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In the Clinic
Community-Acquired
Pneumonia Prevention
C
ommunity-acquired pneumonia (CAP) can
vary from a mild outpatient illness to a more Diagnosis
severe disease requiring hospital admission
and, at times, intensive care. CAP is the eighth lead-
ing cause of death, along with inuenza, and is the Treatment
leading cause of death from infectious diseases in
persons in the United States older than 65 years. The
key management decisions related to CAP are rec- Patient Information
ognition and treatment in a timely and effective
manner, dening the appropriate site of care (home,
hospital, or intensive care unit [ICU]), and ensuring
effective prevention. Health careassociated pneu-
monia (HCAP), or pneumonia in persons in contact
with such health care environments as nursing
homes and chronic hemodialysis centers or persons
recently discharged from the hospital, can be
caused by multidrug-resistant (MDR) organisms.
Whether HCAP is best classied as a form of
community-acquired or hospital-acquired pneumo-
nia is controversial.
The CME quiz is available at www.annals.org/intheclinic.aspx. Complete the quiz to earn up to 1.5 CME
credits.
Physician Writer CME Objective: To review current evidence for prevention, diagnosis, treatment, and practice
Michael S. Niederman, MD improvement of community-acquired pneumonia.
Funding Source: American College of Physicians.
Disclosures: Dr. Niederman, ACP Contributing Author, reports personal fees from Pzer,
personal fees from Thermo Fisher Scientic, grants and personal fees from Merck/Bayer, and
personal fees from Cempra outside the submitted work.
In the Clinic does not necessarily represent ofcial ACP clinical policy. For ACP clinical
guidelines, please go to https://www.acponline.org/clinical_information/guidelines/.
With the assistance of additional physician writers, the editors of Annals of Internal Medicine
develop In the Clinic using MKSAP and other resources of the American College of Physicians.
2015 American College of Physicians
2015 American College of Physicians ITC2 In the Clinic Annals of Internal Medicine 6 October 2015
PCV13 PCV13
8 weeks
8 weeks
PPSV23 PPSV23
Adults aged
5 years
1964 years
1 year 5 years PPSV23
Adults aged
65 years
PCV13 5 years
612 months
PPSV23
The dashed line represents the interval between the two PPSV23 doses. PCV13# = 13-valent pneumococcal conjugate vaccine; PPSV23# =
23-valent pneumococcal polysaccharide vaccine.
* Immunocompromising conditions are dened as congenital or acquired immunodeciency (including B- or T-lymphocyte deciency, com-
plement deciencies, and phagocytic disorders excluding chronic granulomatous disease), HIV infection, chronic renal failure, nephrotic
syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, multiple myeloma, solid organ transplant, and iatrogenic immu-
nosuppression (including long-term systemic corticosteroids and radiation therapy).
Anatomical or functional asplenia is dened as sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic
dysfunction, and splenectomy.
Chronic health conditions are dened as chronic heart disease (including congestive heart failure and cardiomyopathies, excluding hyper-
tension), chronic lung disease (including chronic obstructive lung disease, emphysema, and asthma), chronic liver disease (including cirrhosis),
chronic alcoholism, or diabetes mellitus.
Administer PPSV23 as soon as possible if the 6- to 12-month time window has passed. Reproduced from Reference 3.
1 year after the most recent vac- Although concerns have been
cination. For those with immune- raised about adverse reactions in
compromising conditions, a sec- patients who receive repeated
ond dose of PPS-23 should be vaccination, in 1 study fewer than
given 5 years after the rst dose. 1% of patients who received at
For those who received either 1 least 3 pneumococcal vaccina-
or 2 doses of PPS-23 before 65 tions had an adverse reaction,
years of age, a repeated dose and no reaction was severe, even
should be given at 65 years of when vaccination was repeated
age or older, provided that 5 in less than 6 years (4). Vaccina-
years have passed since the prior tion reduces the frequency of
dose. Although PCV-13 is gener- bacteremic pneumonia in
ally given before PPS-23, current healthy, immune-competent 3. Kim DK, Bridges CB, Harri-
man KH, et al. Advisory
vaccine recommendations allow adults. Not all randomized, con- Committee on Immuniza-
PPS-23 to be given rst in per- trolled trials (RCTs) have found tion Practices Recom-
mended Immunization
sons younger than 65 years who reductions in the frequency of Schedule for Adults Aged
have chronic health conditions bacteremic pneumonia in adults 19 and Older: United
States, 2015. Ann Intern
but are not immune-suppressed with chronic illness, although Med 2015;162:214-23.
PMID: 25654609]
and have not had splenectomy case control studies report 4. Walker FJ, Singleton RJ,
(3) (Figure). reductions from 56% 81%. Bulkow LR, et al. Reactions
after 3 or more doses of
pneumococcal polysaccha-
Pneumococcal vaccination In a double-blind RCT of 84 496 adults older ride vaccine in adults in
should be considered for anyone Alaska. Clin Infect Dis.
than 65 years, PCV-13 prevented both bactere- 2005;40:1730-5. [PMID:
hospitalized for a medical illness. mic and nonbacteremic, vaccine strainspecic 15909258]
6 October 2015 Annals of Internal Medicine In the Clinic ITC3 2015 American College of Physicians
2015 American College of Physicians ITC4 In the Clinic Annals of Internal Medicine 6 October 2015
Table. Modifying Factors That Increase the Risk for Infection With Specic
Pathogens
Organism Risk Factor
Penicillin-resistant and Age >65 years
drug-resistant pneumococci -lactam therapy within the past 3 months
Alcoholism
Immune-suppressive illness (including therapy with
corticosteroids)
Multiple medical comorbid conditions
Exposure to a child in a day care center
Enteric gram-negative bacteria Residence in a nursing home
Underlying cardiopulmonary disease
Multiple medical comorbid conditions
Recent antibiotic therapy
Pseudomonas aeruginosa Structural lung disease (bronchiectasis) 13. Toronto Invasive Bacterial
Corticosteroid therapy (prednisone, >10 mg/d) Disease Network. Predict-
Broad-spectrum antibiotic therapy for >7 d in the ing antimicrobial resis-
past month tance in invasive pneu-
Malnutrition mococcal infections. Clin
Infect Dis. 2005;40:
1288-97. [PMID:
15825031]
6 October 2015 Annals of Internal Medicine In the Clinic ITC5 2015 American College of Physicians
2015 American College of Physicians ITC6 In the Clinic Annals of Internal Medicine 6 October 2015
6 October 2015 Annals of Internal Medicine In the Clinic ITC7 2015 American College of Physicians
2015 American College of Physicians ITC8 In the Clinic Annals of Internal Medicine 6 October 2015
Treatment
How should clinicians the hospital. The BTS rule has patients who had low levels of procalcitonin had
determine whether a patient been condensed into the CURB- low mortality, regardless of PSI class or number
with CAP requires outpatient, 65, which is based on the pres- of CURB-65 points (29).
inpatient, or ICU care? ence of Confusion, blood Urea Current guidelines support ICU
Many site-of-care decisions can nitrogen >7.0 mmol/L (19.6 mg/ care if the patient needs assisted
be facilitated with the pneumonia dL), Respiratory rate 30 ventilation, has septic shock re-
severity index (PSI) or the British breaths/min, systolic Blood pres- quiring vasopressors, or has at
Thoracic Society (BTS) rule. sure <90 mm Hg or diastolic least 3 of the following: respira-
These tools predict risk for death. blood pressure <60 mm Hg, and tory rate 30 breaths/min, PaO2/
Patients at high risk are generally age 65 years. Patients with at FiO2 ratio 250, multilobar inl-
managed in the hospital, and least 2 of these criteria are usu- trates, confusion or
those at highest risk are man- ally admitted to the hospital, disorientation, blood urea nitro-
aged in the ICU. The PSI straties whereas those with at least 3 gen 7.1 mmol/L (20 mg/dL),
patients into 5 categories by us- criteria are considered for ICU leukocyte count <4 109 cells/L,
ing a scoring system based on admission (20, 28, 29). platelet count <100 109
patient age, comorbid illness, cells/L, temperature lower than
physical examination ndings, One prospective study of 3181 patients seen
36 C, and hypotension requir-
and laboratory data. In general, in 32 emergency departments compared the
ing aggressive uid resuscitation
PSI with the CURB and CURB-65 criteria and
patients in classes I and II are (20). One study found that leu-
found that both approaches accurately identi-
treated as outpatients, those in ed low-risk patients. CURB-65 was better for kopenia, thrombocytopenia, and
class III have the site-of-care deci- predicting mortality in high-risk patients (28). In hypothermia were each present
sion based on careful clinical as- another prospective study of 1651 patients, mea- in <5% of all patients; further,
sessment, and those in classes IV surement of serum procalcitonin levels supple- omitting these criteria and re-
and V are generally admitted to mented data obtained by prognostic scoring, and placing them with acidosis sim-
6 October 2015 Annals of Internal Medicine In the Clinic ITC9 2015 American College of Physicians
2015 American College of Physicians ITC10 In the Clinic Annals of Internal Medicine 6 October 2015
started, and which antibiotics -lactam monotherapy was not associated with lower
in-hospital mortality for
inferior to a -lactammacrolide patients with bacteremic
should patients receive if they pneumococcal pneumo-
combination in patients with nia. Clin Infect Dis. 2003;
do not need ICU care?
moderately severe CAP. How- 36:389-95. [PMID:
Patients should receive initial an- ever, patients with atypical
12567294]
38. Garin N, Genne D, Car-
tibiotic therapy as soon as possi- pathogens and those in PSI class ballo S, et al. -Lactam
ble after the diagnosis is estab- monotherapy vs
IV had delayed clinical stability -lactam-macrolide
lished and before they leave the with -lactam monotherapy when
combination treatment
in moderately severe
emergency department. Al-
compared with those receiving community-acquired
though therapy within 4 hours of pneumonia: a random-
combination therapy (38). In an- ized noninferiority trial.
arrival to the hospital has been JAMA Intern Med 2014;
other trial of admitted patients 174:1894-1901. [PMID:
associated with reduced mortal-
with nonsevere CAP, -lactam 25286173]
ity in some studies, undue em- 39. Postma DF, van Werk-
monotherapy was equivalent to a hoven CH, van Elden LJ,
phasis on early therapy can lead
-lactammacrolide combination et al; CAP-START Study
to unnecessary use of antibiotics Group. Antibiotic treat-
for 30 day mortality (which was ment strategies for
and associated complications
<10%) (39). Specic -lactams, community-acquired
pneumonia in adults.
(11, 34). In 1 study, the nal diag-
such as ceftriaxone and cefo- N Engl J Med 2015;372:
nosis of pneumonia in patients 13121323.[PMID:
taxime, are preferred if DRSP is 25830421]
suspected of having pneumonia 40. Lujan M, Gallego M,
suspected because they are ef-
in the emergency department Fontanals D, Mariscal D,
fective at mean inhibitory con- Rello J. Prospective ob-
decreased from 75.9% to 58.9% servational study of bac-
centrations up to 2 mg/L (40). teremic pneumococcal
after the initiation of a program
However, 1 study showed in- pneumonia: Effect of
to give more patients antibiotics discordant therapy on
creased mortality when cefu- mortality. Crit Care Med.
within 4 hours of arrival in the 2004;32:625-31. [PMID:
roxime was used in patients with
emergency department (35). 15090938]
bacteremic DRSP (41). 41. International Pneumo-
coccal Study Group. An
Although guidelines recommend One international study of 4337 hospitalized international prospective
study of pneumococcal
that hospitalized patients who patients with CAP showed that approximately bacteremia: correlation
are not in the ICU receive intrave- 20% had evidence of atypical pathogen infec- with in vitro resistance,
antibiotics administered,
nous azithromycin if they have no tion and that therapy directed against these or- and clinical outcome.
cardiopulmonary disease and no Clin Infect Dis. 2003;37:
ganisms decreased the time to clinical stabil- 230-7. [PMID:
factors that increase the risk for ity, length of stay, and both total and CAP- 12856216]
6 October 2015 Annals of Internal Medicine In the Clinic ITC11 2015 American College of Physicians
2015 American College of Physicians ITC12 In the Clinic Annals of Internal Medicine 6 October 2015
6 October 2015 Annals of Internal Medicine In the Clinic ITC13 2015 American College of Physicians
2015 American College of Physicians ITC14 In the Clinic Annals of Internal Medicine 6 October 2015
In the Clinic
Tool Kit
Patient Information
www.nlm.nih.gov/medlineplus/ency/article/000145
.htm
NIH MedLine Plus.
www.cdc.gov/pneumococcal/clinicians/diagnosis
-medical-mgmt.html
IntheClinic
Centers for Disease Control and Prevention.
http://familydoctor.org/familydoctor/en/diseases
-conditions/pneumonia.html
Community-Acquired http://umm.edu/health/medical/ency/articles
Pneumonia /pneumonia-adults-community-acquired
Patient resources in English.
http://umm.edu/health/medical/spanishency/articles
/neumonia-en-adultos-extrahospitalaria
Patient resources in Spanish.
Guidelines
https://www.thoracic.org/statements/resources/mtpi
/idsaats-cap.pdf
https://www.brit-thoracic.org.uk/guidelines-and
-quality-standards/community-acquired-pneumonia
-in-adults-guideline/
Medical guidelines for clinical practice for the diagnosis
and treatment of community-acquired pneumonia.
6 October 2015 Annals of Internal Medicine In the Clinic ITC15 2015 American College of Physicians
Patient Information
Shortness of breath veins (intravenously).
Chest pains
Feeling tired and weak Questions for My Doctor
Am I contagious?
How Is Pneumonia Diagnosed? What can I do to help relieve my symptoms?
Your doctor will ask you questions about your Why do I still feel so tired?
symptoms and give you a physical How can I prevent another episode of
examination. He or she will listen to your lungs pneumonia?
and heart and check your temperature. Should I be treated at home or in the hospital?
Your doctor will usually order a chest X-ray to When can I start my normal activities again?
see how much your lungs are affected. When can I go back to work?
Your doctor may also order tests of the sputum
(mucous brought up with coughing) and urine to Bottom Line
learn what type of bacteria is causing the Pneumonia is a serious infection of the lungs.
pneumonia. A blood test can show if the infection It is most commonly caused by bacteria.
has spread from the lungs to the blood. Symptoms include shortness of breath,
coughing, chest pains, high fever, and feeling
How Is Pneumonia Treated? cold and shaky.
If your pneumonia is caused by bacteria, your Treatment usually includes antibiotic
doctor will prescribe antibiotics. Your medicines, medicines for cough and fever,
symptoms usually start to go away within a few drinking lots of uids, and rest.
days of starting treatment. It is important to Some people may need to stay in the hospital
nish all of your antibiotics, even if you are if the infection is more serious or if pneumonia
feeling better. does not go away.
bid = twice daily; CAP = community-acquired pneumonia; DNA = deoxyribonucleic acid; DRSP = drug-resistant Streptococcus
pneumonia; FDA = U.S. Food and Drug Administration; IV = intravenous; MIC = minimum inhibitory concentration; MRSA =
methicillin-resistant Staphylococcus aureus; PO = oral; tid = three times daily.
* Black box warning.
6 October 2015 Annals of Internal Medicine In the Clinic 2015 American College of Physicians