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OBJECTIVES

To establish a guideline for the management of Acute Community-Acquired Pneumonia (CAP) in our center, for both outpatient and hospitalized patients, with the aim of:

• Reducing morbidity and mortality associated with the condition.
• Improving the quality of medical care and optimizing hospital resources.
• Delaying the progression of antimicrobial resistance.

SCOPE

All patients over 16 years of age diagnosed with Acute Community-Acquired Pneumonia who are being followed by our institution in an outpatient or inpatient setting.

RESPONSIBILITIES

Physicians from the Medical Clinic, Medical Emergency, Coronary Unit, and Intensive Care Service. Nursing Coordination. Pharmacy Service. Infection Control Committee.

REFERENCES AND BIBLIOGRAPHY

1. Community-Acquired Pneumonia in Adults. Recommendations for its management. Lopardo et al. MEDICINA (Buenos Aires) 2015; 75: 245-257. Argentine Society of Infectiology. ISSN 0025-7680
2. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. 2019. American Journal of Respiratory and Critical Care Medicine Volume 200 Number 7 | October 1, 2019. DOI: 10.1164 rccm.201908-1581ST
3. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Intensive Care Med (2023) 49:615–632 https://doi.org/10.1007/s00134-023-07033-8
4. Antimicrobial resistance. WHO. https://www.who.int/news-room/fact-sheets/detail/antimicrobial resistance
5. Internal Medicine. Farreras-Rosman. Volume I. Elsevier. 2008 Edition.
6. Considerations for the Responsible Use of Antibiotics in COVID-19. Argentine Society of Infectiology. 2020. https://drive.google.com/file/d/1BmXD5x6rEpSqDIc8urccdqLcZKkP3U7X/view
7. Penicillin Allergy. Castells M. New England Journal of Medicine, 381(24), 2338–2351. doi:10.1056 nejmra1807761

INTRODUCTION

Pneumonia is one of the leading causes of morbidity and mortality worldwide, affecting patients of all ages and with various risk factors. Proper management in both outpatient and hospital settings is crucial for improving clinical outcomes and reducing associated complications.

This document aims to standardize and optimize the treatment of pneumonia based on the most current evidence and recommendations from leading scientific organizations. It seeks to be a practical tool for healthcare professionals, providing a clear and concise approach to the diagnosis, treatment, and follow-up of patients with pneumonia.

FOUNDATIONS. HOSPITAL SITUATION ANALYSIS:

• Pneumonias represent a significant burden on the healthcare system due to their high prevalence and potential severity, underscoring the need for a standardized approach.
• A clinical guideline facilitates decision-making, ensuring that all healthcare professionals follow a uniform protocol that integrates best practices, thereby reducing variability in treatments. This allows for better resource utilization, optimizing antibiotic use and reducing the emergence of antimicrobial resistance.
• Antimicrobial resistance has been proposed by the World Health Organization (WHO) and related organizations as the leading cause of death and hospital expenditure by the year 2050.
• Pneumonias in our center, in their various presentations, have shown significant prevalence in hospitalizations according to measurements taken in 2024.
• In our center, antibiotics, as a whole, have been the main source of financial losses related to drugs during the billing cycle from June 2023 to July 2024.

EPIDEMIOLOGICAL SITUATION:

Pneumonias represent a global incidence of 1.26 cases per 1000 inhabitants. It has been documented in some centers that this incidence can increase in patients over 65 years of age, representing 34 cases per 1000 inhabitants. Outpatient mortality varies between 0.1% and 5%, but can reach up to 50% in hospitalized patients, especially those requiring Intensive Care Unit stay.

The main risk factors for developing pneumonia are:

• Chronic Heart Disease.
• Chronic Respiratory Disease.
• Chronic Kidney Disease.
• Advanced-stage HIV infection.
• Immunosuppressed. Solid Organ Transplant. Hematopoietic Stem Cell Transplantation.
• Diabetes mellitus.
• Neoplasms.
• Smoking.
• Chronic use of Corticosteroids or Proton Pump Inhibitors.
• Multiple Myeloma and Hypogammaglobulinemia.
• Anatomical or Functional Asplenia.

The main causative agents of acute community-acquired pneumonia in our setting are:

• Respiratory Viruses (Influenza, SARS-CoV2, RSV).
• Streptococcus pneumoniae.
• Haemophilus influenzae.
• Staphylococcus aureus.
• Mycoplasma pneumoniae and Chlamydophila pneumoniae.

It should be noted that Streptococcus pneumoniae shows a good sensitivity pattern to penicillin and continues to be the most frequent causative microorganism. Haemophilus influenzae only shows beta-lactamase production in 10% to 23% of cases. Staphylococcus aureus in our setting has a low incidence of methicillin resistance, although this possibility should be considered in certain situations and severe clinical presentations. Given these considerations, beta-lactams remain the first-line treatment.

Regarding Pseudomonas aeruginosa isolates, they will only be relevant in patients with risk factors such as bronchiectasis, cystic fibrosis, prior treatment with corticosteroids, or broad-spectrum antibiotics.

Emerging pathogens of some relevance include the eventual emergence of cases caused by Leptospira interrogans, Legionella pneumophila, and Hantavirus. These cases should always be associated with a specific epidemiological link.

DIAGNOSIS

The diagnosis of pneumonia is based on clinical and imaging criteria. For the diagnosis of Acute Community-Acquired Pneumonia, we will consider:

Symptoms and Clinical Signs (at least 1 of the following):

• Fever.
• Altered general condition.
• Cough.
• Sputum production.
• Chest pain.
• Dyspnea.
• Hemoptysis.

plus

Radiopacity on Chest X-ray (Alveolar consolidation with or without air bronchogram, interstitial pattern, bronchiectasis, cavitation, pleural effusion, new radiopacity, etc.). It is always recommended to request both frontal and lateral views.

Chest CT remains a method with greater sensitivity and specificity for evaluating lung parenchyma compared to conventional X-ray in infectious pathology. However, a simple chest X-ray is an adequate method for the initial evaluation of the condition and its complications, which is why a CT scan is not recommended as an initial method for evaluating pneumonia and should always be preceded by a conventional chest X-ray.

CT studies should be considered in the following situations:

• Respiratory failure.
• Evaluation or suspicion of differential diagnoses to Acute Community-Acquired Pneumonia.
• Evaluation or suspicion of complications of Acute Community-Acquired Pneumonia.
• Evaluation of radiological patterns that are not entirely clear on the chest X-ray.

CHOICE OF CARE SITE AND TREATMENT

For the choice of care site and treatment of pneumonia, it is recommended to complement clinical criteria with validated mortality scores associated with risk factors and clinical status.

CURB-65 (1 point for each item):

• Confusion
• Elevated urea greater than 90 mg/dl
• Respiratory rate greater than 30/minute
• Systolic blood pressure < 90 mmHg or diastolic blood pressure < 60 mmHg
• Age equal to or greater than 65 years

Results:

• Groups 0 to 1: Outpatient management.
• Groups 1-2: Admission to General Ward.
• Groups 3-5: Admission to Intensive Care Unit.
• Appendix: A pulse oximetry reading of less than 92% is recommended as an independent factor for inpatient management under expert recommendation to complement the score.

COMPLEMENTARY STUDIES AND CULTURE SAMPLING

Once the diagnosis is completed, the patient’s risk stratification and the choice of admission site are made, the following complementary studies and culture sampling are recommended to proceed with the patient’s study during treatment.

Outpatient patient:

• Pulse Oximetry.
• Laboratory routine (complete blood count, glucose, urea, creatinine, liver function tests).

Inpatient patient in general ward:

• Pulse Oximetry.
• Laboratory routine (complete blood count, glucose, urea, creatinine, liver function tests). Acid-base status if pulse oximetry is less than 92%.
• Sputum sample (Gram stain, culture, antibiogram).
• Blood cultures.
• In the presence of pleural effusion: Thoracentesis. Physical-chemical study for Light’s Criteria. Direct and Culture of Pleural Fluid.

Inpatient patient in intensive care unit:

• Pulse Oximetry.
• Laboratory routine (complete blood count, glucose, urea, creatinine, liver function tests) plus acid-base status.
• Sputum sample (Gram stain, culture, antibiogram). Tracheal aspirate, Mini-BAL, or BAL sampling for patients requiring ARM upon admission.
• Blood cultures.
• Urinary antigen for detection of Streptococcus pneumoniae, if available in microbiology.
• In the presence of pleural effusion: Thoracentesis. Physical-chemical study for Light’s Criteria. Direct and Culture of Pleural Fluid.

Special considerations for Viral Pneumonias:

• We recommend performing a viral panel for Influenza A/B for any pneumonia presenting at least 1 risk factor mentioned during periods of viral circulation in the community.
• We recommend performing a viral panel for SARS-CoV2 for any pneumonia presenting at least 1 risk factor mentioned during periods of viral circulation in the community or having epidemiological criteria of a suspected COVID-19 case.
• The Infection Control Committee will timely inform based on the National Epidemiological Bulletin about the presence of circulating respiratory viruses in our setting.

Special considerations for Atypical Pneumonias and HIV Testing:

• We recommend serological testing for IgM/IgG for Chlamydia and Mycoplasma for any pneumonia presenting a subacute evolution at the time of clinical presentation or clinical-radiological dissociation in its presentation.
• In the suspicion of pneumonia caused by emerging pathogens (Legionella pneumophila, Leptospira interrogans, Hantavirus), consider the necessary epidemiological link as a prior epidemiological background before requesting specific diagnostic tests.
• HIV testing is recommended for all pneumonias, with special emphasis on those that do not present the conventional risk factors mentioned.

ANTIMICROBIAL TREATMENT AND DURATION OF TREATMENT:

Directed antimicrobial treatment will be based on the present risk factors and the choice of care site and treatment.

Outpatient patient <65 years and without risk factors:

First choice:

• Amoxicillin 875mg/12h orally for 5-7 days.

Scheme for history of allergy to Beta-Lactams:

• Clarithromycin 500mg/12h orally for 5 days or
• Azithromycin 500-1000mg/day for 5 days.

Outpatient patient >65 years or with at least 1 risk factor:

First choice:

• Amoxicillin-Clavulanate 1g/12h orally for 7 days.

Scheme for history of allergy to Beta-Lactams:

• Clarithromycin 500mg/12h orally for 5 days or
• Azithromycin 500-1000mg/day orally for 5 days.

Inpatient patient in General Ward <65 years and without risk factors:

First choice:

• Ampicillin-Sulbactam 1.5g/6h IV +/- Clarithromycin 500mg/12h orally/IV for 5-7 days.

Scheme for history of allergy to Beta-Lactams:

• Ceftriaxone 1g/day IV for 5-7 days.

Inpatient patient in General Ward >65 years or with at least 1 risk factor:

First choice:

• Ampicillin-Sulbactam 1.5g/6h IV for 7 days +/- Clarithromycin 500mg/12h orally/IV for 5 days.

Scheme for history of allergy to Beta-Lactams:

• Ceftriaxone 1g/day IV for 7 days.

Inpatient patient in Intensive Care Unit:

First choice:

• Ampicillin-Sulbactam 1.5g/6h IV for 7 days +/- Clarithromycin 500mg/12h orally/IV for 5 days.

Scheme for history of allergy to Beta-Lactams:

• Ceftriaxone 1-2g/day IV for 7 days.

Special Considerations for Inpatients:

Scheme for risk factors for Pseudomonas aeruginosa*:

• Piperacillin/Tazobactam 4.5g/6h IV or Cefepime 2g/8h IV for 7 days +/- Clarithromycin 500mg/12h orally/IV for 5 days.

Scheme for risk factors for Methicillin-Resistant Staphylococcus aureus**:

• Add to conventional scheme: Vancomycin 15-20mg/kg/8-12h IV +/- Clindamycin 600mg/8h IV for 7-14 days.

Aspiration Pneumonia:

First choice:

• Ampicillin-Sulbactam 1.5g/6h IV for 5-7 days.

*Risk factors for Pseudomonas aeruginosa: Bronchiectasis, cystic fibrosis, prior treatment with corticosteroids or broad-spectrum antibiotics. Documented isolates in respiratory cultures of Pseudomonas aeruginosa.

**Risk factors for Methicillin-Resistant Staphylococcus aureus: Previously healthy young patients with severe, necrotizing, and rapidly progressive pneumonia, cavitary infiltrates, hemoptysis, prior influenza, intravenous drug users, rash, leukopenia, recent or concomitant skin and soft tissue infections.

The routine use of corticosteroids in pneumonia is not recommended.

CONSIDERATIONS ON ANTIMICROBIALS IN VIRAL AND ATYPICAL PNEUMONIAS:

In the case of a concomitant antigen test or PCR for Influenza A/B or SARS-CoV2, the following treatment recommendations are made:

Influenza Virus A/B:

First choice:

• Oseltamivir 75mg every 12 hours orally for 5 days. Other considerations:
• In cases of Respiratory Failure in ARM or Obesity: Oseltamivir 150mg every 12 hours orally for 5 days.
• Concomitant antimicrobial treatment is recommended as there is documented frequent association of Influenza Virus and Streptococcus pneumoniae.

COVID-19:

• First choice is conventional treatment with dexamethasone 8 mg IV for 10 days in the event of respiratory failure.
• Routine antimicrobial treatment is not recommended for COVID-19; therefore, upon a positive SARS-CoV2 test, it is recommended to discontinue antimicrobials.

Consider maintaining concomitant antimicrobial treatment only in suspected bacterial infection due to severe presentation:

• Focal alveolar consolidation +/- air bronchogram in imaging studies plus 1 of the following: sepsis, risk factors, and/or immunosuppression.

Atypical Pneumonias with Seroconversion for Chlamydia or Mycoplasma:

First choice:

• Clarithromycin 500mg every 12 hours IV/orally for 14 days.
• Azithromycin 500-1000mg/day IV/orally for 14 days.
• Doxycycline 100mg every 12 hours IV/orally for 14 days.

CONSIDERATIONS ON PENICILLIN AND OTHER BETA-LACTAM ALLERGIES:

Patients who report penicillin allergy are often misclassified. It is documented that more than 95% of patients who report penicillin allergy can receive beta-lactams without any complications. Additionally, penicillin hypersensitivity diminishes over the years.

Allergy to one beta-lactam does not imply the impossibility of using the entire spectrum of beta-lactams, as there are only a few cases of cross-hypersensitivity.

Therefore, we recommend the safe use of beta-lactams except in cases of a reported or documented history of severe allergy to penicillin (anaphylaxis).

In doubtful cases or confirmed allergy events during hospitalization, a consultation with an Allergy Specialist is available to evaluate the case.

FOLLOW-UP IN OUTPATIENT TREATMENT MODALITY

Patients undergoing pneumonia treatment in an outpatient setting can continue their treatment at home, considering advising them to seek further consultation in case of alarm signs (fever that does not subside after 48 to 72 hours, dyspnea, hemoptysis, chest pain, etc.). Nevertheless, it is good practice to consider a follow-up consultation in the emergency department or clinic after 48 to 72 hours of starting antibiotic therapy.

It is not routinely recommended to repeat a chest X-ray or CT scan to evaluate the evolution of pneumonia under outpatient treatment. Only in the case of suspected complications or unfavorable evolution. A follow-up at the end of treatment with the primary care physician is suggested.

FOLLOW-UP IN INPATIENT TREATMENT MODALITY

For hospitalized patients, we should consider transitioning from parenteral medication to oral when the following conditions are met

• Completion of 48 hours of parenteral treatment.
• Presence of a 24-hour afebrile period, with hemodynamic stability and significant clinical improvement.
• Availability of the oral route.

It is not routinely recommended to repeat a chest X-ray or CT scan to evaluate the evolution of pneumonia under outpatient or inpatient treatment. Only in the case of suspected complications or unfavorable evolution.

PREVENTION

The prevention of pneumonia is based on timely immunization with pneumococcal vaccines, influenza vaccination, and COVID-19 vaccination according to the immunization recommendations and current schedule from the Ministry of Health.

ICD-11 CODING

• CA40 - Pneumonia.
• CA40.0 - Bacterial Pneumonia.
• CA40.1 - Viral Bronchopneumonia.
• CA40.2 - Fungal Pneumonia.
• CA40.Z - Pneumonia, organism unspecified.

Autor

Kamo Weasel - MD Infectious Diseases - MD Internal Medicine - #DocChain Community npub1jdvvva54m8nchh3t708pav99qk24x6rkx2sh0e7jthh0l8efzt7q9y7jlj