Optimizing D i ag n o s i s a nd

Management of Community-
a c q u i red Pn e u m o n i a i n th e
E m e r g e n c y De p a r t m e n t
Katherine M. Hunold, MD, MPHa,*, Elizabeth Rozycki, PharmD, BCPSb,
Nathan Brummel, MD, MSCIc

KEYWORDS
 Pneumonia  Community-acquired pneumonia  Diagnosis and management
 Emergency medicine

KEY POINTS
 Community-acquired pneumonia (CAP) is a common cause of emergency department
(ED) visit with higher mortality in the youngest and oldest patients.
 ED-specific guidelines do not recommend the routine use of polymerase-chain reaction
pathogen assays or other biomarkers to guide antibiotic initiation.
 Recommend empiric treatment for low-risk outpatients with no comorbidities is amoxi-
cillin or doxycycline. In patients with comorbidities and/or risk factors for resistant organ-
isms, this should be escalated to combination therapy with a beta-lactam and beta-
lactamase inhibitor plus doxycycline or a macrolide.
 Blood and sputum cultures should be obtained in patients with severe CAP and those initi-
ated on broad-spectrum antibiotics.

INTRODUCTION

Pneumonia is split into 3 diagnostic categories: community-acquired pneumonia

(CAP), health care-associated pneumonia, and ventilator-associated pneumonia.
This classification scheme is driven not only by the location of infection onset but
also by the predominant associated causal microorganisms. Pneumonia is diagnosed
in over 1.5 million US emergency department (ED) visits annually (1.2% of all visits),1

a
Department of Emergency Medicine, The Ohio State University, 376 W 10th Avenue, 760 Prior
Hall, Columbus, OH 43220, USA; b Emergency Medicine, Department of Pharmacy, The Ohio
State University, 376 W 10th Avenue, 760 Prior Hall, Columbus, OH 43220, USA; c Division of
Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State
University, 376 W 10th Avenue, 760 Prior Hall, Columbus, OH 43220, USA
* Corresponding author.
E-mail address: [email protected]

Emerg Med Clin N Am 42 (2024) 231–247

https://doi.org/10.1016/j.emc.2024.02.001 emed.theclinics.com
0733-8627/24/ª 2024 Elsevier Inc. All rights reserved.
232 Hunold et al

and most pneumonia diagnosed by emergency physicians is CAP. CAP is associated

with a low (1%) mortality rate in those treated as an outpatient but up to 50% mortality
of intensive care unit (ICU) patients; both the youngest and oldest age groups experi-
ence higher mortality.2 Further, it is estimated that one-third of hospitalized CAP
patients die within 1 year.3 Thus, a clear understanding of the most up-to-date diag-
nostic modalities and treatment recommendations is critical.

CURRENT GUIDELINES

The most current relevant guidelines for treatment of CAP in the ED are the 2019 In-
fectious Disease Society of American/American Thoracic Society (IDSA/ATS) CAP
guidelines,4 the 2020 American College of Emergency Physicians (ACEP) Clinical Pol-
icy,5 and the 2011 Pediatric Infectious Diseases Society and IDSA CAP pediatric
guidelines.6 Recently published recommendations from the European Respiratory So-
ciety, the European Society of Intensive Care Medicine, and Latin America Thoracic
Association provide guidelines specifically for the management of severe CAP.7

DIAGNOSTIC CRITERIA

Both the 2019 IDSA/ATS CAP guidelines4 and 2020 ACEP Clinical Policy5 define pneu-
monia as symptoms of pneumonia plus radiographic evidence of pneumonia. This
definition was not updated from previous guidelines, and at this time, this clinical/radio-
graphic combination definition is the diagnostic standard. However, these criteria have
significant limitations that must be considered by clinicians including but not limited to
their performance in certain populations and the accuracy of chest radiographs.
CAP is further classified into nonsevere or severe based on the acuity of illness. The
IDSA/ATS provide specific criteria for severe CAP that include factors such as specific
vital sign abnormalities and need for vasopressors or mechanical ventilation.4 Severe
CAP is defined by the presence of at least 1 major criterion or 3 minor criteria. Empiric
antibiotic recommendations vary depending on whether or not the patient meets se-
vere CAP criteria or has risk factors for infection with multidrug-resistant organisms.
Populations that require special therapeutic considerations include pediatrics, geriat-
rics, and those with recent international travel.

PATHOPHYSIOLOGY

In the most basic terms, pneumonia is an infection of the lungs. In the majority of
cases, causative organism enters through inhalation or migration from the upper res-
piratory tract or aspiration. While aspiration causes 5% to 15% of CAP8 and is tradi-
tionally associated with geriatric and comorbid patients, aspirating small volumes of
upper airway secretions can occur in young and healthy individuals during sleep.9
Rarely, pneumonia is caused by hematogenous spread, such as from right-sided
endocarditis.

CAUSES OF PNEUMONIA

CAPs are most commonly caused by single bacteria, virus or in rare circumstances
fungal organisms. Coinfections are rare but can also occur, particularly with a virus
and bacterial pathogen. The causative bacterial agents in CAP are classically identi-
fied, in order, as Streptococcus pneumoniae, Haemophilus influenzae, Staphylo-
coccus aureus, and gram-negative bacilli.10,11 Importantly, the “atypical” bacteria
are also important to consider as Mycoplasma is identified in 4% to 11% of CAP
and Legionella in 3% to 8%.11 A recent study that included only hospitalized CAP
 Community-acquired Pneumonia in the ED 233

patients with a “high-quality” sputum specimens identified a causative pathogen in

95.8%, with one-quarter being components of normal respiratory flora rather than
the bacterial pathogens classically implicated as earlier.12 The authors hypothesized
that aspiration of oral flora may been an important yet underappreciated cause of
CAP. A 2016 meta-analysis examined the use of viral polymerase chain reaction
(PCR) from upper airway swabs in adults with CAP; pooled estimates identified a
viral pathogen in 24.5% (95% CI 21.5%–27.5%). Only 2 studies in the review reported
on viral pathogens from lower respiratory specimens, with prevalence reported at
44.2%. Of note, coinfection by bacteria and viral pathogens doubled the odds of
death.10
Depending on the study, the most common causative pathogens identified varies,
likely due to the varying types of diagnostic modalities used, quality of specimens
and patient populations. For example, PCR assays may have higher diagnostic yield
than traditional culture methods but may also identify colonizing pathogens.13 This likely
explains why some studies have found higher rates of viral organisms and variations
based on age (see Special Populations later section).14,15 It is important to recognize
that diagnostic yield is directly related to the sample quality and consider ED-specific
barriers to optimal collection.16–19 For example, in the ED, expectorated sputum is
the primary sample source, which is associated with known quality limitations.20

COVID-19
The COVID-19 pandemic showed the potential for devastation from a novel viral pneu-
monia pathogen with young children (<1 year) and older adults being at highest risk of
mortality.21 Bacterial coinfection with SARS-CoV-2 estimates vary greatly with a
recent meta-analysis reporting a rate of approximately 7%.22–24 As with non-SARS-
CoV-2 infections, bacterial coinfection with SARS-CoV-2 is associated with increased
risk for severe disease (ICU admission, mechanical ventilation) and death.25 Public
health measures instituted during this pandemic decreased the transmission of other
common pneumonia pathogens.26 COVID-19 is discussed in detail elsewhere in this
issue.

Influenza
Prior to the COVID-19 pandemic, influenza was the most commonly identified cause of
viral CAP,10 with the young children (<5 years of age) and older adults (65 years of age)
at highest risk.27 Peaks of influenza activity occur seasonally.28 The 2019 IDSA/ATS
guidelines recommend rapid testing for influenza during peak times.4 Vaccination de-
creases influenza incidence and associated morbidity and mortality.29 Following the
release of the COVID-19 vaccine, influenza vaccination rates decreased,30 the impact
of which is yet to be determined.

DIAGNOSTIC MODALITIES

There are many potentially useful diagnostic modalities in pneumonia. Importantly, the
utility of the modalities may differ between the ED and inpatient settings. For example,
though frequently obtained in the ED, sputum and blood cultures take several days to
result and are therefore not available to ED physicians. Similarly, laboratory markers
with a single value may have limited value in the ED but may have clinical utility if
trended. Therefore, the following discussion is focused primarily on strategies used
in the ED. Nevertheless, we emphasize that studies that may not be useful in the ED
should still be sent to assist downstream clinicians caring for the patient after ED
disposition, particularly as it pertains to tailoring or de-escalation of antibiotic therapy.
234 Hunold et al

Chest Imaging
One component of the current standard definition of pneumonia is a positive chest
radiograph. However, a recent meta-analysis estimated the sensitivity and specificity
of a chest radiograph for pneumonia to be 75%.31 Debate exists in the literature
among experts about whether positive chest radiography should be required.32
Computed tomography (CT) has been proposed as a potential alternative imaging
test as it is more accurate and this has a demonstrated effect on clinical manage-
ment.33–35 Nevertheless, a recent trial showed no difference in short-term functional
health, hospital admissions, and length of stay, suggesting that though more pneumo-
nias may be detected with CT imaging, these findings may not improve patient out-
comes and therefore there is insufficient evidence to support a change in the
standard of care.36 Further research is needed before a definitive recommendation
can be made about whether CT imaging should be used routinely to diagnose CAP.
The question remains—what should clinicians do with (1) high clinical suspicion and
negative chest radiograph and (2) low clinical suspicion and a vague chest radiograph
report? Based on the available evidence and current guidelines, we recommend treat-
ing empirically in both above cases. The primary driver for this recommendation is the
phenomenon of delayed or initially negative chest radiograph findings37,38 and data
showed positive CT findings of pneumonia with negative chest radiographs.33–36,39
Further, this is consistent with current IDSA/ATS guidelines that no laboratory test
currently exists to reliably and rapidly differentiate viral from bacterial causes of
pneumonia5.4
Ultrasound is another tool that emergency physicians can use to identify lung pa-
thology, including CAP. Lung ultrasound can narrow the differential diagnosis in ED
patients with dyspnea.40 One study demonstrated good accuracy of emergency
physician performed lung ultrasound compared to chest radiograph for pneumonia
diagnosis.41 However, this study enrolled a convenience sample, and ultrasounds
were performed by physicians with ultrasound training and 2 or more years of expe-
rience, limiting generalizability. Another recent study failed to demonstrate an advan-
tage of ultrasound over chest radiograph.42 We recommend considering the use of
lung ultrasound, particularly by emergency physicians with ultrasound training, partic-
ularly as a “rule in” rather than “rule out” tool, pending further studies.

Blood and Sputum Culture

Although the results of blood and sputum cultures will not be available to emergency
physicians when making treatment decisions, it is important that emergency physicians
understand when to send these prior to antibiotic treatment. The 2019 IDSA/ATS guide-
lines recommend blood and sputum cultures in “patients with severe disease as well as
in all inpatients initiated on empiric therapy that includes coverage for Methicillin-resis-
tant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa.” Additionally, the
IDSA/ATS guidelines provide conditional recommendations to obtain blood and
sputum cultures in patients who “were previously infected with MRSA or P aeruginosa
or were hospitalized and received parenteral antibiotics in the last 90 days.” A recent
observational cohort study confirms that the highest utility of blood culture is in patients
with severe CAP (14.7% with bacteremia).43 The centers for medicare & medicaid ser-
vices (CMS) SEP-144 mandate to obtain blood cultures prior administering antibiotics in
patients being admitted with signs of sepsis may further expand the group of patients
requiring blood cultures.
Utility of sputum culture depends on a good quality specimen and the ability to
obtain high-quality sputum specimens in EDs has been questioned. A recent study
 Community-acquired Pneumonia in the ED 235

demonstrated that tracheal suction has superior quality to expiratory techniques45 In

the ED, tracheal suction can be readily performed only in intubated patients. Impor-
tantly, a recent study demonstrated that no ED empiric antibiotic choices were
changed by sputum culture results when available.46 Advances in point of care testing,
such as PCR tests (see later discussion), may lead to better tools for determining CAP
etiology from sputum specimens and potentially affecting ED treatment decisions.
Urine Antigen Detection
Urine antigen testing is available for S pneumoniae and Legionella pneumophila.47 The
IDSA/ATS guidelines do not recommend routinely testing for these causes except in 2
clinical scenarios: (1) based on epidemiologic factors and (2) in those with severe CAP.
Epidemiologic factors include known Legionella outbreak or recent travel to high-risk
areas.4 Their reasoning is that testing did not change patient-centered outcomes
including death, clinical relapse, ICU admission, hospital length of stay, duration of
antibiotic treatment, or cost of treatment.48,49
In the appropriate geographic area, emergency providers should consider testing
for histoplasmosis, coccidioidomycosis, or blastomycosis with urine testing or IgG/
IgM depending on standard at your hospital and can assist with early detection
but is not the gold standard test (identification via culture or histologic
examination).50
The ACEP guidelines do not recommend withholding or altering initial ED antibiotic
treatment based on the result of urinary antigen tests5 due to low rates of definitive
cause identification in previous literature. Of note, due to frequent colonization, urinary
antigen tests are not recommended in children.51
Polymerase Chain Reaction Pathogen Identification
Recent guidelines agree that there is low evidence for the routine use of viral pathogen
PCR assays in CAP.4,5,7 This is because the exact meaning of positive results is un-
known as it may represent only asymptomatic upper respiratory colonization, coinfec-
tion or prior infection, rather than the cause of lower respiratory infection; for example,
one-quarter of asymptomatic children had a positive test.51,52 Newly available PCR
assays that include bacterial and viral targets utilize sputum or bronchial samples.
However, as previously mentioned, obtaining high-quality sputum samples in the
ED is challenging and will impact the diagnostic yield of such assays.20 Bronchiolar
lavage likely provides better accuracy, but it is not feasible for routine use in the ED.
However, counter-arguments emerging in the literature should be considered. A
recent study demonstrated high agreement of PCR testing between oropharyngeal
samples and lower respiratory tract samples in ED patients with CAP.53 Therefore,
the authors recommend determining the potential utility in your own practice based
on (1) quality of procedures for sputum collection in your ED and (2) which pathogens
are included on your hospital’s panel.
Methicillin-resistant Staphylococcus aureus Polymerase Chain Reaction
Nasal MRSA PCR swabs are primarily used for de-escalation, stopping anti-MRSA
therapy in patients who were initially covered for MRSA empirically. While unable to
distinguish infection from colonization, the negative predictive value for MRSA pneu-
monia using the nasal swab ranges from 75% to 99%.4,54,55
Host-response Biomarkers
No available biomarker, in isolation, can reliably identify the presence of pneumonia or
differentiate viral from bacterial pneumonia. Neither ACEP nor IDSA/ATS currently
236 Hunold et al

recommend their routine use.5 However, this is an ongoing area of research and it is
unclear how these assays may perform in combination (eg, viral PCR plus biomarkers)
and in conjunction with estimates of pretest probability.
Procalcitonin
Procalcitonin as a laboratory marker of bacterial pneumonia deserves specific discus-
sion, as research is ongoing and rapidly expanding. The traditional critique of procal-
citonin is that a single value cannot be used to determine decision making. However, a
recent study compared the outcomes of patients with suspected viral lower respira-
tory infection and low procalcitonin randomized to azithromycin or placebo and
demonstrated noninferiority.56 Experts debating the strengths and limitations of this
study conclude that using procalcitonin in this manner, which could be directly applied
to EDs, be considered.57 However, the largest ED-based US trial, ProACT Trial,
demonstrated minimal differences in antibiotic prescribing and no difference in short-
or long-term mortality between those treated on a procalcitonin-guided pathway or
not.58–60 The lack of effect on antibiotic prescribing was in part driven by providers
not following the procalcitonin guidance, suggesting lack of confidence in the test
may be a barrier to adoption. Additionally, emergency providers may be asked to
obtain procalcitonin because serial procalcitonin measurements may have utility in
de-escalating inpatient antibiotic therapy61,62
MeMed BV
Since the publication of existing guidelines, MeMed BV (MeMed Diagnostics, Ltd)
was Food and Drug Administration (FDA)-approved as a test to differentiate bacterial
and viral respiratory infections. A recent study in the US ED demonstrated that while
the test is clinically feasible, less than half of the MeMed BV results were viewed prior
to administration of antibiotics.63 Thus, while the data on MeMed BV are promising,
further study on both implementation and outcomes are necessary before a definitive
recommendation can be made.

RISK STRATIFICATION

There are many risk stratification tools available for CAP to aid the clinician in deciding
appropriate patient disposition (eg, discharge, hospital admission, or ICU admission).
Validated clinical decision rules include the Pneumonia Severity Index (PSI),64 CURB-
65,65 and A-DROP.66 For ED use, the ACEP guidelines recommend PSI and CURB-65
to support clinical judgment to assess which patients may be appropriate for
discharge. The IDSA/ATS favor PSI over CURB-65.4 A recent study showed similar
performance between CURB-65 and A-DROP in ED patients.67 The ACEP guidelines
recommend using the IDSA/ATS minor criteria (see Table 1) to assess need for ICU
admission.5 However, the results of recent literature have been mixed regarding clin-
ical utility of such tools in the ED68,69 supporting the ACEP guideline assertion that
these should only be one part of clinician decision-making.

SPECIAL POPULATIONS
Pediatrics
The 2011 Pediatric Infectious Diseases Society and IDSA CAP pediatric guidelines
are the current standard.6 The most common cause of pneumonia in pediatric
patients is viruses. The advent of widespread vaccine use has decreased the inci-
dence of CAP caused by Haemophilus influenzae type B and Pneumococcal
pneumoniae.51,70
 Community-acquired Pneumonia in the ED 237

Pediatric symptoms of pneumonia are hard to distinguish from other causes of res-
piratory illness.51 Treatment with antibiotics was previously guided by the World
Health Organization respiratory rate criteria70; the goal of this criterion was to identify
children at risk of death. A more recent systematic review did not find tachypnea asso-
ciated with pneumonia. Instead, hypoxemia and work of breathing were associated
with pneumonia diagnosis.70,71
Importantly, the guidelines recommend avoiding routine use of chest radiography in
patients well enough to be treated as an outpatient (discharged from the ED).6 Emer-
gency physicians should be aware of these guidelines as a recent paper suggests
overuse of chest radiograph.72 Further, the use of diagnostic modalities for pediatric
patients with fever differs between general and pediatric EDs.73 Thus, emergency phy-
sicians should aim to follow the guidelines and only obtain chest radiograph in pedi-
atric patients when admission is required.

Geriatrics
Pneumonia incidence74-related hospitalizations15 and in-hospital mortality75 all in-
crease with age. Because 3 out of 4 adults 65 years of age who are hospitalized
with pneumonia are initially treated in the ED,76 emergency providers must know
how to maximize diagnostic accuracy in this population. Unfortunately, CAP in older
adults poses a diagnostic challenge to emergency physicians and our inpatient col-
leagues.77,78 Geriatric-specific factors that contribute to this challenge include atypical
presentations17,18,79–84; having fewer specific symptoms (ie, shortness of breath, fever)
than young patients; reduced accuracy of chest radiographs85; and presence of comor-
bidities that can mimic CAP.86,87 The utility of the current clinical definition of pneumonia
is unknown in this population, and geriatric-specific pneumonia diagnostic criteria have
been developed in non-ED health care settings.88,89 While older adults residing in long-
term care facilities are also at risk for drug-resistant organisms,90 the current guidelines
do not recommend any changes to standard risk factor-based empiric therapy in older
adults with nonsevere CAP, regardless of living situation.4

Recent Foreign Travel

Depending on the site of recent travel, pulmonary symptoms in a returning traveler
may have an atypical cause based on location; for example, in travelers to South
and Central Asia, diphtheria, tuberculosis, and avian flu are common but rare causes
such as Nipah virus may need to be considered.91,92 Clinicians should consider testing
and treatment for atypical causes based on endemic and potential novel pulmonary
diseases found in the areas of recent travel. The Centers for Disease Control and Pre-
vention (CDC) maintains online resources for clinicians including but not limited to re-
gions of common exposure, presentation, incubation periods, and treatment.93 An
infectious disease specialist should also be consulted, when there is suspicion of
pneumonia due to an unusual or novel pathogen acquired while traveling. For
example, at the time of this writing, the CDC includes COVID-19, avian influenza, Mid-
dle East respiratory syndrome, among others for consideration.93

Immunocompromised
Immunocompromised patients are at higher risk for atypical causes of pneumonia
across the age span,51,94 but there is no consensus on how this should affect the
empiric antibiotic treatment.94 Immunocompromised patients are excluded from the
CAP guidelines. Clinicians should consider early infectious disease consultation in
these patients.
238 Hunold et al

Patients at Risk for Aspiration

Aspiration pneumonia has been proposed as a common cause of pneumonia, partic-
ularly in older adults.95–97 Whether or not anaerobic coverage is necessary in sus-
pected aspiration, pneumonia is not clear according to a recent systematic review
and meta-analysis.98 The IDSA/ATS guidelines suggest only adding anaerobic
coverage if lung abscess or empyema is suspected.4

TREATMENT RECOMMENDATIONS

The IDSA/ATS guidelines state, and the ACEP agrees, “there is no current diagnostic
test accurate enough or fast enough to determine that CAP is solely due to a virus at
presentation, our recommendations are to initially treat empirically for possible bacte-
rial infection or coinfection.”4 Thus, empiric treatment with antibiotics is the current
recommendation. The COVID-19 pneumonia may represent an exception to this
recommendation. Empiric therapy recommendations in this section focus on the adult
population. For outpatients with no comorbidities, treatment primarily focuses on
coverage of S pneumoniae with either amoxicillin or doxycycline (Table 1). Doxycy-
cline has the advantage that it covers atypical organisms and may provide H influenza
and S aureus coverage. While azithromycin monotherapy historically has been used
for outpatient pneumonia, macrolide resistance has increased and azithromycin
should only be used if a local antibiogram shows macrolide resistance of less than
25%. Many patients presenting to the ED with pneumonia will have additional comor-
bidities placing them at risk for resistant pathogens and poor outcomes if initial empiric
therapy is inadequate. Thus, in addition to S pneumoniae coverage, outpatients with
significant comorbidities should receive a regimen that covers H influenzae and Mor-
axella catarrhalis, S aureus, some gram-negative bacteria, and atypical pathogens.
This can be accomplished with either combination therapy consisting of a beta-
lactam and a beta-lactamase inhibitor (amoxicillin-clavulanate) plus doxycycline or a
macrolide or monotherapy with a respiratory fluoroquinolone (levofloxacin or moxiflox-
acin). However, providers should consider the potential for collateral damage with flu-
oroquinolones, including tendinitis, tendon rupture, and peripheral and central
nervous system effects. Additionally, a new fluoroquinolone black box warning was is-
sued in 2018 regarding risk for aortic aneurysm or dissection and potential mental
health side effects.99 These black box warnings pertain to older adult patients
disproportionately.
For patients being admitted to the hospital, a beta-lactam plus a macrolide or doxy-
cycline are the favored combination,4,7 but local resistance patterns as well as patient-
specific risk factors will strongly impact the recommended empiric therapy (see
Table 1). The IDSA/ATS guidelines focus on previous growth of MRSA or P aeruginosa
from respiratory cultures, hospitalization with parenteral antibiotics in the past 90 days
as risk factors that should prompt broad-spectrum empiric therapy. The guidelines
also encourage the development of locally validated risk factors for MRSA or P aeru-
ginosa when selecting empiric regimens; the feasibility of this recommendation and
the potential impact on ED empiric therapy selection have just begun to be studied.100
In patients receiving empiric therapy for MRSA and P aeruginosa, it is important to
obtain sputum cultures and nasal MRSA PCR screening, which if negative may allow
de-escalation and less exposure to broad-spectrum antibiotics.
There are recent data confirming that patients meeting the IDSA/ATS criteria for se-
vere CAP4 have higher rates of positive blood cultures and higher organ failure scores
and mortality. While a resistant organism was isolated in about 10% of these cases,
which supports maintaining a low threshold for broad empiric coverage in severe
Table 1
Antimicrobial treatment considerations

Setting and Severity Patient Characteristics Antimicrobial Recommendations

Outpatient No comorbidities or risk factors for MRSA or P Amoxicillin (high dose)
aeruginosa OR
Doxycycline
OR
Macrolidea (only if local pneumococcal resistance is
<25%)
Comorbidities, including chronic heart, lung, liver or Combination therapy
renal disease, diabetes mellitus, alcoholism,  Amoxicillin/clavulanate OR cephalosporinb
malignancy, or asplenia  Atypical coverage (doxycycline OR macrolide)a
OR
Respiratory fluoroquinolone monotherapyc,d
Inpatient, nonsevere pneumonia No prior respiratory cultures with MRSA or P aeruginosa Beta-lactame PLUS atypical coveragea
OR Respiratory fluoroquinolone monotherapyc,d

Community-acquired Pneumonia in the ED

Prior respiratory isolate with MRSA or local validated Add vancomycin or linezolid
risk factors for MRSA f
Prior respiratory isolate with P aeruginosa within 1 y, Antipseudomonal beta-lactamh PLUS atypical
local validated risk factors or advanced structural coveragea OR respiratory fluoroquinolone
lung diseasef
Recent hospitalization with parenteral antibioticsf,h Beta-lactame PLUS macrolidea
OR
Respiratory fluoroquinolone monotherapyc,d

(continued on next page)

239
 240
Hunold et al
Table 1
(continued )
Setting and Severity Patient Characteristics Antimicrobial Recommendations
Inpatient, severe pneumonia No prior respiratory cultures with MRSA or P aeruginosa Beta-lactame PLUS macrolidea
OR
Respiratory fluoroquinolone monotherapyc,d
Prior respiratory isolate with MRSAf or recent Beta-lactamf PLUS macrolidea
hospitalization with parenteral antibiotics and locally OR
validated risk factors for MRSAf Respiratory fluoroquinolonec,d
PLUS vancomycin or linezolid
Prior respiratory isolate with P aeruginosag or recent Antipseudomonal beta-lactamh PLUS macrolidea
hospitalization with parenteral antibiotics and locally
validated risk factors for P aeruginosag
a
Azithromycin, clarithromycin, or doxycycline.
b
Cefpodoxime, cefuroxime.
c
Levofloxacin, moxifloxacin, gemifloxacin
d
Fluoroquinolones should be reserved only if other agents are not clinically appropriate given the potential risks (hypoglycemia, mental status changes, effects on
tendons, joint, muscles and nerves, and aortic aneurysm/dissection)105.
e
Ampicillin/sulbactam, cefotaxime, ceftriaxone.
f
Obtain cultures and/or nasal MRSA PCR.
g
Should be driven by local antibiogram but may include piperacillin/tazobactam, cefepime, ceftazidime, imipenem, meropenem, or aztreonam.
h
Only initiate coverage for MRSA if results positive.
 Community-acquired Pneumonia in the ED 241

CAP, a much higher proportion received vancomycin and/or piperacillin–tazobac-

tam.101 These findings underscore the recommendation above to obtain all appropriate
diagnostic studies, which might allow later de-escalation of broad-spectrum therapy.
A common clinical practice in EDs is to give 1 dose of intravenous antibiotics fol-
lowed by initiation of an oral regimen, based on factors such as antimicrobial bioavail-
ability, intestinal absorption, and ability to tolerate oral medications. The ACEP found a
lack of evidence to support or refute this practice.5 In the absence of clear clinical
benefit, increased cost and potential increased length of ED stay, we do not advise
this practice.
A routine addition of corticosteroids to antibiotics in CAP is not recommended.4
Recently published studies evaluating the use of hydrocortisone and methylpredniso-
lone in patients with severe CAP have shown mixed results, though the expert
consensus seems favor giving steroids in this setting.102,103 Additionally, corticoste-
roids may have a role in patients with shock, acute respiratory distress syndrome
and COVID-19 pneumonia.4,7
The recommended duration of antimicrobial therapy for CAP is a minimum of 5 days,
depending on the antibiotic and measures of clinical stability and improvement.4 For
patients being discharged from the ED, a prescription for 5 days of therapy is often
appropriate. Clear discharge instructions should be provided regarding expected re-
covery and return precautions. A recent randomized controlled trial comparing anti-
biotic duration in pediatric CAP found that a 5 day course was superior to 10 days.104

SUMMARY

The core principles of pneumonia diagnosis have not changed since 2018. However,
the literature regarding diagnostic modalities and treatment strategies is rapidly
changing. Keeping abreast of guidelines on CAP diagnosis and treatment is therefore
critical for high-quality clinical care. Clinicians should consider specific challenges in
certain populations (eg, pediatrics, geriatrics, and international travelers) as well as
patient-specific risk factors when selecting empiric antimicrobial therapy.

DISCLOSURE

Dr K.M. Hunold is funded by the NIH under award K76AG074941 and R01AG071018. Dr
N. Brummel is supported by the NIH under awards R01HD107103 and R01AG077644.

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