Epidemiology

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Microbiology

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Other Conditions Which May Mimic the Presentation of Community-Acquired Pneumonia (CAP)

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Diagnosis

General Comments Regarding Diagnostic Testing for Patients with Community-Acquired Pneumonia (CAP)

• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Patients with CAP Should Diagnostic Testing to Detect Specific Suspected Pathogens that Would Significantly Alter the Choice of Empiric Antibiotic Therapy (Strong Recommendation, Level II Evidence)
  • Routine Diagnostic Testing to Identify an Etiologic Organism in Outpatients with CAP is Optional (Moderate Recommendation, Level III Evidence)

Rapid Microbiologic Diagnostic Platforms (RMDP)

• LightCycler SeptiFast Test (Roche)
• Peptide Nucleic Acid Fluorescence in Situ Hybridization (PNA-FISH) (AdvanDx)
• Matrix-Assisted Laser Desorption-Ionization Time-of-Flight (MALDI-TOF) Mass Spectrometry (MS) (VITEK MS; bioMérieux)
• Polymerase Chain Reaction (PCR) Combined with Electrospray Ionization Mass Spectrometry (PCR/ESI-MS) (Abbott Ibis Biosciences)
• DNA-Based Microarray Platforms
  • Prove-it Sepsis Assay (Mobidiag)
  • Verigene Gram-Positive Blood Culture Assay (Nanosphere)
• ID/AST System (Accelerate Diagnostics): automated microscopy system, currently in development

Serum Procalcitonin (see Serum Procalcitonin, [[Serum Procalcitonin]])

• Rationale: serum procalcitonin is the peptide precursor of calcitonin which is released by parenchymal cells in response to bacterial toxins
  • Serum Procalcitonin is Elevated in Bacterial Infections
  • Serum Procalcitonin is Downregulated in Viral Infections
• Clinical Efficacy
  • Systematic Review of the Utility of Serum Procalcitonin in the Diagnosis of Bacterial Pneumonia (Cochrane Database Syst Rev, 2012) [MEDLINE]
    • Serum Procalcitonin Use to Guide Initiation and Duration of Antibiotic Use Did Not Increase Mortality Rates or Treatment Failures in Any Treatment Setting
    • Serum Procalcitonin Decreased Antibiotic Consumption
    • Further Research is Required to Determine the Safety of Serum Procalcitonin-Guided Therapy in the ICU Setting

Chest X-Ray (CXR) (see Chest X-Ray, [[Chest X-Ray]])

• Findings
  • Alveolar and/or Interstitial Infiltrates
  • Atypical Bronchopneumonia-Type Pattern
    • Mycoplasma Pneumoniae (see Mycoplasma Pneumoniae, [[Mycoplasma Pneumoniae]])
    • Chlamydophila Pneumoniae (see Chlamydophila Pneumoniae, [[Chlamydophila Pneumoniae]])
    • Q Fever (Coxiella Burnetti) (see Q Fever, [[Q Fever]])
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Demonstrable Infiltrate by Chest X-Ray or Chest CT (with/without Supporting Microbiologic Data) is Required for the Diagnosis of Pneumonia (Moderate Recommendation, Level III Evidence)

Chest CT (see Chest Computed Tomography, [[Chest Computed Tomography]])

• Findings
  • Alveolar and/or Interstitial Infiltrates
  • Chest CT has Higher Sensitivity for the Detection of Infiltrates than CXR
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Demonstrable Infiltrate by Chest X-Ray or Chest CT (with/without Supporting Microbiologic Data) is Required for the Diagnosis of Pneumonia (Moderate Recommendation, Level III Evidence)

Blood Culture (see Blood Culture, [[Blood Culture]])

• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Indications
    • Active Alcohol Abuse
    • Asplenia
    • Cavitary Infiltrates
    • Chronic Severe Liver Disease
    • ICU Admission
    • Leukopenia
    • Pleural Effusion
    • Positive Pneumococcal Urinary Antigen Test

Sputum Culture (see Sputum Culture, [[Sputum Culture]])

• Methods
  • Endotracheal Tube Aspirate: when patient intubated
  • Expectorated Sputum Culture: when patient not intubated
• Procedures
  • Bacterial Gram Stain and Culture
  • Fungal Stain and Culture: recommended for patient with cavitary infiltrates, etc
  • Acid Fast Bacterial (AFB) Stain and Culture: recommended for patient with cavitary infiltrates, etc
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Indications
    • Active Alcohol Abuse
    • Cavitary Infiltrates
    • Failure of Outpatient Antibiotic Therapy
    • ICU Admission
    • Pleural Effusion
    • Positive Legionella Urinary Antigen Test
    • Positive Pneumococcal Urinary Antigen Test
    • Severe Obstructive/Structural Lung Disease

Urinary Histoplasma Antigen

• May Be Indicated in Select Cases

Urinary Legionella Antigen (see Urinary Legionella Antigen, [[Urinary Legionella Antigen]])

• Technique
  • Urinary Legionella Antigen Remains Positive for Days After the Start of Antibiotic Treatment
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Indications
    • Active Alcohol Abuse
    • Failure of Outpatient Antibiotic Therapy
    • ICU Admission
    • Pleural Effusion
    • Recent Travel within Past 2 wks

Urinary Pneumococcal Antigen (see Urinary Pneumococcal Antigen, [[Urinary Pneumococcal Antigen]])

• Technique
  • Urinary Pneumococcal Antigen Remains Positive for Days After the Start of Antibiotic Treatment
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Indications
    • Active Alcohol Abuse (see Ethanol, [[Ethanol]])
    • Asplenia (see Asplenia, [[Asplenia]])
    • Chronic Severe Liver Disease (see End-Stage Liver Disease, [[End-Stage Liver Disease]])
    • Failure of Outpatient Antibiotic Therapy
    • ICU Admission
    • Leukopenia (see Leukopenia, [[Leukopenia]])
    • Pleural Effusion (see Pleural Effusion-Parapneumonic, [[Pleural Effusion-Parapneumonic]])

Nasal Influenza Testing (see Influenza Virus, [[Influenza Virus]])

• May Be Indicated

Bronchoscopy (see Bronchoscopy, [[Bronchoscopy]])

• Procedures
  • Bronchoalveolar Lavage (BAL)
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Bronchoscopy May Be Indicated for Patient Admitted to the ICU

Thoracentesis (see Thoracentesis, [[Thoracentesis]])

• May Be Indicated in the Presence of Parapneumonic Effusion (see Pleural Effusion-Parapneumonic, [[Pleural Effusion-Parapneumonic]])

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Clinical Classification of Pneumonia (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]

Pneumonia

• Definition: lung infiltrate associated with clinical evidence that an infiltrate is of an infectious origin (new onset of fever, purulent sputum, leukocytosis, and decline in oxygenation)

Community-Acquired Pneumonia (CAP)

• Definition: pneumonia which occurs either as outpatient or within 48 hrs of hospital admission
• Criteria for Severe Community-Acquired Pneumonia (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Major Criteria
    • Respiratory Failure with Requirement for Invasive Mechanical Ventilation
    • Septic Shock with Vasopressor Requirement
  • Minor Criteria
    • Altered Mental Status
    • Hypotension Requiring Aggressive Intravenous Fluid Resuscitation
    • Hypothermia with Core Temperature <36 Degrees C
    • Leukopenia with WBC <4000 cell/mm3
    • Multilobar Infiltrates
    • pO2/FiO2 Ratio ≤250
    • Respiratory Rate ≥30 breaths/min
    • Thrombocytopenia with Platelets <100k cell/mm3
    • Uremia with BUN ≥20 mg/dL

Healthcare-Associated Pneumonia (HCAP)

• Definition: pneumonia occurring in a patient who has the following risk factors for multidrug-resistant pathogens
  • Chronic Hemodialysis Within 30 Days
  • Family Member with a Multidrug-Resistant Pathogen
  • Home Intravenous Infusion Therapy (Antibiotics, etc)
  • Home Wound Care
  • Residence in a Long-Term Nursing Home/Extended Care Facility
  • Stay in an Acute Care Hospital for ≥2 Days in the Last 90 Days

Hospital-Acquired Pneumonia (HAP) (see Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia, [[Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia]])

• Definition: pneumonia which is not incubating at the time of hospital admission and which occurs ≥48 hrs after admission
  • This Definition Importantly Excludes Any Pneumonia Which is Associated with Mechanical Ventilation

Ventilator-Associated Tracheobronchitis

• Definition: fever (without another recognizable cause) associated with new or increased sputum production, positive endotracheal aspirate culture (>10 to the 6th CFU/mL) yielding a new bacteria and no radiographic evidence of pneumonia (Crit Care, 2005) [MEDLINE]

Ventilator-Associated Pneumonia (VAP) (see Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia, [[Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia]])

• Definition: pneumonia which occurs >48 hours after endotracheal intubation
• Clinical Types of Ventilator-Associated Pneumonia
  • Early Onset Ventilator-Associated Pneumonia (Within 5 Days of Intubation): usually results from aspiration
  • Late Onset Ventilator-Associated Pneumonia (After 5 Days of Intubation): usually caused by antibiotic-resistant pathogens and is associated with increased morbidity and mortality

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Clinical Manifestations

Pulmonary Manifestations

• Cough with Sputum Production (see Cough, [[Cough]])
• Dyspnea (see Dyspnea, [[Dyspnea]])
• Hypoxemia (see Hypoxemia, [[Hypoxemia]])
• Parapneumonic Effusion (see Pleural Effusion-Parapneumonic, [[Pleural Effusion-Parapneumonic]])
• Pleuritic Chest Pain (see Chest Pain, [[Chest Pain]])

Other Manifestations

• Fever (see Fever, [[Fever]])

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Prevention of Community-Acquired Pneumonia (CAP)

Vaccination

• Types of Vaccination
  • Influenza Vaccination (see Influenza Virus, [[Influenza Virus]])
  • Pneumococcal Vaccination (see Streptococcus Pneumoniae, [[Streptococcus Pneumoniae]])
• Clinical Efficacy
  • Standing Orders Have Been Demonstrated to Be the Most Effective Means of Improving Vaccination Rates in Medical Offices/Hospitals/Long-Term Care Settings (JAMA, 2003) [MEDLINE]

Smoking Cessation (see Tobacco, [[Tobacco]])

• Smoking is a Risk Factor for Legionella Infection and Invasive Pneumococcal Disease
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Smoking Cessation is Recommended for Smokers Hospitalized with CAP (Moderate Recommendation, Level III Evidence)
  • Smokers Who Will Not Quit Should Be Vaccinated for Both Pneumococcus and Influenza (Weak Recommendation, Level III Evidence)

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Treatment of Community-Acquired Pneumonia (CAP)

Site of Care

• Clinical Data
  • The Decision to Admit a Patient for CAP is the Most Costly Issue in the Management of CAP
    • Inpatient Care for Pneumonia is 25x as Expensive as Outpatient Care (Clin Ther, 1998) [MEDLINE]
    • Inpatient Care for Pneumonia Consumes the Majority of the Estimated $8.4-10 Billion Spent Annually on Pneumonia Treatment
  • CAP Patients Treated as Outpatients are Able to Resume Normal Activity Sooner than Those Who are Hospitalized
  • Approximately 74% of CAP Patients Prefer Outpatient Treatment (Arch Intern Med, 1996) [MEDLINE]
  • Hospitalization Increases the Risk of Venous Thromboembolism and Superinfection with More Virulent or Resistant Organisms (Arch Intern Med, 2004) [MEDLINE]
• Recommendations-Site of Therapy (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Severity of Illness Scoring (CURB-65 or PSI) is Recommended to Identify Patients with CAP Who May Be Candidates for Outpatient Treatment (Strong Recommendation, Level I Evidence)
    • CURB-65 Criteria: Confusion, Uremia, Respiratory Rate, Low Blood Pressure, Age ≥65 y/o)
    • Pneumonia Severity Index (PSI)
  • Objective Criteria (CURB-65 or PSI) Should Be Supplemented with Provider Judgement (Regarding the Patient’s Ability to Take Oral Meds, Patient’s Outpatient Support System, etc) (Strong Recommendation, Level II Evidence)
  • For Patients with CURB-65 ≥2, Hospitalization or More Intensive Home Health Care Services are Recommended (Moderate Recommendation, Level III Evidence)
  • Direct ICU Admission is Required for Patients with Either of the Two Major Criteria for Severe CAP (Septic Shock Requiring Vasopressors or Respiratory Failure Requiring Invasive Mechanical Ventilation) (Strong Recommendation, Level II Evidence)
  • Direct ICU or Stepdown Unit Admission is Recommended for Patients with 3 of the Minor Criteria for Severe CAP (Moderate Recommendation, Level II Evidence): however, none of the published criteria for severe CAP adequately distinguishes which patients require ICU admission or validates this recommendation

Antibiotics

Clinical Efficacy-Choice of Empiric Antibiotic

• VA Retrospective Cohort Study Examining the Impact of Azithromycin on Mortality and Cardiovascular Events in Older Patients Hospitalized with Pneumonia (JAMA, 2014) MEDLINE]: n = 73,690 patients (from 118 hospitals)
  • Azithromycin Decreased the 90-Day Mortality Rate, as Compared to Other Antibiotics
  • Azithromycin Also Demonstrated a Smaller Increased Risk of Myocardial Infarction, But No Difference in Arrhythmias or Congestive Heart Failure
• CAP-START Trial-Antibiotic Choice in Non-ICU Community-Acquired Pneumonia (NEJM, 2015) [MEDLINE]
  • Empiric Treatment with β-Lactam Monotherapy is Non-Inferior to β-Lactam/Macrolide Combination or Fluoroquinolones with Respect to the 90-Day Mortality Rate

Recommendations-Choice of Empiric Antibiotic (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]

• Outpatient (Previously Healthy and No Use of Antimicrobials within the Last 3 mo)
  • Doxycycline (Weak Recommendation, Level III Evidence) (see Doxycycline, [[Doxycycline]])
  • Macrolide (Azithromycin, Clarithromycin, Erythromycin) (Strong Recommendation, Level I Evidence) (see Macrolides, [[Macrolides]])
    • In Regions with High Rate (>25%) of Infection with High-Level (MIC ≥16 μg/mL) Macrolide-Resistant Streptococcus Pneumoniae, Consider Use of Alternative Agent (Moderate Recommendation, Level III Evidence)
• Outpatient (Presence of Co-Morbidities, Such as Chronic Heart/Lung/Liver/Renal Disease, DM, Alcoholism, Malignancy, Asplenia, Immunosuppression, Use of Antimicrobials within the Last 3 mo)
  • β-Lactam (High-Dose Amoxicillin 1 g TID, Amoxicillin-Clavulanic Acid 2 g BID, Ceftriaxone, Cefpodoxime, and Cefuroxime 500 mg BID) + Macrolide (Azithromycin, Clarithromycin, Erythromycin) (Strong Recommendation, Level I Evidence) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]] and Macrolides, [[Macrolides]])
    • In Regions with High Rate (>25%) of Infection with High-Level (MIC ≥16 μg/mL) Macrolide-Resistant Streptococcus Pneumoniae, Consider Use of Alternative Agent (Moderate Recommendation, Level III Evidence)
  • β-Lactam (High-Dose Amoxicillin 1 g TID, Amoxicillin-Clavulanic Acid 2 g BID, Ceftriaxone, Cefpodoxime, and Cefuroxime 500 mg BID) + Doxycycline (Strong Recommendation, Level II Evidence) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]] and Doxycycline, [[Doxycycline]])
  • Respiratory Fluoroquinolone (Strong Recommendation, Level I Evidence) (see Fluoroquinolones, [[Fluoroquinolones]]): gemifloxacin, levofloxacin (750 mg qday), moxifloxacin
• Inpatient (Non-ICU)
  • β-Lactam (Ampicillin, Cefotaxime, Ceftriaxone) + Macrolide (Strong Recommendation, Level I Evidence) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]] and Macrolides, [[Macrolides]])
  • β-Lactam (Ampicillin, Cefotaxime, Ceftriaxone) + Doxycycline (Strong Recommendation, Level III Evidence) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]] and Doxycycline, [[Doxycycline]])
  • Respiratory Fluoroquinolone (Strong Recommendation, Level I Evidence) (see Fluoroquinolones, [[Fluoroquinolones]]): gemifloxacin, levofloxacin (750 mg qday), moxifloxacin
• Inpatient (ICU)
  • β-Lactam (Cefotaxime, Ceftriaxone, Ampicillin-Sulbactam) + Azithromycin (Level II Evidence) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]] and Azithromycin, [[Azithromycin]])
  • β-Lactam (Cefotaxime, Ceftriaxone, Ampicillin-Sulbactam) + Respiratory Fluoroquinolone (Gemifloxacin, Levofloxacin, Moxifloxacin) (Strong Recommendation, Level I Evidence) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]] and Azithromycin, [[Azithromycin]])
  • Aztreonam + Respiratory Fluoroquinolone (Gemifloxacin, Levofloxacin, Moxifloxacin) (Strong Recommendation, Level I Evidence) (see Aztreonam, [[Aztreonam]] and Azithromycin, [[Azithromycin]]): preferred regimen for patients with penicillin allergy
• If Community-Acquired Staphylococcus Aureus (CA-MRSA) is a Concern
  • Add Linezolid or Vancomycin (Moderate Recommendation, Level III Evidence) (see Linezolid, [[Linezolid]] and Vancomycin, [[Vancomycin]])
• If Pseudomonas is a Concern
  • Anti-Pneumococcal, Anti-Pseudomonal β-Lactam (Piperacillin-Tazobactam, Cefepime, Imipenem, Meropenem) + Levofloxacin (750 mg/day) or Ciprofloxacin (Moderate Recommendation, Level III Evidence) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]], Levofloxacin, [[Levofloxacin]], and Ciprofloxacin, [[Ciprofloxacin]])
    • For Penicillin-Allergic Patients: substitute aztreonam for β-lactam
  • Anti-Pneumococcal, Anti-Pseudomonal β-Lactam (Piperacillin-Tazobactam, Cefepime, Imipenem, Meropenem) + Aminoglycoside + Azithromycin (Moderate Recommendation, Level III Evidence) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]], Aminoglycosides, [[Aminoglycosides]], and Azithromycin, [[Azithromycin]])
    • For Penicillin-Allergic Patients: substitute aztreonam for β-lactam
  • Anti-Pneumococcal, Anti-Pseudomonal β-Lactam (Piperacillin-Tazobactam, Cefepime, Imipenem, Meropenem) + Aminoglycoside + Respiratory Fluoroquinolone (Gemifloxacin, Levofloxacin, Moxifloxacin) (Moderate Recommendation, Level III Evidence) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]], Aminoglycosides, [[Aminoglycosides]], and Fluoroquinolones, [[Fluoroquinolones]])
    • For Penicillin-Allergic Patients: substitute aztreonam for β-lactam

Recommendations-Choice of Targeted Antibiotic Against a Specific Pathogen (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]

• Acinetobacter (see Acinetobacter, [[Acinetobacter]])
  • First-Line
    • Carbapenem (see Carbapenems, [[Carbapenems]]): imipenem, meropenem, ertapenem
  • Alternative
    • Ampicillin-Sulbactam (Unasyn) (see Ampicillin-Sulbactam, [[Ampicillin-Sulbactam]])
    • Cephalosporin + Aminoglycoside (see Cephalosporins, [[Cephalosporins]] and Aminoglycosides, [[Aminoglycosides]])
    • Colistin (see Colistin, [[Colistin]])
• Anaerobes (Aspiration Pneumonia) (see Aspiration Pneumonia, [[Aspiration Pneumonia]])
  • First-Line
    • β-Lactam with β-Lactamase Inhibitor: piperacillin-tazobactam (Zosyn), ticarcillin-clavulanic acid (Timentin), ampicillin-sulbactam (Unasyn), or amoxicillin-clavulanic acid (Augmentin) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]])
    • Clindamycin (see Clindamycin, [[Clindamycin]])
  • Alternative
    • Carbapenem (see Carbapenems, [[Carbapenems]]): imipenem, meropenem, ertapenem
• Bacillus Anthracis (Anthrax) (see Anthrax, [[Anthrax]])
  • First-Line
    • Ciprofloxacin (Cipro) (see Ciprofloxacin, [[Ciprofloxacin]])
    • Doxycycline (see Doxycycline, [[Doxycycline]]): with a second agent
    • Levofloxacin (Levaquin) (see Levofloxacin, [[Levofloxacin]])
  • Alternative
    • β-Lactam: if susceptible
    • Chloramphenicol (see Chloramphenicol, [[Chloramphenicol]])
    • Clindamycin (see Clindamycin, [[Clindamycin]])
    • Gatifloxacin (Tequin) (see Gatifloxacin, [[Gatifloxacin]])
    • Moxifloxacin (Avelox, Avalox, Avelon) (see Moxifloxacin, [[Moxifloxacin]])
    • Rifampin (see Rifampin, [[Rifampin]])
• Blastomycosis (see Blastomycosis, [[Blastomycosis]])
  • First-Line
    • Itraconazole (Sporanox) (see Itraconazole, [[Itraconazole]])
  • Alternative
    • Amphotericin B (see Amphotericin, [[Amphotericin]])
• Bordetella Pertussis (Pertussis) (see Pertussis, [[Pertussis]])
  • First-Line
    • Macrolide (see Macrolides, [[Macrolides]])
  • Alternative
    • Sulfamethoxazole-Trimethoprim (Bactrim, Septra) (see Sulfamethoxazole-Trimethoprim, [[Sulfamethoxazole-Trimethoprim]])
• Burkholderia Pseudomallei (Melioidosis) (see Melioidosis, [[Melioidosis]])
  • First-Line
    • Carbapenem (see Carbapenems, [[Carbapenems]]): imipenem, meropenem, ertapenem
    • Ceftazidime (Ceftaz) (see Ceftazidime, [[Ceftazidime]])
  • Alternative
    • Fluoroquinolone (see Fluoroquinolones, [[Fluoroquinolones]]): levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin
    • Sulfamethoxazole-Trimethoprim (Bactrim, Septra) (see Sulfamethoxazole-Trimethoprim, [[Sulfamethoxazole-Trimethoprim]])
• Chlamydophila Pneumoniae (see Chlamydophila Pneumoniae, [[Chlamydophila Pneumoniae]])
  • First-Line
    • Macrolide (see Macrolides, [[Macrolides]])
    • Tetracycline (see Tetracyclines, [[Tetracyclines]])
  • Alternative
    • Fluoroquinolone (see Fluoroquinolones, [[Fluoroquinolones]]): levofloxacin, moxifloxacin, gatifloxacin
• Chlamydophila Psittaci (Psittacosis) (see Psittacosis, [[Psittacosis]])
  • First-Line
    • Tetracycline (see Tetracyclines, [[Tetracyclines]])
  • Alternative
    • Macrolide (see Macrolides, [[Macrolides]])
• Coccidioides Immitis (Coccidioidomycosis) (see Coccidioidomycosis, [[Coccidioidomycosis]])
  • First-Line
    • Fluconazole (Diflucan) (see Fluconazole, [[Fluconazole]])
    • Itraconazole (Sporanox) (see Itraconazole, [[Itraconazole]])
  • Alternative
    • Amphotericin B (see Amphotericin, [[Amphotericin]])
• Coxiella Burnetti (Q Fever) (see Q Fever, [[Q Fever]])
  • First-Line
    • Tetracycline (see Tetracyclines, [[Tetracyclines]])
  • Alternative
    • Macrolide (see Macrolides, [[Macrolides]])
• Enterobacteriaceae (see Enterobacteriaceae, [[Enterobacteriaceae]])
  • First-Line
    • Carbapenem (see Carbapenems, [[Carbapenems]]): imipenem, meropenem, ertapenem
    • Third-Generation Cephalosporin (see Cephalosporins, [[Cephalosporins]])
  • Alternative
    • β-Lactam with β-Lactamase Inhibitor: piperacillin-tazobactam (Zosyn), ticarcillin-clavulanic acid (Timentin), ampicillin-sulbactam (Unasyn), or amoxicillin-clavulanic acid (Augmentin) (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]])
    • Fluoroquinolone (see Fluoroquinolones, [[Fluoroquinolones]]): levofloxacin, moxifloxacin, gatifloxacin
  • Extended-Spectrum β-Lactamase (ESBL) Producer
    • Carbapenem (see Carbapenems, [[Carbapenems]]): imipenem, meropenem, ertapenem
• Francisella Tularensis (Tularemia) (see Tularemia, [[Tularemia]])
  • First-Line
    • Doxycycline (see Doxycycline, [[Doxycycline]])
  • Alternative
    • Gentamicin (see Gentamicin, [[Gentamicin]])
    • Streptomycin (see Streptomycin, [[Streptomycin]])
• Haemophilus Influenzae (β-Lactamase Negative) (see Haemophilus Influenzae, [[Haemophilus Influenzae]])
  • First-Line
    • Amoxicillin (see Amoxicillin, [[Amoxicillin]])
  • Alternative
    • Azithromycin (Zithromax) (see Azithromycin, [[Azithromycin]]): azithromycin is more active in vitro against Haemophilus Influenzae than clarithromycin
    • Clarithromycin (Biaxin) (see Clarithromycin, [[Clarithromycin]])
    • Doxycycline (see Doxycycline, [[Doxycycline]])
    • Fluoroquinolone (see Fluoroquinolones, [[Fluoroquinolones]]): levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin
• Haemophilus Influenzae (β-Lactamase Positive) (see Haemophilus Influenzae, [[Haemophilus Influenzae]])
  • First-Line
    • Amoxicillin-Clavulanic Acid (Augmentin) (see Amoxicillin-Clavulanic Acid, [[Amoxicillin-Clavulanic Acid]])
    • Second/Third-Generation Cephalosporin (see Cephalosporins, [[Cephalosporins]])
  • Alternative
    • Azithromycin (Zithromax) (see Azithromycin, [[Azithromycin]]): azithromycin is more active in vitro against Haemophilus Influenzae than clarithromycin
    • Clarithromycin (Biaxin) (see Clarithromycin, [[Clarithromycin]])
    • Doxycycline (see Doxycycline, [[Doxycycline]])
    • Fluoroquinolone (see Fluoroquinolones, [[Fluoroquinolones]]): levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin
• Histoplasmosis (see Histoplasmosis, [[Histoplasmosis]])
  • First-Line
    • Itraconazole (Sporanox) (see Itraconazole, [[Itraconazole]])
  • Alternative
    • Amphotericin B (see Amphotericin, [[Amphotericin]])
• Influenza Virus (see Influenza Virus, [[Influenza Virus]])
  • First-Line: therapy should be started within 48 hrs of onset of symptoms of influenza A (Strong Recommendation, Level I Evidence)
    • Oseltamivir (Tamiflu) (see Oseltamivir, [[Oseltamivir]])
    • Zanamivir (Relenza) (see Zanamivir, [[Zanamivir]])
• Legionella (Legionellosis) (see Legionellosis, [[Legionellosis]])
  • First-Line
    • Azithromycin (Zithromax) (see Azithromycin, [[Azithromycin]])
    • Fluoroquinolone (see Fluoroquinolones, [[Fluoroquinolones]]): levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin
  • Alternative
    • Doxycycline (see Doxycycline, [[Doxycycline]])
• Mycobacterium Tuberculosis (see Tuberculosis, [[Tuberculosis]])
  • First-Line
    • Rifampin + Isoniazid + Pyrazinamide + Ethambutol (RIPE) (see Rifampin, [[Rifampin]], Isoniazid, [[Isoniazid]], Pyrazinamide, [[Pyrazinamide]], and Ethambutol, [[Ethambutol]])
  • Alternative
    • Variable
• Mycoplasma Pneumoniae (see Mycoplasma Pneumoniae, [[Mycoplasma Pneumoniae]])
  • First-Line
    • Macrolide (see Macrolides, [[Macrolides]])
    • Tetracycline (see Tetracyclines, [[Tetracyclines]])
  • Alternative
    • Fluoroquinolone (see Fluoroquinolones, [[Fluoroquinolones]]): levofloxacin, moxifloxacin, gatifloxacin
• Pseudomonas Aeruginosa (see Pseudomonas Aeruginosa, [[Pseudomonas Aeruginosa]])
  • First-Line
    • Anti-Pseudomonal β-Lactam (Ticarcillin, Piperacillin, Ceftazidime, Cefepime, Aztreonam, Imipenem, Meropenem) + Ciprofloxacin or Levofloxacin (750 mg qday) or Aminoglycoside (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]], Ciprofloxacin, [[Ciprofloxacin]], Levofloxacin, [[Levofloxacin]], and Aminoglycosides, [[Aminoglycosides]])
  • Alternative
    • Ciprofloxacin or Levofloxacin + Aminoglycoside (see Ciprofloxacin, [[Ciprofloxacin]], Levofloxacin, [[Levofloxacin]], and Aminoglycosides, [[Aminoglycosides]])
• Staphylococcus Aureus (Methicillin-Sensitive, MSSA) (see Staphylococcus Aureus, [[Staphylococcus Aureus]])
  • First-Line
    • Anti-Staphylococcal Penicillin (see Penicillins, [[Penicillins]]): nafcillin, oxacillin, flucloxacillin
  • Alternative
    • Cefazolin (Ancef) (see Cefazolin, [[Cefazolin]])
    • Clindamycin (see Clindamycin, [[Clindamycin]])
• Staphylococcus Aureus (Methicillin-Resistant, MRSA) (see Staphylococcus Aureus, [[Staphylococcus Aureus]])
  • First-Line
    • Linezolid (Zyvox) (see Linezolid, [[Linezolid]])
    • Vancomycin (see Vancomycin, [[Vancomycin]])
  • Alternative
    • Sulfamethoxazole-Trimethoprim (Bactrim, Septra) (see Sulfamethoxazole-Trimethoprim, [[Sulfamethoxazole-Trimethoprim]])
• Streptococcus Pneumoniae (Penicillin-Sensitive, MIC <2 μg/mL)
  • First-Line
    • Amoxicillin (see Amoxicillin, [[Amoxicillin]])
    • Penicillin G (see Penicillin G, [[Penicillin G]])
  • Alternative
    • Cephalosporin (see Cephalosporins, [[Cephalosporins]]): cefpodoxime PO, cefprozil PO, cefuroxime PO/IV, cefdinir PO, cefditoren PO, ceftriaxone IV, cefotaxime IV
    • Clindamycin (see Clindamycin, [[Clindamycin]])
    • Doxycycline (see Doxycycline, [[Doxycycline]])
    • Macrolide (see Macrolides, [[Macrolides]])
    • Respiratory Fluoroquinolone (see Fluoroquinolones, [[Fluoroquinolones]]): gemifloxacin, levofloxacin, moxifloxacin
• Streptococcus Pneumoniae (Penicillin-Resistant, MIC ≥2 μg/mL)
  • First-Line: chose agent based on sensitivity
    • Cefotaxime (Claforan, Cefatam) (see Cefotaxime, [[Cefotaxime]])
    • Ceftriaxone (Rocephin) (see Ceftriaxone, [[Ceftriaxone]])
    • Respiratory Fluoroquinolone (see Fluoroquinolones, [[Fluoroquinolones]]): gemifloxacin, levofloxacin, moxifloxacin
  • Alternative
    • High-Dose Amoxicillin (3 g/day) (see Amoxicillin, [[Amoxicillin]]): for penicillin MIC ≤4 μg/mL
    • Linezolid (Zyvox) (see Linezolid, [[Linezolid]])
    • Vancomycin (see Vancomycin, [[Vancomycin]])
• Yersinia Pestis (Plague) (see Plague, [[Plague]])
  • First-Line
    • Gentamicin (see Gentamicin, [[Gentamicin]])
    • Streptomycin (see Streptomycin, [[Streptomycin]])
  • Alternative
    • Doxycycline (see Doxycycline, [[Doxycycline]])
    • Fluoroquinolone (see Fluoroquinolones, [[Fluoroquinolones]]): levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin

Time to First Antibiotic Dose

• Clinical Efficacy
  • Retrospective Medicare Study of Timing of Antibiotic Administration in Patients Hospitalized with CAP (Arch Intern Med, 2004) [MEDLINE]
    • Early Antibiotic Therapy Within 4 hrs is Associated with Decreased In-Hospital Mortality Rate, 30-Day Mortality Rate, and Hospital Length of Stay
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • For Patients Admitted Via the Emergency Department, First Antibiotic Dose Should Be Administered in the Emergency Department (Moderate Recommendation, Level III Evidence): no specific length of time was specified

Antibiotic Stewardship

• Clinical Efficacy
  • De-Escalation of Antibiotics (Curr Opin Pulm Med, 2006) [MEDLINE]
    • De-Escalation is an Effective Strategy to Limit Antibiotic Exposure During the Course of Pneumonia Treatment

Switch from Intravenous to Oral Antibiotic Therapy

• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Patients Should Be Switched from Intravenous to Oral Antibiotic Therapy When They are Hemodynamically Stable and Improving Clinically, Able to Ingest Medications, and have a Normally Functioning Gastrointestinal Tract (Strong Recommendation, Level II Evidence)
  • Patients Should Be Discharged as Soon as they are Clinically Stable, Have No Other Active Medical Problems, and Have a Safe Environment for Continued Care (Moderate Recommendation, Level II Evidence): inpatient observation while receiving oral therapy is not necessary

Duration of Antibiotic Therapy

• Clinical Efficacy
  • Spanish Multicenter Randomized Trial of Shortened Antibiotic Course in CAP (JAMA Intern Med, 2016) [MEDLINE]: n = 312
    • Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) Guideline for Shortened Antibiotic Course Based on Clinical Stability was Safely Implemented in Hospitalized Patients with CAP: patients in shortened course intervention group were treated for a minimum of 5 days and antibiotics were stopped if body temperature was <37.8 degrees C for 48 hrs and they had ≤1 CAP-associated sign of clinical instability (temperature ≥37.8 degrees C, heart rate ≥100 bpm, respiratory rate ≥24 breaths/min, systolic blood pressure ≤90 mm Hg, room air SaO2 ≤90% or pO2 ≤60, inability to maintain oral intake, or altered mental status)
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Treatment for a Minimum of 5 Days is Recommended (Moderate Recommendation, Level I Evidence)
  • Patient Should Have for Temperature <37.8 degrees C for 48-72 hrs and Have ≤1 CAP-Associated Sign of Clinical Instability (Temperature ≥37.8 degrees C, Heart Rate ≥100 bpm, Respiratory Rate ≥24 breaths/min, Systolic Blood Pressure ≤90 mm Hg, Room Air SaO2 ≤90% or pO2 ≤60, Inability to Maintain Oral Intake, or Altered Mental Status) Prior to Antibiotic Discontinuation (Moderate Recommendation, Level II Evidence)
  • Longer Duration of Antibiotic Therapy May Be Required if Initial Antibiotic Therapy was Not Active Against the Identified Pathogen or if Pneumonia is Complicated by Extrapulmonary Infection (Meningitis, Endocarditis, etc) (Weak Recommendation, Level III Evidence)

Reasons for Failure to Respond to Antibiotic Therapy (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]

• General Comments
  • Approximately 45% of Patients with CAP Who Ultimately Require ICU Admission are Initially Admitted to a Non-ICU Setting and are Transferred Due to Clinical Deterioration (Thorax, 2004) [MEDLINE]
• Etiologies of Failure to Improve
  • Early (<72 hrs of Treatment)
    • Normal Response
  • Delayed
    • Complication of Pneumonia: such as Cryptogenic Organizing Pneumonia (COP) (see Cryptogenic Organizing Pneumonia, [[Cryptogenic Organizing Pneumonia]])
    • Drug Fever
    • Hospital-Acquired Superinfection (Pulmonary or Extrapulmonary)
    • Misdiagnosis: patient may alternately have acute pulmonary embolism (PE), congestive heart failure (CHF), vasculitis (due to SLE), cryptogenic organizing pneumonia (COP), etc
    • Parapneumonic Effusion/Empyema
    • Resistant Organism
    • Uncovered Pathogen
• Etiologies of Clinical Deterioration or Progression
  • Early (<72 hrs of Treatment)
    • Extrapulmonary Focus of Infection: such as meningitis, endocarditis, arthritis, etc
    • Misdiagnosis: patient may alternately have acute pulmonary embolism (PE), congestive heart failure (CHF), vasculitis (due to SLE), cryptogenic organizing pneumonia (COP), etc
    • Parapneumonic Effusion/Empyema
    • Resistant Organism
    • Severity of Illness at Presentation
    • Uncovered Pathogen
  • Delayed
    • Exacerbation of Comorbid Illness: such as COPD exacerbation, etc
    • Hospital-Acquired Superinfection (Pulmonary or Extrapulmonary)
    • Intercurrent Complicating Illness: such as myocardial infarction, acute pulmonary embolism, renal failure, line infection, etc.

Risk of Treatment Failure in Community-Acquired Pneumonia (CAP) (Thorax, 2004) [MEDLINE]

• Lower Risk of Treatment Failure
  • Influenza Vaccination (see Influenza Virus, [[Influenza Virus]])
  • Initial Treatment with Fluoroquinolone with Antipneumococcal Activity (see Fluoroquinolones, [[Fluoroquinolones]])
  • Diagnosis of COPD (see Chronic Obstructive Pulmonary Disease, [[Chronic Obstructive Pulmonary Disease]])
• Higher Risk of Treatment Failure
  • Liver Disease (see End-Stage Liver Disease, [[End-Stage Liver Disease]])
  • Advanced Pneumonia Risk Class
  • Leukopenia (see Leukopenia, [[Leukopenia]])
  • Multilobar Involvement
  • Pleural Effusion (see Pleural Effusion-Parapneumonic, [[Pleural Effusion-Parapneumonic]])
  • Cavitation (see Cystic-Cavitary Lung Lesions, [[Cystic-Cavitary Lung Lesions]])

Corticosteroids (see Corticosteroids, [[Corticosteroids]])

• Clinical Efficacy
  • Systematic Review/Meta-Analysis of Adjuvant Corticosteroid Therapy in CAP (J Hosp Med, 2013) [MEDLINE]: 8 randomized controlled trials (n = 1119)
    • Corticosteroids Decrease the Length of Hospital Stay, but Did Not Decrease the Mortality Rate
    • Corticosteroids Decreased the Persistence of CXR Abnormalities and Decreased the Incidence of Delayed Shock

Hemodynamic Support

• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Severe CAP Patients with Hypotension Requiring Intravenous Fluid Resuscitation Should Be Screened for Occult Adrenal Insufficiency (Moderate Recommendation, Level II Evidence)

Respiratory Support

Types of Respiratory Support

• Supplemental Oxygen (see Oxygen, [[Oxygen]])
• Noninvasive Positive-Pressure Ventilation (NIPPV) (see Noninvasive Positive-Pressure Ventilation, [[Noninvasive Positive-Pressure Ventilation]]): may be indicated in select patients
  • Clinical Efficacy
    • Study of NIPPV Use in COPD Exacerbation Associated with Pneumonia (Thorax, 1995) [MEDLINE]
      • Presence of Pneumonia Increased the Failure Rate for NIPPV
    • Prospective Randomized Trial of NIPPV in Severe CAP (Am J Respir Crit Care Med, 1999) [MEDLINE]
      • NIPPV Decreased the Rate of Endotracheal Intubation and ICU Length of Stay
    • Trial of NIPPV in Severe CAP (J Crit Care, 2010) [MEDLINE]
      • NIPPV Had High Failure Rates in Respiratory Failure Associated with CAP
      • Pre/Post-NIPPV Deltas of pO2/FiO2 and Oxygenation Index Predicted Failure
    • Retrospective Cohort Study of NIPPV in CAP (J Crit Care, 2015) [MEDLINE]
      • NIPPV was Frequently Used in Respiratory Failure Associated with CAP, But Failure Rates were High and There was No Impact on Mortality Rate
• Mechanical Ventilation (see Mechanical Ventilation-General, [[Mechanical Ventilation-General]]): as required
• Specific Treatment of Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome, [[Acute Respiratory Distress Syndrome]])
  • Extracorporeal Membrane Oxygenation (ECMO) (see Extracorporeal Membrane Oxygenation, [[Extracorporeal Membrane Oxygenation]])
  • Proning

Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]

• CAP Patients with Hypoxemia/Acute Respiratory Failure Should Receive a Cautious Trial of Non-Invasive Positive Pressure Ventilation (NIPPV) Unless They Require Immediate Intubation Due to Severe Hypoxemia (pO2/FiO2 Ratio <150) and Bilateral Alveolar Infiltrates (Moderate Recommendation, Level I Evidence) (see Non-Invasive Positive Pressure Ventilation, [[Non-Invasive Positive Pressure Ventilation]])
• Low Tidal Volume Ventilation (6 mL/kg PBW) is Recommended for Mechanical Ventilation of CAP Patients with Diffuse Bilateral Pneumonia or ARDS (Strong Recommendation, Level I Evidence)

---

Prognosis

Hospital Readmission for Pneumonia

• Clinical Data
  • Study of Factors Related to Hospital Readmission for Pneumonia (Clin Infect Dis, 2013) [MEDLINE]
    • Hospital Readmission Rate for Pneumonia: 20%
    • Patients with HCAP were 7.5x More Likely to Be Readmitted than Patients with CAP
    • Criteria in HCAP that Associated with the Risk of Hospital Readmission
      • Admission from Long-term Care (adjusted odds ratio [AOR], 2.2 [95% CI, 1.4-3.4])
      • Immunosuppression (AOR, 1.9 [95% CI, 1.3-2.9])
      • Prior Antibiotics (AOR, 1.7 [95% CI, 1.2-2.6])
      • Prior Hospitalization (AOR, 1.7 [95% CI, 1.1-2.5])

---

References

General

• Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia. Arch Intern Med 1996; 156:1565–71 [MEDLINE]
• A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50 [MEDLINE]
• The cost of treating community-acquired pneumonia. Clin Ther. 1998 Jul-Aug;20(4):820-37 [MEDLINE]
• Risk factors for venous thromboembolism in hospitalized patients with acute medical illness: anal- ysis of the MEDENOX Study. Arch Intern Med 2004; 164:963–8 [MEDLINE]
• Validation of predictive rules and indices of severity for community acquired pneumonia. Thorax 2004; 59:421–7 [MEDLINE]
• Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome. Thorax 2004;59:960-965 [MEDLINE]
• Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72 [MEDLINE]
• CDC EPIC Study. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med. 2015 Jul 30;373(5):415-27. doi: 10.1056/NEJMoa1500245. Epub 2015 Jul 14 [MEDLINE]
• Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. 2016 Sep 1;63(5):e61-e111. doi: 10.1093/cid/ciw353. Epub 2016 Jul 14 [MEDLINE]

Prevention

• Facilitating influenza and pneumococcal vaccination through standing orders programs. JAMA 2003; 289:1238 [MEDLINE]

General Treatment

• The cost of treating community-acquired pneumonia. Clin Ther 1998; 20: 820–37 [MEDLINE]

Antibiotics

• Variations in etiology of ventilator-associated pneumonia across four treatment sites: implications for antimicrobial prescribing practices. Am J Respir Crit Care Med. 1999;160(2):608-613 [MEDLINE]
• PneumA Trial. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003;290(19):2588-2598 [MEDLINE]
• Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med 2004; 164:637–44 [MEDLINE]
• De-escalation in lower respiratory tract infections. Curr Opin Pulm Med. 2006;12(5):364-368 [MEDLINE]
• De-escalation therapy in ventilator-associated pneumonia. Curr Opin Crit Care. 2006;12(5):452-457 [MEDLINE]
• Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia. Chest 2006; 129:1210–1218 [MEDLINE]
• Antibiotic stewardship: overcoming implementation barriers. Curr Opin Infect Dis. 2011;24(4): 357-362 [MEDLINE]
• Antimicrobial stewardship programs: mandatory for all ICUs. Crit Care. 2012;16:179. doi:10.1186/cc11853 [MEDLINE]
• Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome. Crit Care Med. 2013;41:2099–2107. doi: 10.1097/CCM.0b013e31828e9863 [MEDLINE]
• Efficacy of single-dose antibiotic against early-onset pneumonia in comatose patients who are ventilated. Chest. 2013 May;143(5):1219-25. doi: 10.1378/chest.12-1361 [MEDLINE]
• Antibiotic stewardship in hospital-acquired pneumonia. Chest. 2013;143:1195–1196. doi:10.1378/chest.12-2729 [MEDLINE]
• Association of azithromycin with mortality and cardiovascular events among older patients hospitalized with pneumonia. JAMA. 2014 Jun 4;311(21):2199-208. doi: 10.1001/jama.2014.4304 [MEDLINE]
• What can be expected from antimicrobial de-escalation in the critically ill? Intensive Care Med 2014; 40:92–5 [MEDLINE]
• CAP-START Trial. Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med. 2015 Apr 2;372(14):1312-23. doi: 10.1056/NEJMoa1406330 [MEDLINE]
• A Systematic Review of the Definitions, Determinants, and Clinical Outcomes of Antimicrobial De-escalation in the Intensive Care Unit. Clin Infect Dis. 2016 Apr 15;62(8):1009-17. doi: 10.1093/cid/civ1199. Epub 2015 Dec 23 [MEDLINE]
• Duration of Antibiotic Treatment in Community-Acquired Pneumonia
  A Multicenter Randomized Clinical Trial. JAMA Intern Med. 2016 Jul 25. doi: 10.1001/jamainternmed.2016.3633 [MEDLINE]

Corticosteroids

• Adjuvant steroid therapy in community-acquired pneumonia: a systematic review and meta-analysis. J Hosp Med. 2013 Feb;8(2):68-75 [MEDLINE]

Respiratory Support

• Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med. 1999 Nov;160(5 Pt 1):1585-91 [MEDLINE]
• Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. Thorax. 1995 Jul;50(7):755-7 [MEDLINE]
• Predictors of failure of noninvasive ventilation in patients with severe community-acquired pneumonia. J Crit Care. 2010 Sep;25(3):540.e9-14. doi: 10.1016/j.jcrc.2010.02.012 [MEDLINE]
• The role of noninvasive positive pressure ventilation in community-acquired pneumonia. J Crit Care. 2015 Feb;30(1):49-54. doi: 10.1016/j.jcrc.2014.09.021. Epub 2014 Oct 2 [MEDLINE]

Prognosis

• Readmission following hospitalization for pneumonia: the impact of pneumonia type and its implication for hospitals. Clin Infect Dis. 2013 Aug;57(3):362-7 [MEDLINE]
  • Editorial commentary: “excess readmissions” for pneumonia: a dilemma with a penalty. Clin Infect Dis. 2013 Aug;57(3):368-9 [MEDLINE]