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Pulmonary Medicine›Condition·Updated Jul 8, 2026·v1

Community-Acquired Pneumonia [probe-med]

Community-acquired pneumonia is a heterogeneous syndrome requiring rapid severity-based triage and early antimicrobial therapy. While viral etiologies are increasingly recognized, *S. pneumoniae* remains the primary bacterial target. Management has evolved to include precision immunomodulation with steroids for severe cases and biomarker-guided antibiotic stewardship.

High Evidence422 references·9,813 words·40 min read·v1
PneumoniaCAPPulmonologyInfectious DiseaseCritical Care

Quick Reference

RxDrug of choiceCeftriaxone (1-2g IV daily) + Azithromycin (500mg IV/PO daily)
AltAlternativesLevofloxacin (750mg IV/PO daily) or Moxifloxacin (400mg IV/PO daily)
⊘AvoidRoutine corticosteroids in non-severe CAP; NSAIDs in early-stage infection
DxTest of choiceChest Radiograph (initial); Non-contrast Chest CT (if CXR is negative but suspicion high)
ScKey scorePSI (Pneumonia Severity Index) or CURB-65
→When to referCURB-65 score ≥ 3, PSI Class IV-V, or presence of 1 major/3 minor ATS/IDSA severity criteria
CAP management relies on rapid severity stratification and early administration of combination antibiotics; severe cases benefit significantly from adjunctive hydrocortisone.
Community-acquired pneumonia (CAP) is an acute infection of the lung parenchyma acquired outside of the hospital setting, characterized by lower respiratory tract symptoms and a new pulmonary infiltrate on imaging. It remains a leading cause of morbidity and mortality worldwide, particularly among the elderly and those with significant comorbidities. While traditionally viewed as a bacterial disease dominated by [[Streptococcus pneumoniae]], modern molecular diagnostics reveal that respiratory viruses (e.g., [[rhinovirus]], [[influenza]]) are now identified more frequently than bacteria in hospitalized adults. Management is strictly dictated by severity stratification using validated tools like the [[PSI]] or [[CURB-65]] scores. Treatment focuses on prompt antibiotic administration, typically a beta-lactam combined with a macrolide or a respiratory fluoroquinolone, and aggressive supportive care. Recent landmark trials have established a clear mortality benefit for adjunctive [[hydrocortisone]] in severe cases, marking a shift toward precision immunomodulation.

Overview and Recommendations

Background

  • •CAP incidence follows a distinct U-shaped distribution, peaking in children under 2 years (62.2 per 10,000) and adults over 80 years (164.3 per 10,000), with an overall adult incidence of approximately 24.8 cases per 10,000 person-years.
  • •Pathogen distribution has shifted significantly due to vaccination and molecular testing; viruses are now detected in 23% of hospitalized cases compared to bacteria in only 11%, though *
    • remains the most common bacterial isolate and a primary driver of severe disease.
  • •The pathophysiology involves a complex interplay where pathogens like S. pneumoniae actively acidify the alveolar microenvironment to a pH of ~6.0, disrupting the epithelial barrier and facilitating systemic translocation.
  • •Systemic cardiotoxicity is a major prognostic determinant, as nearly 20% of hospitalized patients experience an adverse cardiac event (e.g., , myocardial infarction) due to direct bacterial invasion of the myocardium and systemic inflammatory stress.
  • •Molecular endotypes, such as the Sepsis Response Signatures (SRS1 and SRS2), provide a framework for understanding heterogeneity; the SRS1 phenotype represents an immunosuppressed state with a 2.4-fold higher mortality risk compared to the immune-competent SRS2 phenotype.
  • •The historical classification of Healthcare-Associated Pneumonia (HCAP) has largely been abandoned in favor of individualized risk assessment for multidrug-resistant pathogens (e.g., , ) using scores like the PES score.

Evaluation

  • •Suspect CAP in any patient presenting with the classic triad of cough (present in >90% of children and ~70% of adults), fever, and dyspnea, though elderly patients may present atypically with altered mental status or general decline.
  • •Perform a thorough physical examination to identify focal chest signs such as crackles (85% sensitive), bronchial breath sounds, or dullness to percussion, which are reliable bedside predictors of parenchymal consolidation.
  • •Calculate the Pneumonia Severity Index ( ) or score immediately upon presentation to determine the appropriate site of care (outpatient, inpatient, or ICU).
  • •Order a posteroanterior and lateral chest radiograph as the initial imaging gold standard to confirm the presence of a new pulmonary infiltrate.
  • •Consider a non-contrast chest computed tomography (CT) if clinical suspicion is high despite a negative radiograph; CT identifies an infiltrate in 33% of patients with negative radiographs and excludes pneumonia in 30% of those with suspected infiltrates.
  • •Obtain a (WBC < 10,000/µL often suggests atypical or viral etiology) and a basic metabolic panel to assess for renal dysfunction (BUN > 30 mg/dL) and electrolyte abnormalities.
  • •Measure inflammatory biomarkers such as (CRP) and (PCT) to support the diagnosis; a PCT < 0.1 ng/mL in a high-risk patient should prompt a search for non-bacterial mimics.
  • •Order blood cultures and a high-quality sputum Gram stain/culture for all patients with severe CAP or those being empirically treated for MRSA or P. aeruginosa.
  • •Utilize urinary antigen tests for S. pneumoniae and Legionella pneumophila in patients with severe disease or epidemiological risk factors, as these tests significantly increase the diagnostic yield.
  • •Assess for myocardial injury by ordering a high-sensitivity cardiac in hospitalized patients; levels ≥ 14 ng/L are associated with a massive increase in short-term mortality risk.
  • •Perform an arterial blood gas (ABG) in patients with respiratory distress to calculate the PaO2/FiO2 ratio; a ratio < 250 is a major criterion for severe CAP and ICU admission.
  • •Evaluate for in elderly or frail patients, as this is a potent modifiable risk factor for aspiration-related pneumonia (OR 11.9).

Management

  • •Determine the site of care: PSI classes I-III or CURB-65 scores 0-1 are generally suitable for outpatient management, while CURB-65 ≥ 3 or PSI classes IV-V require hospitalization.
  • •Initiate empiric antibiotic therapy within 4 hours of presentation; delays in treatment are associated with increased mortality and longer hospital stays.
  • •For outpatient management in healthy adults without comorbidities, administer 1 g TID, 100 mg BID, or a macrolide (e.g., 500 mg day 1, then 250 mg daily) if local resistance is < 25%.
  • •For hospitalized patients with non-severe CAP, initiate combination therapy with a beta-lactam ( 1-2 g IV daily or 1.5-3 g IV every 6 hours) plus a macrolide ( 500 mg IV/PO daily).
  • •Utilize respiratory fluoroquinolone monotherapy ( 750 mg IV/PO daily or 400 mg IV/PO daily) as an alternative for patients with beta-lactam allergies.
  • •For severe CAP requiring ICU admission, prioritize combination therapy with a potent beta-lactam plus either a macrolide or a respiratory fluoroquinolone.
  • •Administer adjunctive 200 mg IV daily (either as a continuous infusion or 50 mg every 6 hours) for 4-7 days in patients with severe CAP to reduce 28-day mortality (NNT = 18).
  • •Target a total antibiotic duration of 5 days for most patients, provided they have achieved clinical stability (afebrile for 48-72 hours, heart rate < 100, RR < 24, SBP > 90).
  • •Use kinetics to guide de-escalation; consider discontinuing antibiotics if the PCT level drops below 0.25 µg/L or decreases by ≥ 80% from the peak.
  • •Provide graded respiratory support, starting with supplemental oxygen to maintain SaO2 > 92%; escalate to high-flow nasal oxygen or non-invasive ventilation (NIV) for persistent hypoxemia.
  • •Avoid the routine use of systemic corticosteroids in non-severe CAP, as they may increase the risk of late treatment failure and hyperglycemia without improving cure rates.
  • •Monitor for clinical stability using Halm's criteria; the median time to stability is 4 days, and failure to stabilize by day 3 is a marker for potential complications.
  • •Administer 75 mg BID for 5 days in patients who test positive for , regardless of symptom duration, to reduce the risk of secondary bacterial complications.
  • •Avoid in the acute phase of CAP, as they are independently associated with an increased risk of pleuropulmonary complications like empyema.
  • •Refer for bronchoscopy with bronchoalveolar lavage (BAL) if the patient fails to improve within 72 hours or if an opportunistic infection is suspected in an immunocompromised host.
  • •Ensure all patients receive the and annual prior to discharge or at follow-up to prevent recurrence.

Board Review — High Yield

  • •Frank's sign, A diagonal earlobe crease that, while not diagnostic, correlates with higher cardiovascular risk in CAP patients.
  • •MIRM, Mycoplasma-induced rash and mucositis; characterized by mucosal ulcerations that may precede respiratory symptoms in children.
  • •SRS1 Endotype, A transcriptomic signature of immune exhaustion associated with higher 14-day mortality in CAP-related sepsis.
  • •CbpA and PAFR, Bacterial adhesins used by S. pneumoniae to translocate into the myocardium and cause direct cardiomyocyte death.
  • •PSI vs CURB-65, PSI is more sensitive for identifying low-risk patients (NPV 0.98), while CURB-65 is more specific for identifying high-risk patients.
  • •Procalcitonin (PCT), A level < 0.1 ng/mL has a high negative predictive value for bacterial CAP, though it should not be used alone to withhold therapy in severe cases.
  • •Atypical Pneumonia Criteria, Age < 60, no comorbidities, persistent cough, limited auscultatory findings, and WBC < 10,000/µL suggest Mycoplasma or Chlamydia.
  • •Hydrocortisone NNT, In severe CAP, the number needed to treat (NNT) with hydrocortisone to prevent one death at 28 days is 18.

Deep Dive — Evidence Details

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