Clinical Pathways
Clinical Pathways
Outpatient Treatment
Outpatient Treatment

Outpatient Treatment

View The Full Pathway

Decision

Are significant comorbidities present?

Background

Significant comorbidities include but are not limited to: asthma or chronic obstructive pulmonary disease; diabetes; congestive heart failure; immunosuppressive disorders or therapy; chronic kidney disease; active cancer or chemotherapy; degenerative neurologic disorders; and advanced age.

‣
References
  1. Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence. 2014;5(1):4-11. (Review)
  2. Kalil AC, Metersky ML, Klompas M, et al. Executive summary: management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):575-582. (Guideline)
  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
  4. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. (Guideline)
  5. Roch A, Thomas G, Hraiech S, et al. Hospital-acquired, healthcare-associated and ventilator-associated pneumonia. In: Cohen J, Powderly WG, Opal SM, eds. Infectious Diseases. 4th ed: Elsevier; 2016:258-262. (Textbook)
  6. Seymann GB, Di Francesco L, Sharpe B, et al. The HCAP gap: differences between self-reported practice patterns and published guidelines for health care-associated pneumonia. Clin Infect Dis. 2009;49(12):1868-1874. (Survey; 855 participants)
  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
  8. Weinstock MB, Echenique A, Russell JW, et al. Chest x-ray findings in 636 ambulatory patients with COVID-19 presenting to an urgent care center: a normal chest x-ray is no guarantee. Journal of Urgent Care Medicine. 2020;14(7):13-18. (Retrospective review; 636 patients)
  9. Du Y, Tu L, Zhu P, et al. Clinical features of 85 fatal cases of COVID-19 from Wuhan. A retrospective observational study. Am J Respir Crit Care Med. 2020;201(11):1372-1379. (Case series; 85 patients)
  10. Nori P, Cowman K, Chen V, et al. Bacterial and fungal coinfections in COVID-19 patients hospitalized during the New York City pandemic surge. Infect Control Hosp Epidemiol. 2021;42(1):84-88. (Retrospective review; 4627 patients)
  11. Xu J, Murphy SL, Kochanek KD, et al. Deaths: final data for 2019. Natl Vital Stat Rep. 2021;70(8):1-87. (Summary of statistical data)
  12. Ramirez JA, Wiemken TL, Peyrani P, et al. Adults hospitalized with pneumonia in the United States: incidence, epidemiology, and mortality. Clin Infect Dis. 2017;65(11):1806-1812. (Prospective population-based cohort study; 7449 patients)
  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
  14. Moberley SA, Holden J, Tatham DP, et al. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev. 2008(1):CD000422. (Systematic review)
  15. de Roux A, Marcos MA, Garcia E, et al. Viral community-acquired pneumonia in nonimmunocompromised adults. Chest. 2004;125(4):1343-1351. (Prospective; 338 patients)
  16. Chalmers JD, Rother C, Salih W, et al. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis. 2014;58(3):330-339. (Review)
  17. Musher DM, Roig IL, Cazares G, et al. Can an etiologic agent be identified in adults who are hospitalized for community-acquired pneumonia: results of a one-year study. J Infect. 2013;67(1):11-18. (Retrospective; 259 patients)
  18. Alcón A, Fàbregas N, Torres A. Pathophysiology of pneumonia. Clin Chest Med. 2005;26(1):39-46. (Review)
  19. Mizgerd JP. Acute lower respiratory tract infection. N Engl J Med. 2008;358(7):716-727. (Review)
  20. Almirall J, Bolíbar I, Balanzó X, et al. Risk factors for community-acquired pneumonia in adults: a population-based case-control study. Eur Respir J. 1999;13(2):349-355. (Case control study; 280 patients)
  21. Gulmez SE, Holm A, Frederiksen H, et al. Use of proton pump inhibitors and the risk of community-acquired pneumonia: a population-based case-control study. Arch Intern Med. 2007;167(9):950-955. (Case-control study; 49,460 patients)
  22. Xun X, Yin Q, Fu Y, et al. Proton pump inhibitors and the risk of community-acquired pneumonia: an updated meta-analysis. Ann Pharmacother. 2022;56(5):524-532. (Meta-analysis; 13 studies. 2,098,804 patients)
  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
  24. Gennis P, Gallagher J, Falvo C, et al. Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department. J Emerg Med. 1989;7(3):263-268. (Retrospective; 308 patients)
  25. Spiteri MA, Cook DG, Clarke SW. Reliability of eliciting physical signs in examination of the chest. Lancet. 1988;1(8590):873-875. (Prospective; 24 physicians)
  26. Muder RR, Brennen C, Swenson DL, et al. Pneumonia in a long-term care facility. A prospective study of outcome. Arch Intern Med. 1996;156(20):2365-2370. (Prospective; 108 patients)
  27. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278(17):1440-1445. (Review)
  28. Self WH, Courtney DM, McNaughton CD, et al. High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia. Am J Emerg Med. 2013;31(2):401-405. (Prospective; 3423 patients)
  29. Wunderink RG, Waterer GW. Clinical practice. Community-acquired pneumonia. N Engl J Med. 2014;370(6):543-551. (Review)
  30. Wheeler JH, Fishman EK. Computed tomography in the management of chest infections: current status. Clin Infect Dis. 1996;23(2):232-240. (Review)
  31. Hayden GE, Wrenn KW. Chest radiograph vs. computed tomography scan in the evaluation for pneumonia. J Emerg Med. 2009;36(3):266-270. (Retrospective; 1057 patients)
  32. Hicks J. Point of care ultrasound (POCUS) in urgent care. The Journal of Urgent Care Medicine. Accessed March 10, 2023. (Online review article)
  33. Bourcier JE, Paquet J, Seinger M, et al. Performance comparison of lung ultrasound and chest x-ray for the diagnosis of pneumonia in the ED. Am J Emerg Med. 2014;32(2):115-118. (Prospective; 144 patients)
  34. Chavez MA, Shams N, Ellington LE, et al. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res. 2014;15(1):50. (Systematic review; 1172 patients)
  35. Shaddock EJ. How and when to use common biomarkers in community-acquired pneumonia. Pneumonia (Nathan). 2016;8:17. (Review)
  36. Müller B, Harbarth S, Stolz D, et al. Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia. BMC Infect Dis. 2007;7:10. (Prospective; 545 patients)
  37. Foshaug M, Vandbakk-Rüther M, Skaare D, et al. Mycoplasma pneumoniae detection causes excess antibiotic use in Norwegian general practice: a retrospective case-control study. Br J Gen Pract. 2015;65(631):e82-88. (Retrospective case control; 414 patients)
  38. Falguera M, Ruiz-González A, Schoenenberger JA, et al. Prospective, randomised study to compare empirical treatment versus targeted treatment on the basis of the urine antigen results in hospitalised patients with community-acquired pneumonia. Thorax. 2010;65(2):101-106. (Prospective randomized; 194 patients)
  39. Kennedy M, Bates DW, Wright SB, et al. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005;46(5):393-400. (Prospective; 3926 patients)
  40. Benenson RS, Kepner AM, Pyle DN, 2nd, et al. Selective use of blood cultures in emergency department pneumonia patients. J Emerg Med. 2007;33(1):1-8. (Retrospective; 684 patients)
  41. Musher DM, Montoya R, Wanahita A. Diagnostic value of microscopic examination of Gram-stained sputum and sputum cultures in patients with bacteremic pneumococcal pneumonia. Clin Infect Dis. 2004;39(2):165-169. (Retrospective; 105 patients)
  42. Ewig S, Schlochtermeier M, Göke N, et al. Applying sputum as a diagnostic tool in pneumonia: limited yield, minimal impact on treatment decisions. Chest. 2002;121(5):1486-1492. (Prospective; 116 patients)
  43. May L, Tatro G, Poltavskiy E, et al. Rapid multiplex testing for upper respiratory pathogens in the emergency department: a randomized controlled trial. Open Forum Infect Dis. 2019;6(12):ofz481. (Prospective randomized controlled trial; 191 patients)
  44. Uyeki TM, Bernstein HH, Bradley JS, et al. Clinical practice guidelines by the Infectious Diseases Society of America: 2018 update on diagnosis, treatment, chemoprophylaxis, and institutional outbreak management of seasonal influenza. Clin Infect Dis. 2019;68(6):e1-e47. (Guideline)
  45. 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)
  46. Aujesky D, Fine MJ. The pneumonia severity index: a decade after the initial derivation and validation. Clin Infect Dis. 2008;47 Suppl 3:S133-139. (Review)
  47. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377-382. (Review; 1068 patients)
  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
  50. Ebell MH. Community-acquired pneumonia: determining safe treatment in the outpatient setting. Am Fam Physician. 2019;99(12):768-769. (Review)
  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
  52. Mokabberi R, Haftbaradaran A, Ravakhah K. Doxycycline vs. levofloxacin in the treatment of community-acquired pneumonia. J Clin Pharm Ther. 2010;35(2):195-200. (Prospective; 65 patients)
  53. Dunbar LM, Wunderink RG, Habib MP, et al. High-dose, short-course levofloxacin for community-acquired pneumonia: a new treatment paradigm. Clin Infect Dis. 2003;37(6):752-760. (Multicenter randomized; 390 patients)
  54. Tansarli GS, Mylonakis E. Systematic review and meta-analysis of the efficacy of short-course antibiotic treatments for community-acquired pneumonia in adults. Antimicrob Agents Chemother. 2018;62(9):e00635-18. (Prospective; 390 patients)
  55. Yancy WS, Jr., McCrory DC, Coeytaux RR, et al. Efficacy and tolerability of treatments for chronic cough: a systematic review and meta-analysis. Chest. 2013;144(6):1827-1838. (Systematic review; 3607 patients)
  56. Boulet LP, Milot J, Boutet M, et al. Airway inflammation in nonasthmatic subjects with chronic cough. Am J Respir Crit Care Med. 1994;149(2 Pt 1):482-489. (Prospective; 29 patients)
  57. Stern A, Skalsky K, Avni T, et al. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2017;12(12):CD007720. (Cochrane review)
  58. Tepler P, Zehtabchi S. Corticosteroids for treating pneumonia. The NNT. Updated March 29, 2019. Accessed March 10, 2023. (Online review article)
  59. Lee N, Choi KW, Chan PK, et al. Outcomes of adults hospitalised with severe influenza. Thorax. 2010;65(6):510-515. (Prospective; 754 patients)
  60. Dobson J, Whitley RJ, Pocock S, et al. Oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials. Lancet. 2015;385(9979):1729-1737. (Meta-analysis; 4328 patients)
  61. Uyeki TM, Bernstein HH, Bradley JS, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on diagnosis, treatment, chemoprophylaxis, and institutional outbreak management of seasonal influenzaa. Clin Infect Dis. 2019;68(6):895-902. (Guideline)
  62. Rezaie S. The Tamiflu debacle. REBEL EM - Emergency Medicine Blog. October 24, 2018. Accessed March 10, 2023. (Online review article)
  63. Jefferson T, Jones M, Doshi P, et al. Neuraminidase inhibitors for preventing and treating influenza in healthy adults: systematic review and meta-analysis. BMJ. 2009;339:b5106. (Systematic review and meta-analysis; 20 trials)
  64. File TM, Goldberg L, Das A, et al. Efficacy and safety of Intravenous-to-oral lefamulin, a pleuromutilin antibiotic, for the treatment of community-acquired cacterial pneumonia: The phase III Lefamulin Evaluation Against Pneumonia (LEAP 1) Trial. Clin Infect Dis. 2019;69(11):1856-1867. (Prospective randomized controlled trial; 551 patients)
  65. Pasternak B, Inghammar M, Svanström H. Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study. BMJ. 2018;360:k678. (Historical cohort; 360,088 patients)
  66. Brown SM, Jones BE, Jephson AR, et al. Validation of the Infectious Disease Society of America/American Thoracic Society 2007 guidelines for severe community-acquired pneumonia. Crit Care Med. 2009;37(12):3010-3016. (Retrospective; 2413 patients)

Significant Comorbidities
Significant Comorbidities
No significant comorbidities
No significant comorbidities

FacebookTwitterLinkedInInstagramYouTubePinterest

EB Medicine

FOAMed

Podcast

© EB Medicine. All rights reserved