskclassinvalidationcohort
5.5%predictedand5%observedin100patientsinriskclassI
16.6%predictedand8.2%observedin256patientsinriskclassII
38.7%predictedand28.3%observedin113patientsinriskclassIII
69.3%predictedand48.9%observedin139patientsinriskclassIV
comparedtopneumoniaseverityindex(PSI),predictionrulecorrectlyupwardreclassifiedrisk
in19%ofpatientsanddownwardreclassifiedriskin25%ofpatients
predictionrulehadbetterdiscriminationthanPSI(p=0.03)
ReferenceMayoClinProc2014Jan89(1):60
cardiaccomplicationscommoninpatientshospitalizedwithcommunityacquiredpneumonia
systematicreviewof17cohortstudiesreportingincidenceofcardiaccomplicationsininpatients
withcommunityacquiredpneumonia
pooledincidenceratesfor
overallcardiaccomplications17%in6cohortswith2,119patients
incidentheartfailure14.1%in8cohortswith4,215patients
42/58
acutecoronarysyndromes5.3%in6cohortswith2,657patients
incidentcardiacarrhythmias4.7%in6cohortswith2,596patients
ReferencePLoSMed2011Jun8(6):e1001048EBSCOhostFullTextfulltext
cardiovasculareventsmaybecommoninpatients>65yearsoldhospitalizedwithpneumonia
50,119patients>65yearsold(mean77.5years)evaluatedfromDepartmentofVeteransAffairs
database20012007
90dayincidenceofcardiovasculareventsfollowingadmissionforpneumonia
10.2%forheartfailure
9.5%forarrhythmia
1.5%formyocardialinfarction
0.8%forunstableangina
0.2%forstroke
mosteventsoccurredduringhospitalization
ReferenceAmJMed2011Mar124(3):244
communityacquiredpneumoniaassociatedwithincreasedriskofincidentheartfailureinadults
4,988adults(meanage55years)withcommunityacquiredpneumoniawerematchedwith
23,060adultswithouthistoryofcommunityacquiredpneumoniainpreviousyearandassessed
forheartfailureovermedian9.9years
exclusioncriteriaincludedprevalentheartfailure,tuberculosis,cysticfibrosis,
immunosuppression,andpregnancy
35.3%ofpatientswithpneumoniawere>65yearsold
heartfailureratescomparingadultswithpneumoniavs.adultswithoutpneumonia
overall11.9%vs.7.4%(adjustedhazardratio[HR]1.61,95%CI1.441.81)
inadults65yearsold4.8%vs.2.2%(adjustedHR1.98,95%CI1.52.53)
inadults>65yearsold24.8%vs.18.9%(adjustedHR1.55,95%CI1.361.77)
consistentresultsinanalysesbyfollowupduration(90daysor1year)ortreatmentsetting
(inpatientoroutpatient)
nosignificantdifferencesinriskofstrokeorfracture
ReferenceBMJ2017Feb13356:j413fulltext
19.4%rateofacutecardiaceventsinpatientshospitalizedforpneumococcalpneumonia
170patientsadmittedforpneumococcalpneumoniabetween2001and2005werereviewed
acutecardiaceventsincluded
1ormoremajorcardiaceventsin19.4%
neworworseningheartfailurein14%
myocardialinfarctionin7%
newonsetatrialfibrillationorventriculartachycardiain5%
ReferenceClinInfectDis2007Jul1545(2):158EBSCOhostFullTextfulltext
Thromboticcomplications
acuteinfectionmayincreaseriskfordeepveinthrombosis(DVT)andpulmonaryembolism(PE)
basedonselfcontrolledcaseseriesof7,278firstDVTand3,755firstPEdiagnosesinUnited
Kingdomgeneralpracticedatabase
increasedriskforDVTandPEafterurinarytractinfection
incidenceratio2.1forDVTand2.11forPEinfirst2weeksafterurinarytractinfection
increasedincidenceratiosforDVTandPE(1.152.11)persistedforupto39weeksafter
urinarytractinfection
increasedriskforDVTaftersystemicrespiratorytractinfection
incidenceratio1.91infirst2weeksaftersystemicrespiratorytractinfection
increasedincidenceratios(1.161.62)persistedupto26weeksaftersystemicrespiratory
tractinfection
PEnotevaluatedduetopossiblediagnosticmisclassification
43/58
ReferenceLancet2006Apr1367(9516):1075EBSCOhostFullText,commentarycanbefound
inLancet2006Jul15368(9531):201EBSCOhostFullText
Prognosis
Mortality
Mortalityrates
5.6%overall30daycasefatalityamongadultMedicarepatientswithcommunityacquired
pneumonia
65,804casesofcommunityacquiredpneumoniawereidentifiedinanalysisof20072008
MedicareStandardAnalyticFiles(nationallyrepresentativerandomsampleofthe
approximately35.2millionMedicareenrollees)
30daycasefatality
5.6%overall
8.5%amonghospitalizedpatients
3.8%amongoutpatients
meanlengthofepisodeofcommunityacquiredpneumonia
32.8daysamonginpatients
12.4daysamongoutpatients
meanlengthofhospitalizationamonginpatients8.7days
ReferenceJAmGeriatrSoc2012Nov60(11):2137EBSCOhostFullText
30daymortalityabout10%amongpatients>65yearsoldhospitalizedforpneumoniainUnited
States
basedon1,418,252Medicarepatients>65yearsoldhospitalizedforpneumonia20042006
median30daymortalityabout10%12%acrosshospitals,basedonestimatesfromgraph
ReferenceNEnglJMed2010Mar25362(12):1110fulltext
30dayallcauseriskstandardizedmortalityrate11.6%andreadmissionrate18.2%inpatients
withpneumonia
14,084hospitalswithpatients65yearsoldanddischargediagnosisofacutemyocardial
infarction,heartfailure,orpneumoniawereanalyzed
4,811hospitalswereanalyzedforpneumoniaoutcomes
riskstandardizedmodelswereadjustedforpatientage,gender,and28clinicalcovariatesof
pneumonia
meanriskstandardizedmortalityat30days11.6%forpneumonia
meanriskstandardizedhospitalreadmissionat30days18.2%forpneumonia
noassociationbetweenhospitalreadmissionandmortalityratesforpneumonia
ReferenceJAMA2013Feb13309(6):587EBSCOhostFullText
aboutonehalfofdeathsfrompneumoniamayoccurafterhospitaldischarge
21,223patients65yearsoldwithpneumoniabetween2000and2001wereevaluatedfor
mortalitywithin30daysofhospitaladmission
12.1%diedwithin30daysofhospitaladmission
52.4%duringhospitalstay
47.6%afterdischarge
increasedriskofinhospitalmortality(comparedtopostdischargemortality)associatedwith
mechanicalventilation
bacteremia
acidosis
bloodureanitrogen(BUN)>11mmol/L
arterialPo2<60mmHgorsaturation<90%
ReferenceChest2012Aug142(2):476
44/58
1yearmortality31.1%followinghospitalizationforpneumoniainolderpatients(level2[mid
level]evidence)
patients65yearsoldonMedicarewhosurvivedhospitalizationforheartfailure,acute
myocardialinfarction,orpneumoniawerefollowedforupto1year
951,084patientshad1,125,234hospitalizationsforpneumonia
1yearmortality31.1%
comparedtogeneralMedicarepopulation,patientswithpneumoniahadincreasedmortality
at30days(adjustedstandardizedincidenceratio18,95%CI17.918.2)
at1year(adjustedstandardizedincidenceratio5.6,95%CI5.65.6)
ReferenceBMJ2015Feb5350:h411fulltext
Shorttermmortalityriskfactors
calculatingmortalityrisk
ResearchandQuality(AHRQ)usesPORTstudy
mortality<0.5%ifnoneof
age<50years
neoplasticdisease
heartfailure
cerebrovasculardisease,renaldisease,orliverdisease
alteredmentalstatus
pulse>125beats/minute
temperature>40degreesC(104degreesF)or<35degreesC(95degreesF)
useinteractivePneumoniaSeverityIndexCalculatoravailableviatheAgencyfor
HealthcareResearchandQuality(AHRQ)orseePneumoniaseverityassessmentto
predictmortalityifriskfactors
seePneumoniaseverityassessmentformultiplepredictionrules(includingPneumoniaSeverity
Index[PSI],CURB65,CRB65)
diseaseseverity,causativepathogen,andunderlyingconditionsassociatedwithincreasedriskof
mortalityinadultswithcommunityacquiredpneumonia
basedonmetaanalysisof122studieswith33,148adultswithcommunityacquiredpneumonia
mortality
13.7%overall
5.1%inhospitalizedandambulatorypatients,in6studycohortswith2,097patients
19.6%inbacteremicpatients,in12studycohortswith1,544patients
36.5%inintensivecareunitpatients,in13studycohortswith788patients
byetiology
12.8%in11,229patientswithunknownetiologyofpneumoniain27cohorts
31.8%among157patientswithStaphylococcusaureusin25cohorts
61.1%in18patientswithPseudomonasaeruginosain18cohorts
12.3%in4,432patientswithStreptococcuspneumoniaein59cohorts
7.4%in883patientswithHaemophilusinfluenzaein27cohorts
23.6%in301patientswithpolymicrobialinfectionsin10cohorts
9%in100patientswithinfluenzaAin10cohorts
factorsassociatedwithincreasedriskofmortality
hypothermia(oddsratio[OR]5,95%CI2.410.4)
hypotension(OR4.8,95%CI2.88.3)
neurologicdisease(OR4.6,95%CI2.38.9)
multilobarinfiltrateonxray(OR3.1,95%CI1.95.1)
tachypnea(OR2.9,95%CI1.74.9)
bacteremia(OR2.8,95%CI2.43.1)
neoplasticdisease(OR2.8,95%CI2.43.1)
leukopenia(OR2.5,95%CI1.63.7)
45/58
malesex(OR1.3,95%CI1.21.4)
diabetesmellitus(OR1.3,95%CI1.11.5)
pleuriticchestpainassociatedwithreducedriskofmortality(OR0.5,95%CI0.30.8)
ReferenceJAMA1996Jan10275(2):134,commentarycanbefoundinACPJClub1996Jul
Aug125(1):20
nonambulatorystatus,tachypnea,lowalbumin,andelevatedbloodureanitrogeneach
associatedwithincreasedriskofmortalityinpatientswithcommunityacquiredpneumonia
giveninitialappropriateantibiotictherapy
579adultswithcommunityacquiredpneumoniainJapanwhoreceivedinitialappropriate
antibiotictherapywerereviewed
initialappropriateantibiotictherapydefinedastreatmentwithanagenttowhichtheidentified
pathogenwassusceptible
30daymortality
10.5%overall
byetiology
25%among32patientswithP.aeruginosa
21.7%among23patientswithdrugresistantpathogens
20%among5patientswithmethicillinresistantS.aureus
14%among43patientswithnonpneumoniaestreptococci
13.4%among112patientswithmethicillinsusceptibleS.aureus
13.2%among129patientswithKlebsiellapneumoniae
11.1%among36patientswithChlamydophilapneumoniae
7.7%among39patientswithMoraxellacatarrhalis
7.4%among95patientswithH.influenzae
6%among168patientswithS.pneumoniae
0%among10patientswithMycoplasmapneumoniae
0%among2patientswithLegionellapneumophila
factorsassociatedwithincreasedriskofmortality
nonambulatorystatus(oddsratio[OR]3.34,95%CI1.846.05)
respirationrate30breathsperminute(OR2.33,95%CI1.284.24)
albumin<30mg/L(OR3.39,95%CI1.836.28)
bloodureanitrogen7.14mmol/L(OR2.2,95%CI1.134.3)
bloodpH<7.35(OR3.13,95%CI1.526.42)
ReferenceLancetInfectDis2015Sep15(9):1055,commentarycanbefoundinLancetInfect
Dis2015Sep15(9):1055
DynaMedcommentarycausativeorganismnotincludedinmultivariateanalysis
heartfailureassociatedwithincreasedmortalityinpatientshospitalizedwithpneumonia
33,736adultshospitalizedforfirsttimewithpneumoniainwesternDenmarkbetween1994and
2003werereviewed
9.5%hadpreexistingheartfailure
30daymortality24.4%inpatientswithheartfailurevs.14.4%inpatientswithoutheartfailure
(p<0.01)
ReferenceJGenInternMed2008Sep23(9):1407EBSCOhostFullTextfulltext
diabetestype2andhyperglycemiaassociatedwithincreasedmortalityinpatientshospitalized
forpneumonia
basedonpopulationbasedcohortstudyinDenmark
29,900adultswithfirsttimehospitalizationforpneumoniafrom1997to2004werereviewed
2,931patients(9.8%)haddiabetestype2
mortalityinpatientswithvs.withoutdiabetes
19.9%vs.15.1%after30days(p<0.05)
27%vs.21.6%after90days(p<0.05)
highglucoselevelonadmissionwaspredictorofdeathinpatientswithdiabetes(p<0.05)
diabetestype2notpredictiveofpulmonarycomplicationsorbacteremia
ReferenceDiabetesCare2007Sep30(9):2251EBSCOhostFullTextfulltext
increasedserumglucoseordiabetesathospitaladmissionassociatedwithincreased90day
mortalityinpatientswithcommunityacquiredpneumonia
46/58
6,891patients(meanage60years)withcommunityacquiredpneumoniawereassessedfor
glucoselevelsanddiabetesonadmissionandfollowedupto6months
90daymortality
3%inpatientswithoutdiabetesandserumglucoselevels<6mmol/L(108mg/dL)
10%inpatientswithoutdiabetesbutwithserumglucose>6mmol/Lonadmission
14%inpatientswithdiabetes
increasedriskof90daymortalityassociatedwith
serumglucoselevel610.99mmol/L(108198mg/dL)onadmissioncomparedtonormal
glucoseandnodiabetes(hazardratio1.56,95%CI1.1.222.01)
diabetescomparedtonodiabetes(hazardratio2.47,95%CI2.052.98)
ReferenceBMJ2012May28344:e3397fulltext
abnormalserumphosphoruslevelsathospitaladmissionmaybeassociatedwithincreased30
daymortality
3,894patients>18yearsoldhospitalizedwithcommunityacquiredpneumoniawerereviewed
toidentifyriskfactorsassociatedwith30daymortality
30daymortality17%
inmultivariateanalysis,increasedriskof30daymortalityassociatedwith
low,highnormal,orhighserumphosphoruslevels(comparedto1.513.99mg/dL)
1.5mg/dL(adjustedoddsratio[OR]3.8,95%CI2.16.8)
44.49mg/dL(adjustedOR1.7,95%CI1.32.3)
4.5(adjustedOR3,95%CI2.33.8)
CURB65score
=2(adjustedOR1.4,95%CI1.11.9)
3(adjustedOR3.5,95%CI2.64.7)
age80years(adjustedOR1.6,95%CI1.32)
serumalbumin<2g/dL(adjustedOR3.8,95%CI2.95)
redbloodcelldistributionwidth>15(adjustedOR1.6,95%CI1.31.9)
serumsodium150mmol/L(adjustedOR3.1,95%CI24.9)
ReferenceBMCInfectDis2015Aug1315:332EBSCOhostFullTextfulltext
Dynamedcommentaryhighproportionofpatients65yearsoldandpresenceof
comorbiditiesnotevaluatedmayconfoundanalysis
hyponatremiaathospitaladmissionassociatedwithincreasedmortalityandlongerhospitalstay
342patientshospitalizedwithcommunityacquiredpneumonia
27.9%hadhyponatremia(serumsodiumlevel<136mg/dL[<7.5mmol/L])onadmission
comparingpatientswithhyponatremiaatadmissionvs.thosewithout
hospitalmortalityin9.5%vs.3.4%(p=0.05)
meandurationofhospitalization8.66daysvs.6.4days(p<0.001)
ReferenceAmJNephrol200727(2):184EBSCOhostFullText
mortalityriskmayvarybyserotypeinbacteremicpatientswithinvasivepneumococcaldisease
metaanalysisof9studiesofserotypespecificdiseaseoutcomesin8,253patientswith
pneumococcalpneumoniaandmeningitis
relativeriskofmortalityinpatientswithbacteremicpneumonia(referentwasserotype14)
increasedriskofmortalityinpatientsinfectedwith
serotype3(riskratio[RR]1.9,95%CI1.542.35)
serotype6A(RR1.39,95%CI1.021.91)
serotype6B(RR1.59,95%CI1.22.11)
serotype9N(RR1.53,95%CI1.162.02)
serotype19F(RR2.22,95%CI1.712.88)
reducedriskofmortalityinpatientsinfectedwith
serotype1(RR0.48,95%CI0.370.63)
serotype7F(RR0.58,95%CI0.430.79)
serotype8(RR0.68,95%CI0.50.94)
nosignificantdifferenceinriskofmortalitybyserotypeamongpatientswithmeningitis
47/58
ReferenceClinInfectDis2010Sep1551(6):692EBSCOhostFullTextfulltext
statinusenotassociatedwithchangeinhospitallengthofstayorinhospitalmortalityamong
patientswithcommunityacquiredpneumonia(level2[midlevel]evidence)
2,016adultshospitalizedwithcommunityacquiredpneumoniawerecomparedbasedonuseof
statinsbeforeandduringhospitalization
483patientsusedstatinsbeforeorduringhospitalization
statinusenotassociatedwithhospitallengthofstayorinhospitalmortalityinmultivariate
analyses
ReferenceClinInfectDis2016Jun1562(12):1471
Longtermmortalityriskfactors
hospitalizationforpneumoniaassociatedwithincreasedlongtermmortality
5,888menandwomen>65yearsoldin4UnitedStatescommunitieswerefollowedformedian
10.7years
582(9.9%)patientswerehospitalizedforpneumonia,ofwhom10.3%died
comparedtoparticipantswithnopneumonia,survivingtodischargeafterhospitalizationwith
pneumoniaassociatedwithincreasedmortalityriskthereafter
relativerisk(RR)ofdeathinfirstyearafterhospitalization4.9(95%CI4.16)
RRfordeathafterfirstyear2.6(95%CI2.23.1)
ReferenceJAmGeriatrSoc2005Jul53(7):1108EBSCOhostFullText
comorbidities,poornutritionalstatus,andincreasingageassociatedwithincreasedriskoflong
termmortalityinpatientshospitalizedforpneumonia
1,555patients18yearsoldhospitalizedforpneumoniawereassessed
8.7%mortalitywithin90daysofpresentation
30%mortalitybetweenday91andendoffollowup(mean5.9years)
factorsassociatedwithlongtermmortalityinshorttermsurvivorsinmultivariateanalysis
included
Charlsoncomorbidityscore
12(hazardratio[HR]2.1,95%CI1.52.7)
34(HR3.1,95%CI2.34.3)
5(HR6.3,95%CI4.58.9)
poornutritionalstatus(HR1.7,95%CI1.12.5)
educationallevelnogreaterthanhighschooldiploma(HR1.6,95%CI1.22.1)
malesex(HR1.5,95%CI1.21.8)
glucocorticoiduse(HR1.5,95%CI1.21.9)
nursinghomeresidence(HR1.5,95%CI1.12.1)
pleuraleffusiononbaselineradiograph(HR1.4,95%CI1.11.8)
increasingage,bydecade(HR1.3,95%CI1.21.4)
feelingfeverishassociatedwithimprovedsurvival(HR0.7,95%CI0.60.9)
ReferenceClinInfectDis2003Dec1537(12):1617EBSCOhostFullTextfulltext,editorial
canbefoundinClinInfectDis2003Dec1537(12):1625EBSCOhostFullText
Hospitalreadmission
1yearreadmissionrate55.6%followinghospitalizationforpneumoniainolderpatients(level2
[midlevel]evidence)
patients65yearsoldonMedicarewhosurvivedhospitalizationforheartfailure,acute
myocardialinfarction,orpneumoniawerefollowedforupto1year
951,084patientshad1,125,234hospitalizationsforpneumonia
1yearreadmissionrate55.6%
48/58
comparedtogeneralMedicarepopulation,patientswithpneumoniahadincreasedriskof
readmission
at30days(adjustedstandardizedincidenceratio11.5,95%CI11.411.5)
at1year(adjustedstandardizedincidenceratio2.9,95%CI2.92.9)
ReferenceBMJ2015Feb5350:h411fulltext
readmissionwithin2weekscommonafterhospitalizationforpneumonia
3,047,615hospitalizationsinpatients65yearsoldfrom2007to2009wereanalyzed
1,330,157hospitalizationsforheartfailurewith329,308readmissionsby30days
548,834hospitalizationsforacutemyocardialinfarctionwith108,992readmissionsby30
days
1,168,624hospitalizationsforpneumoniawith214,239readmissionsby30days
22.4%readmissionat30daysforpneumonia(inpatientsoriginallyhospitalizedforpneumonia)
mediantimetoreadmissionforpneumonia12days
ReferenceJAMA2013Jan23309(4):355EBSCOhostFullTextfulltext,editorialcanbe
foundinJAMA2013Jan23309(4):394EBSCOhostFullText
mosthospitalreadmissionsfollowingcommunityacquiredpneumoniaduetocomorbidity
577patients18yearsolddischargedafterhospitalizationforcommunityacquiredpneumonia
evaluated
70(12%)rehospitalizedwithin30days
mediantimetorehospitalization8days(range413days)
rehospitalizationsdueto
comorbidityin52(74%)
pneumoniain14(20%)
ReferenceClinInfectDis2008Feb1546(4):550EBSCOhostFullTextfulltext
swallowingdysfunction,smoking,tranquilizeruse,andloweractivitylevelassociatedwith
increasedreadmissionratesinelderlypatientshospitalizedforpneumonia
basedoncasecontrolstudy
204matchedpairsofpatientshospitalizedforpneumoniawithandwithoutreadmissionfor
pneumoniain30daysto1yearevaluated
factorsassociatedwithincreasedriskofreadmissionincluded
swallowingdysfunction(hazardratio[HR]2.15,95%CI1.462.97)
currentsmoking(HR2.04,95%CI1.482.82)
useoftranquilizers(HR1.5,95%CI1.022.22)
loweractivitiesofdailylivingscores(HR1.06,95%CI1.021.1)
factorsassociatedwithdecreasedriskofreadmissionincluded
angiotensinconvertingenzymeinhibitors(HR0.46,95%CI0.270.78)
priorpneumococcalvaccination(HR0.59,95%CI0.420.82)
ReferenceJAmGeriatrSoc2004Dec52(12):2010EBSCOhostFullText
PreventionandScreening
Prevention
influenzavaccination
CentersforDiseaseControlandPrevention(CDC)recommendsannualvaccination
recommendedforallpersons6monthsoldwithoutcontraindications
seeInfluenzavaccinesinadultsfordetails
pneumococcalvaccination
CDCrecommendationsonpneumococcalvaccination
13valentpneumococcalconjugatevaccine(PCV13)recommendedfor
allchildrenaged259months
personsaged>5yearswithmedicalconditionsassociatedwithincreasedriskof
pneumococcaldiseaseorcomplications
recommendeddosingschedulevarieswithpatientageandimmunestatus
23valentpneumococcalvaccine(Pneumovax,PPSV23)recommendedfor
49/58
allpersonsaged65years
personsaged1964yearswithchronicillness,asplenia,immunocompromise,or
personswhosmoke
children2yearsoldwithunderlyingmedicalconditions(administrationvaries
withpreviousvaccinationstatusandmedicalstatus)
seeStreptococcuspneumoniaepneumonia
InfectiousDiseasesSocietyofAmerica/AmericanThoracicSociety(IDSA/ATS)
recommendationsforpreventionofcommunityacquiredpneumonia(2)
giveinfluenzavaccinationandpneumococcalvaccinesasrecommendedbytheAdvisory
CommitteeonImmunizationPractices,CDC
smokingcessationrecommended(IDSA/ATSModeraterecommendation,LevelIII)
reportpneumoniacasesofpublichealthconcern(IDSA/ATSStrongrecommendation,LevelIII)
userespiratoryhygiene(includinghandhygieneandmasksortissuesforpatientswithcough)
(IDSA/ATSStrongrecommendation,LevelIII)
seealso
Aspirationpneumonia
Legionellainfections
Smokingcessation(listofsmokingcessationrelatedtopics)
QualityImprovement
Medicare/JointCommissionNationalHospitalInpatientQualityMeasures
ED1MedianTimefromEDArrivaltoEDDepartureforAdmittedEDPatients
ED1aoverallrate
ED1breportingmeasure
ED1cpsychiatric/mentalhealthpatients
measuredastime(inminutes)fromemergencydepartment(ED)arrivaltoEDdeparturefor
patientsadmittedtofacilityfromED
ED2AdmitDecisionTimetoEDDepartureTimeforAdmittedPatients
ED2aoverallrate
ED2breportingmeasure
ED2cpsychiatric/mentalhealthpatients
measuredastime(inminutes)fromadmitdecisiontimetotimeofdeparturefromemergency
department(ED)forEDpatientsadmittedtoinpatientstatus
seeMedicare/JointCommissionNationalHospitalInpatientQualityMeasuresforadditional
information
GuidelinesandResources
Guidelines
UnitedStatesguidelines
InfectiousDiseasesSocietyofAmerica/AmericanThoracicSociety(IDSA/ATS)consensusguideline
onmanagementofcommunityacquiredpneumoniainadultscanbefoundinClinInfectDis2007Mar
144Suppl2:S27EBSCOhostFullText,commentarycanbefoundinClinInfectDis2007Jul
145(1):133EBSCOhostFullText,ClinInfectDis2007Sep145(5):670EBSCOhostFullText
ACCPclinicalpositionstatementonmanagementofadultswithcommunityacquiredpneumoniain
homecanbefoundinChest2005May127(5):1752fulltext,summarycanbefoundinAmFam
Physician2005Oct1572(8):1607fulltext
50/58
SocietyofInfectiousDiseasesPharmacists(SIDP)consensusguidelineonaerosolizedantimicrobial
agentscanbefoundinPharmacotherapy2010Jun30(6):562
AmericanAssociationforRespiratoryCare(AARC)clinicalpracticeguidelineoneffectivenessof
nonpharmacologicairwayclearancetherapiesinhospitalizedpatientscanbefoundinRespirCare
2013Dec58(12):2187EBSCOhostFullTextPDForatNationalGuidelineClearinghouse2014Jun
16:47797
AmericanMedicalDirectorsAssociation(AMDA)guidelineoncommoninfectionsinlongtermcare
settingcanbefoundatNationalGuidelineClearinghouse2012Jan2:32667
NewYorkStateDepartmentofHealth2010guidelineoninfectioncontrolcanbefoundatNYSDOH
2010AprPDF
InstituteforClinicalSystemsImprovement(ICSI)guidelineonpreventiveservicesforadultscanbe
foundatICSI2014OctPDF
UnitedKingdomguidelines
NationalInstituteforHealthandCareExcellence(NICE)guidelineondiagnosisandmanagementof
communityandhospitalacquiredpneumoniainadultscanbefoundatNICE2014Dec:CG191PDF
oratNationalGuidelineClearinghouse2016May16:50009,summarycanbefoundinBMJ2014Dec
3349:g6722
BritishThoracicSociety(BTS)guidelineonmanagementofcommunityacquiredpneumoniainadults
canbefoundinThorax2009Oct64Suppl3:iii1fulltextorinPrimCareRespirJ2010Mar19(1):21
BritishThoracicSociety(BTS)guidelineonemergencyoxygenuseinadultpatientscanbefoundin
Thorax2008Oct63Suppl6:vi1,correctioncanbefoundinThorax2009Jan64(1):91,commentary
canbefoundinThorax2008Oct63(10):849
Canadianguidelines
AlbertaClinicalPracticeGuidelines/TowardOptimizedPractice(TOP)guidelineondiagnosisand
managementofcommunityacquiredpneumoniainadultscanbefoundatTOP2008PDF
Europeanguidelines
S3LeitlinieBehandlungvonerwachsenenPatientenmitambulanterworbenerPneumonieund
PrventionfindenSieunterAMWF2016PDF[Deutsch]
DutchWorkingPartyonAntibioticPolicy/DutchAssociationofChestPhysicians(Stichting
WerkgroepAntibioticabeleid/NederlandseVerenigingvanArtsenvoorLongziektenenTuberculose
[SWAB/NVALT])guidelineonmanagementofcommunityacquiredpneumoniainadultscanbefound
inNethJMed2012Mar70(2):90
SwedishSocietyofInfectiousDiseasesguidelineonmanagementofcommunityacquiredpneumonia
inimmunocompetentadultscanbefoundinScandJInfectDis2012Dec44(12):885EBSCOhostFull
Text
EuropeanRespiratorySociety/EuropeanSocietyforClinicalMicrobiologyandInfectiousDiseases
(ERS/ESCMID)guidelineonmanagementofadultlowerrespiratorytractinfectionscanbefoundin
ClinMicrobiolInfect2011Nov17Suppl6:E1EBSCOhostFullTextPDF,summarycanbefoundin
ClinMicrobiolInfect2011Nov17Suppl6:1EBSCOhostFullText
GermanS3summary(DeutchKurzfassungderS3)onmanagementofcommunityacquired
pneumoniaandlowerrespiratorytractinfectionsinadultscanbefoundinDtschMedWochenschr
2010Feb135(8):359[German]
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PaulEhrlichSocietyofChemotherapy/GermanRespiratoryDiseasesSociety/GermanInfectious
DiseasesSociety/CompetenceNetworkCAPNETZguidelineonmanagementoflowerrespiratory
tractinfectionsandcommunityacquiredpneumoniacanbefoundinPneumologie2010Mar64(3):149
SpanishSocietyofChestDiseasesandThoracicSurgery(SociedadEspaoladeNeumologayCiruga
Torcica[SEPAR])guidelineoncommunityacquiredpneumoniacanbefoundinArchBronconeumol
2010Oct46(10):543fulltextorinSpanish
AndalusianSocietyofInfectiousDiseases/AndalusianSocietyofFamilyandCommunityMedicine
(SociedadAndaluzadeEnfermedadesInfecciosas/SociedadAndaluzadeMedicinaFamiliary
Comunitaria)practiceguidelineonclinicalmanagementofcommunityacquiredpneumoniainadults
canbefoundinMedClin(Barc)2009Jun13133(2):63[Spanish]
expertguidelineonsystemicantibiotherapyfortreatmentoflowerrespiratorytractinfections,
communityacquiredpneumonia,andacuteexacerbationofobstructivechronicbronchitiscanbe
foundinMedMalInfect2011May41(5):221[French]
Asianguidelines
JapaneseexpertguidelinesonnursingandhealthcareassociatedpneumoniacanbefoundinNihon
NaikaGakkaiZasshi2012Mar10101(3):787[Japanese]
CentralandSouthAmericanguidelines
expertadaptationmethodologyofguidelineonmanagementofadultswithcommunityacquired
pneumoniacanbefoundinRevMedChil2011Nov139(11):1403fulltext[Spanish]
BrazilianThoracicAssociation(SociedadeBrasileiradePneumologiaeTisiologia)guidelineon
communityacquiredpneumoniainimmunocompetentadultscanbefoundinJBrasPneumol2009
Jun35(6):574EBSCOhostFullTextfulltext[English,Portuguese]
SociedadeBrasileiradePneumologiaeTisiologiadiretrizparapneumoniasadquiridasnacomunidade
(PAC)emadultosimunocompetentespodeserencontradaemJornalBrasileirodePneumologia2004
PDF[Portuguese]
SouthAmericanWorkingGroup(ConsenSurII)updatedacutecommunityacquiredpneumoniain
adultsguidelineoninitialantimicrobialtherapybasedonlocalevidencecanbefoundinRevChilena
Infectol2010Jun27Suppl1:S9fulltext[Spanish]
Reviewarticles
reviewcanbefoundinAnnInternMed2015Oct6163(7):ITC1
reviewcanbefoundinLancet2015Sep12386(9998):1097
reviewcanbefoundinNEnglJMed2014Oct23371(17):1619
reviewofdurationofpneumoniatherapyandtheroleofbiomarkerscanbefoundinCurrOpinInfect
Dis2017Apr30(2):221
reviewofdiagnosisandmanagementofcommunityacquiredpneumoniainadultscanbefoundinAm
FamPhysician2016Nov194(9):698EBSCOhostFullText
reviewofmacrolidetherapyforpneumoniacanbefoundinCurrOpinInfectDis2016Apr29(2):212
reviewofantibiotictherapyforadultshospitalizedwithcommunityacquiredpneumoniacanbefound
inJAMA2016Feb9315(6):593EBSCOhostFullText
reviewofemergencymanagementofcommunityacquiredbacterialpneumoniacanbefoundinAmJ
EmergMed2013Mar31(3):602EBSCOhostFullText
reviewofacutepneumoniaandthecardiovascularsystemcanbefoundinLancet2013Feb
9381(9865):496
reviewofviralpneumoniacanbefoundinLancet2011Apr9377(9773):1264
reviewofdiagnostictestsforagentsofcommunityacquiredpneumoniacanbefoundinClinInfect
Dis2011May52Suppl4:S296EBSCOhostFullText
reviewofmanagementofcommunityacquiredpneumoniainadultscanbefoundinBMJ2008Jun
21336(7658):1429,commentarycanbefoundinBMJ2008Jul1337:a598
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reviewofuseofcorticosteroidsintreatinginfectiousdiseasescanbefoundinArchInternMed2008
May26168(10):1034EBSCOhostFullText
reviewofdiagnosisandmanagementofcommunityacquiredpneumoniainpregnancycanbefoundin
ObstetGynecol2009Oct114(4):915
brief"Whatyoushoulddo"reviewonacutecoughinadultscanbefoundinBMJ2010Feb
12340:c574
reviewoftigecyclineandcommunityacquiredpneumoniacanbefoundinDrugs
200868(18):2633EBSCOhostFullText
casepresentationsoncommunityacquiredpneumoniainadultscanbefoundinAmJMed2010
Apr123(4Suppl):S4
MEDLINEsearch
tosearchMEDLINEfor(communityacquiredpneumonia)withtargetedsearch(ClinicalQueries),
clicktherapy,diagnosis,orprognosis
PatientInformation
handoutfromAmericanLungAssociation
handoutonpneumoniafromAmericanAcademyofFamilyPhysiciansorinSpanish
handoutfromPatientUKPDF
handoutfromMayoClinic
ICD9/ICD10Codes
ICD9codes
480viralpneumonia
480.0pneumoniaduetoadenovirus
480.1pneumoniaduetorespiratorysyncytialvirus
480.2pneumoniaduetoparainfluenzavirus
480.8pneumoniaduetoothervirusnotelsewhereclassified
480.9viralpneumonia,unspecified
481pneumococcalpneumonia[Streptococcuspneumoniaepneumonia]
482otherbacterialpneumonia
482.0pneumoniaduetoKlebsiellapneumoniae
482.1pneumoniaduetoPseudomonas
482.2pneumoniaduetoHemophilusinfluenzae(H.influenzae)
482.3pneumoniaduetostreptococcus
482.30pneumoniaduetostreptococcus,unspecified
482.31pneumoniaduetostreptococcus,groupA
482.32pneumoniaduetostreptococcus,groupB
482.39pneumoniaduetootherstreptococcus
482.4pneumoniaduetoStaphylococcus
482.40pneumoniaduetoStaphylococcus,unspecified
482.41methicillinsusceptiblepneumoniaduetoStaphylococcusaureus
482.42methicillinresistantpneumoniaduetoStaphylococcusaureus
482.49otherStaphylococcuspneumonia
482.8pneumoniaduetootherspecifiedbacteria
482.81pneumoniaduetoanaerobes
482.82pneumoniaduetoEscherichiacoli[E.coli]
482.83pneumoniaduetoothergramnegativebacteria
482.84Legionnaires'disease
482.89pneumoniaduetootherspecifiedbacteria
482.9bacterialpneumonia,unspecified
483pneumoniaduetootherspecifiedorganism
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483.0pneumoniaduetoMycoplasmapneumoniae
483.1pneumoniaduetoChlamydia
483.9pneumoniaduetootherspecifiedorganism
484pneumoniaininfectiousdiseasesclassifiedelsewhere
484.1pneumoniaincytomegalicinclusiondisease
484.3pneumoniainwhoopingcough
484.5pneumoniainanthrax
484.6pneumoniainaspergillosis
484.7pneumoniainothersystemicmycoses
484.8pneumoniainotherinfectiousdiseasesclassifiedelsewhere
485bronchopneumonia,organismunspecified
486pneumonia,organismunspecified
487.0influenzawithpneumonia
ICD10codes
J09influenzaduetocertainidentifiedinfluenzavirus
J10.0influenzawithpneumonia,otherinfluenzavirusidentified
J11.0influenzawithpneumonia,virusnotidentified
J12viralpneumonia,notelsewhereclassified
J12.0adenoviralpneumonia
J12.1respiratorysyncytialviruspneumonia
J12.2parainfluenzaviruspneumonia
J12.8otherviralpneumonia
J12.9viralpneumonia,unspecified
J13pneumoniaduetoStreptococcuspneumoniae
J14pneumoniaduetoHaemophilusinfluenzae
J15bacterialpneumonia,notelsewhereclassified
J15.0pneumoniaduetoKlebsiellapneumoniae
J15.1pneumoniaduetoPseudomonas
J15.2pneumoniaduetostaphylococcus
J15.3pneumoniaduetostreptococcus,groupB
J15.4pneumoniaduetootherstreptococci
J15.5pneumoniaduetoEscherichiacoli
J15.6pneumoniaduetootheraerobicGramnegativebacteria
J15.7pneumoniaduetoMycoplasmapneumoniae
J15.8otherbacterialpneumonia
J15.9bacterialpneumonia,unspecified
J16pneumoniaduetootherinfectiousorganisms,notelsewhereclassified
J16.0chlamydialpneumonia
J16.8pneumoniaduetootherspecifiedinfectiousorganisms
J17pneumoniaindiseasesclassifiedelsewhere
J17.0pneumoniainbacterialdiseasesclassifiedelsewhere,suchas
A01.0typhoidfever
A02.2localizedsalmonellainfections
A21.2pulmonarytularaemia
A22.1pulmonaryanthrax
A37whoopingcough
A42.0pulmonaryactinomycosis
A43.0pulmonarynocardiosis
A54.8othergonococcalinfections
J17.1pneumoniainviraldiseasesclassifiedelsewhere,suchas
B01.2varicellapneumonia
B05.2measlescomplicatedbypneumonia
B06.8rubellawithothercomplications
B25.0cytomegaloviralpneumonitis
J17.2pneumoniainmycoses,suchas
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B37.1pulmonarycandidiasis
B38coccidioidomycosis
B38.0acutepulmonarycoccidioidomycosis
B38.1chronicpulmonarycoccidioidomycosis
B38.2pulmonarycoccidioidomycosis,unspecified
B39histoplasmosis
B39.0acutepulmonaryhistoplasmosiscapsulati
B39.1chronicpulmonaryhistoplasmosiscapsulati
B39.2pulmonaryhistoplasmosiscapsulati,unspecified
B44aspergillosis
J17.3pneumoniainparasiticdiseases,suchas
B58.3pulmonarytoxoplasmosis
B65schistosomiasis[bilharziasis]
B77.8ascariasiswithothercomplications
J17.8pneumoniainotherdiseasesclassifiedelsewhere,suchas
A69.8otherspecifiedspirochaetalinfections
A70chlamydiapsittaciinfection
A78Qfever
I00rheumaticfeverwithoutmentionofheartinvolvement
J18pneumonia,organismunspecified
J18.0bronchopneumonia,unspecified
J18.1lobarpneumonia,unspecified
J18.2hypostaticpneumonia,unspecified
J18.8otherpneumonia,organismunspecified
J18.9pneumonia,unspecified
P23congenitalpneumonia
P23.0congenitalpneumoniaduetoviralagent
P23.1congenitalpneumoniaduetoChlamydia
P23.2congenitalpneumoniaduetostaphylococcus
P23.3congenitalpneumoniaduetostreptococcus,groupB
P23.4congenitalpneumoniaduetoEscherichiacoli
P23.5congenitalpneumoniaduetoPseudomonas
P23.6congenitalpneumoniaduetootherbacterialagents
P23.8congenitalpneumoniaduetootherorganisms
P23.9congenitalpneumonia,unspecified
References
Generalreferencesused
1.WunderinkRG,WatererGW.Clinicalpractice.Communityacquiredpneumonia.NEnglJMed.
2014Feb6370(6):54351fulltext,commentarycanbefoundinNEnglJMed2014May
8370(19):1861
2.MandellLA,WunderinkRG,AnzuetoA,etal.InfectiousDiseasesSocietyofAmerica/American
ThoracicSocietyconsensusguidelinesonthemanagementofcommunityacquiredpneumoniain
adults.ClinInfectDis.2007Mar144Suppl2:S2772EBSCOhostFullTextfulltext,commentarycan
befoundinClinInfectDis2007Jul145(1):133EBSCOhostFullText
3.FileTM.Communityacquiredpneumonia.Lancet.2003Dec13362(9400):19912001EBSCOhost
FullText
4.WatkinsRR,LemonovichTL.Diagnosisandmanagementofcommunityacquiredpneumoniain
adults.AmFamPhysician.2011Jun183(11):1299306EBSCOhostFullTextfulltext
Recommendationgradingsystemsused
InfectiousDiseasesSocietyofAmerica/AmericanThoracicSociety(IDSA/ATS)gradingsystem
gradesofrecommendation
55/58
Strong
Moderate
Weak
levelsofevidence
LevelI(high)evidencefromwellconducted,randomizedcontrolledtrials
LevelII(moderate)
evidencefromwelldesigned,controlledtrialswithoutrandomization(including
cohort,patientseries,andcasecontrolstudies)
levelIIstudiesalsoincludeanylargecaseseriesinwhichsystematicanalysisof
diseasepatternsand/ormicrobialetiologywasconducted,aswellasreportsofdata
onnewtherapiesthatwerenotcollectedinarandomizedfashion
LevelIII(low)
evidencefromcasestudiesandexpertopinion
insomeinstances,therapyrecommendationscomefromantibioticsusceptibility
datawithoutclinicalobservations
ReferenceIDSA/ATSconsensusguidelineonmanagementofcommunityacquiredpneumonia
inadults(ClinInfectDis2007Mar144Suppl2:S27EBSCOhostFullTextfulltext)
SynthesizedRecommendationGradingSystemforDynaMedPlus
DynaMedsystematicallymonitorsclinicalevidencetocontinuouslyprovideasynthesisofthemost
validrelevantevidencetosupportclinicaldecisionmaking(see7StepEvidenceBased
Methodology).
GuidelinerecommendationssummarizedinthebodyofaDynaMedtopicareprovidedwiththe
recommendationgradingsystemusedintheoriginalguideline(s),andallowDynaMeduserstoquickly
seewhereguidelinesagreeandwhereguidelinesdifferfromeachotherandfromthecurrentevidence.
InDynaMedPlus(DMP),wesynthesizethecurrentevidence,currentguidelinesfromleading
authorities,andclinicalexpertisetoproviderecommendationstosupportclinicaldecisionmakingin
theOverview&Recommendationssection.
WeusetheGradingofRecommendationsAssessment,DevelopmentandEvaluation(GRADE)to
classifysynthesizedrecommendationsasStrongorWeak.
Strongrecommendationsareusedwhen,basedontheavailableevidence,clinicians(without
conflictsofinterest)consistentlyhaveahighdegreeofconfidencethatthedesirable
consequences(healthbenefits,decreasedcostsandburdens)outweightheundesirable
consequences(harms,costs,burdens).
Weakrecommendationsareusedwhen,basedontheavailableevidence,cliniciansbelievethat
desirableandundesirableconsequencesarefinelybalanced,orappreciableuncertaintyexists
aboutthemagnitudeofexpectedconsequences(benefitsandharms).Weakrecommendations
areusedwhencliniciansdisagreeinjudgmentsofrelativebenefitandharm,orhavelimited
confidenceintheirjudgments.Weakrecommendationsarealsousedwhentherangeofpatient
valuesandpreferencessuggeststhatinformedpatientsarelikelytomakedifferentchoices.
DynaMedPlus(DMP)synthesizedrecommendations(intheOverview&Recommendationssection)
aredeterminedwithasystematicmethodology:
Recommendationsareinitiallydraftedbyclinicaleditors(including1withmethodological
expertiseand1withcontentdomainexpertise)awareofthebestcurrentevidenceforbenefits
andharms,andtherecommendationsfromguidelines.
Recommendationsarephrasedtomatchthestrengthofrecommendation.Strong
recommendationsuse"shoulddo"phrasing,orphrasingimplyinganexpectationtoperformthe
recommendedactionformostpatients.Weakrecommendationsuse"consider"or"suggested"
phrasing.
RecommendationsareexplicitlylabeledasStrongrecommendationsorWeak
recommendationswhenaqualifiedgrouphasexplicitlydeliberatedonmakingsucha
recommendation.Groupdeliberationmayoccurduringguidelinedevelopment.Whengroup
deliberationoccursthroughDynaMedinitiatedgroups:
ClinicalquestionswillbeformulatedusingthePICO(Population,Intervention,
Comparison,Outcome)frameworkforalloutcomesofinterestspecifictothe
recommendationtobedeveloped.
56/58
Systematicsearcheswillbeconductedforanyclinicalquestionswheresystematic
searcheswerenotalreadycompletedthroughDynaMedcontentdevelopment.
Evidencewillbesummarizedforrecommendationpanelreviewincludingforeach
outcome,therelativeimportanceoftheoutcome,theestimatedeffectscomparing
interventionandcomparison,thesamplesize,andtheoverallqualityratingforthebody
ofevidence.
Recommendationpanelmemberswillbeselectedtoincludeatleast3membersthat
togetherhavesufficientclinicalexpertiseforthesubject(s)pertinenttothe
recommendation,methodologicalexpertisefortheevidencebeingconsidered,and
experiencewithguidelinedevelopment.
Allrecommendationpanelmembersmustdiscloseanypotentialconflictsofinterest
(professional,intellectual,andfinancial),andwillnotbeincludedforthespecificpanelif
asignificantconflictexistsfortherecommendationinquestion.
PanelmemberswillmakeStrongrecommendationsifandonlyifthereisconsistent
agreementinahighconfidenceinthelikelihoodthatdesirableconsequencesoutweigh
undesirableconsequencesacrossthemajorityofexpectedpatientvaluesandpreferences.
PanelmemberswillmakeWeakrecommendationsifthereislimitedconfidence(or
inconsistentassessmentordissentingopinions)thatdesirableconsequencesoutweigh
undesirableconsequencesacrossthemajorityofexpectedpatientvaluesandpreferences.
Norecommendationwillbemadeifthereisinsufficientconfidencetomakea
recommendation.
Allstepsinthisprocess(includingevidencesummarieswhichweresharedwiththepanel,
andidentificationofpanelmembers)willbetransparentandaccessibleinsupportofthe
recommendation.
Recommendationsareverifiedby1editorwithmethodologicalexpertise,notinvolvedin
recommendationdraftingordevelopment,withexplicitconfirmationthatStrong
recommendationsareadequatelysupported.
Recommendationsarepublishedonlyafterconsensusisestablishedwithagreementinphrasing
andstrengthofrecommendationbyalleditors.
Ifconsensuscannotbereachedthentherecommendationcanbepublishedwithanotationof
"dissentingcommentary"andthedissentingcommentaryisincludedinthetopicdetails.
Ifrecommendationsarequestionedduringpeerrevieworpostpublicationbyaqualified
individual,orreevaluationiswarrantedbasedonnewinformationdetectedthroughsystematic
literaturesurveillance,therecommendationissubjecttoadditionalinternalreview.
DynaMededitorialprocess
DynaMedtopicsarecreatedandmaintainedbytheDynaMedEditorialTeamandProcess.
Alleditorialteammembersandreviewershavedeclaredthattheyhavenofinancialorothercompeting
interestsrelatedtothistopic,unlessotherwiseindicated.
DynaMedprovidesPracticeChangingDynaMedUpdates,withsupportfromourpartners,McMaster
UniversityandF1000.
Specialacknowledgements
MichaelK.Mansour,MD,PhD(InstructorofInternalMedicine,HarvardMedicalSchool
Massachusetts,UnitedStates)
ZbysFedorowicz,MSc,DPH,BDS,LDSRCS(DirectorofBahrainBranchoftheUnitedKingdom
CochraneCenter,TheCochraneCollaborationAwali,Bahrain)
AlanEhrlich,MD(ExecutiveEditorClinicalAssociateProfessorofFamilyMedicine,Universityof
MassachusettsMedicalSchoolMassachusetts,UnitedStates)
TheAmericanCollegeofPhysicians(MarjorieLazoff,MD,FACPACPDeputyEditor,Clinical
DecisionResource)providedreviewinacollaborativeefforttoensureDynaMedprovidesthemost
57/58
validandclinicallyrelevantinformationininternalmedicine.
DynaMedPlustopicsarewrittenandeditedthroughthecollaborativeeffortsoftheaboveindividuals.
DeputyEditors,SectionEditors,andTopicEditorsareactiveinclinicaloracademicmedicalpractice.
RecommendationEditorsareactivelyinvolvedindevelopmentand/orevaluationofguidelines.
EditorialTeamroledefinitions
TopicEditorsdefinethescopeandfocusofeachtopicbyformulatingasetofclinicalquestionsand
suggestingimportantguidelines,clinicaltrials,andotherdatatobeaddressedwithineachtopic.
TopicEditorsalsoserveasconsultantsfortheinternalDynaMedPlusEditorialTeamduringthe
writingandeditingprocess,andreviewthefinaltopicdraftspriortopublication.
SectionEditorshavesimilarresponsibilitiestoTopicEditorsbuthaveabroaderrolethatincludesthe
reviewofmultipletopics,oversightofTopicEditors,andsystematicsurveillanceofthemedical
literature.
RecommendationsEditorsprovideexplicitreviewofDynaMedPlusOverviewand
Recommendationssectionstoensurethatallrecommendationsaresound,supported,andevidence
based.Thisprocessisdescribedin"SynthesizedRecommendationGrading."
DeputyEditorsareemployeesofDynaMedandoverseeDynaMedPlusinternalpublishinggroups.
Eachisresponsibleforallcontentpublishedwithinthatgroup,includingsupervisingtopic
developmentatallstagesofthewritingandeditingprocess,finalreviewofalltopicspriorto
publication,anddirectionofaninternalteam.
Howtocite
NationalLibraryofMedicine,or"Vancouverstyle"(InternationalCommitteeofMedicalJournal
Editors):
DynaMedPlus[Internet].Ipswich(MA):EBSCOInformationServices.1995.RecordNo.
115170,Communityacquiredpneumoniainadults[updated2017Mar08,citedplacecited
datehere][about34screens].Availablefromhttp://www.dynamed.com/login.aspx?
direct=true&site=DynaMed&id=115170.Registrationandloginrequired.
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