What is the diagnosis and treatment for Community-Acquired Pneumonia (CAP)?

From the Guidelines

Community-Acquired Pneumonia (CAP) Diagnosis and Treatment

The diagnosis and treatment of Community-Acquired Pneumonia (CAP) should be guided by the severity of the disease and the risk of drug-resistant pathogens, with empiric antibiotic therapy initiated promptly, as recommended by the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) guidelines 1.

Key Considerations

• Risk factors for severe CAP include age >65 years, co-morbid conditions, lack of fever, and recent hospitalization or parenteral antibiotics 1.
• Diagnostic testing should include sputum culture and rapid diagnostic tests to identify organisms causing CAP, especially when there are risk factors for antibiotic-resistant pathogens 1.
• Empiric antibiotic therapy should be initiated promptly, with the choice of antibiotics guided by the severity of the disease and the risk of drug-resistant pathogens, such as MRSA and P. aeruginosa 1.
• Treatment strategies for inpatients with CAP should be based on the level of severity and risk for drug resistance, with options including β-lactam plus macrolide or β-lactam plus fluoroquinolone 1.

Important Details

• The ATS and IDSA guidelines recommend vancomycin or linezolid for MRSA coverage and piperacillin-tazobactam or cefepime for P. aeruginosa coverage 1.
• Delay in ICU care and use of inappropriate antibiotics are associated with worse outcomes in severe CAP patients, emphasizing the importance of prompt and appropriate treatment 1.
• The emergence of PES pathogens requires closer consideration of the appropriate choice of antibiotics, with levofloxacin or moxifloxacin recommended for severe CAP patients 1.

From the Research

Diagnosis of Community-Acquired Pneumonia (CAP)

• Community-acquired pneumonia is diagnosed by clinical features (e.g., cough, fever, pleuritic chest pain) and by lung imaging, usually an infiltrate seen on chest radiography 2
• Diagnosis can be suggested by a history of cough, dyspnea, pleuritic pain, or acute functional or cognitive decline, with abnormal vital signs (e.g., fever, tachycardia) and lung examination findings 3
• Validated prediction scores for pneumonia severity can guide the decision between outpatient and inpatient therapy 2, 3
• Using procalcitonin as a biomarker for severe infection may further assist with risk stratification 3, 4

Treatment of Community-Acquired Pneumonia (CAP)

• Initial outpatient therapy should include a macrolide or doxycycline 2
• For outpatients with comorbidities or who have used antibiotics within the previous three months, a respiratory fluoroquinolone (levofloxacin, gemifloxacin, or moxifloxacin), or an oral beta-lactam antibiotic plus a macrolide should be used 2
• Inpatients not admitted to an intensive care unit should receive a respiratory fluoroquinolone, or a beta-lactam antibiotic plus a macrolide 2
• Patients with severe community-acquired pneumonia or who are admitted to the intensive care unit should be treated with a beta-lactam antibiotic, plus azithromycin or a respiratory fluoroquinolone 2, 5
• Hospitalized patients without risk factors for resistant bacteria can be treated with β-lactam/macrolide combination therapy, such as ceftriaxone combined with azithromycin, for a minimum of 3 days 5
• Systemic corticosteroid administration within 24 hours of development of severe CAP may reduce 28-day mortality 5, 3

Prevention of Community-Acquired Pneumonia (CAP)

• Physicians should promote pneumococcal and influenza vaccination as a means to prevent community-acquired pneumonia and pneumococcal bacteremia 2, 3
• The 23-valent pneumococcal polysaccharide and 13-valent pneumococcal conjugate vaccinations are both recommended for adults 65 years and older to decrease the risk of invasive pneumococcal disease, including pneumonia 3

Guideline Adherence

• Adherence to the Infectious Diseases Society of America/American Thoracic Society guidelines for the management of community-acquired pneumonia has been shown to improve patient outcomes 2
• Guideline adherence for the administration of empiric antibiotics was documented/recorded in 75% of cases in a Swiss general hospital 4
• Further research is needed to identify the reasons for guideline non-adherence, and to find effective measures for the improvement of guideline adherence 4