Community-Acquired Pneumonia in Urgent Care Medicine (Pharmacology CME and Infectious Disease CME)

Table of Contents

 

About This Course

Patients who present to urgent care with symptoms of community-acquired pneumonia (CAP) must be carefully evaluated, risk stratified, and dispositioned appropriately. Recommendations for diagnosis and treatment of CAP have evolved in the past few years. In this issue, you will learn:

The most common presenting symptoms of CAP

The high-risk CAP mimics for which clinicians must be alert

The special considerations for CAP in the era of COVID-19

The signs and symptoms that are concerning for sepsis related to pneumonia

The most useful diagnostic imaging and laboratory testing for CAP in the urgent care setting

The utility of the CRB-65 and other risk stratification tools for CAP in urgent care

The latest guidelines on treatment of CAP, including antibiotic selection and the use of corticosteroids and antitussives

CHARTING & CODING: Learn how to select the appropriate level of service for encounters with patients with suspected CAP

1. About This Course
2. Abstract
3. Case Presentations
4. Introduction
5. Community-Acquired Pneumonia in the Era of COVID-19
6. Epidemiology
7. Pathophysiology
8. Differential Diagnosis
9. Urgent Care Evaluation
10. Diagnostic Studies
    1. Chest Radiography
    2. Computed Tomography
    3. Ultrasound
    4. Laboratory Testing
       1. Biomarkers
          • Mycoplasma pneumoniae Testing
       2. Urine Antigen Testing
       3. Blood Cultures
       4. Sputum Cultures
       5. Viral Respiratory Panel
11. Using Severity and Risk Scoring Systems for Disposition
    1. Pneumonia Severity Index
    2. CURB-65 Score
    3. CRB-65 Score
12. Treatment
    1. Antibiotic Selection
    2. Antibiotic Duration
    3. Antitussives
13. Controversies and Cutting Edge
    1. Corticosteroids
    2. Influenza, Antiviral Agents, and Community-Acquired Pneumonia
14. Summary
15. Risk Management Pitfalls for Community-Acquired Pneumonia in Urgent Care
16. 5 Things That Will Change Your Practice
17. Time- and Cost-Effective Strategies
18. Critical Appraisal of the Literature
19. Case Conclusions
20. Charting & Coding: What You Need to Know
    1. Medical Decision Making
       1. Problems Addressed Category
       2. Complexity of Data Category
       3. Risk of Complications Category
21. Clinical Pathway for Urgent Care Management of Community-Acquired Pneumonia
22. References

Abstract

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 urgent care setting, including key physical examination findings, diagnostic studies, and treatment options. Various clinical decision aids are compared in the context of their utility in outpatient facilities. A clinical pathway for urgent care management of community-acquired pneumonia is provided to help guide disposition decision making and delineate optimal antibiotic regimens based on patient comorbidities and risk factors.

Case Presentations

A 30-year-old man with no significant past medical history presents to the urgent care clinic with 2 days of fever, cough productive of green sputum, and malaise...

• Physical examination reveals left-sided rhonchi that do not clear with coughing.
• The patient has a heart rate of 105 beats/min and a temperature of 39.1°C. He is normotensive, has a respiratory rate of 22 breaths/min, is speaking in full sentences, and has 95% oxygen saturation on room air.
• COVID-19 rapid PCR, influenza A virus, and influenza B virus testing are all negative.
• X-rays show a left-sided retrocardiac opacity concerning for pneumonia.
• When you suggest to the patient that he may require treatment in a hospital, he states he would prefer 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.

Her physical examination reveals normal vital signs and slightly diminished breath sounds in the right lung fields. X-rays show 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 mellitus and chronic kidney disease presents with 3 days of a nonproductive cough, fever, and lethargy...

• 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 his respiratory rate is 26 breaths/min. His oxygen saturation is at 88% on room air.
• X-ray findings include bilateral infiltrates concerning for multifocal pneumonia and a left-sided pleural effusion.
• The patient’s wife states she will bring him to the hospital after she goes home, packs the patient a bag, and lets the dog outside...

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Urgent Care Management of Community-Acquired Pneumonia

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Key References

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

3. * 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

7. * Metlay JP, Waterer GW. Treatment of community-acquired pneumonia during the coronavirus disease 2019 (COVID-19) pandemic. Ann Intern Med. 2020;173(4):304-305. (Guideline) DOI: 10.7326/M20-2189

13. * Jain S, Self WH, Wunderink RG, et al. Community-acquired peumonia requiring hopitalization among U.S. adults. N Engl J Med. 2015;373(5):415-427. (Prospective; 2400 patients) DOI: 10.1056/NEJMoa1405870

23. * 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). (Prospective; 28,883 patients) DOI: 10.1183/13993003.00434-2017

32. Hicks J. Point of care ultrasound (POCUS) in urgent care. The Journal of Urgent Care Medicine. Accessed March 10, 2023. (Online review article)

48. * Bauer TT, Ewig S, Marre R, et al. CRB-65 predicts death from community-acquired pneumonia. J Intern Med. 2006;260(1):93-101. (Multicenter prospective study; 1343 patients) DOI: 10.1111/j.1365-2796.2006.01657.x

49. * Ebell MH, Walsh ME, Fahey T, et al. Meta-analysis of calibration, discrimination, and stratum-specific likelihood ratios for the CRB-65 score. J Gen Intern Med. 2019;34(7):1304-1313. (Meta-analysis; 29 studies) DOI: 10.1007/s11606-019-04869-z

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

58. Tepler P, Zehtabchi S. Corticosteroids for treating pneumonia. The NNT. Updated March 29, 2019. Accessed March 10, 2023. (Online review article)

62. Rezaie S. The Tamiflu debacle. REBEL EM - Emergency Medicine Blog. October 24, 2018. Accessed March 10, 2023. (Online review article)

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Keywords: community-acquired pneumonia, CAP, COVID-19, influenza, Streptococcus, Mycoplasma, Pseudomonas, upper respiratory infection, cough, fever, chills, fatigue, culture, testing, CURB-65, CRB-65, PSI, antibiotics, antitussive, corticosteroids