Clinical Practice

Guidelines
Pneumonia
 REFERENCES
Clinical
Practice
Guidelines
Management
and Prevention
of Adult
Community
Acquired
Pneumonia

2020 Update
 OBJECTIVES OF THIS REPORT
At the end of this report, we, as clinicians, will able:

1. To recognize clinical features, identify diagnostic procedures, and formulate therapeutic

management and preventive measures in pediatric and adult patients with community
acquired pneumonia.

2. To differentiate three categories namely bacterial, viral, and atypical pathogens causing
pneumonia.

3. To be guided regarding our clinical judgment in the overall care of our patients with CAP.
 #1
Clinical Guide Question:
Among adult patients diagnosed with
CAP, when should Gram stain and
Culture with Sensitivity (GS/CS)
testing of respiratory secretions be
performed?
#2
Clinical Guide Question:
Among adult patients
diagnosed with CAP, when
should blood cultures be
requested?
#3
Clinical Guide Question:
Among adult patients with CAP, should
testing of respiratory secretions for
Influenza Virus at the time of diagnosis
be done to minimize morbidity and
mortality?

#4
Clinical Guide Question:
Among patients with CAP, should
Legionella urine antigen test be
requested?
#5
Clinical Guide Question:
Among adult patient with CAP, what is
the clinical utility of multiplex PCR?
#6
Clinical Guide Question:
What antibiotics are
recommended for the empiric
treatment of low-risk CAP?

#7
Clinical Guide Question:
What antibiotics are
recommended for the empiric
treatment of moderate risk
CAP?
#8
Clinical Guide Question:
What antibiotics are
recommended for the empiric
treatment of high risk CAP?
#9
Clinical Guide Question:
Among adults with suspected
aspiration pneumonia, should
additional anaerobic coverage beyond
empiric treatment for CAP be given?
 #10
Clinical Guide Question:
Among patients with CAP, who are the
patients at risk for MRSA,
Pseudomonas aeruginosa, ESBL
producing organisms and should
receive empiric antibiotic coverage for
these organisms?
#13
Clinical Guide Question:
Among adult patients with CAP,
what is the appropriate duration of
treatment?
#16
Clinical Guide Question:
Among adult patients, how effective
are pneumococcal and influenza
vaccines in preventing pneumonia
and its complications?
#11 #12
Clinical Guide Question: Clinical Guide Question:
Among adult patients with CAP Among adults with CAP, how soon
who test positive for Influenza should empiric treatment be started?
virus, should antiviral therapy
be started?
#14 #15
Clinical Guide Question:
Clinical Guide Question: Among patients with clinical
Among patients on empiric antibiotic improvements while ongoing
therapy for CAP, should de-escalation treatment, should the following tests be
be done? performed to monitor response to
treatment?
#17
Clinical Guide Question:
What should be done for patients
who are not improving after 72
hours of empiric antibiotic
therapy?
#1 Clinical Guide Question:
Among adult patients diagnosed with CAP, when should Gram stain and
Culture with Sensitivity (GS/CS) testing of respiratory secretions be
performed?

• We do not recommend gram stain and culture of respiratory secretions

for CAP-LR
(strong recommendation, low qaulity evidence)

Sputum GS is HIGHLY SPECIFIC

for identifying S. pneumoniae, H.
influenzae, S. aureus and Gram-
negative bacilli
Negative GS results cannot be used to conclude
absence of respiratory pathogen; hence,
discontinuation of antimicrobials in GS-negative
#1 Clinical Guide Question:
Among adult patients diagnosed with CAP, when should Gram stain and
Culture with Sensitivity (GS/CS) testing of respiratory secretions be
performed?

• We do not recommend gram stain and culture of respiratory secretions

for CAP-LR
(strong recommendation, low qaulity evidence)

• Recommended for patients with moderate to high risk CAP, or with

risk factors for MDRO infection (strong recommendation, low qaulity evidence)
 Clinical Guide Question:
#2 Among adult patients diagnosed with CAP, when should blood cultures
be requested?

• Blood cultures for patients with moderate and high risk CAP
(strong recommendation, low qaulity evidence)

4 variables were significantly associated with positive blood culture

results:
- WBC <4.5×109/L
- serum creatinine >106 μmol/L
- rum glucose <6.1 mmol/L
- temperature >38°C
the NICE guidelines for the same condition recommend that blood
cultures be done only for individuals with moderate- or high-severity
 Clinical Guide Question:
Among adult patients with CAP, should testing of respiratory secretions
#3 for Influenza Virus at the time of diagnosis be done to minimize
morbidity and mortality?
• We recommend testing of respiratory secretions for influenza using
RNAT during period of high influenza activity (July to January) for
patients with CAP-HR preceded by influenza-like symptoms (sore
throat, rhinorrhea, body malaise, joint pains) and any of the following
risk factors (conditional recommendation, low-moderate quality evidence)
• 60 years old and above
• Pregnant
• Asthmatic
• Other co-morbids: DM, active malignancies, neurologic diseases,
CHF, unstable CAD, renal failure on dialysis, uncompensated COPD,
decompensated liver disease
#4 Clinical Guide Question:
Among patients with CAP, should Legionella urine antigen test be
requested?
• Legionella urine antigen test may be considered for patients with
CAP-HR
(conditional recommendation, moderare quality of evidence)

Clinical Guide Question:

Among adult patient with CAP, what is the clinical utility of multiplex
#5 PCR?
• We do not recommend the routine use of multiplex PCR among adult
patients with community acquired pneumonia
(strong recommendation, moderate qaulity evidence)
 Clinical Guide Question:
#6 What antibiotics are recommended for the empiric treatment of low-risk
community acquired pneumonia?

• The following antibiotics should be started for empiric treatment

of patients with low risk CAP without co-morbidities:
• Amoxicillin 1g TID, or
• Clarithromycin 500mg BID
• Azithromycin 500mg OD

Strong recommendation, low quality of evidence

 Clinical Guide Question:
#6 What antibiotics are recommended for the empiric treatment of low-risk
community acquired pneumonia?

• The following antibiotics should be started for empiric treatment

of patients with low risk CAP with stable co-morbidities:
• Beta-lactam: Co-Amoxiclav 625mg TID, or 1g BID, or
• Cefuroxime 500mg BID
Strong recommendation, moderate quality of evidence

• Plus or minus:
• Macrolide: Clarithromycin 500mg BID / Azithromycin
500mg OD
• Or: Doxycycline 100mg BID
Strong recommendation, low quality of evidence
 Clinical Guide Question:
#7 What antibiotics are recommended for the empiric treatment of moderate
risk community acquired pneumonia?

• The following antibiotics should be started for empiric treatment

of patients with moderate risk CAP without MDRO infection:
• Non-pseudomonal Beta-lactam: Ampicillin – Sulbactam
1.5g – 3g q6h
• Or: Cefotaxime 1-2g Strong
q8h recommendation, moderate quality of evidence
• Or: Ceftriaxone 1-2g OD

• Plus:
• Macrolide: Azithromycin 500mg daily, or
• Clarithromycin 500mgStrong
BIDrecommendation, low quality of evidence
 Clinical Guide Question:
#8 What antibiotics are recommended for the empiric treatment of high risk
community acquired pneumonia?

• The following antibiotics should be started for empiric treatment

of patients with high risk CAP without MDRO infection:
• FIRST LINE THERAPY: Non-pseudomonal Beta-lactam
antibiotic
• Cefotaxime 1-2g IV q8h OR Ceftriaxone 1-2g IV OD
• PLUS:
• Macrolide
• Azithromycin 500mg po/IV OD,
• Clarithromycin 500mg PO po BID daily
• Erythromycin 500mg PO q6h
Conditional recommendation, low quality of evidence
 Clinical Guide Question:
#8 What antibiotics are recommended for the empiric treatment of high risk
community acquired pneumonia?

• The following antibiotics should be started for empiric treatment

of patients with high risk CAP without MDRO infection:
• ALTERNATIVE THERAPY
• Respiratory fluoroquinolone*
• Levofloxacin 750mg PO/IV daily OR
• Moxifloxacin 400mg PO/IV daily
*given as 1 hour IV infusion
Conditional recommendation, low quality of evidence
 Clinical Guide Question:
#9 Among adults with suspected aspiration pneumonia, should additional
anaerobic coverage beyond empiric treatment for CAP be given?

• Routine anaerobic coverage for suspected aspiration pneumonia

is NOT recommended, unless lung abscess or empyema is
suspected

Conditional recommendation, very low quality of evidence

 Clinical Guide Question:
#10 Among patients with CAP, who are the patients at risk for MRSA,
Pseudomonas aeruginosa, ESBL producing organisms and should receive
empiric antibiotic coverage for these organisms?

• The following antibiotics should be started for empiric treatment

of patients with moderate to high risk CAP and with risk factors
for MDROs:
Risk for MRSA
• Prior colonization or Non-pseudomonal B-lactam
infection with MRSA within PLUS
1 year Macrolide OR
• Intravenous antibiotic Respiratory fluoroquinolone*
therapy within 90 days

Conditional recommendation, low to moderate quality of ev

 Clinical Guide Question:
#10 Among patients with CAP, who are the patients at risk for MRSA,
Pseudomonas aeruginosa, ESBL producing organisms and should receive
empiric antibiotic coverage for these organisms?

• The following antibiotics should be started for empiric treatment

of patients with moderate to high risk CAP and with risk factors
for MDROs:
Risk for MRSA PLUS: Vancomycin 15mg/kg
• Prior colonization or IV q12h
infection with MRSA within OR: Linezolid 600mg IV q12h
1 year OR: Clindamycin 600mh IV
• Intravenous antibiotic q8h
therapy within 90 days

Conditional recommendation, low to moderate quality of ev

 Clinical Guide Question:
#10 Among patients with CAP, who are the patients at risk for MRSA,
Pseudomonas aeruginosa, ESBL producing organisms and should receive
empiric antibiotic coverage for these organisms?
• The following antibiotics should be started for empiric treatment
of patients with moderate to high risk CAP and with risk factors
for MDROs:
REPLACE Non-pseudomonal
Risk for ESBL B-lactam antibiotic with:
• Prior colonization or - Ertapenem 1g IV q24h
infection with ESBL- - Meropenem 1g IV q8h (if
producing organisms within Ertapenem is not available)
1 year PLUS:
- Macrolide OR Respiratory
Fluoroquinolone*

Conditional recommendation, low to moderate quality of ev

 Clinical Guide Question:
#10 Among patients with CAP, who are the patients at risk for MRSA,
Pseudomonas aeruginosa, ESBL producing organisms and should receive
empiric antibiotic coverage for these organisms?
• The following antibiotics should be started for empiric treatment
of patients with moderate to high risk CAP and with risk factors
for MDROs:
Risk for Pseudomonas REPLACE Non-pseudomonal
aeruginosa Beta lactam antibiotic with
• Prior colonization or Piperacillin-Tazobactam 4.5g
infection with P. aeruginosa IV q6h
within 1 year OR: Cefepime 2g IV q8h
• Severe bronchopulmonary OR: Ceftazidime 2g IV q8h
disease (severe COPD, OR: Aztreonam 2g IV q8h
bronchoectasis, prior OR: Meropenem 1g IV q8h
tracheostomy) (especially if with ESBL risk)
Conditional recommendation, low to moderate quality of ev
 Clinical Guide Question:
#11 Among adult patients with CAP who test positive for Influenza virus,
should antiviral therapy be started?
• We recommend an antiviral therapy in addition to antibacterial
therapy among patients with high risk CAP and any of the
following risk factors:
• 60 years old and above
• Pregnant
• Asthmatic
• Other co-morbidities: uncontrolled DM, active
malignancies, neurologic disease in evolution, congestive
heart failure class II-IV, unstable CAD, renal failure on
dialysis, uncompensated COPD, decompensated liver
disease) WHO TEST POSITIVE FOR INFLUENZA VIRUS

Conditional recommendation, low to moderate quality of ev

 Clinical Guide Question:
#12 Among adults with CAP, how soon should empiric treatment be started?

• As soon as diagnosis is established, treatment of community

acquired pneumonia, regardless of risk, should be initiated
within 4 hours.
Strong recommendation, moderate quality of evidence
 Clinical Guide Question:
#13 Among adult patients with CAP, what is the appropriate duration of
treatment?
• Low to moderate risk CAP: treatment duration of 5 days
(as long as the patient is clinically
stable)
• May be extended according to:
- pneumonia not resolving
- pneumonia complicated by sepsis, meningitis,
endocarditis and other deep-seated infection
- infection with less common pathogens (i.e. Burkholderia
pseudomallei, Mycobacterium tuberculosis,
endemic fungi, etc)
- infection with a drug resistant pathogens
Best practice
 Clinical Guide Question:
#14 Among patients on empiric antibiotic therapy for CAP, should de-
escalation be done?

• De-escalation of initial empiric broad spectrum or extended

spectrum antibiotic with coverage for MRSA, Pseudomonas or
ESBL to targeted or oral antibiotics based on culture results is
recommended once the patient is:
• clinically improving
• hemodynamically stable
• able to tolerate oral medications

Strong recommendation, moderate quality of evidence

 Clinical Guide Question:
#15 Among patients with clinical improvements while ongoing treatment,
should the following tests be performed to monitor response to treatment?

• Monitoring response with Chest Xray: Among adult patients

who are being treated for community-acquired pneumonia and
who are clinically improving, follow up chest x-ray should
NOT routinely be performed to monitor response to treatment.

Recommendation: Post-treatment CXR after 6-8 weeks

Strong recommendation, low quality of evidence

 Clinical Guide Question:
#15 Among patients with clinical improvements while ongoing treatment,
should the following tests be performed to monitor response to treatment?

• Monitoring response with CRP:

• We do not recommend the use of CRP to monitor treatment
response among patients with CAP

Strong recommendation, low quality of evidence

 Clinical Guide Question:
#15 Among patients with clinical improvements while ongoing treatment,
should the following tests be performed to monitor response to treatment?

• Monitoring response with Procalcitonin:

• We do not recommend the use of procalcitonin to
monitor treatment response among patients with
moderate or high risk CAP.
• Procalcitonin may be used to guide antibiotic
discontinuation among patients with moderate or high
risk CAP

Strong recommendation, low quality of evidence

 Clinical Guide Question:
#16 Among adult patients, how effective are pneumococcal and influenza
vaccines in preventing pneumonia and its complications?

• Pneumoccal and influenza vaccine

• Pneumococcal polysaccharide vaccine (PPSV) or
pneumococcal conjugate vaccine (PCV) are recommended
for the prevention of invasive pneumococcal disease in
adults 50 years old and older.
• PCV:
• To prevent pneumococcal pneumonia
• Mortality from IPD or pneumonia
• Pneumonia among high-risk groups and adults 50 years
old above

Strong recommendation, low quality of evidence

 Clinical Guide Question:
#16 Among adult patients, how effective are pneumococcal and influenza
vaccines in preventing pneumonia and its complications?

• Influenza vaccine is recommended to prevent influenza,

influenza-like hospital illness and hospitalization in all
adults

• Administration of both influenza and pneumococcal vaccine

is recommended to prevent pneumonia, hospitalization and
mortality in adults 50 years old and above.