Community-Acquired Pneumonia in the Emergency Department (Infectious Disease CME)

Table of Contents

 

About This Issue

When a patient presents to the ED with suspected community-acquired pneumonia, it is most important to be sure that diagnostic and treatment strategies follow the latest evidence and that patients are dispositioned to the optimal level of care.

Has widespread vaccination for Streptococcus pneumoniae affected the pathophysiology of CAP?

What symptom is most common in patients with CAP?

What are the 4 signs that are the most predictive of CAP?

What is the most typical presenting symptom for elderly patients with CAP?

Does imaging with x-ray, CT, or ultrasound have any value?

Which laboratory tests are useful, and which are not?

How should blood and sputum culture results be used to determine antibiotic use?

How should risk stratification systems – CURB-65, PSI, SMART-COP, and ATS/IDSA criteria – be used to determine treatment and disposition strategies?

What are the current recommendations on administration of antibiotics for severe/nonsevere CAP in and out of the hospital?

How should emergency clinicians manage patients with CAP when COVID-19 alters the clinical picture?

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Community-Acquired Pneumonia in the Era of COVID-19
6. Epidemiology
7. Pathophysiology
8. Differential Diagnosis
9. Prehospital Care
10. Emergency Department Evaluation
11. Diagnostic Studies
    1. Chest Radiography
    2. Computed Tomography
    3. Ultrasound
    4. Laboratory Testing
       1. Biomarkers
       2. Mycoplasma pneumoniae Testing
       3. Urine Antigen Testing
       4. Blood Cultures
       5. Sputum Cultures
       6. Viral Respiratory Panel
12. Using Severity and Risk Scoring Systems for Treatment and Disposition
    1. CURB-65 Score
    2. Pneumonia Severity Index
       1. Comparison of CURB-65 and Pneumonia Severity Index Scores
    3. Intensive Care Unit Admission
       1. SMART-COP and ATS/IDSA Criteria
13. Treatment
    1. Inpatient Treatment
       1. Nonsevere Community-Acquired Pneumonia
       2. Severe Community-Acquired Pneumonia
    2. Outpatient Treatment
    3. Antibiotic Duration
    4. Antitussives
14. Special Populations
    1. Pediatric Patients
    2. Risk of Multidrug-Resistant Organisms
15. Controversies and Cutting Edge
    1. Corticosteroids
    2. Influenza, Antiviral Agents, and Community-Acquired Pneumonia
    3. Novel Antibiotics
16. Risk Management Pitfalls for Community-Acquired Pneumonia in the Emergency Department
17. Summary
18. Time- And Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathway for Emergency Department Management of Community-Acquired Pneumonia
21. Tables and Figures
    1. Table 1. CURB-65 Scoring
    2. Table 2. SMART-COP Score for Pneumonia Severity
    3. Table 3. 2007 IDSA/ATS Criteria for Defining Severe Community-Acquired Pneumonia
    4. Figure 1. Pneumonia Severity Index
    5. Antibiotic Regimens for Community-Acquired Pneumonia
22. References

Abstract

As recommendations for the diagnosis, treatment, and disposition of patients with community-acquired pneumonia continue to evolve, this issue reviews the current evidence and guidelines for managing these patients in the emergency department. The various clinical decision aids are compared, as they assist in determining the level of inpatient care required and allow for a greater proportion of patients to be treated successfully as outpatients. A clinical pathway for emergency department management delineates optimal antibiotic regimens based on severity, comorbidities, and risk factors.

Case Presentations

A 30-year-old man with no significant medical history presents to the ED with 2 days of fever, cough productive of green sputum, and malaise…

• Examination reveals left-sided rhonchi that do not clear with cough.
• The patient has a heart rate of 105 beats/min and a temperature of 39.1°C. He is normotensive and has a 95% oxygen saturation on room air.
• Labs show a WBC count of 17K, but are otherwise unremarkable. X-ray shows a left-sided retrocardiac opacity concerning for pneumonia.
• The patient is clearly symptomatic, but he is asking to go home…

An 82-year-old woman with a history of mild COPD presents from an assisted living facility with 3 days of mild cough productive of yellow sputum…

• She reports no fever/chills, chest pain, shortness of breath, orthopnea, or paroxysmal nocturnal dyspnea. Physical exam reveals normal vital signs and slightly diminished breath sounds in the right lung fields.
• Labs, including lactic acid, are within normal limits, and x-ray shows a right-sided infiltrate consistent with pneumonia.
• The patient’s daughter is concerned about the risk for an adverse outcome, but the patient says she would like to return to her assisted living facility…

A 55-year-old man with a history of diabetes and chronic kidney disease presents with 3 days of nonproductive cough, fever, and altered mental status…

• He is in moderate distress, is breathing with accessory muscles, and has rhonchi and rales in all lung fields.
• The patient is febrile and has a heart rate of 130 beats/min. His initial blood pressure is 88/50 mm Hg and is breathing at 26 breaths/min with room-air oxygen saturation at 88%.
• Labs show a WBC of 19K, a lactic acid of 4.2 mg/dL, and an anion gap of 22 mEq/L. X-ray shows bilateral infiltrates concerning for multifocal pneumonia and a left-sided pleural effusion.
• Before you admit the patient, you need to determine whether he needs to be placed in the intensive care unit...

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Clinical Pathway for Emergency Department Management of Community-Acquired Pneumonia

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

12. * Jain S, Self WH, Wunderink RG, et al. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015;373(5):415-427. (Prospective; 2400 patients) DOI: 10.1056/NEJMoa1500245

21. * Moore M, Stuart B, Little P, et al. Predictors of pneumonia in lower respiratory tract infections: 3C prospective cough complication cohort study. Eur Respir J. 2017;50(5):1700434. (Prospective; 28,883 patients) DOI: 10.1183/13993003.00434-2017

38. * Metlay JP, Waterer GW, Long AC, et al. 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. Am J Respir Crit Care Med. 2019;200(7):e45-e67. (Guideline) DOI: 10.1164/rccm.201908-1581ST

47. * Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336(4):243-250. (Retrospective; 14,199 patients) DOI: 10.1056/NEJM199701233360402

59. * Pakhale S, Mulpuru S, Verheij TJM, et al. Antibiotics for community-acquired pneumonia in adult outpatients. Cochrane Database Syst Rev. 2014(10):CD002109. (Cochrane review; 11 randomized controlled trials, 3352 participants) DOI: 10.1002/14651858.CD002109.pub4

75. Walker G. Corticosteroids for treating pneumonia. The NNT 2019. Accessed December 9, 2019. (Website)

79. Rezaie S. The Tamiflu debacle. REBEL EM - Emergency Medicine Blog 2019. Accessed January 10, 2021. (Website)

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Keywords: community-acquired pneumonia, COVID-19, Streptococcus, Mycoplasma, Pseudomonas, upper respiratory infection, cough, fever, chills, fatigue, biomarkers, culture, testing, CURB-65, PSI, severity index, SMART-COP, antibiotics, antitussive, pediatric, corticosteroids, influenza