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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. Initial evaluation should determine the need for hospitalization versus outpatient management using validated mortality or severity prediction scores. Selected diagnostic laboratory testing, such as sputum and blood cultures, is indicated for inpatients with severe illness but is rarely useful for
outpatients. Initial outpatient therapy should include a macrolide or doxycycline. 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. Inpatients not admitted
to an intensive care unit should receive a respiratory fluoroquinolone, or a beta-lactam antibiotic plus a macrolide.
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. Those with risk factors for Pseudomonas should be treated with a beta-lactam antibiotic (piperacillin/tazobactam, imipenem/cilastatin, meropenem,
doripenem, or cefepime), plus an aminoglycoside and azithromycin or an antipseudomonal fluoroquinolone (levofloxacin or ciprofloxacin). Those with risk factors for methicillin-resistant Staphylococcus aureus should be given
vancomycin or linezolid. Hospitalized patients may be switched from intravenous to oral antibiotics after they have
clinical improvement and are able to tolerate oral medications, typically in the first three days. 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. Physicians should promote pneumococcal and influenza
vaccination as a means to prevent community-acquired pneumonia and pneumococcal bacteremia. (Am Fam Physician. 2011;83(11):1299-1306. Copyright 2011 American Academy of Family Physicians.)
ommunity-acquired pneumonia
(CAP) is a significant cause
of morbidity and mortality in
adults. CAP is defined as an infection of the lung parenchyma that is not
acquired in a hospital, long-term care facility, or other recent contact with the health
care system. Table 1 includes common etiologies of CAP.1-3 This article discusses the
important studies and guidelines for CAP
that have been published since the topic was
last reviewed in American Family Physician.4
Epidemiology
Pneumonia and influenza combined is the
eighth leading cause of death in the United
States and the most common cause of
infection-related mortality.5 In 2007, about
52,700 persons died from the conditions.5
The overall annual incidence of CAP ranges
from five to 11 per 1,000 persons, with more
cases occurring in the winter months.1 In
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2011 American Academy of Family Physicians. For the private, noncommer-
Evidence
rating
References
C
C
12
12
22-24
A
B
28
12, 35-37
chest pain, and a cough producing mucopurulent sputum. Overall, physician judgment is moderately accurate for diagnosis of pneumonia, especially for ruling it
out (LR+ = 2.0, negative likelihood ratio [LR] = 0.24).7
Absence of fever and sputum also significantly reduces
the likelihood of pneumonia in outpatients.8
High fever (greater than 104F [40C]), male sex,
multilobar involvement, and gastrointestinal and neurologic abnormalities have been associated with CAP
caused by Legionella infection.9 The clinical presentation
of CAP is often more subtle in older patients, and many
of these patients do not exhibit classic symptoms.1 They
often present with weakness and decline in functional
and mental status.
The patient history should focus on detecting symptoms
consistent with CAP, underlying defects in host defenses,
and possible exposure to specific pathogens. Persons with
chronic obstructive pulmonary disease or human immunodeficiency virus infection have an increased incidence
of CAP. Patients should be asked about occupation, animal exposures, and sexual history to help identify a specific infectious agent. A recent travel history (within two
weeks) may help identify Legionella pneumonia, which
has been associated with stays at hotels and on cruise
ships. Influenza is often suggested on the basis of typical
symptoms during peak influenza season.
Physical examination may reveal fever, dullness to
percussion, egophony, tachycardia (LR+ = 2.1), and
tachypnea (LR+ = 3.5). Asymmetric breath sounds,
pleural rubs, egophony, and increased fremitus are relatively uncommon, but are highly specific for pneumonia
(LR+ = 8.0); these signs help rule in pneumonia when
present, but are not helpful when absent.8 Rales or bronchial breath sounds are helpful, but much less accurate
than chest radiography.10 Tachypnea is common in older
patients with CAP, occurring in up to 70 percent of those
older than 65 years.11 Pulse oximetry screening should
be performed in all patients with suspected CAP.12
Etiology
Frequency
(median
percentage)
Frequency
(median
percentage)
Etiology
Outpatients
Mycoplasma pneumoniae
Respiratory viruses
Streptococcal pneumoniae
Chlamydophila pneumoniae
Legionella species
Haemophilus influenzae
Unknown
16
15
14
12
2
1
44
Etiology
Frequency
(median
percentage)
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June 1, 2011
Community-Acquired Pneumonia
Table 2. Patients with Acute Respiratory Illness
Who Benefit from Chest Radiography
Chest radiography should be performed in:
Any patient with at least one of the following abnormal
vital signs:
Temperature > 100F (37.8C)
Heart rate > 100 beats per minute
Respiratory rate > 20 breaths per minute
Any patient with at least two of the following clinical
findings:
Decreased breath sounds
Crackles (rales)
Absence of asthma
Adapted from Ebell MH. Predicting pneumonia in adults with respiratory illness. Am Fam Physician. 2007;76(4):562.
RADIOLOGIC EXAMINATION
LABORATORY TESTING
Sputum
culture
Legionella urine
antigen test
Pneumococcal
urine antigen test
Alcohol abuse
Asplenia
Cavitary infiltrates
Leukopenia
Indication
Endotracheal aspirate
if intubated
Fungal and
tuberculosis cultures
Thoracentesis and
pleural fluid cultures
Other
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S40.
June 1, 2011
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Community-Acquired Pneumonia
cultures. Urine antigen tests are helpful when an adequate sputum culture is unobtainable or when antibiotic
therapy has already been started. The sensitivity of the
pneumococcal urine antigen test is 50 to 80 percent with
a specificity of greater than 90 percent. Although the
urine antigen test only detects Legionella serogroup 1,
this serogroup causes 80 to 95 percent of CAP from Legionella; the test is 70 to 90 percent sensitive and 99 percent specific for serogroup 1. Urine antigen test results
are positive on the first day of illness and remain positive for several weeks.12 In general, urine antigen tests
are better at ruling in disease when positive; a negative
test result does not rule out infection with a specific
pathogen given its somewhat limited sensitivity.
Acute- and convalescent-phase serologic testing is the
standard for other atypical causes of pneumonia. However,
treating patients based on a positive acute-phase titer result
has been shown to be unreliable.21 Therefore, serology for
other atypical pathogens should not be routinely ordered.
Rapid antigen testing or direct fluorescent antibody testing for influenza can help with consideration of antiviral
therapy and may decrease use of antibacterial agents.12
Table 4. Criteria for Severe CommunityAcquired Pneumonia
Minor criteria
Blood urea nitrogen level 20 mg per dL (7.14 mmol per L)
Confusion/disorientation
Hypotension requiring aggressive fluid resuscitation
Hypothermia (core temperature < 96.8F [36C])
Leukopenia (white blood cell count < 4,000 per mm3
[4.00 109 per L])
Multilobar infiltrates
PaO2/FiO2 ratio 250
Respiratory rate 30 breaths per minute
Thrombocytopenia (platelet count < 100 103 per mm3
[100 109 per L])
Major criteria
Invasive mechanical ventilation
Septic shock with need for vasopressors
Any major criterion is an absolute indication for admission to an
intensive care unit. One or more minor criteria indicate increased risk
of death, and admission to an intensive care unit may be appropriate.
NOTE:
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June 1, 2011
Community-Acquired Pneumonia
Table 5. CURB-65 Mortality Prediction Tool for
Patients with Community-Acquired Pneumonia
Prognostic variables*
Confusion
Blood urea nitrogen level > 20 mg per dL (7.14 mmol per L)
Respiratory rate 30 breaths per minute
Blood pressure (systolic < 90 mm Hg or diastolic 60 mm Hg)
Age 65 years
30-day
Score
Inpatient vs. outpatient
mortality (%)
0 or 1 point
2 points
3 points
Treat as outpatient
Treat as inpatient
Treat in intensive care unit
0.7 to 2.1
9.2
15 to 40
Management
The initial management of CAP depends on the patients
severity of illness; underlying medical conditions and
risk factors, such as smoking; and ability to adhere to a
treatment plan. The need for hospitalization is the first
decision that needs to be made after CAP is diagnosed
or suspected.
INPATIENT VS. OUTPATIENT CARE
Points
2
1
1
1
Score
0 to 2 points
3 or 4 points
5 or 6 points
7 points
Low
Moderate (one in eight patients)
High (one in three patients)
Very high (two in three patients)
1
1
2
0 points
1 point
2 points
3 points
4 points
Very low
Low (one in 20 patients)
Moderate (one in 10 patients)
High (one in six patients)
High (one in three patients)
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Community-Acquired Pneumonia
Initial therapy
A macrolide or doxycycline
Inpatients, non-ICU
Inpatients, ICU
Special considerations
Risk factors for Pseudomonas species
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June 1, 2011
Community-Acquired Pneumonia
Considerations*
Delayed
response
to therapy
with no
improvement
after 72 hours
Clinical
deterioration
or continued
progression of
illness
ADJUNCTIVE THERAPIES
NOTE:
*Further workup and management for unresponsive illness include blood cultures,
repeat sputum culture (interpret with caution because of possible colonization), urine
antigen testing for Streptococcal pneumoniae and Legionella if not previously done,
chest computed tomography, thoracentesis if significant pleural effusion is present
with fluid analysis and culture, and bronchoscopy with bronchoalveolar lavage and
transbronchial biopsies.
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines
on the management of community-acquired pneumonia in adults. Clin Infect Dis.
2007;44(suppl 2):S57.
June 1, 2011
The Authors
RICHARD R. WATKINS, MD, MS, is a staff physician in the Division of Infectious Diseases at Akron General Medical Center in Ohio.
TRACY L. LEMONOVICH, MD, is a staff physician in the Division of Infectious
Diseases at University Hospitals Case Medical Center in Cleveland, Ohio.
Address correspondence to Richard R. Watkins, MD, MS, Akron General
Medical Center, 224 W. Exchange St., Ste. 290, Akron, OH 44302 (e-mail:
rwatkins@agmc.org). Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
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