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Pulmonary Medicine›Condition·Updated Jul 11, 2026·v1

Community-Acquired Pneumonia

Community-acquired pneumonia is a common and serious infection requiring prompt diagnosis, severity stratification, and empiric antibiotic therapy guided by site of care. Key steps: confirm with imaging, assess CURB-65/PSI for disposition, initiate beta-lactam plus macrolide for inpatients, add hydrocortisone for severe CAP, use PCT to shorten duration to 5 days, and vaccinate before discharge to mitigate long-term mortality risk (HR 1.65).

High Evidence423 references·9,862 words·40 min read·v1
community-acquired pneumoniaCAPpneumoniarespiratory infectionantibioticscorticosteroidsseverity scoringvaccination

Quick Reference

RxDrug of choiceOutpatient: oral amoxicillin 1 g TID or doxycycline 200 mg load then 100 mg BID. Inpatient non-ICU: ceftriaxone 2 g IV daily plus azithromycin 500 mg IV daily. ICU: ceftriaxone 2 g IV daily plus levofloxacin 750 mg IV daily; add vancomycin for MRSA if indicated.
AltAlternativesLevofloxacin 750 mg IV/oral daily (monotherapy); piperacillin-tazobactam 4.5 g IV q6h for Pseudomonas risk; cefepime 2 g IV q8h plus ciprofloxacin 400 mg IV q12h for severe Pseudomonas.
⊘AvoidNSAIDs in early CAP (increase empyema risk); corticosteroids in nonsevere CAP; benzodiazepines (increase CAP incidence and mortality); non-dihydropyridine CCBs in heart failure (no direct CAP contraindication but avoid if concomitant HF).
DxTest of choiceChest radiograph (first-line); chest CT if X-ray negative but suspicion remains. For hospitalized: blood cultures (if severe), pneumococcal + Legionella urinary antigen, respiratory viral PCR. Procalcitonin to guide antibiotic duration.
ScKey scoreCURB-65 (site of care); PSI (mortality risk); IDSA/ATS minor criteria (ICU triage); PES score (drug-resistant pathogen risk).
→When to referInfectious disease for immunocompromised, refractory, or drug-resistant cases; pulmonary for bronchoscopy, pleural drainage, or advanced ventilatory support; cardiology if new cardiac event; speech therapy for dysphagia screening.
Initiate empiric antibiotics stratified by severity (outpatient: amoxicillin/doxycycline; inpatient: beta-lactam + macrolide; ICU: add anti-Pseudomonas + consider MRSA). Add hydrocortisone 200 mg IV daily for severe CAP (especially if CRP >204 mg/L). Use PCT to limit duration to ≤5 days. Vaccinate before discharge.
Community-acquired pneumonia (CAP) is an acute infection of the lung parenchyma acquired outside healthcare settings, defined by a new pulmonary infiltrate on imaging with compatible clinical features. It remains a leading infectious cause of hospitalization and death worldwide, with 30-day mortality ranging from 4% in mild cases to over 30% in ICU patients. Management hinges on early severity stratification, prompt empiric antibiotics, and recognition that CAP carries long-term mortality risk (HR 1.65 over 10 years). This page provides evidence-based guidance for diagnosis, risk assessment, treatment, and prevention.

Overview and Recommendations

Background

  • •Community-acquired pneumonia (CAP) is defined as an acute infection of the lung parenchyma acquired outside a hospital or long-term care facility, confirmed by a new pulmonary infiltrate on imaging and compatible clinical features. It is the leading infectious cause of hospitalization among U.S. adults, with an annual incidence of 24.8 per 10,000, rising to 164.3 per 10,000 in those aged ≥80 years.
  • •The etiologic spectrum is dominated by Streptococcus pneumoniae (the most common bacterial cause), followed by Haemophilus influenzae, Mycoplasma pneumoniae, Legionella species, respiratory viruses (influenza, SARS-CoV-2, rhinovirus), and, in immunocompromised hosts, Pneumocystis jirovecii and fungi. Atypical pathogens (Mycoplasma, Chlamydophila, Legionella) account for 20-30% of cases and require distinct antibiotic coverage.
  • •Key risk factors include smoking (OR 2-4), COPD, diabetes, chronic heart disease, alcoholism, poor dental hygiene, and aspiration risk (dysphagia, neurologic disease). HIV remains a dominant driver in sub-Saharan Africa (seroprevalence ~78% in hospitalized CAP). Smoking cessation and pneumococcal/influenza vaccination are the most impactful modifiable preventive measures, with pneumococcal vaccine reducing CAP in COPD patients (NNT = 21).
  • •CAP is classified by etiology (typical vs. atypical), severity (outpatient, ward, ICU), host immune status, and aspiration risk. Aspiration CAP accounts for 25% of cases in older adults and independently doubles mortality. The historic category 'healthcare-associated pneumonia' (HCAP) has been abandoned due to lack of outcome benefit from broad-spectrum therapy; current guidelines favor individual risk assessment for multidrug-resistant pathogens.
  • •The pathophysiology involves microbial invasion overcoming alveolar macrophage defenses, triggering innate immune activation, alveolar-capillary barrier disruption (driven by microenvironmental acidification to pH ~6), and systemic inflammation. Transcriptomic profiling identifies two sepsis response signatures: SRS1 (immunosuppressed phenotype, 41% of patients) with 14-day mortality HR 2.4, and SRS2 (inflamed). This host-response heterogeneity explains why mortality has remained static despite antibiotics.
  • •Long-term outcomes are poor: over 9.8 years of follow-up, CAP survivors have an adjusted HR for death of 1.65, with 30-day readmission rate of 15.7%. Cardiovascular complications (myocardial infarction, new atrial fibrillation, heart failure) affect 18-30% of hospitalized patients and drive in-hospital and post-discharge mortality. Pneumolysin and hydrogen peroxide from S. pneumoniae directly invade myocardium, causing necroptosis and scarring.

Evaluation

  • •Suspect CAP in any patient with acute cough, fever, dyspnea, pleuritic chest pain, or unexplained fatigue, symptoms typically evolve over 1-7 days. In elderly patients, fever and cough are often absent; instead, look for confusion, falls, functional decline, or anorexia. Auscultate for crackles, bronchial breath sounds, egophony, and dullness to percussion (LR+ 2-6 for bronchial breath sounds). Tachypnea >30/min, hypotension, or hypoxemia (SpO₂ <90%) signal severe disease.
  • •Confirm the diagnosis with a chest radiograph showing a new infiltrate (lobar, multilobar, or interstitial). Up to 33% of infiltrates are missed on plain film; if clinical suspicion remains high despite a negative radiograph, obtain a chest CT or lung ultrasound. CT modifies management in 59% of cases, initiating antibiotics in 16% and discontinuing in 9%.
  • •Assess severity immediately to determine site of care. Use CURB-65 (Confusion, Urea >7 mmol/L, Respiratory rate ≥30, Blood pressure <90/60, age ≥65), a score ≥2 recommends admission, ≥3 suggests ICU. The Pneumonia Severity Index (PSI) has higher sensitivity (NPV 0.98 for mortality) and is better for identifying low-risk outpatients. For ICU triage, the IDSA/ATS 2007 minor criteria (≥3 of 9) have sensitivity 94% for need for mechanical ventilation or vasopressors.
  • •Order bilateral blood cultures only in severe CAP (ICU admission or septic shock), positivity rate ~10%. Obtain sputum Gram stain and culture if a purulent specimen can be collected. For all hospitalized patients, perform pneumococcal urinary antigen (sensitivity 60-75%, specificity 99.7%) and Legionella urinary antigen (serogroup 1, sensitivity ~70%). Add a respiratory viral PCR panel (nasopharyngeal swab) to identify influenza, SARS-CoV-2, RSV, and other viruses.
  • •Check laboratory markers: CRP and procalcitonin (PCT) are complementary. In early presenters (<3 days of symptoms), CRP may be low and PCT high ; in later presenters, CRP rises and PCT falls. A PCT <0.25 ng/mL can help defer antibiotics in low-risk outpatients. Also obtain renal function (creatinine, urea), liver enzymes, and CBC. For hypoxemic patients, an arterial blood gas defines PaO₂/FiO₂ ratio (<300 indicates respiratory failure) and PaCO₂.
  • •Consider additional testing in special populations: in immunocompromised hosts (HIV, transplant, neutropenia), broaden workup to include BAL with metagenomic NGS for Pneumocystis, CMV, fungi, and mycobacteria. In patients with aspiration risk factors (dysphagia, bedridden, enteral feeding), assess with volume-viscosity swallow test. For patients from endemic areas, add serology for Coccidioides or Histoplasma.
  • •Evaluate for complications early: if a patient fails to stabilize by 48-72 hours, repeat blood cultures, obtain a chest CT, and consider bronchoscopy with BAL for culture and targeted NGS. Look for parapneumonic effusion (5-12% of CAP), empyema, lung abscess, or noninfectious mimics like vasculitis, organizing pneumonia, or pulmonary embolism.
  • •Consider alternative diagnoses in non-responders: pulmonary embolism (especially if D-dimer >3.13 mg/L in elderly), heart failure, malignancy causing post-obstructive pneumonia, drug-induced pneumonitis, or granulomatous disease (TB, fungal). In patients with prior antibiotic use, structural lung disease (COPD, bronchiectasis), or chronic steroid use, consider Pseudomonas aeruginosa or MRSA, use the PES score to risk-stratify for these drug-resistant pathogens (NPV 98% at score <5).
  • •Document clinical stability criteria daily: temperature ≤37.2°C, heart rate ≤100/min, respiratory rate ≤24/min, systolic BP ≥90 mm Hg, SpO₂ ≥90% on room air. Once stable for 48-72 hours, plan IV-to-oral switch and discharge. Procalcitonin guidance can shorten antibiotic duration: use PCT <0.1 µg/L to strongly discourage antibiotics, <0.25 µg/L to discourage, this reduces exposure by 48% without worsening outcomes.

Management

  • •Start empiric antibiotics immediately after diagnosis, within 4 hours of presentation. For outpatients (CURB-65 0-1, PSI I-II): prescribe oral 1 g three times daily OR 200 mg loading then 100 mg twice daily for 5 days (minimum 3 days if clinically stable). Alternatively, 500 mg orally on day 1 then 250 mg days 2-5 can be used if local macrolide resistance rates are low.
  • •For non-ICU hospitalized patients (CURB-65 2-3): initiate a beta-lactam plus a macrolide. Preferred: 2 g IV daily PLUS 500 mg IV daily. Alternatives: 1 g IV q8h, 1.5 g IV q6h, or 750 mg IV daily as monotherapy. Beta-lactam monotherapy is acceptable in patients without SIRS or ≥2, based on CAP-START trial noninferiority.
  • •For ICU patients (severe CAP, CURB-65 ≥4, IDSA/ATS major criteria): initiate 2 g IV daily plus 500 mg IV daily OR 750 mg IV daily. The network meta-analysis identifies ceftriaxone plus levofloxacin as having highest probability for mortality benefit. For patients with risk factors for Pseudomonas (COPD, bronchiectasis, prior antibiotics, corticosteroids), use 4.5 g IV q6h or 2 g IV q8h plus an antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin).
  • •In suspected MRSA (cavitary infiltrates, prior MRSA, IV drug use, end-stage renal disease), add 15-20 mg/kg IV q12h (target trough 15-20 µg/mL) or 600 mg IV q12h. Do not routinely cover MRSA or Pseudomonas in low-risk patients; the PES score (≥5: high risk) helps discriminate.
  • •For severe CAP requiring ICU care, add adjunctive hydrocortisone 200 mg IV daily (continuous infusion or divided q6h) for 4-7 days, then taper. The CAPE COD trial demonstrated reduction in 28-day mortality from 11.9% to 6.2% (NNT = 18). The benefit is concentrated in patients with CRP >204 mg/L (OR 0.43 for mortality). Do NOT use corticosteroids in nonsevere CAP, prednisolone 40 mg daily increased late failure (19.2% vs 6.4%).
  • •Provide oxygen to target SpO₂ ≥92% (PaO₂ ≥60 mm Hg). For moderate hypoxemic respiratory failure (PaO₂/FiO₂ 210-285), use helmet CPAP, median time to PaO₂/FiO₂ >315 is 1.5 h vs 48 h with standard oxygen. If CPAP fails or PaO₂/FiO₂ <150, escalate to noninvasive ventilation (NIV) or high-flow nasal oxygen. NIV reduces intubation risk (OR 0.26) and ICU mortality (OR 0.28) in CAP with ARDS.
  • •For invasive mechanical ventilation, use lung-protective strategy: tidal volume 6 mL/kg predicted body weight, plateau pressure ≤30 cm H₂O. In severe ARDS, consider prone positioning and early neuromuscular blockade. In extreme cases, ECMO may be considered in specialist centers.
  • •Monitor for clinical stability daily. Once stable for 48-72 h, switch from IV to oral antibiotics. Use procalcitonin guidance to limit duration: for nonsevere CAP, treat for 5 days (minimum 3) if stable; for severe CAP, treat for 5-7 days. Longer courses reserved for complications (empyema, lung abscess, necrotizing pneumonia). Do NOT extend beyond 7 days routinely, inflection point at 7.4 days associates with increased length of stay.
  • •If no response by 72 h, evaluate for complications: repeat chest CT, bronchoscopy with BAL for culture and metagenomic NGS. Consider pleural drainage for parapneumonic effusion (chest tube with fibrinolytics: urokinase or alteplase). For empyema, VATS is preferred if fibrinolytics fail. Drainage of complicated effusion reduces hospital stay by ~5 days.
  • •For patients with aspiration pneumonia (gravity-dependent opacity, dysphagia risk): cover anaerobes with 3 g IV q6h, , or 500 mg IV q8h added to a beta-lactam. Avoid clindamycin due to high resistance rates.
  • •What NOT to do: Avoid NSAIDs in early CAP, they increase odds of pleuropulmonary complications (empyema, cavitation) 8-fold. Do not use benzodiazepines routinely, they increase CAP incidence (OR 1.54) and mortality (HR 1.22). Do not use corticosteroids for parapneumonic effusions (no benefit, trend toward harm). Do not use routine antifungal coverage in immunocompetent patients.
  • •When to refer: Consider infectious disease consultation for immunocompromised hosts, patients with drug-resistant pathogens, or refractory cases. Consider pulmonary consultation for bronchoscopy, chest tube drainage, or advanced ventilatory support. For patients with functional decline after hospitalization, refer to pulmonary rehabilitation.
  • •Discharge planning: Ensure all patients receive pneumococcal vaccination (PCV13 or PCV20 + PPSV23 per schedule) and influenza vaccination (in season). Assess cardiovascular risk: check high-sensitivity troponin and consider optimizing guideline-directed medical therapy for heart disease. Screen for dysphagia in elderly. Educate on smoking cessation and dental hygiene.
  • •Antibiotic drug doses in special populations: Renal impairment, adjust beta-lactams, fluoroquinolones, vancomycin based on eGFR. Obesity, use actual body weight for aminoglycosides, adjusted body weight for vancomycin. Elderly, no specific dose changes for most beta-lactams and macrolides, but monitor renal function. Pregnancy, beta-lactams and azithromycin are safe; avoid tetracyclines and fluoroquinolones.

Board Review — High Yield

  • •CURB-65, Clinical score for severity: Confusion, Urea >7, RR ≥30, BP <90/60, age ≥65; ≥2 recommends admission, ≥3 suggests ICU.
  • •Procalcitonin (PCT), Biomarker to guide antibiotic initiation and duration; <0.25 ng/mL discourages antibiotics in low-risk outpatients; <0.1 µg/L strongly discourages.
  • •CAPE COD trial, Demonstrated hydrocortisone 200 mg IV daily reduces 28-day mortality in severe CAP from 11.9% to 6.2% (NNT=18); benefit concentrated with CRP >204 mg/L.
  • •PES score, Predicts drug-resistant etiology (Pseudomonas, ESBL, MRSA); score ≥5 had NPV 98% for ruling out non-core pathogens.
  • •Long-term mortality, CAP carries HR 1.65 for death over 9.8 years vs controls; 30-day readmission rate 15.7%; need vaccination and CV risk modification after discharge.
  • •Aspiration CAP, Independent predictor of mortality (HR 5.69); screen for dysphagia; cover anaerobes with ampicillin-sulbactam or metronidazole-beta-lactam combination.
  • •SRS1 transcriptomic signature, Immunosuppressed phenotype in 41% of CAP patients; associated with higher 14-day mortality (HR 2.4); identifies candidates for immunomodulation.
  • •Urinary antigen testing, Pneumococcal (sensitivity 60-75%, specificity 99.7%) and Legionella (serogroup 1) are rapid, noninvasive tests that increase diagnostic yield in hospitalized CAP.
  • •Helmet CPAP, In moderate hypoxemic respiratory failure (PaO2/FiO2 210-285), improves oxygenation faster than standard oxygen (1.5 h vs 48 h to reach PaO2/FiO2 >315).
  • •Pneumococcal vaccination NNT, In COPD, 21 patients need to be vaccinated to prevent one episode of CAP (OR 0.62). Influenza vaccine reduces symptomatic influenza by 70%.

Deep Dive — Evidence Details

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