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Community-Acquired Pneumonia in the Era of COVID-19

April 1, 2022

Table 1. Indication for Ordering Blood Cultures²
Blood Cultures Indicated	Blood Cultures Not Indicated
Sepsis Septic shock Severe CAP Antimicrobial treatment targeting MRSA or Pseudomonas History of previous infection with MRSA History of previous infection with Pseudomonas Hospitalization and parenteral antibiotics in 90 days	Routine hospitalization for CAP Outpatient treatment of CAP
CAP: community-acquired pneumonia; MRSA: methicillin-resistant Staphylococcus aureus

Table 2. Criteria for Severe Community-Acquired Pneumonia^2,53
Severe community-acquired pneumonia = 1 major or 3 minor criteria
Major Criteria: Any 1 criterion	Minor Criteria: 3 or more criteria
Septic shock with need for vasopressors Respiratory failure requiring invasive mechanical ventilation	Respiratory rate ≥ 30 PaO₂/FiO₂ ratio ≤ 250 Multilobular infiltrates Confusion/disorientation Uremia Leukopenia (WBC < 4,000) Thrombocytopenia (PLT <100,000) Hypothermia (temperature < 36°C) Hypotension requiring aggressive fluid resuscitation
WBC: white blood cells; PLT: platelets

Figure 2. Patient with Severe Pneumonia

The patient presented with hypoxemia and in respiratory distress, requiring bilevel positive airway pressure (BiPAP) and intensive care unit hospitalization. The patient had positive polymerase chain reaction testing for SARS-CoV-2. During hospitalization, patient also had positive sputum and blood cultures for Streptococcus pneumoniae and sputum cultures positive for Acinetobacter baumannii.

Table 3. Outpatient Community-Acquired Pneumonia Treatment²
Outpatient CAP treatment, healthy patient	Amoxicillin 1 g PO TID OR Doxycycline 100 mg PO BID OR Azithromycin 500 mg PO followed by 250 mg PO daily for four days OR Clarithromycin 500 mg PO BID or clarithromycin extended release 1,000 mg daily
CAP: community-acquired pneumonia; PO: per os; TID: three times per day; BID: two times per day

Table 4. Outpatient Community-Acquired Pneumonia Treatment for Patients with Comorbidities²
Outpatient CAP treatment, patient with comorbidities
Amoxicillin/ clavulanate 500 mg/125 mg PO TID OR Amoxicillin/ clavulanate 875 mg/125 mg PO BID OR Amoxicillin/ clavulanate 2,000 mg/125 mg PO BID OR Cefpodoxime 200 mg BID OR Cefuroxime 500 mg PO BID	AND	Doxycycline 100 mg PO BID OR Azithromycin 500 mg PO followed by 250 mg PO daily for four days	OR	Monotherapy Levofloxacin 750 mg PO daily OR Moxifloxacin PO 400 mg daily OR Gemifloxacin 320 mg PO daily
PO: per os; TID: three times per day; BID: two times per day

Figure 3. Aspiration Pneumonia in a Patient with Recent COVID-19

Debris is seen within the right lower lobe bronchus.

Table 5. Treatment of Patients with Non-Severe Pneumonia Who Require Hospitalization²
Inpatient CAP treatment – non-severe
Ampicillin/sulbactam 1.5 g to 3 g IV q6h OR Cefotaxime 1g to 2 g IV q8h OR Ceftriaxone 1 g to 2 g IV daily OR Ceftaroline 600 mg IV q12h	AND	Azithromycin IV 500 mg daily OR Clarithromycin IV 500 mg BID OR Doxycycline 100 mg IV or PO BID (if intolerant to both fluoroquinolone and macrolide)	OR	Monotherapy Levofloxacin 750 mg PO daily OR Moxifloxacin PO 400 mg daily
CAP: community-acquired pneumonia; IV: intravenous; PO: per os; BID: two times per day

Table 6. Treatment of Patients with Severe Pneumonia Who Require Hospitalization²
Inpatient Pneumonia Treatment: Severe Pneumonia
Ampicillin/sulbactam 1.5 g to 3 g q6h IV OR Cefotaxime 1 g to 2 g IV q8h OR Ceftriaxone 1 g to 2 g IV daily OR Ceftaroline 600 mg IV q12h	AND	Azithromycin 500 mg IV daily OR Clarithromycin 500 mg IV q12h OR Levofloxacin 750 mg IV or PO daily OR Moxifloxacin 400 mg IV or PO daily
IV: intravenous; PO: per os

Table 7. Clinical Elements of Pneumonia Severity Scores^54,55
PSI/PORT Score: Pneumonia Severity Index for CAP elements Age Sex Nursing home resident Neoplastic disease Liver disease history CHF history Cerebrovascular disease history Renal disease history Altered mental status Respiratory rate ≥ 30 breaths/min Systolic blood pressure < 90 mmHg Temperature < 35°C or > 39.9°C Pulse ≥ 125 beats/min pH < 7.35 BUN ≥ 30 mg/dL or ≥ 11 mmol/L Sodium < 130 mmol/L Glucose ≥ 250 mg/dL Hematocrit < 30% Partial pressure of oxygen < 60 mmHg Pleural effusion on X-ray	CURB-65 Score for Pneumonia Severity Elements Confusion BUN > 19 mg/dL Respiratory Rate ≥ 30 Systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg Age ≥ 65 years
PSI/PORT: pneumonia severity index; CAP: community-acquired pneumonia; CHF: congestive heart failure; BUN: blood urea nitrogen; BP: blood pressure

Issue Date: April 1, 2022

Table of Contents

Community-Acquired Pneumonia in the Era of COVID-19

Financial Disclosure: None of the authors or planners for this educational activity have relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients

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Figure 1. Lobar Consolidation in an Elderly Patient with Suspected Bacterial Community-Acquired Pneumonia

Community-Acquired Pneumonia in the Era of COVID-19

EXECUTIVE SUMMARY

Epidemiology

Etiology

Pathophysiology

Clinical Features

Historical Elements

Diagnostic Studies

Figure 1. Lobar Consolidation in an Elderly Patient with Suspected Bacterial Community-Acquired Pneumonia

Radiographic Imaging in COVID-19

Additional Testing

Table 1. Indication for Ordering Blood Cultures2

Table 2. Criteria for Severe Community-Acquired Pneumonia2,53

Figure 2. Patient with Severe Pneumonia

Bacterial Coinfection in COVID-19

Management

Outpatient Management of Healthy Patients

Table 3. Outpatient Community-Acquired Pneumonia Treatment2

Outpatient Management for Patients with Comorbidities

Table 4. Outpatient Community-Acquired Pneumonia Treatment for Patients with Comorbidities2

Parenteral Antibiotics in the ED for Outpatient CAP

Aspiration Pneumonia

Figure 3. Aspiration Pneumonia in a Patient with Recent COVID-19

Inpatient CAP

Table 5. Treatment of Patients with Non-Severe Pneumonia Who Require Hospitalization2

Table 6. Treatment of Patients with Severe Pneumonia Who Require Hospitalization2

Corticosteroids

Influenza

COVID-19 Pneumonia

Ambulatory Management of COVID-19 Pneumonia

Hospital Management of COVID-19 Pneumonia

Disposition

Table 7. Clinical Elements of Pneumonia Severity Scores54,55

Summary

REFERENCES

Table 1. Indication for Ordering Blood Cultures²

Table 2. Criteria for Severe Community-Acquired Pneumonia^2,53

Table 3. Outpatient Community-Acquired Pneumonia Treatment²

Table 4. Outpatient Community-Acquired Pneumonia Treatment for Patients with Comorbidities²

Table 5. Treatment of Patients with Non-Severe Pneumonia Who Require Hospitalization²

Table 6. Treatment of Patients with Severe Pneumonia Who Require Hospitalization²

Table 7. Clinical Elements of Pneumonia Severity Scores^54,55