Pneumonia: Updates, Best Practices, and Controversies-Slides

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Dr. Joanna M. Bonsall’s presentation outlines current best practices and controversies in managing pneumonia, focusing on hospital-acquired pneumonia (HAP), community-acquired pneumonia (CAP), and aspiration pneumonia in inpatient settings. The 2017 ATS/IDSA guidelines for HAP and 2019 guidelines for CAP guide diagnosis, severity assessment, and treatment.<br /><br />Key points include the use of clinical prediction tools like the Pneumonia Severity Index (PSI) and IDSA/ATS 2007 criteria to determine hospitalization need and ICU admission. For example, PSI class IV denotes significant risk requiring admission. Diagnostic testing depends on severity and risk factors, including sputum and blood cultures, MRSA nasal swabs, Legionella and pneumococcal urinary antigen tests, viral panels, and molecular assays (e.g., multiplex PCR). Lung ultrasound (LUS/POCUS) offers rapid, radiation-free imaging comparable to CT scans, useful especially in indeterminate cases.<br /><br />Procalcitonin has limited sensitivity and specificity but can guide antibiotic duration to avoid unnecessarily prolonged therapy, which is common and associated with adverse events. Empiric antibiotics for CAP without MRSA or Pseudomonas risks include β-lactams plus macrolides or respiratory fluoroquinolones; doxycycline is a viable alternative and may reduce Clostridioides difficile risk. For patients with MRSA or gram-negative risk, empiric coverage should be broader, guided by risk factors (e.g., recent hospitalization, antibiotic use, nursing home residence) and clinical scores like DRIP. Pre-treatment cultures and nasal swabs help de-escalate therapy.<br /><br />Severe CAP patients may benefit from adjunctive corticosteroids (hydrocortisone), which reduce mortality and complications, though contraindications (immunosuppression, active influenza) must be considered. Aspiration pneumonia management differentiates macroaspiration, often treated like HAP, from chronic microaspiration treated as CAP. Routine anaerobic coverage is generally not recommended unless anaerobic infection is strongly suspected.<br /><br />Treatment duration for CAP should be five days or three days post-clinical stability, avoiding excessive antibiotic exposure. Oral step-down regimens depend on prior inpatient therapy and risk profiles. Overall, combining clinical judgment with validated guidelines, incorporating advanced diagnostics, and judicious antibiotic use optimizes pneumonia care quality and safety.

Keywords

Hospital-acquired pneumonia (HAP)

Community-acquired pneumonia (CAP)

Aspiration pneumonia

ATS/IDSA guidelines

Pneumonia Severity Index (PSI)

Diagnostic testing in pneumonia

Procalcitonin-guided antibiotic therapy

Empiric antibiotic treatment

Adjunctive corticosteroids in severe CAP

Antibiotic stewardship and treatment duration