SHM's Clinical Quick Talks-Community-Acquired Pneumonia

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**Summary:**<br /><br />Community-Acquired Pneumonia (CAP) is a prevalent cause of hospitalization, respiratory failure, and septic shock. Rapid diagnosis and appropriate treatment are crucial for improving patient outcomes. The document highlights key learning points to accurately diagnose and treat CAP according to guidelines.<br /><br />**Etiology and Presentation:**<br />Common bacterial causes include S. pneumoniae, Mycoplasma, H. influenzae, Moraxella, Chlamydia, Legionella, and S. aureus. Viral agents include influenza, COVID-19, RSV, rhinovirus, and parainfluenza, while fungal causes involve Cocci, histoplasmosis, and PJP. Patients typically present with dyspnea, fever, chills, cough, and purulent sputum; elderly patients may exhibit falls or confusion. Diagnostic findings often include hypoxia, rhonchi, crackles, and egophony.<br /><br />**Diagnostic Workup:**<br />Imaging, predominantly chest X-rays (CXR), identifies new infiltrates. Labs include WBC count, sodium levels, LDH, and procalcitonin. Etiologic tests involve PCR for viruses, influenza, and COVID-19, alongside urine ELISA for S. pneumoniae and Legionella in severe cases. Blood and sputum cultures are advised under specific conditions, such as prior hospitalization or the presence of multidrug-resistant organisms (MDRO).<br /><br />**Hospitalization Criteria:**<br />Patients requiring hospitalization include those with oxygen needs, IV antibiotics, close monitoring, or sepsis management. Tools like the Pneumonia Severity Index and CURB-65 assist in determining hospitalization necessity, with considerations for ICU admission.<br /><br />**Treatment Guidelines:**<br />Initial antibiotics should be tailored to risk factors. Usual patients may receive beta-lactams combined with macrolides, or respiratory fluoroquinolone monotherapy. Coverage for MRSA or Pseudomonas is necessary for patients with prior cultures indicating MDRO presence or recent hospitalizations. For aspiration pneumonia, anaerobic coverage is rarely needed. Special protocols apply for influenza or COVID-19 cases.<br /><br />The document emphasizes initiating antibiotics promptly, avoiding delays for cultures, and considering the duration of therapy to be five days or longer based on clinical stability and procalcitonin levels. Steroids may be considered for severe CAP in ICU settings.<br /><br />**Clinical Pearls:**<br />Cultures are generally low yield but should not delay antibiotic initiation. Viral pneumonias, such as influenza and COVID, should be tested and treated appropriately. Early guideline-concordant antibiotics, minimal separate anaerobe coverage, and reevaluation for non-improving patients are essential practices.<br /><br />The script aims to guide antibiotic selection and solidify diagnostic and treatment principles in early-career practitioners. High-value resources include recent publications from the Annals of Internal Medicine, ATS/IDSA guidelines, and NEJM studies.
Asset Subtitle
Greg Seymann, Ian Jenkins
Keywords
Community-Acquired Pneumonia
CAP
diagnosis
treatment
guidelines
antibiotics
hospitalization
etiology
diagnostic workup
clinical pearls