Community-acquired pneumonia in adults: Risk stratification and the decision to admit
- Donald M Yealy, MD, FACEP
Donald M Yealy, MD, FACEP
- Professor and Chair of Emergency Medicine
- University of Pittsburgh
- Michael J Fine, MD, MSc
Michael J Fine, MD, MSc
- Professor of Medicine
- University of Pittsburgh and VA Pittsburgh Healthcare System
Community-acquired pneumonia (CAP) is a common and potentially serious illness, accounting for the single largest group of sepsis-triggering events. It is associated with considerable morbidity and mortality, particularly in older adult patients and those with coexisting comorbidities. (See "Prognosis of community-acquired pneumonia in adults".)
Hospital admission rates in the United States for adults with CAP vary widely and are often not directly related to local disease severity, suggesting that clinicians use inconsistent criteria when making the initial decision about the appropriate site of care. In addition, clinicians often overestimate patient risk of short-term mortality, even among low-risk patients . A likely consequence of these overestimates is unnecessary admissions; low-risk patients with a physician-estimated risk of death in excess of 5 percent were over six times more likely to be hospitalized after adjusting for other potential confounders of hospitalization .
This topic review focuses on clinical prediction rules and practice guidelines to determine the initial site of treatment for CAP and to avoid unnecessary hospitalizations.
A variety of other important issues related to CAP are discussed separately. These include:
●The diagnostic approach to patients with CAP. (See "Diagnostic approach to community-acquired pneumonia in adults".)
- Fine MJ, Hough LJ, Medsger AR, et al. The hospital admission decision for patients with community-acquired pneumonia. Results from the pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med 1997; 157:36.
- Fine MJ, Hanusa BH, Lave JR, et al. Comparison of a disease-specific and a generic severity of illness measure for patients with community-acquired pneumonia. J Gen Intern Med 1995; 10:359.
- Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336:243.
- Community-acquired pneumonia in adults in British hospitals in 1982-1983: a survey of aetiology, mortality, prognostic factors and outcome. The British Thoracic Society and the Public Health Laboratory Service. Q J Med 1987; 62:195.
- Black ER, Mushlin AI, Griner PF, et al. Predicting the need for hospitalization of ambulatory patients with pneumonia. J Gen Intern Med 1991; 6:394.
- Daley J, Jencks S, Draper D, et al. Predicting hospital-associated mortality for Medicare patients. A method for patients with stroke, pneumonia, acute myocardial infarction, and congestive heart failure. JAMA 1988; 260:3617.
- Fine MJ, Orloff JJ, Arisumi D, et al. Prognosis of patients hospitalized with community-acquired pneumonia. Am J Med 1990; 88:1N.
- Fine MJ, Smith DN, Singer DE. Hospitalization decision in patients with community-acquired pneumonia: a prospective cohort study. Am J Med 1990; 89:713.
- Keeler EB, Kahn KL, Draper D, et al. Changes in sickness at admission following the introduction of the prospective payment system. JAMA 1990; 264:1962.
- Kurashi NY, al-Hamdan A, Ibrahim EM, et al. Community acquired acute bacterial and atypical pneumonia in Saudi Arabia. Thorax 1992; 47:115.
- Marrie TJ, Durant H, Yates L. Community-acquired pneumonia requiring hospitalization: 5-year prospective study. Rev Infect Dis 1989; 11:586.
- Ortqvist A, Hedlund J, Grillner L, et al. Aetiology, outcome and prognostic factors in community-acquired pneumonia requiring hospitalization. Eur Respir J 1990; 3:1105.
- Porath A, Schlaeffer F, Lieberman D. Appropriateness of hospitalization of patients with community-acquired pneumonia. Ann Emerg Med 1996; 27:176.
- Torres A, Serra-Batlles J, Ferrer A, et al. Severe community-acquired pneumonia. Epidemiology and prognostic factors. Am Rev Respir Dis 1991; 144:312.
- Conte HA, Chen YT, Mehal W, et al. A prognostic rule for elderly patients admitted with community-acquired pneumonia. Am J Med 1999; 106:20.
- Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58:377.
- España PP, Capelastegui A, Gorordo I, et al. Development and validation of a clinical prediction rule for severe community-acquired pneumonia. Am J Respir Crit Care Med 2006; 174:1249.
- Wasson JH, Sox HC, Neff RK, Goldman L. Clinical prediction rules. Applications and methodological standards. N Engl J Med 1985; 313:793.
- Atlas SJ, Benzer TI, Borowsky LH, et al. Safely increasing the proportion of patients with community-acquired pneumonia treated as outpatients: an interventional trial. Arch Intern Med 1998; 158:1350.
- Marrie TJ, Lau CY, Wheeler SL, et al. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin. JAMA 2000; 283:749.
- Yealy DM, Auble TE, Stone RA, et al. Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial. Ann Intern Med 2005; 143:881.
- Carratalà J, Fernández-Sabé N, Ortega L, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med 2005; 142:165.
- Marrie TJ, Huang JQ. Low-risk patients admitted with community-acquired pneumonia. Am J Med 2005; 118:1357.
- Labarere J, Stone RA, Obrosky DS, et al. Comparison of outcomes for low-risk outpatients and inpatients with pneumonia: A propensity-adjusted analysis. Chest 2007; 131:480.
- Labarere J, Stone RA, Scott Obrosky D, et al. Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial. J Gen Intern Med 2006; 21:745.
- Metlay JP, Atlas SJ, Borowsky LH, Singer DE. Time course of symptom resolution in patients with community-acquired pneumonia. Respir Med 1998; 92:1137.
- Renaud B, Coma E, Labarere J, et al. Routine use of the Pneumonia Severity Index for guiding the site-of-treatment decision of patients with pneumonia in the emergency department: a multicenter, prospective, observational, controlled cohort study. Clin Infect Dis 2007; 44:41.
- Mandell L. Decisions about treating community-acquired pneumonia. Ann Intern Med 2005; 142:215.
- Chalmers JD, Akram AR, Hill AT. Increasing outpatient treatment of mild community-acquired pneumonia: systematic review and meta-analysis. Eur Respir J 2011; 37:858.
- Marrie TJ. The Pneumonia Severity Index score: time to move to a prospective study of patients with community-acquired pneumonia who are discharged from emergency departments to be managed on an ambulatory basis. Clin Infect Dis 2007; 44:50.
- Chalmers JD, Singanayagam A, Hill AT. Predicting the need for mechanical ventilation and/or inotropic support for young adults admitted to the hospital with community-acquired pneumonia. Clin Infect Dis 2008; 47:1571.
- Bauer TT, Ewig S, Marre R, et al. CRB-65 predicts death from community-acquired pneumonia. J Intern Med 2006; 260:93.
- Aujesky D, Auble TE, Yealy DM, et al. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med 2005; 118:384.
- Yandiola PP, Capelastegui A, Quintana J, et al. Prospective comparison of severity scores for predicting clinically relevant outcomes for patients hospitalized with community-acquired pneumonia. Chest 2009; 135:1572.
- Charles PG, Wolfe R, Whitby M, et al. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008; 47:375.
- Mandell LA. Severe community-acquired pneumonia (CAP) and the Infectious Diseases Society of America/American Thoracic Society CAP guidelines prediction rule: validated or not. Clin Infect Dis 2009; 48:386.
- Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
- Liapikou A, Ferrer M, Polverino E, et al. Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission. Clin Infect Dis 2009; 48:377.
- Chalmers JD, Taylor JK, Mandal P, et al. Validation of the Infectious Diseases Society of America/American Thoratic Society minor criteria for intensive care unit admission in community-acquired pneumonia patients without major criteria or contraindications to intensive care unit care. Clin Infect Dis 2011; 53:503.
- Majumdar SR, Eurich DT, Gamble JM, et al. Oxygen saturations less than 92% are associated with major adverse events in outpatients with pneumonia: a population-based cohort study. Clin Infect Dis 2011; 52:325.
- Marrie TJ. Pneumonia in the long-term-care facility. Infect Control Hosp Epidemiol 2002; 23:159.
- Loeb M, McGeer A, McArthur M, et al. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. Arch Intern Med 1999; 159:2058.
- Gill TM, Allore HG, Holford TR, Guo Z. Hospitalization, restricted activity, and the development of disability among older persons. JAMA 2004; 292:2115.
- Loeb M, Carusone SC, Goeree R, et al. Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial. JAMA 2006; 295:2503.
- CLINICAL PREDICTION RULES FOR SEVERITY
- Pneumonia Severity Index
- - Methods
- - Results
- - Potential admission strategies
- - Limitations
- - Effectiveness and safety
- - Other applications
- CURB-65 score
- - Comparison to PSI
- Severe community-acquired pneumonia score
- PRACTICE GUIDELINES
- Site of treatment
- Admission to intensive care
- OXYGEN SATURATION
- NURSING HOME RESIDENTS
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS