How to Manage Pneumonia in the Outpatient

Pneumonia is simply a type of infection of one or both lungs.

Community acquired pneumonia (CAP) describes the clinical scenario where signs and symptoms of a lung infection started outside of the hospital OR within 48 hours (2 days) of hospital admission.

Within this timeframe, it is likely the patient encountered the bug and it has been incubating prior to being admitted.

The first part of this series, Respiratory Tract Infections: Pneumonia covers the basics of pneumonia. It explains the different types of pneumonia, how we assess a patient and the 3 “where” questions that must be answered when a patient presents with sign and symptoms of pneumonia. It sets the foundation for understanding how we treat each subset of pneumonia.

The following chart provides a general summary of the content covered in that unit. Details on all the steps illustrated can be found here.

For this study unit we will assume that our patient had signs and symptoms of pneumonia outside of the hospital or within 48 hours of hospital admission: the diagnosis is community acquired pneumonia (CAP).

Let us first consider those patients with a CURB-65 score of <2 i.e. patients suitable for treatment of pneumonia in outpatient settings.

Treatment of CAP: Outpatient

We have a diagnosis (pneumonia) based on sign/symptoms, labs and imaging. We know where the infection started (outside of hospital/community) and where the patient will be treated (outpatient, CURB/CRB<2).

At this point there are only 2 clinical scenarios for treatment that is dependent on whether our patient has disease states that place them at risk of infection by resistant bugs. Theses includes:

Clinical Scenario 1: CAP Outpatient

Your patient has NO disease states that places them at risk for potential infection by resistant bugs.

In otherwise healthy patients the guidelines recommend treatment of pneumonia in outpatient with amoxicillin. If patient has an allergy we can use doxycycline, azithromycin or clarithromycin.

Clinical Scenario 2: CAP Outpatient

Your patient has one or more of these diseases that places them at risk for potential infection by resistant bugs.

If your patient has one or more of the comorbidities listed, then we can use either combination therapy or monotherapy to treatment pneumonia in outpatient. In the illustration above you can substitute any of the drugs in the primary regimens for an alternative listed in the corresponding category.

Please note that there are some cases where a patient has a CURB/CRB score of <2 and requires hospitalization. For instance, a patient may not be able to tolerate oral medications. They may have a lifestyle or home environment that has a high likelihood of not reliably completely antibiotics like drug abuse, cognitive impairment or functional impairment. Clinical judgement must always be used in conjunction with validated prognostic tools.

Alternative Antibiotics

When are they needed?

The primary regimen provided in each clinical scenario includes antibiotics that are fairly common throughout the United States. A common reason you will have to deviate from this standard regimen is allergy.

Pneumonia guidelines are laced with beta lactams. Unfortunately penicillin is also the most commonly reported drug allergy. Whether these are true anaphylactic responses or simply drug intolerances/unfavorable side effects is another discussion in itself.

It is a good idea to know a non-penicillin antibiotic for each clinical scenario so that you are prepared when the the first line agent is not an option. Sometimes, in the inpatient setting, a beta lactam may be given despite a listed penicillin allergy with close monitoring. This is not an option in the outpatient setting because your patient will be taking the medication at home.

Sputum Cultures:

When are they needed in CAP?

Sputum cultures are NOT recommended for CAP managed in the outpatient setting. Most clinics will not have the staff needed to obtain sputum cultures. As we’ve discussed earlier, the like causative agents in CAP are going to be susceptible because there is relatively less antibiotic exposure to foster conversion to MDR bugs.

Guidelines consider the cost utility of the interventions that are recommended. Getting cultures on samples that will routinely be susceptible adds unnecessary costs to the outpatient treatment of pneumonia.

Blood Cultures:

When are they needed in CAP?

ATS/IDSA guidelines recommended that blood cultures be drawn only in patients hospitalized with CAP. We will discuss patients with CAP requiring hospitalization in a different study unit.

Duration of Treatment

The ATS/IDSA guidelines are pretty straightforward with regard to the duration of treatment for CAP

Treatment should be no less than 5 days even if patient is clinically stable before then i.e. complete the course of therapy, even if patient starts to feel better before it ends

This unit serves a good launching pad to dive into the diagnosis and treatment guidelines for community acquired pneumonia from the American Thoracic Society (ATS) and IDSA.

Hopefully the way the guidelines have been deconstructed here will make it easier to apply in your practice. CAP is one of those disease states you will see over and over again. Use theses aids and illustrations as a reference and soon it will become second nature.

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