FEBRUARY 2021 | VOLUME 23 | ISSUE 2 @Em_RockStars

Emergency Medicine Practice Evidence-Based Education • Practical Application

LEARNING OBJECTIVES:

• What are the best risk

stratification tools for use
in the ED?
• Which imaging is best? Chest
x-ray or CT?
• What are the safest and most
effective antibiotic regimens
for the ED patient?
• Are there any adjunctive
therapies that will be helpful?

Authors
Matthew DeLaney, MD, FACEP,
FAAEM
Associate Professor, Assistant Residency Program
Director, Department of Emergency Medicine,
University of Alabama at Birmingham School of
Medicine, Birmingham, AL

Charles Khoury, MD, MSHA, FACEP Community-Acquired

Associate Professor, Assistant Residency Program
Director, Department of Emergency Medicine,
University of Alabama at Birmingham School of
Medicine, Birmingham, AL
Peer Reviewers
Daniel J. Egan, MD
Harvard University Affiliated Emergency
Medicine Residency, Massachusetts General
Hospital/Brigham and Women's Hospital,
Boston, MA
Benjamin Christian Renne, MD
Critical Care Physician, Division of Trauma,
Emergency Surgery, and Critical Care,
Massachusetts General Hospital, Boston, MA
Prior to beginning this activity, please review
“CME Information” on page 22.
Pneumonia in the
Emergency Department
n Abstract
As recommendations for the diagnosis, treatment, and disposition
of patients with community-acquired pneumonia continue to
evolve, this issue reviews the current evidence and guidelines
for managing these patients in the emergency department.
The various clinical decision aids are compared, as they assist
in determining the level of inpatient care required and allow
for a greater proportion of patients to be treated successfully
as outpatients. A clinical pathway for emergency department
management delineates optimal antibiotic regimens based on
severity, comorbidities, and risk factors.

For online access, scan with your

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This issue is eligible for 4 Infectious Disease CME credits. See page 22. EBMEDICINE.NET
 Case Presentations
A 30-year-old man with no significant medical history presents to the ED with 2 days of fever, cough
productive of green sputum, and malaise…
• Examination reveals left-sided rhonchi that do not clear with cough.
CASE 1

• The patient has a heart rate of 105 beats/min and a temperature of 39.1°C. He is normotensive and has
a 95% oxygen saturation on room air.
• Labs show a WBC count of 17K, but are otherwise unremarkable. X-ray shows a left-sided retrocardiac
opacity concerning for pneumonia.
• The patient is clearly symptomatic, but he is asking to go home…

An 82-year-old woman with a history of mild COPD presents from an assisted living facility with 3
days of mild cough productive of yellow sputum…
• She reports no fever/chills, chest pain, shortness of breath, orthopnea, or paroxysmal nocturnal
CASE 2

dyspnea. Physical exam reveals normal vital signs and slightly diminished breath sounds in the right
lung fields.
• Labs, including lactic acid, are within normal limits, and x-ray shows a right-sided infiltrate consistent
with pneumonia.
• The patient’s daughter is concerned about the risk for an adverse outcome, but the patient says she
would like to return to her assisted living facility…

A 55-year-old man with a history of diabetes and chronic kidney disease presents with 3 days of
nonproductive cough, fever, and altered mental status…
• He is in moderate distress, is breathing with accessory muscles, and has rhonchi and rales in all lung
fields.
CASE 3

• The patient is febrile and has a heart rate of 130 beats/min. His initial blood pressure is 88/50 mm Hg
and is breathing at 26 breaths/min with room-air oxygen saturation at 88%.
• Labs show a WBC of 19K, a lactic acid of 4.2 mg/dL, and an anion gap of 22 mEq/L. X-ray shows
bilateral infiltrates concerning for multifocal pneumonia and a left-sided pleural effusion.
• Before you admit the patient, you need to determine whether he needs to be placed in the intensive
care unit...

n Introduction within the prior 3 months.3 This category was used to

Community-acquired pneumonia (CAP) is a relatively
common disease process resulting from acute
infection of the lung parenchyma in patients who
have not been hospitalized recently or had recent
exposure to the healthcare system. CAP accounts for
the largest group of sepsis-triggering events and is
responsible for significant morbidity and mortality.1
The American Thoracic Society (ATS)/Infectious
Diseases Society of America (IDSA) guidelines
describe 2 additional types of pneumonia: (1)
hospital-acquired (nosocomial) pneumonia (HAP),
pneumonia that occurs 48 hours or more after
admission to a healthcare facility that did not appear
to be present at the time of admission; and (2)
ventilator-associated pneumonia (VAP), a type of
HAP that develops ≥48 hours after endotracheal
intubation.2
The term healthcare-associated pneumonia
(HCAP) was included in the 2005 ATS/IDSA guide-
lines. It referred to pneumonia acquired in healthcare
facilities such as hemodialysis centers, nursing homes,
outpatient clinics, or during inpatient hospitalization
identify patients at risk for infection with multidrug-
resistant organisms, but it was found to be overly
sensitive, which increased rates of inappropriate anti-
biotic use. Although patients with recent contact with
healthcare facilities are at increased risk for infection
with multidrug-resistant organisms, for most patients,
this risk is small, and the overall prevalence is low.4
Thus, the category of HCAP was omitted from the
2016 ATS/IDSA guidelines.
The literature on hospital admission for pneumo-
nia suggests that approximately 1 in 5 patients with
pneumonia are readmitted to the hospital within 30
days of discharge.5 Given this data, it is imperative
that clinicians understand how to appropriately risk
stratify patients with pneumonia in order to provide
them with the proper disposition (intensive care unit
[ICU], a medical floor, or home with oral antibiotic
treatment). Despite its broad impact, there is wide
variation among emergency clinicians regarding the
diagnosis, treatment, risk stratification, and disposi-
tion of patients with CAP.6 This issue of Emergency
Medicine Practice will review various aspects of the

FEBRUARY 2021 • www.ebmedicine.net 2 ©2021 EB MEDICINE

diagnosis and management of CAP, including its epi-
demiology, pathophysiology, prehospital care, emer-
gency department (ED) evaluation, utility of various
diagnostic studies, treatment modalities (including
antibiotic options), and evidence-based disposition of
patients.
n Critical Appraisal of the Literature
A literature search was performed in PubMed using
the terms community-acquired pneumonia (CAP),
pneumonia, cough, and related terms. Given the
extensive body of literature concerning CAP, the
search focused on the presentation and management
of CAP in settings relevant to emergency practice,
including ambulatory clinics and urgent care. Forty
systematic reviews from the Cochrane Database of
Systematic Reviews were relevant. We searched for
studies, specifically evaluating the risk stratification
and management of CAP with a particular focus
on patient-oriented outcomes. In addition to our
literature search, we reviewed available guidelines
from the American College of Emergency Physicians
(ACEP), IDSA, and ATS.
n Community-Acquired Pneumonia in
the Era of COVID-19
Prior to December 2019, any discussion of viral
pneumonia would have been limited, because the
bulk of morbidity surrounding pneumonia involved
bacterial pathogens. However, in the subsequent
months, as COVID-19 has spread worldwide,
presence of this novel viral pathogen must be
considered in any patient with possible CAP. In 2020,
the co-chairs of the ATS/IDSA CAP guidelines issued
a series of recommendations on the management of
CAP in the era of COVID-19.7
From a diagnostic standpoint, there are no
historical or physical examination findings that can
differentiate reliably between CAP and COVID-19.
Unfortunately, the utility of chest x-ray for patients
with COVID-19 remains unclear. In an early case
series of patients who were hospitalized with
COVID-19, 59% of patients had findings on x-ray that
were consistent with pneumonia. When computed
tomography (CT) was used, 86% of patients had
abnormal findings.8 Conversely, in a review of more
than 600 patients seen in an urgent care facility,
Weinstock et al found that the chest x-ray was normal
in approximately 58% of patients with COVID-19
and only “mildly abnormal” in approximately 89% of
cases.9 As with CAP in a patient with a high pretest
probability of having COVID-19, a normal chest x-ray
does not rule out an underlying pneumonia.
In terms of treatment, Metlay et al recommend
empiric antibiotic coverage for patients with CAP
without confirmed COVID-19, but state that antibiot-
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ics should not be required for all patients with con-
firmed COVID-19.7 Worldwide, there is variable ac-
cess to rapid COVID-19 tests, making differentiation
between CAP and COVID-19 even more challenging.
In this situation, we recommend the use of antibiotics
to cover bacterial pathogens according to the ATS/
IDSA guidelines, based on patient demographics,
treatment setting, and severity of illness.7
No clear evidence exists to guide the use of
antibiotics in patients with confirmed COVID-19.
Theoretically, the pulmonary manifestations of
COVID-19 should be strictly viral or related to a host-
related immunologic response, yet Du et al reported
high rates of bacterial co-infection, with 27% of
patients having Mycoplasma IgM antibodies and 34%
testing positive for Chlamydia.8 Retrospective data
from the initial New York COVID-19 surge showed
lower rates of co-infection but also illustrated the
difficulty in differentiating between bacterial and viral
pathogens.9 In a review of patients admitted with
COVID-19, Nori et al found that only 2% of patients
had a respiratory bacterial co-infection, while 70% of
patients received at least 1 dose of antibiotics.10
COVID-19 has presented a dynamic, rapidly
changing clinical situation. When it comes to patients
with possible CAP, emergency clinicians need to
consider the possibility of COVID-19. When available,
rapid testing may help confirm the presence of the
pathogen, but it does not rule out the possibility of a
coexisting bacterial pathogen.
n Epidemiology
CAP is the leading cause of infectious disease-
related death and the eighth most common cause
of death in the United States.11 As expected,
the rate of CAP increases with age. Of the many
pathogens responsible for CAP, the most commonly
identified bacterial cause is Streptococcus
pneumoniae. Historically, S pneumoniae was thought
to be responsible for up to 90% of the cases of
pneumonia. More recently, the incidence of cases
of S pneumoniae has decreased significantly, and
while it is still the most commonly isolated bacterial
pathogen, it is now responsible for only 10% to
15% of hospitalized cases of CAP.12 This decline is
thought to be due largely to the development of the
pneumococcal vaccine, as rates of S pneumoniae are
notably higher in areas where there is not widespread
use of this vaccine. While the pneumococcal
vaccine has been shown to reduce rates of invasive
pneumococcal pneumonia, it has not been shown to
reduce mortality.13
Other common pathogens include Haemophilus
influenzae, Pseudomonas aeruginosa, and Moraxella
catarrhalis. Certain patient populations have a higher
incidence of particular pathogens, such as increased
rates of P aeruginosa in patients with underlying lung
3 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
disease, including chronic obstructive pulmonary
disease. The incidence of atypical bacterial causes
of CAP, including Mycoplasma pneumoniae and
Chlamydophila pneumoniae is somewhat unclear,
but likely underreported. Patients with atypical
pathogens typically have a more benign disease
course and may be less likely to seek medical care.
Current testing for atypical pathogens is suboptimal,
making it difficult to quantify the true burden of
disease. Pathogens such as Legionella pneumophila
may occur in geographic clusters related to specific
exposures but are not typically seen in isolation in the
general population. Viral causes include influenza,
parainfluenza, adenovirus, and human respiratory
syncytial virus. Viruses cause approximately 20%
of cases of CAP, with a higher incidence seen year-
round in children and in all patients during seasonal
influenza outbreaks.14
In a notable number of cases diagnosed as CAP,
the etiology remains either unclear or is found to
be noninfectious. In an observational study of 259
patients who were hospitalized with a diagnosis of
CAP, Musher et al found a causative bacterium in
only 23.2% of cases. A viral pathogen was identified
in 16.2% of cases, and 26.6% of patients were diag-
nosed with a noninfectious syndrome. Despite exten-
sive testing, no cause for CAP was found in 45.9% of
patients.15 It can be nearly impossible to identify the
exact pathogens in a patient presenting to the ED
with CAP, and the available data suggest that this di-
agnostic uncertainty persists throughout the patient’s
hospital course.
n Pathophysiology
Pneumonia is an infectious process that results
from the infiltration of pathogens into the lung
parenchyma, provoking the production of intra-
alveolar exudates. The development of pneumonia
requires that a pathogen reach the alveoli and that
host defenses are overwhelmed by either the micro-
organism’s virulence or by the inoculum’s size. The
introduction of a pathogen into the lower respiratory
tract is typically the result of aspiration from the
upper respiratory tract. Although the outcome of a
lower respiratory tract infection can depend on the
virulence of the organism, individuals may experience
a wide spectrum of severity due to the inflammatory
response in the lung.16
Younger or healthier patients can typically mount
an effective immune response when small numbers
of low-virulence microbes are deposited in the lungs.
Immune defenses include mucociliary clearance
(often referred to as the mucociliary escalator),
antimicrobial proteins in airway surfactant, and
alveolar macrophages. Older patients, patients with
underlying lung disease, and immunocompromised
patients may have a more difficult time clearing
FEBRUARY 2021 • www.ebmedicine.net 4
even small numbers of microbes. In contrast,
numerous or more virulent microbes often result in
the development of a large inflammatory response in
most patients. Although this response is essential to
clear the respiratory tract of microbes, it contributes
directly to the development of more severe
symptoms and to lung injury.17
The pathogens that cause pneumonia can be
transmitted from person to person by airborne drop-
lets but may already be present in native oral and
nasal flora. The most common way that pathogens
reach the lower respiratory tract is by microaspiration.
Hematogenous spread from a distant infected site
may also result in pneumonia, but this is a much less
likely cause.18
Many conditions can predispose patients to the
development of pneumonia. Specifically, chronic lung
disease (chronic obstructive pulmonary disease, bron-
chiectasis), smoking, older age, and immunocom-
promise are significant risk factors.19 Some studies
have suggested that long-term use of medications,
including proton-pump inhibitors, H2 blockers, and
antipsychotic agents may be linked to an increased
risk of pneumonia, but these studies have shown only
observational associations that have not been dem-
onstrated in any randomized controlled trials.20
n Differential Diagnosis
Given the broad range of disease severity, patients
with CAP can present with a wide range of symptoms,
and emergency clinicians must have a broad
differential when evaluating any patient who may
have CAP, because commonly reported symptoms
can often be caused by other more insidious medical
conditions. High-risk CAP mimics include congestive
heart failure exacerbation, acute coronary syndromes,
pulmonary embolism, neoplastic lesions, and
pulmonary abscess/empyema. Pulmonary embolism
can be particularly easy to miss if there is pulmonary
infarct resulting in a CAP-like radiographic infiltrate.
Neoplasia should be suspected in a patient with CAP
who does not improve with antimicrobials over weeks
or has other ominous constitutional signs.
These disease processes should be ruled out
clinically or diagnostically prior to the definitive
diagnosis of CAP. In some cases, a detailed history
and physical examination may be enough to rule out
these causes. In others, a more thorough work-up
including an electrocardiogram, laboratory testing,
radiographs, and advanced imaging modalities may
be merited.
Lower-risk CAP mimics include uncomplicated
bronchitis, viral upper respiratory infections, and
minor asthma exacerbations. Although these
conditions are generally not as severe as CAP, it is
important to make an accurate diagnosis to prevent
overtreatment with antibiotic therapy.
©2021 EB MEDICINE
n Prehospital Care
In the prehospital setting, the application of supple-
mental oxygen to hypoxemic patients is the most
important intervention. Oxygenation includes supple-
mentation by nasal cannula, face mask, or even posi-
tive pressure ventilation. Intravenous (IV) access and
fluid resuscitation are important but should not pre-
cede the correction of severe hypoxia. Early but judi-
cious administration of crystalloid fluid is beneficial
in patients with hypotension or other signs of shock.
Given the current COVID-19 pandemic, prehospital
providers should use personal protective equipment
when encountering any patient with possible CAP.
n Emergency Department Evaluation
In the ED, initial stabilization includes ensuring that
the patient is protecting their airway. A thorough
history and physical examination will aid in ruling
out other disease processes and will assist in the
diagnosis of pneumonia, though they will almost
always require augmentation by laboratory studies
and imaging. Identification of sepsis related to
pneumonia is imperative and includes an assessment
of the patient’s vital signs and the clinical signs and
symptoms of severe sepsis and septic shock.
The presence of fever, hypoxia, tachycardia, and
crackles on auscultation are suggestive of CAP. All 4
variables are noted to be specific independent pre-
dictors of radiograph-proven pneumonia in a clinical
setting. In contrast, demographic information and
historical factors are less likely to provide predictive
information for the diagnosis of CAP. Although CAP
is more common in the elderly population, age, sex,
smoking history, and past medical history provide no
predictive information for a pneumonia diagnosis.21
Although the classic history for CAP often
includes the presence of productive cough, fever,
shortness of breath, and pleuritic chest pain, these
signs do not help reliably confirm or rule out
an underlying pneumonia. The most frequently
reported clinical symptom in patients with CAP is
cough, which is observed in 80% to 90% of patients
with the disease. Shortness of breath is also a
frequently reported symptom and is found in 70% of
patients.22 In patients confirmed to have CAP, sputum
production and pleuritic pain are reported in roughly
50% of cases.
Despite the frequent presence of certain
symptoms in patients with CAP, the accuracy of the
history in the diagnosis of CAP remains a debated
issue. Review of the major studies reveals the
predictive utility of 4 of the major symptoms: fever,
chills, cough, and night sweats. Likelihood ratios (LRs)
of these symptoms include: (1) fever: positive LR, 2.1;
negative LR, 0.7; (2) chills: positive LR, 1.7; negative
LR, 0.85; (3) cough: positive LR, 1.8; negative LR,
0.31; and (4) night sweats: positive LR, 1.7; negative
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LR, 0.83.23 From a clinical standpoint, these signs and
symptoms are most useful in making the diagnosis
of CAP when they present concurrently, as a
constellation of symptoms.
Diagnosing CAP in elderly patients can present
a challenge, as classic features such as fever, cough,
and shortness of breath are present in only a minority
of elderly patients who are ultimately diagnosed
with pneumonia.24 Elderly patients are more likely
to present with atypical symptoms, including altered
mental status and fatigue.
Numerous studies have demonstrated limited
diagnostic efficacy of auscultation for pneumonia.
The presence of crackles on physical examination is
useful in making the diagnosis of CAP, but absence
of the finding cannot be relied upon for the exclusion
of the disease. In most studies, the positive LR of
crackles is 1.6 to 2.7 for pneumonia, and decreased
breath sounds have a LR of 2.6 and a negative LR
of 0.64. Studies have shown that the sign with the
highest LR for pneumonia is egophony (8.6), followed
by dullness to percussion (4.3).25 The diagnosis of
pneumonia cannot be reliably confirmed or excluded
by the presence of absence of a particular finding on
physical examination; rather, the clinical examination
can be very useful to the creation of a differential
diagnosis.26 For this reason, clinical decision rules
have incorporated the likelihood of CAP based on
multiple signs and symptoms. For more information
on the use of clinical decision rules in diagnosis of
CAP, see the “Using Severity and Risk Scoring
Systems for Treatment and Disposition” section,
beginning on page 8.
n Diagnostic Studies
Chest Radiography
Chest x-ray remains a hallmark of the diagnosis of
CAP despite a fairly low sensitivity for detection.
Chest x-ray is an important tool in the evaluation
of patients with cough, shortness of breath, and
chest pain, and can assist with, but not exclude,
the diagnosis of CAP. Numerous studies have been
performed to assess the utility of chest x-ray in the
diagnosis of CAP. Using CT as the gold standard,
chest x-ray has moderate specificity (93%) but fairly
low sensitivity (range of 46%-77%).27 Based on these
sensitivities, the exclusive use of chest x-ray would
result in missing the diagnosis of CAP in one-third
to one-half of presenting patients and should thus
not be relied on heavily for exclusion of the disease
process. Despite low sensitivity, chest x-ray remains
a recommendation for all patients in whom CAP is
suspected, and it can point the clinician to other
disease processes, including congestive heart failure,
malignancy, effusion, and pulmonary infarction.28
Although portable single-view radiography—
which often utilizes the single anterior-posterior
5 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
view—is frequently used, we have no evidence
comparing the accuracy of this study compared to the
traditional 2 views (posterior-anterior and lateral) in
patients with possible CAP.
Computed Tomography
CT of the chest is a much more sensitive test for
pulmonary infiltrates (approaching 100%) than chest
x-ray, but it is associated with increased radiation
exposure and cost.29 For this reason, chest x-ray
remains the initial testing modality for patients in
whom there is suspicion for CAP. CT may be a useful
diagnostic tool for patients without pulmonary
infiltrate on chest x-ray but who present with
complicating factors. Immunocompromised patients,
elderly patients, and patients with undifferentiated
sepsis or septic shock may particularly benefit from
further characterization with CT.30
Ultrasound
Ultrasound is another useful modality for the
diagnosis of CAP.31 Meta-analysis of the use of lung
ultrasound has demonstrated a pooled sensitivity
and sensitivity for the diagnosis of pneumonia of 94%
and 96%, respectively; pooled positive and negative
LRs were 16.8 and 0.07, respectively.32 However,
sensitivity and specificity depend greatly on the skill
level and experience of the sonographer. Because
this test relies heavily on operator expertise, it is not
an ideal first-line test for clinicians who are not trained
in its use.
Laboratory Testing
Ideally, laboratory testing would be able to help
differentiate between viral and bacterial pathogens
and risk-stratify patients. Unfortunately tests such
as white blood cell count (WBC) and erythrocyte
sedimentation rate (ESR) have erratic sensitivity
and poor specificity, and do not appear to offer
reliable diagnostic or prognostic information. While
laboratory tests may identify other possible medical
issues in terms of how CAP is diagnosed and
managed, they have limited utility.
Biomarkers
Over the past several decades, various biomarkers
have been used to evaluate patients with CAP. More
recently, biomarkers such as C-reactive protein (CRP)
and procalcitonin (PCT) have been studied in patients
with suspected pneumonia. CRP is released primarily
from the liver in response to elevated inflammatory
mediators generated by the body’s response to
pathogens. PCT is produced in the thyroid and
becomes detectable after 2 to 4 hours of infection.
Early studies across a wide variety of settings have
reported that PCT is able to predict the presence of a
bacterial infection and, when trended, can illustrate a
response to antibiotics.33
FEBRUARY 2021 • www.ebmedicine.net 6
The clinical utility of these biomarkers remains
somewhat unclear. Müller et al evaluated the
use of PCT and CRP alongside traditional clinical
features (fever, cough, sputum production, abnormal
chest auscultation, and dyspnea) and WBC count.
When CRP and PCT were added to the traditional
examination findings, the area under the curve
increased from 0.79 to 0.90. When used to identify
these patients, PCT and CRP were more accurate
than physical examination features but were not
statistically superior to WBC count.34
As with WBC count, the diagnostic accuracy of
PCT and CRP is linked to the levels detected. When
applied to a subset of patients who have possible
CAP and an infiltrate on chest radiography, there
is great variability in how the tests perform. At low
levels (>40 mg/L) CRP has a sensitivity of 90%, with a
specificity of only 17%. When >200 mg/L, the sensi-
tivity is 36% with a specificity of 91%. PCT performs
similarly, with a reported specificity of 39% at low
levels (>0.1 mcg/L) and a sensitivity of 90%. In a study
of hospitalized patients, Self et al found that elevated
PCT levels correlated with an increased likelihood of
an underlying bacterial infection. Despite this corre-
lation, the authors were unable to identify a reliable
threshold at which PCT could consistently differenti-
ate between viral and bacterial pathogens.35
To date, the role of biomarkers in the workup
of CAP remains unclear. In patients with markedly
elevated levels, clinicians may be able to confirm
the diagnosis; however, these patients likely have a
moderate to high pretest probability of disease, so it
is not clear that the addition of these biomarkers adds
meaningful clinical data.
Various studies have evaluated the role of PCT
in making the decision to start or stop antibiotics in
patients with CAP. In a prospective randomized con-
trolled trial of ED patients with possible respiratory
tract infections, patients were randomized to either
standard care or a PCT-guided algorithm using vary-
ing PCT thresholds. At <0.1 mcg/L, antibiotic use was
strongly discouraged; at 0.1-0.25 mcg/L, antibiotic
use was discouraged; and at >0.25 mcg/L, antibiotic
use was encouraged. When the PCT algorithm was
applied, patients had lower rates of antibiotic use,
fewer antibiotic-related side effects, and no increase
in adverse events, including death or ICU admission,
compared to standard care.36
A multicenter randomized controlled trial of
over 1500 patients compared the use of PCT-
guided protocol to standard care in ED patients with
suspected lower respiratory tract infection in cases
where the clinician was “uncertain whether antibiotic
therapy was indicated.” There was no significant
difference in terms of the duration of antibiotic use or
the rate of adverse events within 30 days.37
The 2019 ATS/IDSA guidelines give a strong
recommendation, based on a moderate quality of
©2021 EB MEDICINE
evidence, that patients with clinical and radiographic
findings of CAP should be started on empiric anti-
biotics regardless of initial PCT results.38 Currently,
despite more widespread use across a variety of set-
tings, PCT should not be part of the standard workup
of ED patients with suspected CAP.
Mycoplasma pneumoniae Testing
M pneumoniae accounts for approximately 5%
to 15% of cases of CAP, with the highest rates
occurring in children and young adults. Cases of
mycoplasma pneumonia typically occur during
winter months, are thought to be highly contagious,
and can lead to clusters of outbreaks. Making the
diagnosis of mycoplasma pneumonia can be a
challenge, as patients typically have lower rates of
abnormal pulmonary findings on examination and
chest radiography. IgM and IgG antibody titers
and PCR testing are available, but may not have
meaningful clinical impact, as patients have a high
rate of asymptomatic carriage. In a study of healthy
volunteers, 13.5% of patients without symptoms were
found to harbor M pneumoniae in the oropharynx
during the season of peak mycoplasma pneumonia
prevalence. Overall incidence of M pneumoniae
detection in healthy volunteers was approximately
5%.39 Given that mycoplasma pneumonia typically
has a benign disease course and rarely results in
hospitalization or significant morbidity, there is little
clinical imperative for providers to use this test when
evaluating patients.
Urine Antigen Testing the past 90 days. Rather than empirically ordering
Urine antigen testing is available for both S pneu-
moniae and L pneumophila. Initial studies reported
test characteristics that were comparable to those
seen with blood and sputum cultures, though the
clinical impact of this testing remains somewhat
unclear. In a trial of 194 patients who were hospital-
ized with CAP, Falguera et al randomized patients to
either empiric treatment based on available guide-
lines or targeted therapy based on the results of urine
antigen testing. Antigen testing influenced antibiotic
choice in 28.4% of patients; however, despite this
additional data, there was no difference between the
groups in terms of overall treatment cost, exposure
to broad-spectrum antibiotics, or the incidence of
adverse events.40
The 2019 ATS/IDSA guidelines do not recom-
mend routine testing for pneumococcal antigen other
than in cases of severe pneumonia; however, this is a
conditional recommendation based on a low overall
quality of evidence. Similarly, patients should not be
tested routinely for Legionella antigen other than in
cases of severe CAP or unless there is an elevated
clinical concern based on recent outbreaks.38
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Blood Cultures
Blood cultures have a limited role in the diagnosis
and treatment of CAP because they have a low
sensitivity, a high rate of false-positives, and rarely
offer data that positively alters a patient’s clinical
course. A prospective study of 414 patients with
CAP in an ED reported true-positive cultures in only
7% of patients. Overall, blood cultures altered the
treatment plan in only 3.6% of cases and, in most
instances, the data were used to narrow rather
than broaden antibiotic coverage (2.7% vs 1%).41 A
similar retrospective review of ED patients with CAP
found a false-positive culture rate of 7.8% versus a
true-positive rate of only 3.4%. In patients with true
positives, the number needed to treat in terms of a
blood culture changing the treatment plan was 250.42
Prior to 2014, the Centers for Medicare and Med-
icaid Services and the Joint Commission mandated
that patients should have 2 sets of blood cultures
obtained prior to starting antibiotics. Given the low
diagnostic yield of such testing, this requirement is no
longer a core measure of quality. The 2019 ATS/IDSA
guidelines strongly recommend that blood cultures
should not be obtained for any outpatients, and
they give a conditional recommendation that blood
cultures should not be routinely ordered for inpatients
with CAP. As with antigen testing, blood cultures are
still recommended for hospitalized patients with se-
vere CAP and also for patients who have been or are
being treated for methicillin-resistant Staphylococcus
aureus (MRSA) or P aeruginosa, and for patients who
have been hospitalized and given IV antibiotics within
blood cultures on all patients with CAP, clinicians
should first try to risk stratify patients for the potential
for drug-resistant pathogens.38
Sputum Cultures
The diagnostic performance of sputum cultures
is variable. Gram staining and culture of sputum
may be positive in 80% of cases of pneumococcal
pneumonia, with much lower rates seen with other
pathogens.43 From a practical standpoint, sputum
cultures are difficult to obtain and rarely affect
patient management. In a prospective analysis of
116 immunocompetent patients with CAP, Ewig et
al found that sputum cultures could be obtained in
only 36% of patients. Even when obtained, 69% were
not obtained until at least a day after admission and
the samples were “microscopically valid” in only 50%
of cases. In terms of diagnostic yield, 50% of the
cultures showed mixed flora, with only 20% having an
isolated positive Gram stain. Culture results changed
the treatment course in only 1 patient who had failed
to clinically respond to initial antibiotic therapy.44
In the 2019 guidelines, the ATS/IDSA
recommended against obtaining sputum cultures in
outpatients. For inpatients, the authors acknowledge
7 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
the overall low quality of evidence but recommend
that sputum cultures be used in cases of severe CAP
and for patients in whom there is concern for MRSA
or P aeruginosa. Sputum cultures should also be
considered in patients who have been hospitalized
and given IV antibiotics during the previous 90 days.
The authors acknowledge that previously published
risk factors for MRSA and P aeruginosa largely show
weak associations and suggest that for patients with
these risk factors, negative sputum cultures may help
clinicians de-escalate therapy.38 In general, for the
vast majority of patients with CAP in the ED, there is
almost no role for routine sputum cultures.44
Viral Respiratory Panel
Recently, viral respiratory panels have been
developed that, using a variety of techniques, can
help identify various viral pathogens, with rapid
turnaround time. In terms of accuracy, most of the
commercially available tests can reliably identify viral
pathogens, most frequently respiratory syncytial
virus, but the clinical utility of these panels remains
unproven. In a randomized controlled trial comparing
viral respiratory panels to usual care, May et al
found that the viral respiratory panels identified a
viral pathogen in 55% of cases, yet there was no
statistically significant difference in antibiotic use
between the 2 groups.45 Similarly, the widespread
use of rapid testing for influenza has been shown to
reliably identify cases of influenza and is endorsed by
the ATS/IDSA; nonetheless, it has not been shown to
have an impact on patient-oriented outcomes.
n Using Severity and Risk Scoring
Systems for Treatment and
Disposition
Treatment choices depend largely on whether the
patient is being admitted or discharged. Scoring
systems have been developed to risk stratify patients
in terms of their disposition. The 2 most common
validated decision instruments are the CURB-65 score
and the pneumonia severity index (PSI).46,47
CURB-65 Score
CURB-65 uses a 5-point scoring system. Patients with
scores of 0 or 1 are safe for discharge; patients with
a score of 2 can be observed or admitted; patients
with scores ≥3 should be admitted; if the score is ≥3,
possibly to the ICU. (See Table 1.)
Pneumonia Severity Index
The pneumonia severity index (PSI) requires a 2-step
process. In step 1, clinicians attempt to determine
whether patients are considered to be at low risk, or
“class I.” If the patient is aged <50 years and has no
significant chronic medical conditions or abnormal
vital signs, they can be categorized as class I and are
FEBRUARY 2021 • www.ebmedicine.net 8
considered safe for discharge. If the patient has any
of these characteristics, the clinician then proceeds to
step 2, which involves a scoring system incorporating
age, chronic medical conditions, laboratory features,
and radiographic findings. Based on the results of
step 2, patients are categorized as being at low risk
(class II or class III), moderate risk (class IV), or high
risk (class V), with recommendations ranging from
outpatient care to observation or inpatient admission.
(See Figure 1, page 9.)
Comparison of CURB-65 and Pneumonia Severity
Index Scores
Both the CURB-65 and the PSI scores have reliable
sensitivity in identifying high-risk patients, but CURB-
65 is more specific (74.6% vs 52.2%). One possible
explanation for the lower specificity of the PSI is its
inclusion of comorbidities. With PSI, otherwise well-
appearing patients with comorbid conditions may
have an elevated score without increased mortality.
Conversely, when using CURB-65, consider the
presence of significant underlying medical conditions
when evaluating a patient, as the score does not
incorporate these elements.48
In a prospective study of over 3000 patients,
Aujesky et al found that, when compared to CURB-
65, PSI more accurately predicted mortality and was
able to categorize a larger subset of patients as low
risk.49 Subsequent studies have found consistently
that PSI can be used to identify patients who can be
treated as outpatients, without any increase in the
rate of mortality or adverse events.50 In their 2019
guidelines, the ATS/IDSA conditionally recommend
the PSI score over CURB-65, but emphasized that any
scoring system should be used in conjunction with
clinical judgment.38
Table 1. CURB-65 Scoring46
Symptom Points
Confusion 1
Urea: BUN >19 mg/dL (>7 mmol/L) 1
Respiratory rate ≥30 breaths/min 1
Systolic BP <90 mm Hg or diastolic BP ≤60 mm Hg 1
Age ≥65 years 1
Total ______
Score Risk Disposition
0 or 1 1.5% mortality Outpatient care
2 9.2% mortality Inpatient versus observation admission
≥3 22% mortality Inpatient admission; consider ICU
admission with score of 4 or 5
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; ICU,
intensive care unit.
©2021 EB MEDICINE
 An online calculator for the CURB-65
score is available at:
www.mdcalc.com/curb-65-score-
pneumonia-severity
An online calculator for the PSI score is
available at:
www.mdcalc.com/psi-port-score-
pneumonia-severity-index-cap
Intensive Care Unit Admission
When admitting a patient with CAP to the hospital,
the need for ICU level of care must be considered.
A 2018 Canadian study prospectively evaluated 657
patients with suspected infection who were admitted
to the ICU within 72 hours of ED presentation.
Patients were categorized into 3 groups:
(1) admitted to the ICU from the ED; (2) admitted
to the wards but moved to the ICU within 72
hours due to deterioration; or (3) discharged from
the ED, but admitted to the ICU within 72 hours
due to deterioration. The ICU patients initially
admitted directly to the ICU had an in-hospital
mortality of 29.5% compared to 42.7% for those
initially admitted to the wards and 61.2% for those
initially discharged home. It is not unexpected that
patients ultimately requiring critical care who were
appropriately triaged to the ICU had lower mortality;
likewise, overall costs were significantly lower in
the patients who were admitted to the ICU initially.
While the authors did not have a formal approach
to risk stratification, their findings emphasize the
importance of placing patients into the appropriate
level of care from the ED.51

Figure 1. Pneumonia Severity Index47

Step 1 Step 2: Assign patient to risk class II-V based on points

Is ≥1 of the following characteristics assigned
present? Finding Points
• Age >50 years
Age
• Neoplastic disease
• Congestive heart failure • Men Age (yr)
• Cerebrovascular disease • Women Age (yr)-10
• Renal disease YES
Nursing Home Resident 10
• Liver disease
• Altered mental status Coexisting Illness
• Pulse ≥125 beats/min • Neoplastic disease 30
• Respiratory rate ≥30 breaths/min
• Liver disease 20
• Systolic blood pressure <90 mm Hg
• Temperature <35°C or ≥40°C • Congestive heart failure 10
• Cerebrovascular disease 10
NO • Renal disease 10
Physical Examination Findings
• Altered mental status 20
Assign patient to risk class I
• Respiratory rate ≥30 breaths/min 20
• Systolic blood pressure <90 mm Hg 20
• Temperature <35°C or ≥40°C 15

Points assignment corresponds to the • Pulse ≥125 beats/min 10

following risk classes: ≤70 class II, 71-90 Laboratory and Radiographic Findings
class III, 91-130 class IV, >130 class V • Arterial pH <7.35 30
• BUN ≥30 mg/dL (11 mmol/L) 20
• Sodium <130 mmol/L 20

Score/Class Risk Disposition • Glucose ≥250 mg/dL (14 mmol/L) 10

≤70, class II Low Outpatient care • Hematocrit <30% 10

71-90, class III Low Outpatient versus observation admission PaO2 <60 mm Hg or oxygen saturation <90% 10
on pulse oximetry
91-130, class IV Moderate Inpatient admission
Pleural effusion 10
>130, class V High Inpatient admission
Total _________

Abbreviations: BUN, blood urea nitrogen; PaO2, partial pressure of oxygen, arterial.

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SMART-COP and ATS/IDSA Criteria
SMART-COP is a scoring system that can be used to
predict a patient’s need for ICU admission. (See Table
2.) In a study of 862 patients with CAP, Charles et al
found that the SMART-COP score was significantly
more sensitive (92.3%) and specific (62.3%) compared
with the sensitivities of PSI class IV and V (73.6%)
and CURB-65 group 3 (38.5%).52 In a subsequent
validation study, SMART-COP outperformed (positive/
negative LR, 2.6/0.15) both CURB 65 (2.1/0.64) and PSI
(1.5/0.53) in predicting the need for ICU admission.53 other than mechanical ventilation is notoriously
The 2019 ATS/IDSA guidelines list major and
minor criteria for ICU admission, and recommend
ICU admission for any patient who has 1 or more
major criteria.38 (See Table 3.) For patients who do
not require vasopressors or mechanical ventilation,
the authors recommend that a combination of clinical
judgment and any of the findings noted in Table 3
(minor criteria) be used to determine the need for ICU
admission.
A 2012 meta-analysis found that using 1 major
or 3 minor criteria resulted in a pooled sensitivity
of 84% and specificity of 78% for predicting ICU
admission.53 An online calculator for the SMART-COP
Table 2. SMART-COP Score for Pneumonia
Severity52
Factor
Systolic blood pressure <90 mm Hg
Multilobar chest x-ray involvement
Albumin <3.5 g/dL
Respiratory rate age-adjusted cutoffs
• Age ≤50 years: ≥25 breaths/min
• Age > 50 years: ≥30 breaths/min
Tachycardia ≥125 beats/min
Confusion (new onset)
Oxygen low
• Age ≤50 years: PaO2 <70 mm Hg
(or SaO2 ≤93% or P/F ratio <333)
• Age >50 years: PaO2 <60 mm Hg
(or SaO2 ≤90% or P/F ratio <250)
Arterial pH <7.35
Total score
SMART-COP Risk Group
Score
0-2 Low
3-4 Moderate
5-6 High: consider ICU admission
≥7 Very high: consider ICU admission
*Risk for patient requiring intensive respiratory or vasopressor support.
Abbreviations: ICU, intensive care unit; PaO2, partial pressure of oxygen,
arterial; P/F ratio, PaO2/fraction of inspired oxygen (FiO2) ratio; SaO2,
arterial oxygen saturation.
FEBRUARY 2021 • www.ebmedicine.net 10
Studies comparing these major and minor
criteria to SMART-COP have been mixed. In 2009,
Brown et al reported that the major/minor criteria
outperformed other models,54 but in 2011 Chalmers
et al reported a similar performance between the
2 scores.55 SMART-COP may be more difficult to
calculate in the ED, as it requires albumin, PaO2, and
blood pH, tests that may not be necessary or readily
available during the patient’s initial visit; moreover,
quantification of the delivered FiO2 by any method
imprecise. The authors of the ATS/IDSA guidelines
cite ease of use of the major/minor criteria as the
rationale behind their recommendation of these
criteria over other scoring systems.
While the evidence behind any particular tool
is mixed and the guidelines support some clinician
variability, clinicians should use one of these tools
for all patients with CAP. The key to risk stratification
seems to be to first consider the decision to admit
or discharge and then subsequently to consider the
need for ICU admission.
score is available at:
www.mdcalc.com/smart-cop-score-
pneumonia-severity
Points Table 3. 2007 IDSA/ATS Criteria for
2 Defining Severe Community-Acquired
1 Pneumonia
1 Validated definition includes either 1 major criterion or ≥3 minor
criteria
1 • Minor Criteria
l
Respiratory rate ≥30 breaths/min
l
PaO2/FiO2 ratio ≤250
1 l
Multilobar infiltrates
1
l
Confusion/disorientation
l
Uremia (blood urea nitrogen level ≥20 mg/dL)
1 l
Leukopenia* (white blood cell count <4000 cells/mcL)
l
Thrombocytopenia (platelet count <100,000/mcL)
l
Hypothermia (core temperature <36ºC)
l
Hypotension requiring aggressive fluid resuscitation
• Major Criteria
2
l
Septic shock with need for vasopressors
________ l
Respiratory failure requiring mechanical ventilation
Risk* *Due to infection alone (ie, not chemotherapy induced).
Abbreviations: ATS, American Thoracic Society; FiO2, fraction of inspired
oxygen; IDSA, Infectious Diseases Society of America; PaO2, arterial
Minimal oxygen pressure.
1 in 8 Reprinted with permission of the American Thoracic Society. Copyright ©
1 in 3 2021 American Thoracic Society. All rights reserved. Metlay JP, Waterer
GW, Long AC, et al. 2019. Diagnosis and treatment of adults with
2 in 3 community-acquired pneumonia. An official clinical practice guideline
of the American Thoracic Society and Infectious Diseases Society of
America. American Journal of Respiratory and Critical Care Medicine.
Volume 200, Issue 7, pages 45-67. The American Journal of Respiratory
and Critical Care Medicine is an official journal of the American
Thoracic Society.
©2021 EB MEDICINE
n Treatment
Inpatient Treatment
The current guidelines use 2 risk stratification branch
points to determine appropriate antibiotic therapy.
First, patients are categorized as having severe or
nonsevere pneumonia. (See Table 3, page 10.)
Severe pneumonia is defined as having at least 1
major criterion or at least 3 minor criteria. Following
this delineation, patients are treated based on the
presence or absence of risk factors for MRSA and
P aeruginosa.38
Nonsevere Community-Acquired Pneumonia
For cases of nonsevere CAP without additional risk
factors, 2 treatment regimens are given a strong
recommendation:38
1. Combination therapy with a beta-lactam
• Ampicillin + sulbactam 1.5-3 g IV every 6 hours
• Cefotaxime 1-2 g IV every 8 hours
• Ceftriaxone 1-2 g IV daily
• Ceftaroline 600 mg IV every 12 hours
PLUS
• Macrolide
l Azithromycin 500 mg orally or IV daily or
clarithromycin 500 mg orally twice daily
OR
• Doxycycline, 100 mg orally or IV twice daily
(if QTC prolongation is a consideration or if
patient is unable to take fluoroquinolones or
macrolides [conditional recommendation])
2. Monotherapy with a respiratory fluoroquinolone
• Levofloxacin 750 mg orally or IV, daily
• Moxifloxacin 400 mg orally or IV, daily
For patients with nonsevere CAP who have previ-
ously had a respiratory isolation of MRSA and/or P
aeruginosa, the guidelines suggest obtaining blood
and sputum cultures and treating the patient empiri-
cally for the respective previous isolation until the
culture data result.
ATS/IDSA guidelines regarding inpatient manage-
ment recommend 2 potential treatment options for
patients with previous MRSA isolation:38
• Vancomycin 15 mg/kg IV every 12 hours;
adjust based on levels
• Linezolid 600 mg IV every 12 hours
For patients with history of previous P aeruginosa
isolation, the following regimens are recommended
by the guidelines:38
• Piperacillin-tazobactam 4.5 g IV every 6 hours
• Cefepime 2 g IV every 8 hours
• Ceftazidime 2 g IV every 8 hours (consider
local resistance)
• Imipenem 500 mg IV every 6 hours
• Meropenem 1 g IV every 8 hours
• Aztreonam 2 g IV every 8 hours
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
For patients with nonsevere CAP with recent hos-
pitalization (≥2 days in the last 90 days), parenteral
antibiotic administration, and locally validated risk
factors for MRSA and/or P aeruginosa, cultures should
be obtained, but patients do not need to be empiri-
cally treated for MRSA and/or P aeruginosa, pending
results of these tests.
Severe Community-Acquired Pneumonia
In contrast to patients with nonsevere pneumonia,
patients with severe CAP and risk factors for MRSA
and/or P aeruginosa should be given empiric
coverage for these respective pathogens pending
culture results.38 The drug resistance in pneumonia
(DRIP) score is a prospectively validated tool that can
be used to risk stratify patients in terms of their risk
for having drug-resistant pathogens.56 When applied
to ED patients admitted with CAP, a DRIP score of
≥4 had a sensitivity of 70.6% and a specificity 82.3%
for identifying drug-resistant pathogens. When
compared to traditional HCAP criteria, the DRIP score
resulted in a 38% decrease in unnecessary broad-
spectrum antibiotic use.57
An online calculator for the DRIP score is
available at:
www.mdcalc.com/drug-resistance-
pneumonia-drip-score
The 2019 guidelines38 call for continued use
of macrolides for inpatients, while the use of these
agents in outpatients has been curtailed due to
increasing resistance to S pneumoniae worldwide.
This recommendation seems to come largely from
retrospective data showing an association between
the use of macrolide therapy and reduced rates of
mortality. In a 2014 meta-analysis, Sligl et al reported
an 18% relative and 3% absolute reduction in mortality
when hospitalized patients were treated with regimens
that contained macrolides.58 While resistance for S
pneumoniae is increasing, macrolides are still effective
against most atypical pathogens, which may explain
some of this associated mortality benefit.
Outpatient Treatment
The overall quality of evidence evaluating ideal
outpatient antibiotic choice is poor. In 2014, a
Cochrane meta-analysis evaluated 11 trials including
over 3000 patients and concluded, “there were not
enough trials to compare the effects of different
antibiotics for pneumonia acquired and treated in the
community.”59 The authors of the 2019 ATS/IDSA
CAP guidelines took a broader look at the available
data and reviewed studies involving inpatients who
were treated with oral antibiotics, based on the
theory that the majority of inpatients typically suffer
from similar pathogens.38 Due in part to the inclusion
11 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
of this inpatient data, there were some notable
changes in the updated guidelines in terms of first-
line antibiotic choice.
Due to increasing rates of macrolide-resistant
pneumococcus, these agents are now recommended
only in areas where known resistance is <25%.
Worldwide incidence of macrolide resistance varies
widely, but recent studies in North America have
shown widespread resistance rates >30%, making
macrolides a poor choice for a large number of
clinicians.60
The recommendation for the use of high-
dose amoxicillin (1 g orally 3 times per day) comes
from a handful of inpatient studies that showed
similar outcomes when comparing amoxicillin to
various fluoroquinolones.61 One potential limitation
of amoxicillin is that it does not cover atypical
pathogens sufficiently. Despite this limitation, the
ATS/IDSA authors based their recommendation
on the handful of studies showing the efficacy of
amoxicillin even with this likely lack of coverage for
atypical pathogens.62 Similarly, the overall quality
of evidence behind the use of doxycycline is limited
to mostly small studies of inpatients receiving IV
formulations.63 The ATS/IDSA authors recognize this
limited base of evidence, yet still recommend the use
of doxycycline as a first-line agent based largely on its
“broad spectrum of action.”38
Unfortunately, there are no studies evaluating the
effect of these new recommendations. In terms of
potential monotherapy per these recommendations,
we are left with using amoxicillin and under-treating
atypical pathogens, using a macrolide and risking
inadequate treatment of Streptococcus, or using
doxycycline, which has largely theoretical efficacy.
Without prospective data, it would be reasonable to
use a combination of amoxicillin and a macrolide to
ensure adequate coverage, leaving doxycycline as
the only potential monotherapy.
For healthy outpatient adults without risk factors
for drug-resistant organisms, the following treatment
regimens are recommended:38
• Amoxicillin 1 g orally 3 times daily
OR
• Doxycycline 100 mg orally 2 times daily
OR
• A macrolide (only in areas with pneumococcal
resistance to macrolides <25%)
l Azithromycin 500 mg orally on the first
day, then 250 mg orally daily
l Clarithromycin 500 mg orally 2 times
daily or clarithromycin extended release
1000 mg orally daily
For outpatients with comorbidities (chronic
heart, lung, liver, or renal disease; diabetes mellitus;
alcoholism; malignancy; or asplenia) either of the
following 2 regimens are recommended:
FEBRUARY 2021 • www.ebmedicine.net 12
1. Combination therapy
• Amoxicillin/clavulanate
l 500 mg/125 mg orally 3 times daily
l 875 mg/125 mg orally 2 times daily
l 2000 mg/125 mg orally 2 times daily
OR
• Cephalosporin
l Cefpodoxime 200 mg orally 2 times daily
l Cefuroxime 500 mg orally 2 times daily
PLUS
• Macrolide
l Azithromycin 500 mg orally on the first
day, then 250 mg orally daily
l Clarithromycin 500 mg orally 2 times daily
or extended-release 1000 mg orally once
daily
2. Monotherapy
• Doxycycline 100 mg orally 2 times daily
OR
• Respiratory fluoroquinolone
l Levofloxacin 750 mg orally daily
l Moxifloxacin 400 mg orally daily
l Gemifloxacin 320 mg orally daily
Antibiotic Duration
There is limited evidence to identify an ideal duration
of antibiotic therapy, but recent studies have
suggested that abbreviated courses are both safe
and effective. Dunbar et al found no difference in
outcomes when comparing 5 days of levofloxacin 750
mg daily to a 10-day course of levofloxacin 500 mg
daily.64 In a meta-analysis, Tansarli et al found that
patients who took <6 days of antibiotics had fewer
adverse events and lower reported mortality when
compared with patients who took antibiotics for >7
days.65 Recent guidelines recommend a minimum
of 5 days of antibiotic therapy even if the patient is
improving clinically.38
Antitussives
Treatment of cough in patients with pneumonia is
somewhat controversial, as many of the proposed
treatments are relatively ineffective and can
have side effects. Because the cough is typically
self-limited, treatment aimed at the underlying
pneumonia is successful in the majority of cases.66
Specific treatments for cough include centrally
active antitussive agents (opioid and nonopioid),
peripherally acting antitussive agents (benzonatate),
inhaled glucocorticoids, and inhaled bronchodilators.
Codeine has been used extensively in the treatment
of cough, often in combination with other agents, but
it has not been found to have a statistically significant
effect on cough suppression.67 Although morphine
has proven somewhat more effective, it is not
recommended for routine treatment of cough, given
its side-effect profile and its addictive properties.
Benzonatate, a peripherally acting antitussive, acts
©2021 EB MEDICINE
by anesthetizing stretch receptors in the lungs. Its
efficacy has not been proven, but it is often used
as an alternative to opioids. Studies on antitussive
agents, inhaled glucocorticoids, and inhaled
bronchodilators have shown limited, if any, effect on
cough from pneumonia.68
Given the lack of efficacy of antitussives, patient
education and effective discharge instructions are
very important in the treatment of CAP. Patients
should be counseled that the majority of antitussive
treatments are often ineffective and that cough
in pneumonia is usually self-limited and improves
with resolution of pneumonia. Patients should be
advised to return to the ED if they are unable to
control their secretions or if their cough is causing
shortness of breath. If the patient is prescribed a
opioid antitussive, they should be counseled on
the side effects and risks, which include respiratory
depression.
n Special Populations
Pediatric Patients
There are several important differences between adult
and pediatric patients regarding the diagnosis and
management of CAP. Viral pathogens are a common
cause of pneumonia in pediatric patients, specifically
in children younger than 2 years, with rates of viral
pathogens decreasing as children age. Recent IDSA
guidelines emphasize the high rate of viral pathogens
and encourage the use of viral testing in an effort to
limit unnecessary antibiotic use; however, rapid viral
testing is not widely available in most EDs, nor has
its use been shown to improve patient outcomes. S
pneumoniae is the most common bacterial pathogen,
yet the overall incidence continues to decrease, as
pneumococcal immunization is used broadly.
From a diagnostic standpoint, physical
examination findings and diagnostic studies have
limitations similar to those in the adult population
(poor sensitivity, poor specificity, and inability to
differentiate between bacterial and viral causes). A
2017 systematic review found that classic vital sign
abnormalities such as fever and tachypnea did not
reliably help make the diagnosis of pneumonia.
(Fever >37.5°C [LR range, 1.7-1.8]: sensitivity, 80%-
92%; specificity, 47%-54%; tachypnea (respiratory
rate >40 breaths/min; LR, 1.5 [95% confidence
interval (CI), 1.3-1.7]: sensitivity, 79%; specificity,
51%.) Other examination findings, including abnormal
lung auscultation, were not strongly associated
with the presence of pneumonia. Increased work of
breathing (grunting, flaring, retractions) were weakly
associated with the diagnosis of CAP (+LR, 2.1; 95%
CI, 1.6-2.7). The presence or absence of moderate
hypoxemia (oxygen saturation ≤96%) had more
diagnostic accuracy than any other finding (+LR, 2.8;
95% CI, 2.1-3.6; -LR, 0.47; 95% CI, 0.32-0.67).69
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
For children, less emphasis is placed on scoring
systems or decision aids to determine disposition.
The IDSA recommends hospitalization for patients
with any of the following findings:
• Children and infants who have moderate to
severe CAP, as defined by several factors,
including respiratory distress and hypoxemia
(sustained saturation of peripheral oxygen [SpO2]
<90% at sea level)
• Age <3-6 months
• The presence of a pathogen with increased
virulence, such as S aureus
• Clinician concern about careful observation at
home or ability to comply with therapy
More recent studies have attempted to identify
pediatric patients with CAP who may benefit
from hospitalization. A prospective cohort study
evaluated the ability of various examination and
diagnostic findings to identify children who were at
increased risk for needing major medical intervention
(including supplemental oxygen, supplemental fluid,
respiratory support, intensive care, or treatment for
complications during admission). The presence of
both retractions and hypoxemia were associated
with increased rates of medical interventions, with a
specificity of 94% and a positive LR of 6.4; however,
these findings had a sensitivity of only 40%, which
limits their use in terms of identifying patients who
are at low risk for needing a major intervention.
Laboratory findings including CRP and WBC were
not able to reliably identify at-risk patients, while the
presence of multifocal radiographic changes was
weakly associated with an increased rate of medical
interventions.70
In cases of suspected bacterial pneumonia,
amoxicillin is the recommended first-line therapy for
previously healthy immunized children. S pneumoniae is
the most common invasive bacterial pathogen seen in
children and is generally susceptible to amoxicillin. For
school-aged children, the rate of atypical pathogens such
as M pneumoniae increases. If there is high suspicion for
atypical CAP, current guidelines recommend treating with
macrolides rather than amoxicillin.
For children who are hospitalized with CAP,
ampicillin or penicillin G are the recommended first-
line agents for otherwise healthy, fully immunized
patients. For unimmunized patients, patients with
life-threatening infection, or in areas with known
penicillin-resistant pneumococcus, a third-generation
cephalosporin should be used. If S aureus is a
suspected pathogen, patients should be treated with
vancomycin or clindamycin.71
13 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
Risk of Multidrug-Resistant Organisms
Historically, patients who have frequent or recent
interactions with the healthcare system were
thought to have an increased risk of developing
pneumonia from multidrug-resistant organisms and
were categorized as having healthcare-associated
pneumonia (HCAP). In a meta-analysis including over
24,000 patients, Chalmers et al found no increase
in the incidence of multidrug-resistant organisms
in patients with HCAP compared with patients with
CAP,72 and updated guidelines have moved away
from this classification. Instead, the latest guidelines
classify nosocomial pneumonia as either hospital-
acquired pneumonia or ventilator-associated
pneumonia.2
n Controversies and Cutting Edge
While antibiotics remain the mainstay of treatment
for CAP, more recent data have evaluated the use of
adjunctive medications.
Corticosteroids
The 2019 ATS/IDSA guidelines recommend using
corticosteroids for CAP and refractory septic
shock but recommend against the routine use of
corticosteroids in all other cases.38 The authors
commented that while no study has shown excess
mortality in CAP patients who have received
corticosteroids, the overall risk for adverse events
outweighs any potential benefits.
Despite these recommendations, the available
literature regarding the role of corticosteroids
suggests that the balance between potential harm
and potential benefit may be more subtle. In cases
of nonsevere CAP, multiple studies have shown an
improvement in outcomes that may be clinically
significant, including lower rates of mechanical
ventilation and decreased inpatient lengths of stay.73
Conversely, multiple studies have shown increased
rates of hyperglycemia and secondary infection in
patients who are given corticosteroids.74 In cases of
severe CAP, the available evidence supporting the
use of corticosteroids seems to be more clear, with
a reported number needed to treat of 17 to prevent
1 death, though in this same subset of patients, the
reported number needed to harm is 11. While this
number needed to treat is greater than the reported
number needed to harm, the relative risks of harm
(largely in the form of hyperglycemia) may be justified
by the potential mortality benefit.75
Influenza, Antiviral Agents, and Community-
Acquired Pneumonia
Based on low-quality evidence, the ATS/IDSA
guidelines advocate for the use of oseltamivir in all
patients with CAP who test positive for influenza.
Despite the lack of studies specifically assessing
the use of antiviral agents in patients with CAP and
FEBRUARY 2021 • www.ebmedicine.net 14
influenza, the authors based their recommendations
on observational studies showing an association
between the use of oseltamivir and a reduced
mortality in patients who are hospitalized with
influenza.76 For the outpatient setting, the guideline
authors38 recommend using oseltamivir despite a
patient’s duration of symptoms, citing a paper by
Dobson et al77 that reported a decreased rate of
lower respiratory complications in patients with
influenza (but not necessarily pneumonia) who were
treated with antivirals. This recommendation for fairly
widespread use of antivirals closely mirrors the 2018
IDSA guideline on seasonal influenza, which similarly
advocated for the use of these medications.78
There are several potential issues with these
recommendations. First, none of the studies cited
specifically evaluated patients who have both
pneumonia and influenza. The authors asserted that,
given the reported benefits of oseltamivir in patients
with isolated influenza, patients with influenza and
CAP would similarly benefit from an aggressive
use of antiviral agents. While this may prove to be
true, the evidence behind this recommendation is
lacking. A second issue with these recommendations
involves the ongoing debate regarding the efficacy
and tolerability of oseltamivir. While multiple large
meta-analyses and systematic reviews concluded that
oseltamivir can reduce symptoms and downstream
complications, most of these publications have
significant methodologic limitations that call into
question the reported efficacy of these agents.79
Clinicians should weigh ATS/IDSA guidelines calling
for widespread use of oseltamivir, due to the limited
quality of available evidence.80
Novel Antibiotics
Omadacycline, a tetracycline derivative, and
lefamulin, a semisynthetic pleuromutilin antibiotic,
are 2 newer agents that have demonstrated efficacy
against common pathogens seen in CAP. Both agents
were shown to be noninferior to moxifloxacin using
study protocols that started with IV formulations
before transitioning to oral dosing.81,82 Though these
drug company-sponsored studies suggested that
these novel agents would be reasonable first-line
agents for CAP, they offered no evidence to suggest
that these drugs would improve patient-oriented
outcomes compared to the current approach. Given
the current data, these drugs appear to be, at best,
expensive replacements for current tools, and they
should not be used routinely to treat CAP.
©2021 EB MEDICINE
 Risk Management Pitfalls for Community-Acquired
Pneumonia in the Emergency Department
1. “I knew she had pneumonia, but she looked
fine; I didn’t think she was septic.” Sepsis is
an often-missed diagnosis in the ED and results
in increased mortality. Frequent reassessment
of patients and re-evaluation of vital signs,
particularly the respiratory rate, can help avoid
the underdiagnosis of sepsis.
2. “I thought the tachycardia and hypoxemia
were due to the pneumonia.” When CAP is not
the most likely diagnosis, consider using clinical
decision tools such as the PERC rule (www.
mdcalc.com/perc-rule-pulmonary-embolism) and
Wells criteria (www.mdcalc.com/wells-criteria-
pulmonary-embolism) to evaluate for pulmonary
embolism. Patients with atypical signs and
symptoms of CAP (sudden onset of shortness
of breath; multiple risk factors for pulmonary
embolism) or with findings on imaging that could
be consistent with pulmonary infarctions should
be evaluated further.
3. “Azithromycin seemed like a good choice for
her.” The choice of antibiotic therapy should
be made in coordination with the most up-to-
date recommendations. The choice of antibiotic
therapy varies, depending on treatment as an
outpatient, inpatient, or ICU, and the local and
community biogram.
4. “The boy had been coughing for a week;
it seemed like he would benefit from
antibiotics.” Pediatric patients with respiratory
complaints have a high rate of viral pathogens.
Existing IDSA guidelines recommend the use
of available viral testing to curtail inappropriate
antibiotic use in this patient population.
5. “Would you send a 70-year-old patient
home with pneumonia?” Scoring systems
that incorporate age or medical comorbidities
may increase the patient’s score while not
accurately reflecting the actual risk to the patient.
Emergency clinicians should consider the
influence that age and other historical elements
have in the development of these scores and
use these in conjunction with their overall clinical
impression to avoid overestimating the patient’s
actual risk of adverse event.
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6. “I just gave him a dose of IV antibiotics to
get things started.” For patients who are able
to tolerate oral intake, there are essentially no
data to suggest that patients need a dose of IV
antibiotics prior to discharge from the ED.83
7. “He was a normal 40-year-old, I thought he’d
be fine on the floor.” When admitting a patient
with CAP, emergency clinicians need to consider
the likelihood that the patient will need invasive
respiratory or vasopressor support. Clinical
scores such as SMART-COP can help risk stratify
patients with CAP and predict the need for an
ICU level of care.
8. “Is it really that bad to give a short course of
moxifloxacin?” While commonly prescribed and
recommended, fluoroquinolones have several
FDA black box warnings and should be used with
caution. Patients taking quinolones are thought
to have an increased risk of tendon rupture,
neuropathy, and aortic aneurysm/dissection.
Clinicians should consider the risk for these
complications in all patients before using these
agents.84
9. “I was sure she had pneumonia, but the x-ray
was normal.” Chest radiography is beneficial
in the diagnosis of CAP but cannot rule out the
disease process. Chest x-ray should be used in
conjunction with a thorough history and complete
clinical picture to make the diagnosis. If a patient
has a high pretest probability of CAP and a
negative chest x-ray, it would be reasonable to
either treat for presumed pneumonia or obtain
further imaging, such as CT or ultrasound.
10. “He looked good, but the M pneumoniae
test was positive, so it must be walking
pneumonia.” Cases of mycoplasma or atypical
pneumonia can have a variable and often less
severe presentation. The rate of asymptomatic
M pneumoniae carriage can be as high as 5%,
resulting in a significant rate of false positives
when patients are tested.
15 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
 Case Conclusions
The 30-year-old man with no significant medical history who presented with 2 days of fever, cough
productive of green sputum, and malaise…
CASE 1

You noted that the patient was otherwise well-appearing, and he did not have any risk factors for drug-
resistant organisms or any other significant medical comorbidities. You prescribed amoxicillin 1 g orally,
3 times daily for 5 days. The patient called back to the ED and said he had improved clinically and was
essentially asymptomatic by day 3. He was encouraged to complete his 5-day course of antibiotics.

The 82-year-old woman from an assisted living facility with a history of mild COPD who presented
with 3 days of mild cough productive of yellow sputum…
CASE 2

Although she had a mild, productive cough, the patient was overall well-appearing and had a PSI score of
82. You discussed with her the potential risks and benefits of inpatient versus outpatient treatment, and she
stated very clearly that she wanted to go back to her assisted living facility. Given her history of COPD, you
prescribed her amoxicillin/clavulanate 875/125 mg orally twice daily and doxycycline 100 mg orally twice
daily for 5 days. The patient returned home and had an uneventful recovery.

The 55-year-old man with a history of diabetes and chronic kidney disease who presented with 3 days
of nonproductive cough, fever, and altered mental status…
You determined that this patient needed to be treated as an inpatient. He was initially hypotensive, but was
CASE 3

normotensive after 3 L of lactated Ringer’s solution. You judged that he would benefit from admission to the
ICU, but the intensivist on call thought that he was suitable for a floor bed. Based on the presence of 3 mi-
nor ATS/IDSA criteria, you raised concern that he would deteriorate, and the intensivist accepted him to the
ICU. Due to the patient’s presentation and comorbidities, you treated him with broad-spectrum antibiotics.

n Summary a 5-day course of antibiotics and have them be

CAP is a common pathology seen across a wide
range of patient populations. From a diagnostic
standpoint, recent innovations such as procalcitonin
and viral panel testing show some promise, but
are not ready for widespread use. Tools such as
the PSI and CURB-65 scores can be used to risk
stratify patients and have been shown to effectively
permit the treatment of a larger subset of patients
as outpatients. ATS/IDSA major/minor criteria and
SMART-COP have both been used to help identify
patients who are likely to need an ICU level of care.
Macrolide monotherapy for CAP is no longer
recommended as a first-line outpatient agent in
most geographic areas, due to increasing rates of
resistance. Recent guidelines have emphasized the
use of blood and sputum cultures for patients who
have an increased risk for MRSA and P aeruginosa
infection, in an effort to balance the risk posed by
these pathogens and the risks posed by the overuse
of broad-spectrum antibiotics.
n Time- And Cost-Effective Strategies
• For patients who show signs of improvement,
limit antibiotic use to 5 days. Previous studies
suggest that patients who take longer courses
of antibiotics have similar rates of clinical cure,
yet have a higher incidence of adverse events.
It would be reasonable to start all patients on
reassessed if they are not improving by the end
of their prescription.
• Use available risk stratification tools to identify
patients who can be safely treated as outpatients.
Compared to the CURB-65, the PSI has been
shown to identify a larger subset of patients who
can safely undergo outpatient treatment.
• Do not order routine follow-up imaging for
patients after completion of their antibiotic
therapy. The recent ATS/IDSA guidelines
recommend against follow-up imaging unless
there is a suspicion for underlying malignancy.
• Other than testing for influenza when clinically
indicated, do not routinely order viral testing
panels. While viral panel testing may help identify
specific underlying pathogens, these tests often
carry a significant cost and have not been shown
to reliably improve patient outcomes.
• Do not overestimate the risk of underlying drug-
resistant organisms. Previous guidelines called
for the use of broad-spectrum antibiotics in
patients who were at risk for developing drug-
resistant organisms. For patients with nonsevere
CAP, the updated guidelines call for blood and
sputum cultures but discourage the empiric use
of broad-spectrum antibiotics pending the results
of culture data.

FEBRUARY 2021 • www.ebmedicine.net 16 ©2021 EB MEDICINE

n References
Evidence-based medicine requires a critical appraisal
of the literature based upon study methodology and
number of subjects. Not all references are equally
robust. The findings of a large, prospective, random-
ized, and blinded trial should carry more weight than
a case report.
To help the reader judge the strength of each refer-
ence, pertinent information about the study, such as the
type of study and the number of patients in the study is
included in bold type following the references, where
available. The most informative references cited in this
paper, as determined by the authors, are noted by an
asterisk (*) next to the number of the reference.
1. Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis.
Virulence. 2014;5(1):4-11. (Review)
2. Kalil AC, Metersky ML, Klompas M, et al. Management of
adults with hospital-acquired and ventilator-associated pneu-
monia: 2016 clinical practice guidelines by the Infectious Dis-
eases Society of America and the American Thoracic Society.
Clin Infect Dis. 2016;63(5):e61-e111. (Guideline)
3. Roch A, Thomas G, Hraiech S, et al. Hospital-acquired,
healthcare-associated and ventilator-associated pneumonia. In:
Cohen J, Powderly WG, Opal SM, eds. Infectious Diseases. 4th
ed. Elsevier; 2017:258-262. (Textbook)
4. Seymann GB, Di Francesco L, Sharpe B, et al. The HCAP gap:
differences between self-reported practice patterns and pub-
lished guidelines for health care-associated pneumonia. Clin
Infect Dis. 2009;49(12):1868-1874. (Survey; 855 participants)
5. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of
30-day readmissions after hospitalization for heart failure, acute
myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-
363. (Retrospective; 652,539 patients)
6. Aujesky D, McCausland JB, Whittle J, et al. Reasons why emer-
gency department providers do not rely on the pneumonia
severity index to determine the initial site of treatment for pa-
tients with pneumonia. Clin Infect Dis. 2009;49(10):e100-e108.
(Retrospective; 1306 patients)
7. Metlay JP, Waterer GW. Treatment of community-acquired
pneumonia during the coronavirus disease 2019 (COVID-19)
pandemic. Ann Intern Med. 2020;173(4):304-305. (Letter to
the editor)
8. Du Y, Tu L, Zhu P, et al. Clinical features of 85 fatal cases of CO-
VID-19 from Wuhan. A retrospective observational study. Am
J Respir Crit Care Med. 2020;201(11):1372-1379. (Case series;
85 patients)
9. Weinstock MB, Echenique A, Russell JW, et al. Chest x-ray
findings in 636 ambulatory patients with COVID-19 presenting
to an urgent care center: a normal chest x-ray is no guarantee.
Journal of Urgent Care Medicine. 2020;14(7):13-18. (Retro-
spective review; 636 patients)
10. Nori P, Cowman K, Chen V, et al. Bacterial and fungal coinfec-
tions in COVID-19 patients hospitalized during the New York
City pandemic surge. Infect Control Hosp Epidemiol. 2020:1-5.
(Retrospective review; 4627 patients)
11. Xu J, Murphy SL, Kochanek KD, et al. Deaths: final data for
2013. Natl Vital Stat Rep. 2016;64(2):1-119. (Review)
12.* Jain S, Self WH, Wunderink RG, et al. Community-acquired
pneumonia requiring hospitalization among U.S. adults. N Engl
J Med. 2015;373(5):415-427. (Prospective; 2400 patients)
DOI: 10.1056/NEJMoa1500245
13. Moberley SA, Holden J, Tatham DP, et al. Vaccines for prevent-
ing pneumococcal infection in adults. Cochrane Database Syst
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
Rev. 2008(1):CD000422. (Systematic review)
14. de Roux A, Marcos MA, Garcia E, et al. Viral community-ac-
quired pneumonia in nonimmunocompromised adults. Chest.
2004;125(4):1343-1351. (Prospective; 338 patients)
15. Musher DM, Roig IL, Cazares G, et al. Can an etiologic agent
be identified in adults who are hospitalized for community-
acquired pneumonia: results of a one-year study. J Infect.
2013;67(1):11-18. (Retrospective; 259 patients)
16. Alcón A, Fàbregas N, Torres A. Pathophysiology of pneumonia.
Clin Chest Med. 2005;26(1):39-46. (Review)
17. Mizgerd JP. Acute lower respiratory tract infection. N Engl J
Med. 2008;358(7):716-727. (Review)
18. Wunderink RG, Waterer GW. Community-acquired pneumonia:
pathophysiology and host factors with focus on possible new
approaches to management of lower respiratory tract infec-
tions. Infect Dis Clin North Am. 2004;18(4):743. (Review)
19. Almirall J, Bolíbar I, Balanzó X, et al. Risk factors for community-
acquired pneumonia in adults: a population-based case-control
study. Eur Respir J. 1999;13(2):349-355. (Case control study;
280 patients)
20. Gulmez SE, Holm A, Frederiksen H, et al. Use of proton pump
inhibitors and the risk of community-acquired pneumonia:
a population-based case-control study. Arch Intern Med.
2007;167(9):950-955. (Case-control study; 49,460 patients)
21.* Moore M, Stuart B, Little P, et al. Predictors of pneumonia
in lower respiratory tract infections: 3C prospective cough
complication cohort study. Eur Respir J. 2017;50(5):1700434.
(Prospective; 28,883 patients)
DOI: 10.1183/13993003.00434-2017
22. Spiteri MA, Cook DG, Clarke SW. Reliability of eliciting physical
signs in examination of the chest. Lancet 1988;1(8590):873-875.
(Prospective; 24 physicians)
23. Rosh AJ, Newman DH. Evidence-based emergency medicine/
rational clinical examination abstract. Diagnosing pneumonia
by medical history and physical examination. Ann Emerg Med.
2005;46(5):465-467. (Review)
24. Muder RR, Brennen C, Swenson DL, et al. Pneumonia in a long-
term care facility. A prospective study of outcome. Arch Intern
Med. 1996;156(20):2365-2370. (Prospective; 108 patients)
25. Gennis P, Gallagher J, Falvo C, et al. Clinical criteria for the
detection of pneumonia in adults: guidelines for ordering chest
roentgenograms in the emergency department. J Emerg Med.
1989;7(3):263-268. (Retrospective; 308 patients)
26. Metlay JP, Kapoor WN, Fine MJ. Does this patient have
community-acquired pneumonia? Diagnosing pneumonia by
history and physical examination. JAMA. 1997;278(17):1440-
1445. (Review)
27. Self WH, Courtney DM, McNaughton CD, et al. High discor-
dance of chest x-ray and computed tomography for detec-
tion of pulmonary opacities in ED patients: implications for
diagnosing pneumonia. Am J Emerg Med. 2013;31(2):401-405.
(Prospective; 3423 patients)
28. Wunderink RG, Waterer GW. Clinical practice. Community-
acquired pneumonia. N Engl J Med. 2014;370(6):543-551.
(Review)
29. Wheeler JH, Fishman EK. Computed tomography in the
management of chest infections: current status. Clin Infect Dis.
1996;23(2):232-240. (Review)
30. Hayden GE, Wrenn KW. Chest radiograph vs. computed to-
mography scan in the evaluation for pneumonia. J Emerg Med.
2009;36(3):266-270. (Retrospective; 1057 patients)
31. Bourcier J-E, Paquet J, Seinger M, et al. Performance com-
parison of lung ultrasound and chest x-ray for the diagnosis of
pneumonia in the ED. Am J Emerg Med. 2014;32(2):115-118.
(Prospective; 144 patients)
32. Chavez MA, Shams N, Ellington LE, et al. Lung ultrasound for
17 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
 Clinical Pathway for Emergency Department Management
of Community-Acquired Pneumonia

Patient presents with high probability of having CAP

Calculate PSI score; see page 9 or go to

www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap (Class I)

Score, Class Risk Disposition

≤70, class II Low Outpatient care
71-90, class III Low Outpatient versus observation admission
91-130, class IV Moderate Inpatient admission
>130, class IV High Inpatient admission

Outpatient treatment Inpatient treatment

Evaluate for CAP major/minor criteria (see Table 3, page 10)

Significant comorbidities present?
(Class II)

NO YES

0 major or <3 minor criteria 1 major or ≥3 minor criteria

Use Rx1 (see page 19) Use Rx2 (see page 19)

Admit to floor Admit to ICU

Use Rx3 pending

culture results YES Risk factors* for MRSA/ Previous MRSA/Pseudomonas Risk factors* for MRSA/
(see page 19) Pseudomonas aeruginosa? NO aeruginosa isolation? Pseudomonas aeruginosa?
NO (Class III) (Class III) (Class III)
Use Rx3
(see page 19) YES NO YES

*Risk factors include recent hospitalization with parenteral antibiotics and locally
Use Rx4 Use Rx5 Use Rx4
validated risk factors for MRSA and Pseudomonas aeruginosa.
(see page (see page (see page
Abbreviations: CAP, community-acquired pneumonia; ICU, intensive care unit; MRSA,
19) 19) 19)
methicillin-resistant Staphylococcus aureus; PSI, pneumonia severity index.

Class of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

Class I Class II
• Always acceptable, safe • Safe, acceptable Class III Indeterminate
• Definitely useful • Probably useful • May be acceptable • Continuing area of research
• Proven in both efficacy and effectiveness • Possibly useful • No recommendations until further
Level of Evidence: • Considered optional or alternative research
Level of Evidence: • Generally higher levels of evidence treatments
• One or more large prospective studies • Nonrandomized or retrospective stud- Level of Evidence:
are present (with rare exceptions) ies: historic, cohort, or case control Level of Evidence: • Evidence not available
• High-quality meta-analyses studies • Generally lower or intermediate levels • Higher studies in progress
• Study results consistently positive and • Less robust randomized controlled trials of evidence • Results inconsistent, contradictory
compelling • Results consistently positive • Case series, animal studies, • Results not compelling
consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2021 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

FEBRUARY 2021 • www.ebmedicine.net 18 ©2021 EB MEDICINE

 the diagnosis of pneumonia in adults: a systematic review and
meta-analysis. Respir Res. 2014;15(1):50. (Systematic review;
1172 patients)
33. Shaddock EJ. How and when to use common biomarkers
in community-acquired pneumonia. Pneumonia (Nathan).
2016;8:17. (Review)
34. Müller B, Harbarth S, Stolz D, et al. Diagnostic and prognostic
accuracy of clinical and laboratory parameters in community-
acquired pneumonia. BMC Infect Dis. 2007;7:10. (Prospective;
545 patients)
35. Self WH, Wunderink RG, Jain S, et al. Procalcitonin as a marker
of etiology in adults hospitalized with community-acquired
pneumonia. Clin Infect Dis. 2018;66(10):1640-1641. (Prospec-
tive; 1735 patients)
36. Schuetz P, Christ-Crain M, Thomann R, et al. Effect of procalci-
tonin-based guidelines vs standard guidelines on antibiotic use
in lower respiratory tract infections: the PROHOSP randomized
controlled trial. JAMA. 2009;302(10):1059-1066. (Prospective
randomized controlled; 1359 patients)
37. Huang DT, Yealy DM, Filbin MR, et al. Procalcitonin-guided
use of antibiotics for lower respiratory tract infection. N Engl J
Med. 2018;379(3):236-249. (Prospective randomized; 1656
patients)
38.* Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treat-
Antibiotic Regimens for Community-Acquired Pneumonia38
Rx 1:
• Amoxicillin 1 g orally 3 times daily (Class II) or
• Doxycycline 100 mg orally 2 times daily (Class III) or
• A macrolide (azithromycin 500 mg orally on the first day, then
250 mg orally daily; or clarithromycin 500 mg orally 2 times daily or
clarithromycin extended release 1000 mg orally daily) only in areas
with pneumococcal resistance to macrolides <25% (Class II)
Rx 2:
1. Combination therapy (oral) (Class III)
• Amoxicillin/clavulanate:
l 500 mg/125 mg 3 times daily  OR
l 875 mg/125 mg 2 times daily  2. Monotherapy with a respiratory fluoroquinolone (Class I)
l 2000 mg/125 mg 2 times daily
or
• Cephalosporin (cefpodoxime 200 mg 2 times daily or
cefuroxime 500 mg 2 times daily)
PLUS
• One of 2 macrolides  l Vancomycin 15 mg/kg every 12 hours, adjust based on levels
l Azithromycin 500 mg on the first day then 250 mg daily or
l Clarithromycin 500 mg 2 times daily or extended release
1000 mg 1 time daily
OR
2. Respiratory fluoroquinolone (oral) (Class II)
• Levofloxacin 750 mg daily
• Moxifloxacin 400 mg daily  l Meropenem 1 g every 8 hours
• Gemifloxacin 320 mg daily
For class of evidence definitions, see page 18.
Abbreviations: IV, intravenous; MRSA, methicillin-resistant
Staphylococcus aureus.
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
ment of adults with community-acquired pneumonia. An official
clinical practice guideline of the American Thoracic Society and
Infectious Diseases Society of America. Am J Respir Crit Care
Med. 2019;200(7):e45-e67. (Guideline)
DOI: 10.1164/rccm.201908-1581ST
39. Foshaug M, Vandbakk-Rüther M, Skaare D, et al. Mycoplasma
pneumoniae detection causes excess antibiotic use in norwe-
gian general practice: a retrospective case-control study. Br J
Gen Pract. 2015;65(631):e82-e88. (Retrospective case control;
414 patients)
40. Falguera M, Ruiz-González A, Schoenenberger JA, et al.
Prospective, randomised study to compare empirical treatment
versus targeted treatment on the basis of the urine antigen
results in hospitalised patients with community-acquired pneu-
monia. Thorax. 2010;65(2):101-106. (Prospective randomized;
194 patients)
41. Kennedy M, Bates DW, Wright SB, et al. Do emergency depart-
ment blood cultures change practice in patients with pneumo-
nia? Ann Emerg Med. 2005;46(5):393-400. (Prospective; 3926
patients)
42. Benenson RS, Kepner AM, Pyle DN 2nd, et al. Selective use of
blood cultures in emergency department pneumonia patients.
J Emerg Med. 2007;33(1):1-8. (Retrospective; 684 patients)
43. Musher DM, Montoya R, Wanahita A. Diagnostic value of
Rx 3:
1. Combination therapy (Class I)
• One of the following beta-lactams (IV)
l Ampicillin + sulbactam 1.5-3 g every 6 hours
l Cefotaxime 1-2 g every 8 hours
l Ceftriaxone 1-2 g daily
l Ceftaroline 600 mg every 12 hours
PLUS
• Macrolide
l Azithromycin 500 mg orally or IV daily
l Clarithromycin 500 mg orally 2 times daily
• Levofloxacin 750 mg orally or IV daily
• Moxifloxacin 400 mg orally or IV daily
Rx 4:
• Previous MRSA isolation (Class I)
l Linezolid 600 mg every 12 hours
• Previous evidence of Pseudomonas aeruginosa (Class I)
l Piperacillin-tazobactam 4.5 g every 6 hours
l Cefepime 2 g every 8 hours
l Ceftazidime 2 g every 8 hours
l Imipenem 500 mg every 6 hours
l Aztreonam 2 g every 8 hours
Rx 5:
1. Combination therapy (Class II)
• One of the following beta-lactams (IV)
l Ampicillin + sulbactam 1.5-3 g every 6 hours 
l Cefotaxime 1-2 g every 8 hours 
l Ceftriaxone 1-2 g daily 
l Ceftaroline 600 mg every 12 hours 
PLUS
• Azithromycin 500 mg IV daily
OR
2. Beta-lactam plus 1 of 2 respiratory fluoroquinolones (IV) (Class II)
• Levofloxacin 750 mg daily
• Moxifloxacin 400 mg daily
19 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
 microscopic examination of gram-stained sputum and sputum
cultures in patients with bacteremic pneumococcal pneumo-
nia. Clin Infect Dis. 2004;39(2):165-169. (Retrospective; 105
patients)
44. Ewig S, Schlochtermeier M, Göke N, et al. Applying sputum as
a diagnostic tool in pneumonia: limited yield, minimal impact
on treatment decisions. Chest. 2002;121(5):1486-1492. (Pro-
spective; 116 patients)
45. May L, Tatro G, Poltavskiy E, et al. Rapid multiplex testing
for upper respiratory pathogens in the emergency depart-
ment: a randomized controlled trial. Open Forum Infect Dis.
2019;6(12):ofz481. (Prospective randomized controlled trial;
191 patients)
46. Lim WS, van der Eerden MM, Laing R, et al. Defining commu-
nity acquired pneumonia severity on presentation to hospi-
tal: an international derivation and validation study. Thorax.
2003;58(5):377-382. (Review; 1068 patients)
47.* Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify
low-risk patients with community-acquired pneumonia. N Engl
J Med. 1997;336(4):243-250. (Retrospective; 14,199 patients)
DOI: 10.1056/NEJM199701233360402
48. Ravindranath M, Raju C. Validity of pneumonia severity index/
pneumonia outcome research trial and CURB-65 sever-
ity scoring systems in community acquired pneumonia in
Indian setting. International Journal of Advances in Medicine.
2017;3(2):338-334. (Prospective; 150 patients)
49. Aujesky D, Auble TE, Yealy DM, et al. Prospective comparison
of three validated prediction rules for prognosis in community-
acquired pneumonia. Am J Med. 2005;118(4):384-392. (Pro-
spective; 3181 patients)
50. Carratalà J, Fernández-Sabé N, Ortega L, et al. Outpatient care
compared with hospitalization for community-acquired pneu-
monia: a randomized trial in low-risk patients. Ann Intern Med.
2005;142(3):165-172. (Prospective; 224 patients)
51. Fernando SM, Rochwerg B, Reardon PM, et al. Emergency
department disposition decisions and associated mortality
and costs in ICU patients with suspected infection. Crit Care.
2018;22(1):172-172. (Prospective; 657 patients)
52. Charles PGP, Wolfe R, Whitby M, et al. SMART-COP: a tool for
predicting the need for intensive respiratory or vasopressor
support in community-acquired pneumonia. Clin Infect Dis.
2008;47(3):375-384. (Prospective; 862 patients)
53. Marti C, Garin N, Grosgurin O, et al. Prediction of severe
community-acquired pneumonia: a systematic review and
meta-analysis. Crit Care. 2012;16(4):R141. (Meta-analysis)
54. Brown SM, Jones BE, Jephson AR, et al. Validation of the Infec-
tious Disease Society of America/American Thoracic Society
2007 guidelines for severe community-acquired pneumonia.
Crit Care Med. 2009;37(12):3010-3016. (Retrospective; 2413
patients)
55. Chalmers JD, Mandal P, Singanayagam A, et al. Severity as-
sessment tools to guide ICU admission in community-acquired
pneumonia: systematic review and meta-analysis. Intensive
Care Med. 2011;37(9):1409-1420. (Review)
56. Webb BJ, Dascomb K, Stenehjem E, et al. Derivation and
multicenter validation of the drug resistance in pneumonia
clinical prediction score. Antimicrob Agents Chemother.
2016;60(5):2652-2663. (Retrospective; 200 patients)
57. Webb BJ, Sorensen J, Mecham I, et al. Antibiotic use and
outcomes after implementation of the drug resistance in pneu-
monia score in ED patients with community-onset pneumonia.
Chest. 2019;156(5):843-851. (Retrospective; 2169 patients)
58. Sligl WI, Asadi L, Eurich DT, et al. Macrolides and mortality
in critically ill patients with community-acquired pneumo-
nia: a systematic review and meta-analysis. Crit Care Med.
2014;42(2):420-432. (Systematic review; 9850 patients)
FEBRUARY 2021 • www.ebmedicine.net 20
59.* Pakhale S, Mulpuru S, Verheij TJM, et al. Antibiotics for
community-acquired pneumonia in adult outpatients. Cochrane
Database Syst Rev. 2014(10):CD002109. (Cochrane review; 11
randomized controlled trials, 3352 participants)
DOI: 10.1002/14651858.CD002109.pub4
60. Kim L, McGee L, Tomczyk S, et al. Biological and epidemiologi-
cal features of antibiotic-resistant Streptococcus pneumoniae in
pre- and post-conjugate vaccine eras: a United States perspec-
tive. Clin Microbiol Rev. 2016;29(3):525-552. (Review)
61. Petitpretz P, Arvis P, Marel M, et al. Oral moxifloxacin vs high-
dosage amoxicillin in the treatment of mild-to-moderate,
community-acquired, suspected pneumococcal pneumonia in
adults. Chest. 2001;119(1):185-195. (Prospective; 411 patients)
62. Hagberg L, Torres A, van Rensburg D, et al. Efficacy and toler-
ability of once-daily telithromycin compared with high-dose
amoxicillin for treatment of community-acquired pneumonia.
Infection. 2002;30(6):378-386. (Prospective; 404 patients)
63. Mokabberi R, Haftbaradaran A, Ravakhah K. Doxycycline vs.
levofloxacin in the treatment of community-acquired pneumo-
nia. J Clin Pharm Ther. 2010;35(2):195-200. (Prospective; 65
patients)
64. Dunbar LM, Wunderink RG, Habib MP, et al. High-dose, short-
course levofloxacin for community-acquired pneumonia: a
new treatment paradigm. Clin Infect Dis. 2003;37(6):752-760.
(Multicenter randomized; 390 patients)
65. Tansarli GS, Mylonakis E. Systematic review and meta-analysis of
the efficacy of short-course antibiotic treatments for community-
acquired pneumonia in adults. Antimicrob Agents Chemother.
2018;62(9):e00635-00618. (Prospective; 390 patients)
66. Irwin RS, Curley FJ, French CL. Chronic cough. The spectrum
and frequency of causes, key components of the diagnostic
evaluation, and outcome of specific therapy. Am Rev Respir
Dis. 1990;141(3):640-647. (Prospective; 102 patients)
67. Yancy WS Jr, McCrory DC, Coeytaux RR, et al. Efficacy and
tolerability of treatments for chronic cough: a systematic review
and meta-analysis. Chest. 2013;144(6):1827-1838. (Systematic
review; 3607 patients)
68. Boulet LP, Milot J, Boutet M, et al. Airway inflammation in non-
asthmatic subjects with chronic cough. Am J Respir Crit Care
Med. 1994;149(2 Pt 1):482-489. (Prospective; 29 patients)
69. Shah SN, Bachur RG, Simel DL, et al. Does this child have
pneumonia?: the rational clinical examination systematic review.
JAMA. 2017;318(5):462-471. (Review)
70. Berg AS, Inchley CS, Fjaerli HO, et al. Assessing severity
in pediatric pneumonia: predictors of the need for major
medical interventions. Pediatr Emerg Care. 2017:10.1097/
PEC.0000000000001179. (Prospective; 659 patients)
71. Esposito S. Management of community-acquired pneumonia
in infants and children older than 3 months. Clin Infect Dis.
2012;54(6):884-885. (Guideline)
72. Chalmers JD, Rother C, Salih W, et al. Healthcare-associated
pneumonia does not accurately identify potentially resistant
pathogens: a systematic review and meta-analysis. Clin Infect
Dis. 2014;58(3):330-339. (Review)
73. Stern A, Skalsky K, Avni T, et al. Corticosteroids for pneumo-
nia. Cochrane Database Syst Rev. 2017;12(12):CD007720-
CD007720. (Cochrane review)
74. Waljee AK, Rogers MAM, Lin P, et al. Short term use of oral
corticosteroids and related harms among adults in the United
States: population based cohort study. BMJ. 2017;357:j1415-
j1415. (Retrospective)
75. Walker G. Corticosteroids for treating pneumonia. The NNT
2019; https://www.thennt.com/nnt/corticosteroids-treating-
pneumonia. Accessed December 9, 2019. (Website)
76. Lee N, Choi KW, Chan PKS, et al. Outcomes of adults hos-
pitalised with severe influenza. Thorax. 2010;65(6):510-515.
©2021 EB MEDICINE
 (Prospective; 754 patients)
77. Dobson J, Whitley RJ, Pocock S, et al. Oseltamivir treatment for
influenza in adults: a meta-analysis of randomised controlled
trials. Lancet. 2015;385(9979):1729-1737. (Meta-analysis; 4328
patients)
78. Uyeki TM, Bernstein HH, Bradley JS, et al. Clinical practice
guidelines by the Infectious Diseases Society of America: 2018
update on diagnosis, treatment, chemoprophylaxis, and institu-
tional outbreak management of seasonal influenzaa. Clin Infect
Dis. 2019;68(6):895-902. (Guideline)
79. Rezaie S. The Tamiflu debacle. REBEL EM - Emergency Medi-
cine Blog 2019; https://rebelem.com/the-tamiflu-debacle/.
Accessed January 10, 2021. (Website)
80. Jefferson T, Jones M, Doshi P, et al. Neuraminidase inhibitors
for preventing and treating influenza in healthy adults: system-
atic review and meta-analysis. BMJ. 2009;339:b5106. (System-
atic review and meta-analysis; 20 trials)
81. Stets R, Popescu M, Gonong JR, et al. Omadacycline for
community-acquired bacterial pneumonia. N Engl J Med.
2019;380(6):517-527. (Randomized controlled trial; 774
patients)
82. File TM, Goldberg L, Das A, et al. Erratum to: efficacy and safe-
ty of intravenous-to-oral lefamulin, a pleuromutilin antibiotic, for
the treatment of community-acquired bacterial pneumonia: the
phase III Lefamulin Evaluation Against Pneumonia (LEAP 1) trial.
Clin Infect Dis. 2020;70(11):2459. (Prospective randomized
controlled trial; 551 patients)
83. File TM Jr, Segreti J, Dunbar L, et al. A multicenter, randomized
study comparing the efficacy and safety of intravenous and/or
oral levofloxacin versus ceftriaxone and/or cefuroxime axetil in
treatment of adults with community-acquired pneumonia. An-
timicrob Agents Chemother. 1997;41(9):1965-1972. (Prospec-
tive; 590 patients)
84. Pasternak B, Inghammar M, Svanström H. Fluoroquinolone
use and risk of aortic aneurysm and dissection: Nationwide
cohort study. BMJ. 2018;360:k678. (Historical cohort; 360,088
patients)
n CME Questions
Current subscribers receive CME credit
absolutely free by completing the
following test. Each issue includes 4 AMA
PRA Category 1 CreditsTM, 4 ACEP
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credits, or 4 AOA Category 2-A or 2-B credits.
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1. The most commonly identified bacterial cause
of CAP in the United States is:
a. Staphylococcus aureus
b. Streptococcus pneumoniae
c. Pseudomonas aeruginosa
d. Haemophilus influenzae
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
2. Which of the following statements regarding
mycoplasma pneumonia is TRUE?
a. Mycoplasma pneumoniae accounts for
approximately 50% of cases of pediatric CAP.
b. Cases of mycoplasma pneumonia typically
occur during summer months.
c. IgM and IgG antibody titers are helpful in
making a definitive diagnosis of mycoplasma
pneumonia.
d. Mycoplasma pneumonia typically has a
benign disease course and rarely results in
hospitalization or significant morbidity.
3. Urine antigen testing is indicated in which of
the following patients?
a. 60-year-old man with recent foreign travel
history and CAP
b. 34-year-old woman with possible exposure to
Legionella
c. 77-year-old man with severe CAP being
admitted to the ICU
d. 19-year-old man with HIV and CAP
4. Blood cultures should be obtained in which of
the following patients?
a. 22-year-old woman with diabetes being
treated as an outpatient for CAP
b. 80-year-old woman who is in an assisted
living facility
c. 40-year-old man who has received IV
antibiotics within the past 90 days
d. 60-year-old man being admitted for non-
severe CAP
5. 2019 ATS/IDSA guidelines support routine
testing for which viral pathogen in patients
with possible CAP?
a. Influenza
b. Rhinovirus
c. Adenovirus
d. Coronavirus
6. Which of the following clinical scoring systems
should be used to risk stratify patients with
CAP to determine the need for admission
versus outpatient management?
a. SMART-COP
b. Pneumonia severity index (PSI)
c. qSOFA
d. ATS/IDSA major/minor criteria
7. Which tool can be used to identify patients
who may need to be admitted to an ICU?
a. PSI
b. SIRS criteria
c. CURB-65
d. ATS/IDSA major/minor criteria
21 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
8. In an otherwise healthy adult male with CAP,
no comorbidities, and without risk factors
for drug-resistant organisms, which antibiotic
regimen would be the most appropriate initial
treatment, according to the 2019 ATS/IDSA
guidelines?
a. Amoxicillin 1 g 3 times daily for 5 days
b. Amoxicillin/clavulanate 875 mg/125 mg twice
daily for 10 days
c. Levofloxacin 750 mg daily for 7 days
d. Azithromycin 500 mg on the first day, then
250 mg daily
9. The IDSA recommends hospitalization for
pediatric patients with CAP and which of the
following findings?
a. Children and infants who have moderate to
severe CAP, as defined by several factors,
including respiratory distress and hypoxemia
b. Infants aged <3 to 6 months
c. The presence of a pathogen with increased
virulence, such as Staphylococcus aureus
d. All of the above
10. Corticosteroids should be used routinely in
which of the following cases?
a. Outpatient CAP in an otherwise healthy
patient
b. Inpatient CAP in patients with risk for drug-
resistant pathogens
c. ICU management of CAP with refractory
septic shock
d. Outpatient management of CAP with influenza
Stay up-to-date on the most relevant
topics in emergency medicine with EMplify
at www.ebmedicine.net/podcast.
FEBRUARY 2021 • www.ebmedicine.net 22
CME Information
Date of Original Release: February 1, 2021. Date of
most recent review: January 10, 2021. Termination date:
February 1, 2024.
Accreditation: EB Medicine is accredited by the
Accreditation Council for Continuing Medical Education (ACCME) to
provide continuing medical education for physicians. This activity has
been planned and implemented in accordance with the accreditation
requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a
maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim
only the credit commensurate with the extent of their participation in the
activity.
Specialty CME: Included as part of the 4 credits, this CME activity is
eligible for 4 Infectious Disease CME credits.
ACEP Accreditation: Emergency Medicine Practice is approved by
the American College of Emergency Physicians for 48 hours of ACEP
Category I credit per annual subscription.
AAFP Accreditation: This Enduring Material activity, Emergency
Medicine Practice, has been reviewed and is acceptable for credit by
the American Academy of Family Physicians. Term of approval begins
07/01/2020. Term of approval is for one year from this date. Physicians
should claim only the credit commensurate with the extent of their par-
ticipation in the activity. Approved for 4 AAFP Prescribed credits..
AOA Accreditation: Emergency Medicine Practice is eligible for 4
Category 2-A or 2-B credit hours per issue by the American Osteopathic
Association.
Needs Assessment: The need for this educational activity was determined
by a survey of medical staff, including the editorial board of this publica-
tion; review of morbidity and mortality data from the CDC, AHA, NCHS,
an ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency
medicine physicians, physician assistants, nurse practitioners, and
residents.
Goals: Upon completion of this activity, you should be able to: (1)
demonstrate medical decision-making based on the strongest clinical
evidence; (2) cost-effectively diagnose and treat the most critical ED
presentations; and (3) describe the most common medicolegal pitfalls
for each topic covered.
CME Objectives: Upon completion of this activity, you should be able
to: (1) develop an evidence-based approach to risk stratifying patients
with community-acquired pneumonia (CAP); (2) order appropriate imag-
ing and laboratory testing of patients with CAP, based on clinical utility;
(3) prescribe the safest and most effective antibiotic regimens, inpatient
and outpatient, for patients with CAP; and (4) evaluate the evidence be-
hind adjunctive therapy and medications that can be used to treat CAP.
Discussion of Investigational Information: As part of the journal, faculty
may be presenting investigational information about pharmaceutical
products that is outside Food and Drug Administration approved label-
ing. Information presented as part of this activity is intended solely as
continuing medical education and is not intended to promote off-label
use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity,
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activities. All faculty participating in the planning or implementation of
a CME activity are expected to disclose to the participants any relevant
financial relationships and to assist in resolving any conflict of interest
that may arise from the relationship. In compliance with all ACCME
accreditation requirements and policies, all faculty for this CME activ-
ity were asked to complete a full financial disclosure statement. The
information received is as follows: Dr. DeLaney, Dr. Khoury, Dr. Egan,
Dr. Renne, Dr. Toscano, Dr. Mishler, Dr. Jagoda, and their related par-
ties report no significant financial interest or other relationship with
the manufacturer(s) of any commercial product(s) discussed in this
educational presentation.
Commercial Support: This issue of Emergency Medicine Practice did
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CME Answer And Evaluation Form with your June and December issues
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©2021 EB MEDICINE
The Emergency Medicine Practice Editorial Board
EDITOR-IN-CHIEF
Andy Jagoda, MD, FACEP
Professor and Chair Emeritus, Department
of Emergency Medicine; Director, Center
for Emergency Medicine Education and
Research, Icahn School of Medicine at
Mount Sinai, New York, NY
ASSOCIATE EDITOR-IN-CHIEF
Kaushal Shah, MD, FACEP
Vice Chair for Education, Department of
Emergency Medicine, Weill Cornell School
of Medicine, New York, NY
EDITORIAL BOARD
Saadia Akhtar, MD, FACEP
Associate Professor, Department of
Emergency Medicine, Associate Dean for
Graduate Medical Education, Program
Director, Emergency Medicine Residency,
Mount Sinai Beth Israel, New York, NY
William J. Brady, MD
Professor of Emergency Medicine and
Medicine; Medical Director, Emergency
Management, UVA Medical Center;
Operational Medical Director, Albemarle
County Fire Rescue, Charlottesville, VA
Calvin A. Brown III, MD
Director of Physician Compliance,
Credentialing and Urgent Care Services,
Department of Emergency Medicine,
Brigham and Women's Hospital, Boston,
MA
Peter DeBlieux, MD Emergency Medicine, Harvard Medical
Professor of Clinical Medicine, Louisiana
State University School of Medicine; Chief
Experience Officer, University Medical
Center, New Orleans, LA
Deborah Diercks, MD, MS, FACEP,
FACC
Professor and Chair, Department of
Emergency Medicine, University of Texas
Southwestern Medical Center, Dallas, TX
Daniel J. Egan, MD
Harvard University Affiliated Emergency
Medicine Residency, Massachusetts General
Hospital/Brigham and Women's Hospital,
Boston, MA
Marie-Carmelle Elie, MD
Associate Professor, Department of
Emergency Medicine & Critical Care
Medicine, University of Florida College of
Medicine, Gainesville, FL
Nicholas Genes, MD, PhD
Associate Professor, Department of
Emergency Medicine, Icahn School of
Medicine at Mount Sinai, New York, NY
Michael A. Gibbs, MD, FACEP
Professor and Chair, Department of
Emergency Medicine, Carolinas Medical
Center, University of North Carolina School
of Medicine, Chapel Hill, NC
Steven A. Godwin, MD, FACEP
Professor and Chair, Department of
Emergency Medicine, Assistant Dean,
Simulation Education, University of Florida
COM-Jacksonville, Jacksonville, FL
Joseph Habboushe, MD MBA
Assistant Professor of Emergency Medicine,
NYU/Langone and Bellevue Medical
Centers, New York, NY; CEO, MD Aware
LLC
Eric Legome, MD
Chair, Emergency Medicine, Mount Sinai
West & Mount Sinai St. Luke's; Vice Chair,
Academic Affairs for Emergency Medicine,
Mount Sinai Health System, Icahn School of
Medicine at Mount Sinai, New York, NY
Keith A. Marill, MD, MS
Associate Professor, Department of
School, Massachusetts General Hospital,
Boston, MA
Angela M. Mills, MD, FACEP
Professor and Chair, Department of
Emergency Medicine, Columbia University
Vagelos College of Physicians & Surgeons,
New York, NY
Charles V. Pollack Jr., MA, MD,
FACEP, FAAEM, FAHA, FACC, FESC
Clinician-Scientist, Department of
Emergency Medicine, University of
Mississippi School of Medicine, Jackson MS
Ali S. Raja, MD, MBA, MPH
Executive Vice Chair, Emergency Medicine,
Massachusetts General Hospital; Associate
Professor of Emergency Medicine and
Radiology, Harvard Medical School, Boston,
MA
Robert L. Rogers, MD, FACEP,
FAAEM, FACP
Assistant Professor of Emergency Medicine,
The University of Maryland School of
Medicine, Baltimore, MD
Alfred Sacchetti, MD, FACEP
Assistant Clinical Professor, Department of
Emergency Medicine, Thomas Jefferson
University, Philadelphia, PA
Robert Schiller, MD
Chair, Department of Family Medicine,
Beth Israel Medical Center; Senior Faculty,
Family Medicine and Community Health,
Icahn School of Medicine at Mount Sinai,
New York, NY
Scott Silvers, MD, FACEP
Associate Professor of Emergency Medicine,
Chair of Facilities and Planning, Mayo Clinic,
Jacksonville, FL
Corey M. Slovis, MD, FACP, FACEP
Professor and Chair, Department of
Emergency Medicine, Vanderbilt University
Medical Center, Nashville, TN
Ron M. Walls, MD
Professor and COO, Department of
Emergency Medicine, Brigham and
Women's Hospital, Harvard Medical School,
Boston, MA
CRITICAL CARE EDITORS
William A. Knight IV, MD, FACEP,
FNCS
Associate Professor of Emergency Medicine
and Neurosurgery, Medical Director, EM
Advanced Practice Provider Program;
Associate Medical Director, Neuroscience
ICU, University of Cincinnati, Cincinnati, OH
Scott D. Weingart, MD, FCCM
Professor of Emergency Medicine; Chief,
EM Critical Care, Stony Brook Medicine,
Stony Brook, NY
RESEARCH EDITORS
Aimee Mishler, PharmD, BCPS
Emergency Medicine Pharmacist, Program
Director, PGY2 EM Pharmacy Residency,
Valleywise Health, Phoenix, AZ
Joseph D. Toscano, MD
Chief, Department of Emergency Medicine,
San Ramon Regional Medical Center, San
Ramon, CA
INTERNATIONAL EDITORS
Peter Cameron, MD
Academic Director, The Alfred Emergency
and Trauma Centre, Monash University,
Melbourne, Australia
Andrea Duca, MD
Attending Emergency Physician, Ospedale
Papa Giovanni XXIII, Bergamo, Italy
Suzanne Y.G. Peeters, MD
Attending Emergency Physician, Flevo
Teaching Hospital, Almere, The Netherlands
Edgardo Menendez, MD, FIFEM
Professor in Medicine and Emergency
Medicine; Director of EM, Churruca Hospital
of Buenos Aires University, Buenos Aires,
Argentina
Dhanadol Rojanasarntikul, MD
Attending Physician, Emergency Medicine,
King Chulalongkorn Memorial Hospital;
Faculty of Medicine, Chulalongkorn
University, Thailand
Stephen H. Thomas, MD, MPH
Professor & Chair, Emergency Medicine,
Hamad Medical Corp., Weill Cornell
Medical College, Qatar; Emergency
Physician-in-Chief, Hamad General Hospital,
Doha, Qatar
Edin Zelihic, MD
Head, Department of Emergency Medicine,
Leopoldina Hospital, Schweinfurt, Germany

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 Points & Pearls
QUICK READ
FEBRUARY 2021 | VOLUME 23 | ISSUE 2
Points
• CAP is an acute infection of the lung parenchyma
in patients who have not been hospitalized or
had recent exposure to the healthcare system.
• Though the most commonly identified pathogen
in CAP is Streptococcus pneumoniae, it is respon-
sible for only 10% to 15% of hospitalized cases.
• High-risk CAP mimics include congestive heart
failure exacerbation, acute coronary syndromes,
pulmonary embolism, neoplastic lesions, and pul-
monary abscess/empyema.
• Identification of sepsis related to pneumonia is
imperative and includes an assessment of the
patient’s vital signs and the clinical signs and
symptoms of severe sepsis and septic shock.
• The most frequently reported symptom in
patients with CAP is cough, observed in 80% to
90% of patients. Antitussives are not very effec-
tive, and patients should be counseled on the
risks of opioid agents and assured that the cough
will improve as the pneumonia resolves.
• The clinical utility of biomarkers in the workup
of CAP remains unclear. When used to identify
patients with CAP, PCT and CRP were more accu-
rate than physical examination features but were
not statistically superior to WBC.34
• Blood cultures have a limited role in the diag-
nosis and treatment of CAP; however, as with
antigen testing, they are still recommended for
hospitalized patients with CAP and those with
MRSA/P aeruginosa isolates or risk factors.
• In general, for the vast majority of patients with
CAP in the ED, there is almost no role for routine
sputum cultures44 except in cases of severe CAP
and in patients where there is concern for MRSA
or P aeruginosa.
• Determine the severity of CAP with the CURB-65
or PSI score. (See Table 1 and Figure 1.) Both
have reliable sensitivity in identifying high-risk
patients, but CURB-65 is more specific.48
• The key to risk stratification is to first consider
the decision to admit or discharge, and then to
consider ICU admission.
FEBRUARY 2021 • www.ebmedicine.net 24
Community-Acquired
Pneumonia in the
Emergency Department
Pearls
• Elderly patients are more likely to present
with atypical symptoms, including altered
mental status and fatigue.
• Chest x-ray cannot exclude the diagnosis
of CAP, but it can point the clinician to
other disease processes, such as heart
failure, malignancy, effusion, and pulmonary
infarction.
• Rather than empirically ordering blood
cultures on all patients with CAP, first risk-
stratify patients for the potential for drug-
resistant pathogens.38
• Risk stratification tools such as CURB-65,
SMART-COP, and the IDSA/ATS criteria for
severe CAP can help determine the patient's
disposition to discharge, floor admission,
or ICU admission; these determinations will
guide antibiotic therapy.
• Appropriate disposition to the ICU from the
ED has been shown to improve mortality
and lower overall costs.54
• For patients with nonsevere CAP, determine
whether the patient has risk factors for MRSA or
P aeruginosa or there is a history of MRSA or P
aeruginosa isolation; these factors will determine
the need for blood and sputum cultures and will
dictate antibiotics regimens. (See the Clinical
Pathway.)
• Patients with severe CAP should be given em-
piric coverage for MRSA/P aeruginosa pending
culture results.
• The 2019 ATS/IDSA guidelines recommend use
of corticosteroids in CAP patients with refractory
septic shock only.38
• In the era of COVID-19, the presence of the
COVID-19 virus in patients with suspected CAP
must be considered, but there are no historical
or physical examination findings that can reliably
differentiate between the two.
©2021 EB MEDICINE
 Calculated
Decisions
Clinical Decision Support for Emergency Medicine Practice Subscribers
CURB-65 Score for Pneumonia
Severity
The CURB-65 score estimates mortality risk for community-
acquired pneumonia and helps guide inpatient versus
Click the thumbnail
to access the calculator.
outpatient treatment decisions.
 About the Score
The CURB-65 score can be used in the emergency
department setting to risk stratify patients who pres-
ent with community-acquired pneumonia (CAP). The
score can be computed quickly, uses patient infor-
mation that is often already available, and provides
an excellent risk stratification for CAP. It can also
help to facilitate better utilization of resources and
treatment initiation.
The CURB-65 score does not assign points
for comorbid illness and nursing home residence,
because the original study accounted for many of
those conditions. The score includes points for con-
fusion and blood urea nitrogen levels, which could
be attributable to a variety of factors in an acutely ill
elderly patient. The CURB-65 score may not iden-
tify patients requiring intensive care unit admission
as well as the pneumonia severity index (PSI). The
CURB-65 score offers equal sensitivity of mortality
prediction due to CAP as compared with the PSI.
Notably, CURB-65 has a higher specificity (74.6%)
than the PSI (52.2%). For patients scoring high on
CURB-65, it is prudent to ensure initial triage has
not missed the presence of sepsis. Evaluation for
systemic inflammatory response syndrome criteria
would be beneficial for these patients.
While pneumonia is often viral in nature, typical
practice is to provide a course of antibiotics because
CALCULATOR REVIEW AUTHOR
Sagar Patel, MD
Huntsman Cancer Institute, Blood and Marrow
Transplantation, University of Utah, Salt Lake City, UT
FEBRUARY 2021 • www.ebmedicine.net 1
POWERED BY
the pneumonia could be bacterial. Disposition
(inpatient vs outpatient) often dictates further care
and management, including laboratory testing and
blood cultures.
 Evidence Appraisal
The original CURB-65 study was a retrospective
review of 3 prospective studies from the United
Kingdom, New Zealand, and the Netherlands,
including a total of 1068 patients. The 5-point score
was developed to stratify CAP patients into differ-
ent treatment groups, using confusion, blood urea
nitrogen level, respiratory rate, blood pressure, and
age as the score components. The study included
comorbidity variables such as chronic lung dis-
ease, chronic liver disease, congestive heart failure,
cardiovascular disease, and diabetes mellitus, and
controlled for these variables when developing the
relevant risk-stratification criteria.
The initial validation study was conducted in
India and included 150 patients. More recent vali-
dation studies conducted in other countries have
shown increasing mortality and need for intubation
with increasing CURB-65 scores, at rates ranging
from 0% to 1.1% for a score of 0 and from 17% to
60% for a score of 5. When combined, these studies
included more >3100 patients.
 Use the Calculator Now
Access the CURB-65 Score on MDCalc.
 Calculator Creator
John Macfarlane, MD
Read more about Dr. Macfarlane.
©2021 EB MEDICINE
 References
Original/Primary Reference
• Lim WS, van der Eerden MM, Laing R, et al. Defining com-
munity acquired pneumonia severity on presentation to
hospital: an international derivation and validation study.
Thorax. 2003;58(5):377-382. DOI: 10.1136/thorax.58.5.377
Validation References
• Shah BA, Ahmed W, Dhobi GN, et al. Validity of pneumo-
nia severity index and CURB-65 severity scoring systems in
community acquired pneumonia in an Indian setting. Indian
J Chest Dis Allied Sci. 2010;52(1):9-17. PMID: 20364609
• Aujesky D, Auble TE, Yealy DM, et al. Prospective comparison
of three validated prediction rules for prognosis in communi-
PSI/PORT Score: Pneumonia
Severity Index for Community-
Acquired Pneumonia
Click the thumbnail
The PSI/PORT score estimates mortality for adult patients with
to access the calculator. community-acquired pneumonia.
 About the Score
The pneumonia severity index (PSI), or pneumonia
Patient Outcomes Research Team (PORT) score, can
be used in the emergency department setting to
risk stratify patients who present with community-
acquired pneumonia. In most situations, however,
the CURB-65 score is easier to use and requires
fewer inputs.
Because the PSI assigns points by absolute
age, it may underestimate severe pneumonia in an
otherwise healthy young patient. Patients aged >50
years are automatically classified as risk class 2, even
if they have no additional risk criteria.
It is recommended that clinicians consider
sepsis in patients with pneumonia. The PSI was
developed prior to aggressive sepsis screening with
lactate testing. For patients scoring high on the PSI,
it would be prudent to ensure that initial triage has
not missed the presence of sepsis. Evaluation for
systemic inflammatory response syndrome criteria
would be beneficial for these patients.
Clinicians should assess potential barriers to
treatment such as vomiting, alcohol or drug use,
psychosocial conditions, or cognitive impairments,
CALCULATOR REVIEW AUTHOR
Sagar Patel, MD
Huntsman Cancer Institute, Blood and Marrow
Transplantation, University of Utah, Salt Lake City, UT
FEBRUARY 2021 • www.ebmedicine.net 2
ty-acquired pneumonia. Am J Med. 2005;118(4):384-392.
DOI: 10.1016/j.amjmed.2005.01.006
• Myint PK, Kamath AV, Vowler SL, et al. Severity assessment
criteria recommended by the British Thoracic Society (BTS)
for community-acquired pneumonia (CAP) and older pa-
tients. Should SOAR (systolic blood pressure, oxygenation,
age and respiratory rate) criteria be used in older people? A
compilation study of two prospective cohorts. Age Ageing.
2006;35(3):286-291. DOI: 10.1093/ageing/afj081
• Capelastegui A, España PP, Quintana JM, et al. Validation
of a predictive rule for the management of community-
acquired pneumonia. Eur Respir J. 2006;27(1):151-157.
DOI: 10.1183/09031936.06.00062505
even if a patient is categorized by PSI as appropri-
ate for outpatient treatment.
While pneumonia is often viral in nature, typical
practice is to provide a course of antibiotics because
the pneumonia could be bacterial. Disposition
(inpatient vs outpatient) often dictates further care
and management, including laboratory testing and
blood cultures.
 Evidence Appraisal
The original PSI study created a 5-tier risk stratifica-
tion based on 14,199 inpatients with community-
acquired pneumonia. Subsequent studies validated
the PSI on 38,039 inpatients, and then on an
additional 2287 inpatients and outpatients. The PSI
assigns points based on age, comorbid disease,
abnormal physical findings, and abnormal labora-
tory test results.
The PSI and the CURB-65 score offer equal
sensitivity for mortality prediction in community-
acquired pneumonia, but the CURB-65 score has a
higher specificity (74.6%) than the PSI (52.2%). How-
ever, the CURB-65 score had a lower sensitivity than
the PSI for predicting intensive care unit admission.
 Use the Calculator Now
Access the PSI/PORT Score on MDCalc.
 Calculator Creator
Michael J. Fine, MD, MSc
Read more about Dr. Fine.
©2021 EB MEDICINE

 References
Original/Primary Reference
• Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to
identify low-risk patients with community-acquired pneumo-
nia. N Engl J Med. 1997;336(4):243-250.
DOI: 10.1136/thorax.58.5.377
Validation Reference
• Shah BA, Ahmed W, Dhobi GN, et al. Validity of pneumo-
nia severity index and CURB-65 severity scoring systems in
SMART-COP Score for Pneumonia
Severity
The SMART-COP score predicts the need for intensive
respiratory or vasopressor support in community-acquired
Click the thumbnail
to access the calculator.
pneumonia.
 About the Score
The SMART-COP score for pneumonia severity was
developed to identify patients at increased risk for
intensive respiratory or vasopressor support (IRVS).
The score should be used for patients with commu-
nity-acquired pneumonia (CAP) who may require
intensive care unit (ICU) care. The tool does not
estimate mortality and does not apply to patients
with significant immunosuppression.
The SMART-COP score includes age-adjusted
cutoffs for respiratory rate and oxygen levels, but
otherwise does not explicitly include patient age as
a variable, in contrast with the PSI and the CURB-
65 score. This may preserve the positive predictive
value with advancing age.
CAP is the single most common cause of sepsis
in older patients, but can be difficult to recognize
due to blunted fever and tachycardic responses to
infection in these patients. Consideration of other
variables not included in the SMART-COP score, such
as comorbidities, functional status, frailty, and clini-
cian gestalt, may still result in a recommendation for
ICU admission.
The SMART-COP score uses readily available
patient information. It can help identify which pa-
tients need ICU admission, with 92.3% sensitivity,
CALCULATOR REVIEW AUTHOR
Jennifer Chen, MD, MPH
Director/Medical Director, Los Angeles County
Department of Health Services, San Fernando Valley
Health Center Group, Los Angeles, CA
FEBRUARY 2021 • www.ebmedicine.net 3
community acquired pneumonia in an Indian setting. Indian
J Chest Dis Allied Sci. 2010;52(1):9-17. PMID: 20364609
Additional Reference
• United States Department of Health & Human Services,
Agency for Healthcare Research and Quality. Pneumonia:
new prediction model proves promising. 1997. Accessed
February 1, 2021. Available at: http://archive.ahrq.gov/
clinic/pneuclin.htm
62.3% specificity, and an area under the curve (AUC)
of 0.87, leading to better utilization of resources
and treatment initiation. Delayed admission to the
ICU is associated with higher 30-day mortality rates
in patients with CAP (Restrepo 2010). SMART-COP
performs comparably with the minor criteria for
severe CAP recommended by the 2007 Infectious
Diseases Society of America/American Thoracic
Society consensus guidelines.
Patients who do not meet criteria for ICU admis-
sion using the SMART-COP score should still be
evaluated for the need for inpatient admission. They
should also receive timely and appropriate empiric
antibiotics for CAP, generally a beta-lactam plus a
macrolide, or a fluoroquinolone. Goals of care and
other variables may recommend against ICU admis-
sion even if the SMART-COP score is high.
For patients with high SMART-COP scores,
clinicians should consider broadening the antibiotic
regimen to include methicillin-resistant Staphylococ-
cus aureus coverage (for ICU admission, necrotiz-
ing or cavitary infiltrates, or empyema, or previous
methicillin-resistant Staphylococcus aureus infection)
and/or to include antipseudomonal coverage (for
history of structural lung disease, immunocompro-
mise, or previous Pseudomonas aeruginosa infec-
tion). Clinicians should also be aware of the risk for
associated sepsis and treat accordingly.
 Evidence Appraisal
The original SMART-COP study published by
Charles et al in 2008 prospectively examined
patients with CAP at 6 hospitals in Australia over a
28-month period. It included 865 CAP episodes,
©2021 EB MEDICINE
with a mean patient age of 65.1 years. The SMART-
COP score was developed to stratify patients into
need for ICU admission based on risk for IRVS.
The study cohort had a 13.4% ICU admission
rate, a 10.3% IRVS rate, and a 5.7% 30-day mortality
rate. In the derivation study, the SMART-COP score
demonstrated 92.3% sensitivity and 62.3% specific-
ity (AUC = 0.87) for accurately predicting the need
for IRVS, compared with 73.6% sensitivity for PSI
classes IV and V, and compared with 38.5% sensitiv-
ity for CURB-65 group 3 patients.
The original study also validated the SMART-
COP score using 5 existing databases (including the
PORT database) with a total of 7464 patients. When
applied to these 5 external databases, the SMART-
COP score had an AUC of 0.72 to 0.87.
One database analysis study found that among
hospitalized Medicare patients with pneumonia, ICU
admission of patients for whom the admission decision
appeared to be discretionary was associated with a
5.7% absolute survival advantage at 30 days compared
with patients admitted to general wards (Valley 2015).
 Use the Calculator Now
Access the SMART-COP Score on MDCalc.
MDCalc.
Drug Resistance in Pneumonia (DRIP)
Score
The DRIP score predicts risk for community-acquired pneumonia
due to drug-resistant pathogens.
Click the thumbnail
to access the calculator.
 About the Score
The drug resistance in pneumonia (DRIP) score
should be used for patients who have community-
acquired pneumonia with a bacterial cause. The
goal of the DRIP score is to determine when broad-
spectrum antibiotics should be used, both to de-
termine effective treatment and to avoid increasing
antibiotic resistance. A patient with a DRIP score <4
can be treated effectively without broad-spectrum
antibiotic coverage, while a patient with a score ≥4
is more likely to require broad-spectrum antibiotic
coverage.
CALCULATOR REVIEW AUTHOR
John Dayton, MD
Department of Emergency Medicine, University of Utah,
Salt Lake City, UT
FEBRUARY 2021 • www.ebmedicine.net 4
 Calculator Creator
Patrick Charles, MBBS, FRACP, PhD
Read more about Dr. Charles
Charles..
 References
Original/Primary Reference
• Charles PG, Wolfe R, Whitby M, et al. SMART-COP: a tool
for predicting the need for intensive respiratory or vasopres-
sor support in community-acquired pneumonia. Clin Infect
Dis.. 2008;47(3):375-384. DOI: 10.1086/589754
Dis
Validation Reference
• Marti C, Garin N, Grosgurin O, et al. Prediction of severe
community-acquired pneumonia: a systematic review and
meta-analysis. Crit Care.
Care. 2012;16(4):R141.
DOI: 10.1186/cc11447
Additional References
• Valley TS, Sjoding MW, Ryan AM, et al. Association of inten-
sive care unit admission with mortality among older patients
with pneumonia. JAMA
JAMA.. 2015;314(12):1272-1279.
DOI: 10.1001/jama.2015.11068
• Restrepo MI, Mortensen EM, Rello J, et al. Late admission to
the ICU in patients with community-acquired pneumonia is
associated with higher mortality. Ches
Chest.
t. 2010;137(3):552-557.
DOI: 10.1378/chest.09-1547
False negatives on the DRIP score can occur in
the following situations: methicillin-resistant Staphy-
lococcus aureus or P aeruginosa infection; severe
chronic obstructive pulmonary disease (requiring
oxygen and steroids); intravenous drug use; psychi-
atric conditions; and homelessness. False positives
can occur with S pneumoniae and methicillin-sus-
ceptible Staphylococcus aureus.
aureus.
The DRIP score is more predictive than the
healthcare-associated pneumonia (HCAP) criteria
for drug-resistant pathogens, and may have the
potential to decrease antibiotic overutilization in
pneumonia. At a cutoff of ≥4 points, the DRIP score
optimally differentiates high and low risk for drug-
resistant pneumonia, supporting the utility of the
score as a clinical decision tool to guide empiric
antibiotic selection (Webb 2019).
©2021 EB MEDICINE
 Evidence Appraisal
Webb et al created the DRIP score with a 2016
study that both derived and validated a clinical
prediction tool to help predict which cases of bacte-
rial pneumonia may be antibiotic resistant. Their
research goal was to create a predictive score that
would be more accurate than HCAP criteria. Dur-
ing the derivation portion of the study, multiple risk
factors for drug-resistant pathogens were evaluated
using logistic regression, for a cohort of 200 cases of
confirmed bacterial pneumonia.
In the original study, the DRIP score was found
to be more sensitive (82% vs 79%) and more specific
(81% vs 65%) than HCAP criteria. It decreased use
of unnecessary extended-spectrum antibiotics by
46% as compared to HCAP criteria.
A 2019 validation study by the original study
authors found that the DRIP score decreased the
use of unnecessary extended-spectrum antibiotics
by 38% as compared with HCAP criteria. The study
evaluated a broader set of risk factors than the
HCAP definition. It reaffirmed that antibiotic use and
hospitalization 60 days prior are major contributors
to drug resistance, but did not find a strong associa-
tion between severity of illness and drug resistance.
The DRIP score was also found to be more specific
and more accurate than 8 other predictive models,
including the Shorr score.
 Use the Calculator Now
Access the DRIP Score on MDCalc.
 Calculator Creator
Brandon Webb, MD
Read more about Dr. Webb
Webb..
 References
Original/Primary Reference
• Webb BJ, Dascomb K, Stenehjem E, et al. Derivation and
multicenter validation of the drug resistance in pneumonia
clinical prediction score. Antimicrob Agents Chemother.
2016;60(5):2652-2663. DOI: 10.1128/AAC.03071-15
Validation References
• Webb BJ, Dascomb K, Stenehjem E, et al. Derivation and
multicenter validation of the drug resistance in pneumonia
clinical prediction score. Antimicrob Agents Chemother.
2016;60(5):2652-2663. DOI: 10.1128/AAC.03071-15
• Webb BJ, Sorensen J, Mecham I, et al. Antibiotic use and
outcomes after implementation of the drug resistance in
pneumonia score in ED patients with community-onset
pneumonia. Chest. 2019;156(5):843-851.
DOI: 10.1016/j.chest.2019.04.093

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