Treatment of community-acquired pneumonia in adults in the outpatient setting
- Thomas M File, Jr, MD
Thomas M File, Jr, MD
- Professor of Medicine
- Northeast Ohio Medical University
Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma in a patient who has acquired the infection in the community, as distinguished from hospital-acquired (nosocomial) pneumonia (HAP).
CAP is a common and potentially serious illness [1-4]. It is associated with considerable morbidity and mortality, particularly in older adult patients and those with major comorbidities. (See "Prognosis of community-acquired pneumonia in adults".)
The treatment of CAP in adults in the outpatient setting will be reviewed here. 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".)
●How one makes the decision to admit patients with CAP to the hospital. (See "Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care".)
- File TM. Community-acquired pneumonia. Lancet 2003; 362:1991.
- 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.
- Wunderink RG, Waterer GW. Clinical practice. Community-acquired pneumonia. N Engl J Med 2014; 370:543.
- Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med 2014; 371:1619.
- American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388.
- Kalil AC, Metersky ML, Klompas M, et al. 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. Clin Infect Dis 2016; 63:e61.
- Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis 2014; 58:330.
- Gross AE, Van Schooneveld TC, Olsen KM, et al. Epidemiology and predictors of multidrug-resistant community-acquired and health care-associated pneumonia. Antimicrob Agents Chemother 2014; 58:5262.
- Yap V, Datta D, Metersky ML. Is the present definition of health care-associated pneumonia the best way to define risk of infection with antibiotic-resistant pathogens? Infect Dis Clin North Am 2013; 27:1.
- Shorr AF, Zilberberg MD, Reichley R, et al. Validation of a clinical score for assessing the risk of resistant pathogens in patients with pneumonia presenting to the emergency department. Clin Infect Dis 2012; 54:193.
- Webb BJ, Dascomb K, Stenehjem E, et al. Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score. Antimicrob Agents Chemother 2016; 60:2652.
- Marrie TJ, Shariatzadeh MR. Community-acquired pneumonia requiring admission to an intensive care unit: a descriptive study. Medicine (Baltimore) 2007; 86:103.
- 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.
- Metlay JP, Fine MJ. Testing strategies in the initial management of patients with community-acquired pneumonia. Ann Intern Med 2003; 138:109.
- 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.
- Jain S, Self WH, Wunderink RG, et al. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med 2015; 373:415.
- Marrie TJ, Poulin-Costello M, Beecroft MD, Herman-Gnjidic Z. Etiology of community-acquired pneumonia treated in an ambulatory setting. Respir Med 2005; 99:60.
- Lim WS, Macfarlane JT, Boswell TC, et al. Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax 2001; 56:296.
- Malcolm C, Marrie TJ. Antibiotic therapy for ambulatory patients with community-acquired pneumonia in an emergency department setting. Arch Intern Med 2003; 163:797.
- Read RC. Evidence-based medicine: empiric antibiotic therapy in community-acquired pneumonia. J Infect 1999; 39:171.
- File TM Jr, Niederman MS. Antimicrobial therapy of community-acquired pneumonia. Infect Dis Clin North Am 2004; 18:993.
- Kuster SP, Rudnick W, Shigayeva A, et al. Previous antibiotic exposure and antimicrobial resistance in invasive pneumococcal disease: results from prospective surveillance. Clin Infect Dis 2014; 59:944.
- Chalmers JD, Al-Khairalla M, Short PM, et al. Proposed changes to management of lower respiratory tract infections in response to the Clostridium difficile epidemic. J Antimicrob Chemother 2010; 65:608.
- Lim WS, Baudouin SV, George RC, et al. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009; 64 Suppl 3:iii1.
- Johnstone J, Mandell L. Guidelines and quality measures: do they improve outcomes of patients with community-acquired pneumonia? Infect Dis Clin North Am 2013; 27:71.
- National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. https://www.nice.org.uk/guidance/cg191/resources/pneumonia-in-adults-diagnosis-and-management-35109868127173 (Accessed on March 11, 2016).
- Arnold FW, Summersgill JT, Lajoie AS, et al. A worldwide perspective of atypical pathogens in community-acquired pneumonia. Am J Respir Crit Care Med 2007; 175:1086.
- Daneman N, McGeer A, Green K, et al. Macrolide resistance in bacteremic pneumococcal disease: implications for patient management. Clin Infect Dis 2006; 43:432.
- Low DE. What is the relevance of antimicrobial resistance on the outcome of community-acquired pneumonia caused by Streptococcus pneumoniae? (should macrolide monotherapy be used for mild pneumonia?). Infect Dis Clin North Am 2013; 27:87.
- Vanderkooi OG, Low DE, Green K, et al. Predicting antimicrobial resistance in invasive pneumococcal infections. Clin Infect Dis 2005; 40:1288.
- File TM Jr, Garau J, Blasi F, et al. Guidelines for empiric antimicrobial prescribing in community-acquired pneumonia. Chest 2004; 125:1888.
- Mills GD, Oehley MR, Arrol B. Effectiveness of beta lactam antibiotics compared with antibiotics active against atypical pathogens in non-severe community acquired pneumonia: meta-analysis. BMJ 2005; 330:456.
- Li JZ, Winston LG, Moore DH, Bent S. Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis. Am J Med 2007; 120:783.
- Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, et al. Short- versus long-course antibacterial therapy for community-acquired pneumonia : a meta-analysis. Drugs 2008; 68:1841.
- Metlay JP, Atlas SJ, Borowsky LH, Singer DE. Time course of symptom resolution in patients with community-acquired pneumonia. Respir Med 1998; 92:1137.
- Marrie TJ, Beecroft MD, Herman-Gnjidic Z. Resolution of symptoms in patients with community-acquired pneumonia treated on an ambulatory basis. J Infect 2004; 49:302.
- Fine MJ, Stone RA, Singer DE, et al. Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study. Arch Intern Med 1999; 159:970.
- Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis 2000; 31:347.
- MANAGEMENT OF HEALTHCARE-ASSOCIATED PNEUMONIA
- INDICATIONS FOR HOSPITALIZATION
- PRINCIPLES OF ANTIMICROBIAL THERAPY
- Establishing the diagnosis
- Empiric therapy
- Common pathogens
- Risk factors for drug resistance
- Caveats for fluoroquinolones and macrolides
- North America
- United Kingdom
- Coverage of atypical pathogens
- TREATMENT REGIMENS
- No comorbidities, no recent antibiotic use
- - Low rate (<25 percent) of macrolide resistance
- - High rate (≥25 percent) of macrolide resistance (includes United States)
- Comorbidities or recent antibiotic use
- Pathogen-directed therapy
- Treatment duration and response
- Clinical follow-up
- Follow-up chest radiograph
- The nonresponding patient
- SMOKING CESSATION
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS