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Infectious Diseases›Condition·Updated Jul 8, 2026·v1

Community-Acquired Pneumonia [probe-off]

Community-acquired pneumonia is a high-stakes respiratory infection requiring rapid triage via the PSI score. Treatment has evolved toward shorter antibiotic durations (3-5 days) and the use of adjunctive steroids in severe cases, while the diagnostic focus has shifted toward identifying viral etiologies and de-escalating MDRO coverage using tools like MRSA nasal screening.

High Evidence360 references·8,955 words·36 min read·v1
PneumoniaInfectious DiseasesPulmonologyAntibioticsSepsis

Quick Reference

RxDrug of choiceCeftriaxone (1-2g IV daily) + Azithromycin (500mg daily)
AltAlternativesRespiratory fluoroquinolones (Levofloxacin 750mg daily) or Ceftriaxone + Doxycycline
⊘AvoidNon-dihydropyridine CCBs (in HF-related CAP); Macrolide monotherapy in areas with >25% S. pneumoniae resistance
DxTest of choiceChest X-ray (CXR) for diagnosis; PSI for triage
ScKey scorePneumonia Severity Index (PSI)
→When to referPSI Class IV-V, CURB-65 ≥2, or any patient with respiratory failure/septic shock
CAP is a major cause of mortality; manage with rapid severity scoring, early empiric antibiotics (beta-lactam + macrolide), and short-course therapy (3-5 days) if stable.
Community-acquired pneumonia (CAP) is an acute infection of the pulmonary parenchyma acquired outside of the hospital setting. It remains the leading infectious cause of death worldwide, resulting in approximately 1.5 million adult hospitalizations and 100,000 in-hospital deaths annually in the United States. While Streptococcus pneumoniae was historically the dominant pathogen, the widespread use of conjugate vaccines and advanced molecular diagnostics has shifted the landscape; respiratory viruses (e.g., rhinovirus, influenza) are now detected more frequently than bacteria in many hospitalized cohorts. Management is centered on rapid severity stratification using validated tools like the Pneumonia Severity Index (PSI), followed by the initiation of empiric antibiotics, typically a beta-lactam combined with a macrolide. Recent evidence emphasizes shorter treatment durations (3-5 days) for clinically stable patients and the use of adjunctive corticosteroids in severe cases to reduce mortality.

Overview and Recommendations

Background

  • •Community-acquired pneumonia (CAP) is clinically defined by the presence of two or more signs (temperature >38°C or ≤36°C; leukocyte count <4,000/μL or >10,000/μL) or symptoms (new cough, dyspnea) in conjunction with radiographic evidence of a new pulmonary infiltrate.
  • •Streptococcus pneumoniae remains the most frequent bacterial isolate and a primary driver of mortality, particularly through its association with major adverse cardiovascular events (MACE), which occur in 28% of hospitalized CAP patients due to the cardiotoxic effects of the pore-forming toxin pneumolysin.
  • •Respiratory viruses, including human rhinovirus (9%) and influenza (6%), are now more commonly identified than typical bacteria in hospitalized adults, though bacterial co-infection remains a critical concern in severe presentations.
  • •Atypical pathogens such as and require specific consideration; M. pneumoniae is the leading bacterial cause in children ≥5 years, while Legionella is a common cause of severe CAP requiring ICU admission.
  • •The historical classification of healthcare-associated pneumonia (HCAP) has been largely abandoned in favor of specific risk-factor assessment, as HCAP criteria poorly predict multidrug-resistant organisms (MDROs) compared to prior colonization (OR 7.43) or nursing home residence (OR 4.19).

Evaluation

  • •Suspect CAP in any patient presenting with acute cough, dyspnea, pleuritic chest pain, and systemic signs such as fever or rigors; note that elderly patients may present atypically with confusion or functional decline rather than respiratory symptoms.
  • •Order a chest X-ray (CXR) as the first-line diagnostic test to confirm the presence of an infiltrate; lung ultrasound is a validated alternative when performed by experienced clinicians, while CT is generally reserved for suspected complications or diagnostic uncertainty.
  • •Calculate the (PSI) or score immediately to determine the appropriate site of care (outpatient vs. inpatient vs. ICU); the PSI is the gold standard for identifying low-risk patients who can be safely managed at home.
  • •Obtain blood cultures and a high-quality sputum Gram stain/culture in all patients with severe CAP or those being treated empirically for MRSA or before the first dose of antibiotics.
  • •Utilize urinary antigen tests for rapid detection of and (serogroup 1) in hospitalized patients with severe disease or during known outbreaks.
  • •Perform an MRSA nasal PCR screen to assist in antimicrobial stewardship; a negative result has a 98.1% negative predictive value, allowing for the confident de-escalation of or .
  • •Order a and metabolic panel to assess for leukocytosis, renal dysfunction, and electrolyte abnormalities (e.g., hyponatremia, which is classically associated with Legionella).
  • •Consider serum (PCT) as a prognostic marker rather than a diagnostic one; while PCT can help predict bacteremia and the need for ICU care, it should not be used in isolation to withhold antibiotics in a patient with radiographic pneumonia.
  • •Screen for comorbid in elderly patients with CAP and a D-dimer >0.50 mg/L, as the two conditions frequently coexist in this population.
  • •Evaluate for endemic fungi like in patients with recent travel to the southwestern United States, especially if the pneumonia is accompanied by a rash or arthralgias.

Management

  • •Initiate empiric antibiotics within 4 to 8 hours of hospital arrival; for non-severe inpatients, the standard regimen is a (e.g., 1-2 g IV daily) plus a (e.g., 500 mg IV/PO daily).
  • •Use 100 mg BID as an alternative to macrolides for atypical coverage in mild-to-moderate CAP, though observational data suggests azithromycin may have a superior mortality benefit in hospitalized cohorts.
  • •Administer 600 mg IV every 12 hours as an alternative to ceftriaxone for patients in PORT risk class III-IV, as it has shown higher clinical cure rates (84% vs 74%) in some populations.
  • •Escalate to anti-pseudomonal coverage (e.g., 4.5 g every 6 hours or 2 g every 8 hours) only if the patient has specific risk factors such as prior colonization or recent hospitalization with broad-spectrum antibiotics.
  • •Add (trough 15-20 mcg/mL) or 600 mg BID for suspected MRSA in patients with necrotizing features, post-influenza pneumonia, or a positive nasal screen.
  • •Prescribe adjunctive 200 mg IV daily (tapered over 8-14 days) for patients with severe CAP requiring ICU admission; this has been shown to reduce 28-day mortality (NNT = 18).
  • •Utilize 0.5 mg/kg every 12 hours for 5 days in patients with severe CAP and a high inflammatory response (C-reactive protein >150 mg/L) to reduce treatment failure.
  • •Transition from IV to oral antibiotics once the patient is hemodynamically stable, able to ingest medications, and shows improving respiratory symptoms (usually by hospital day 3).
  • •Limit the total duration of antibiotic therapy to 3-5 days for patients who achieve clinical stability by day 3; short-course therapy is non-inferior to traditional 7-10 day courses and reduces the risk of and resistance.
  • •Monitor for cardiovascular complications, including myocardial infarction and new-onset heart failure, which are common during the acute phase and the first year following CAP recovery.
  • •Refer patients with complicated parapneumonic effusions or empyema for thoracic surgery evaluation or interventional radiology for chest tube drainage and potential intrapleural fibrinolytics.
  • •Ensure all patients receive the or vaccine (as per current age-based guidelines) and an annual influenza vaccine prior to discharge to prevent recurrence.

Board Review — High Yield

  • •Pneumolysin, Pore-forming toxin of S. pneumoniae that drives myocardial injury and MACE.
  • •MRSA Nasal PCR, High NPV (98%) allows safe discontinuation of vancomycin in CAP.
  • •CURB-65, Confusion, Urea >7, RR ≥30, BP <90/60, Age ≥65; score ≥2 suggests hospitalization.
  • •Atypical Pathogens, Legionella, Mycoplasma, and Chlamydia; not visible on Gram stain and require macrolides/quinolones.
  • •Rust-colored sputum, Classic buzzword for Streptococcus pneumoniae pneumonia.
  • •Hyponatremia, Often associated with Legionella pneumophila due to SIADH or renal loss.
  • •3-Day Antibiotic Course, Non-inferior to 8 days in clinically stable patients (PTC trial).
  • •PCV13 Efficacy, Reduces vaccine-type CAP by ~46% in adults ≥65 years.
  • •Panton-Valentine Leukocidin (PVL), Toxin in MRSA causing necrotizing pneumonia and leukopenia.

Deep Dive — Evidence Details

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