Elyse Watkins, DHSc, PA-C, DFAAPA
In the United States, Community-Acquired Pneumonia (CAP) is responsible for 5 million illnesses, 1 million hospitalizations, and 60 thousand deaths annually.1,2 As a common cause of morbidity and mortality, it is imperative that PAs in ambulatory, inpatient, and emergency medicine remain up to date on evidence-based practice guidelines. The year 2019 brought many changes in recommendations surrounding the prevention, diagnosis, and management of CAP including the Advisory Committee on Immunization Practices (ACIP) updating pneumococcal vaccination recommendations for adults older than 65.3,4 In October 2019, the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) published practice-changing evidence-based guidelines on the diagnosis and management of community-acquired pneumonia.5 Before the 2019 updates, the ATS/IDSA had not published guideline updates since 2007.6 This review will focus on practice-changing evidence-based guideline updates relevant to the outpatient provider. Although the guidelines include vital information for inpatient management, a review of those changes falls outside the scope of this review. A critical emerging etiology of CAP, Novel virus Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), will fall outside the scope of this review.
The IDSA/ATS and ACIP guidelines were reviewed with a focus on practice changing updates. A PubMed search was conducted with the key words, “community acquired pneumonia” and was filtered by results from 2015 and newer. This search yielded 25 results. Studies which did not address diagnosis or empiric treatment of pneumonia were excluded. The CDC website was reviewed for information on pneumococcal vaccination recommendations. A second PubMed search was conducted with the keywords, “AICP and pneumococcal” and filtered for results since 2019 which yielded 2 results.
The diagnosis of CAP includes history and physical examination with a radiographic confirmation. During influenza season, all patients with CAP should be tested for influenza using the nucleic amplification test. Validated risk stratification tools should augment clinical judgment when diagnosing severity and site of care. The PSI/PORT score is preferred over the CURB-65 score, though both scores require laboratory evaluation not readily available in many outpatient settings, thus requiring an increased reliance on clinical judgment. Procalcitonin levels, sputum cultures, blood cultures, and antigen testing for specific pathogens are not routinely indicated in outpatient settings.
Treatment of CAP depends on the severity of the disease and the health of the patient. Due to S. pneumoniae macrolide resistance exceeding 30% in much of the U.S., the ATS/IDSA does not recommend macrolide monotherapy in most communities. Influenza positive CAP should be treated with antiviral treatment in combination with empiric antibiotics regardless of the duration of illness. Patient comorbidities guide the choice of empiric outpatient antimicrobial therapy. Treatment should last for a minimum of five days, and total duration should be individualized based on a return to clinical stability. The 13 valent pneumococcal conjugate vaccine recommendations have been modified for adults over 65 and should now be administered after shared decision making based on individual risk factors.
Empiric treatment of CAP will continue to evolve with the challenges associated with antibiotic resistance and changes in vaccination recommendations. Ongoing research will be required in the fields of diagnosis and therapy. Clinicians should continue to review and implanted changes to their practice based on the best available evidence.
"Outpatient Diagnosis and Management of Community-Acquired Pneumonia,"
Lynchburg Journal of Medical Science: Vol. 2
, Article 47.
Available at: https://digitalshowcase.lynchburg.edu/dmscjournal/vol2/iss4/47
Available when accessing via a campus IP address or logged in with a University of Lynchburg email address.
Off-campus users can also use 'Off-campus Download' button above for access.