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Treatment update:

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neumonia is a leading cause of morbidity and mortality in the US and a primary cause of hospitalization nationwide, particularly

for older adults.1,2 Pneumonia results in 1.7 million ED visits annually.3 In combination with infl uenza, pneumonia was the eighth-leading cause of death in the US in 2017 and resulted in over 55,000 deaths that year; 84% of those deaths were in people age 65 and older.4 Despite this, current estimates indicate that about one-third of patients over age 65 have not been vaccinated for pneumococcal pneumonia, which is the leading pathogenic cause of pneumonia in all age groups.5

According to the Infectious Diseases Society of America (IDSA), for a patient to qualify for a community-acquired pneumonia (CAP) diagnosis, he or she must not have been hospitalized nor resided in a long-term-care facility for, at minimum, 14 days prior to the onset of symptoms.6 The healthcare com- munity has been awaiting the release of an updated CAP guideline for years. The newest clinical practice

By Jana Esden, DNP, APRN, FNP-BC, CNE

Outpatient management of community-acquired pneumonia

Abstract: Pneumonia is a leading cause of

morbidity and mortality in the US and a

primary cause of hospitalization nationwide.

A recent guideline update from the American

Thoracic Society and Infectious Diseases

Society of America provides evidence-based

recommendations for managing adults with

community-acquired pneumonia in the

outpatient setting.

Keywords: American Thoracic Society, CAP, community-acquired pneumonia, guideline, hospitalization, Infectious Diseases Society of

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www.tnpj.com The Nurse Practitioner • March 2020 17

Treatment update: Outpatient management of community-acquired pneumonia

18 The Nurse Practitioner • Vol. 45, No. 3 www.tnpj.com

guideline, approved by the American Thoracic Society (ATS) and the IDSA, was published in October 2019.7

The 2019 ATS/IDSA guideline was developed us- ing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) technique, which is a method of appraising available studies to make recommendations based both on the quality of evidence and the strength of the recommendation as separate measures.7 The guideline is an update to the 2007 IDSA/ATS CAP guideline and is written in question/answer format with the answer including 1) the recommendation, 2) a summary of the avail- able evidence, and 3) the rationale for the authors’ recommendation.7 For the treatment of outpatients with CAP, the most signifi cant departure from the 2007 guideline is the antibiotic choice for previously healthy individuals with no risk factors for drug- resistant pathogens.6,7 Amoxicillin is now the fi rst-line choice, with macrolide therapy falling out of favor due to Streptococcus pneumoniae resistance.7

■ Pathogens Pneumonia, which causes infl ammation and purulent fl uid buildup in the alveoli, can be caused by viruses, bacteria, or fungi, with bacteria being the most com- mon pathogens.8 S. pneumoniae, which causes pneu- mococcal disease, continues to be the most common bacterial pathogen in pneumonia, accounting for approximately 36% of all cases of adult CAP in the US according to the CDC.8,9 Pneumococcal pneumonia is also a frequent bacterial complication of infl uenza virus infection.8,9 Pneumococcal pneumonia con- tributes to over 400,000 hospitalizations annually,

and more than one quarter of patients with pneu- mococcal pneumonia go on to have pneumococcal bacteremia.9 In recent years, the number of cases of pneumococcal pneumonia have declined rapidly, most likely due to increasing rates of pneumococcal vaccination in both adults and children as well as reduced rates of cigarette smoking.7,10 Although case estimations can vary widely due to the frequency of empiric treatment, particularly in outpatients, this

pathogen definitively remains the most common cause of CAP.9,11

Other examples of bacterial pathogens that con- tribute to CAP include Haemophilus influenzae, Staphylococcus aureus, Legionella pneumophila, which causes Legionnaires disease, and Mycoplasma pneu- moniae, which is associated with “walking pneumo- nia.”8,10,12 The influenza virus is the most common cause of viral pneumonia in adults, and respiratory syncytial virus is the most common cause of viral pneumonia in children.8 Additionally, it is common to have viral and bacterial coinfection in CAP.7

■ Pathophysiology and risk factors Pneumonia is an acute infection of the lung paren- chyma.6 The lung parenchyma includes the alveoli which are responsible for gas exchange and therefore oxygenation of the body’s blood supply.13 The lungs are a sterile environment protected by innate defenses such as the fi ltering capabilities of the airway; small, fl exible bodies called cilia, which move particles up and away from the lungs; and the glottic refl exes, which prevent particles and mucus from descending into the lower airways.14-16 Although microorganisms colonize the nasopharynx and oropharynx in even healthy in- dividuals, these defenses, along with the human im- mune system, work to ensure that aspirated pathogenic organisms do not inhabit the lungs.14

Pneumonia develops when the body’s natural defenses are overwhelmed by a virulent microor- ganism or microorganisms.14 Some risk factors for pneumonia relate to inhibition of the body’s natural defenses. For example, smoking impairs the function

of cilia and is a primary risk factor for pneumonia.8,17 An altered level of consciousness can impair the gag refl ex, so individuals who drink al- cohol excessively or who are other- wise overly sedated are at increased risk as well as those who have an

impaired gag refl ex due to a medical condition such as a cerebrovascular accident.8,17 People with com- promised immune function are also at increased risk. This includes patients with underlying chronic illnesses and patients who are very young (under age 2 years) and over age 65.8,17

A recent systematic review used observational studies to determine risk factors for CAP and dis- covered robust evidence of risk in several patient

Amoxicillin is now the fi rst-line choice of

treatment, with macrolide therapy falling out of

favor due to Streptococcus pneumoniae resistance.

Treatment update: Outpatient management of community-acquired pneumonia

www.tnpj.com The Nurse Practitioner • March 2020 19

characteristics, lifestyle factors, and clinical factors.18 Specifi cally, Almirall and colleagues found the stron- gest correlations for CAP risk with older age, a previous history of CAP, current tobacco use, environmental ir- ritant exposures, poor oral health or nutritional status, functional impairment, comorbid chronic obstructive pulmonary disease or asthma, immunosuppressive therapy, oral steroid use, and the use of gastric-acid suppressive drugs such as proton pump inhibitors and H2 antagonists.18 Dang and colleagues had simi- lar fi ndings in systematic review of risk factors for CAP.17 Additionally, Dang and colleagues found that functional impairment and the use of medications such as corticosteroids and proton pump inhibitors signifi cantly increased risk of recurrent pneumonia in older adults.17

■ Patient presentation Transmission of pneumococcal pneumonia results from either person-to-person transfer of respiratory droplets or by autoinoculation in people carrying the S. pneumoniae bacteria in the nasopharynx or oro- pharynx.8 The incubation period for pneumococcal pneumonia is 1 to 3 days, and patients with pneumo- coccal pneumonia often present with sudden onset of fever, chills, cough, dyspnea, pleuritic chest pain, weakness, and malaise.9,19 Although cough is a cardinal symptom, it may be productive or nonproductive.19 Clinicians may also note vital sign instability such as tachycardia, tachypnea, and hypoxia in patients with pneumococcal pneumonia.9 Older adults may not present with classic symptoms and instead may be afebrile and can present with confusion and changes in functional status.19,20 Symptoms in older adults may also be underreported due to underlying cognitive impairment, neurologic impairment, or the presence of chronic respiratory or cardiac conditions.19

Although the symptom profile for atypical pathogens such as M. pneumoniae varies from typi- cal pathogens such as S. pneumoniae, evidence sug- gests that differentiating between typical and atypical pathogens using patient symptoms and even a chest radiograph is not reliable and should not be used to determine antibiotic choice.16 Transmission of M. pneumoniae results from person-to-person transfer of respiratory droplets, and the incubation period is between 1 and 4 weeks.21 M. pneumoniae starts as a systemic illness with symptoms such as fever, sore throat, headache, and cough.21 Symptoms tend to

gradually worsen over a period of weeks and then self-resolve.21 Only 10% of people who contract M. pneumoniae illness will go on to have pneumonia, and symptoms are generally considered to be milder in nature which has led to the use of the term “walking pneumonia.”21

A careful physical exam is helpful in differentiat- ing pneumonia from other acute, upper respiratory tract infections such as acute bronchitis. Although remote studies have indicated that poor interobserv- er reliability exists and that no single exam finding confirms or excludes a diagnosis of pneumonia, the lung exam is still an important piece of the office visit for patients with symptoms of CAP.22-25 Within the lung, pneumonia causes a consolidation, which is an area filled with fluid as opposed to air. Some classic lung exam findings that indicate consolida- tion include dullness to percussion, increased tactile fremitus, crackles, bronchophony (bronchial breath sounds), and egophony25,26 (See Lung exam findings and definitions.) Marchello and colleagues recently determined, through systematic review and meta- analysis, that patients with normal vital signs and no abnormal lung findings are at extremely low risk for CAP.27 The authors recommend that in these

Lung exam fi ndings and defi nitions25

Finding Defi nition

Crackles Discontinuous, interrupted, explosive sounds that may occur in early or late inspiration

Rhonchi Continuous, low-pitched sounds in early inspiration that clear or decrease following cough

Wheezes Continuous, high-pitched hissing sounds that may occur during inspira- tion or expiration

Tactile fremitus Unilateral increase in palpable vocal vibrations transmitted through the chest wall as the patient says “ ninety-nine”

Bronchophony An increase in the intensity and clarity of the patient’s spoken voice as perceived by the examiner when auscultating transthoracically

Egophony A nasal or bleating quality of trans- mitted vocal sounds that is elicited when the patient says the letter “E” and to the examiner, it sounds like the letter “A”

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situations the diagnosis for CAP can be ruled out and no additional diagnostic testing is required.27

■ Diagnostic testing Imaging. Generally, a diagnosis of pneumonia is made if patients demonstrate symptoms of lower respiratory infection, exhibit clinical signs of pneumonia on the physical exam, and their chest radiograph reveals an acute infi ltrate.6,7 The IDSA and ATS emphasize the need for a new, visible infi ltrate on chest radiograph to make a diagnosis of pneumonia due to the imprecision of clinical signs and symptoms.7,16 To avoid needless adverse medication reactions and the increasing resis- tance of microorganisms, it is critical to abstain from treating lower respiratory infections empirically with antibiotics without obtaining chest imaging.7,16 At the same time, concerns exist regarding the low sensitiv- ity of chest radiographs. Up to one-third of initial chest radiographs may be negative in patients with pneumonia, with the identifi cation of new lung infi l- trates being less clear in patients with obesity or with underlying chronic lung disease.10,19 Clinicians can increase the accuracy of chest radiography by ensuring that both posteroanterior and laterolateral images are obtained.16 Marrie and File recommend repeating the chest radiograph after 24 hours for patients in whom CAP is strongly suspected and who have an initial negative chest radiograph.19

Recent research has focused on the use of lung ultrasonography as a viable alternative to chest radi- ography. Lung ultrasonography has a high sensitivity and specifi city for diagnosing pneumonia and can be particularly helpful in older patients and patients who are immobile; however, it is clear that results are dependent on the skill of the operator.16,19 A meta- analysis by Ye and colleagues documents a pooled sensitivity of lung ultrasonography at 95% with a specifi city of 90%.28 In this meta-analysis, the pooled sensitivity for chest radiography was only 77% with a specificity of 91%.28 A second meta-analysis by Orso and colleagues found a similar sensitivity and specifi city for lung ultrasound in the diagnosis of pneumonia at 92% and 93%, respectively.29 Although computed tomography is most accurate for the di- agnosis of pneumonia, this test is limited by its cost and by concerns of radiation exposure.16

Other testing. The newest ATS/IDSA guideline continues to recommend against obtaining sputum cultures in the outpatient setting.7 Reasoning for this

includes challenges in proper collection of sputum samples, limitations in the ability of the sputum Gram stain and culture to detect the causative organism, and a lack of evidence indicating the intervention improves patient outcomes.7 Collection of blood cultures is also not recommended in the outpatient setting.7

Newer diagnostic testing procedures such as urine testing for pneumococcal antigen and the use of pro- calcitonin are also not recommended as routine tests at this time.7 Urine antigen testing for S. pneumoniae and/or Legionella is recommended in hospitalized patients with severe disease as it may reduce mor- tality in this subset of patients, but there is no clear benefi t for routine use.7 There is a signifi cant amount of new research available on procalcitonin testing with studies focused on determining the sensitivity and specifi city of the test in differentiating bacterial versus viral infections as well as concentration cutoff points to assist providers in making the decision of whether or not to treat the patient’s pneumonia with antibiotics.10,16 Although this is an emerging area of research, the ATS/IDSA guideline recommends be- ginning empiric antibiotic therapy in patients with CAP regardless of the serum procalcitonin level.7 Concerns with the use of serum procalcitonin level testing include the unknown threshold level that properly differentiates bacterial from viral pathogens, the inconsistent results of studies, and the need for additional studies.7 In support of this recommenda- tion, a recent systematic review and meta-analysis on the use of procalcitonin to distinguish bacterial from viral pneumonia reported sensitivity and specifi city of the test at 55% and 76%, respectively, indicating that antibiotics should not be withheld based on procalcitonin level.30

The infl uenza virus is a common cause of pneumo- nia and can lead to secondary bacterial infection.10 It is common to have viral and bacterial coinfection, and a recent meta-analysis reported a signifi cantly increased risk for mortality with coexistent viral and bacterial pathogens.31 The ATS/IDSA guideline recommends testing patients with CAP for infl uenza at the time of diagnosis if the virus is active in the community.7 Rapid infl uenza molecular assays are preferred over rapid infl uenza diagnostic tests in the outpatient set- ting as the sensitivity of the molecular assay method, at 90% to 95%, is signifi cantly better than rapid in- fl uenza diagnostic test, which is an antigen test with

Treatment update: Outpatient management of community-acquired pneumonia

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a sensitivity of 50% to 70%.32,33 In adult outpatients who have CAP and a positive infl uenza molecular assay test, the ATS/IDSA guideline sug- gests that treatment with antivirals be initiated, regardless of symptom duration.7 Patients with CAP who test positive for influenza should also receive empiric treatment with antibiotics due to the frequency of bacterial coinfection and risk of de- laying antimicrobial treatment.7

■ Clinical prediction rules for prognosis The ATS/IDSA guideline recom- mends that clinicians use a validated clinical prediction rule for progno- sis to help guide the plan of care for adults with CAP.7 Clinical predic- tion rules assist in clinical decision- making and are used in combination with clinical judgment. A clinical prediction rule is a grouping of clini- cal findings that statistically dem- onstrate predictability for aspects of disease such as a specifi c diagnosis or clinical prognosis.34

With regard to CAP, clinical pre- diction rules for prognosis are used to help clinicians predict a patient’s mortality risk to determine whether inpatient care is needed.7 Two com- monly used tools exist: the Pneu- monia Severity Index (PSI) and the CURB-65 tool.35- 37 The preferred clinical prediction rule for prognosis of the ATS/IDSA is the PSI.7,35 (See PSI.) The PSI considers age, comorbidities, physical exam fi ndings, and the results of diagnostic testing, including arterial blood gas values and chest X-ray fi ndings.35,37 In addition to accurately predicting mor- tality risk in patients with CAP, the PSI is better at identifying patients at low risk for mortality when compared with the CURB-65.7 The PSI would be the best tool for clinicians to use in an ED setting as there is generally access to all the diagnostic tests needed to accurately calculate risk.

Although the PSI is the most sensitive tool, studies indicate that the CURB-65 tool is still useful and can

accurately predict mortality in patients with CAP.37-39 The CURB-65 uses confusion, blood urea nitrogen, respiratory rate, BP, and age (≥65) to calculate mor- tality risk36 (see CURB-65.) The ATS/IDSA provide a conditional recommendation for the CURB-65 due to its simplicity of use.7 The CURB-65 is a reasonable tool to use in the outpatient offi ce setting as it does not include values obtained by an arterial blood gas. It is important to note that the CURB-65 becomes a less sensitive tool if the blood urea nitrogen (BUN) is not evaluated and included in the analysis.37 It is also criti- cal for clinicians to consider that any clinical prediction rule for prognosis must be used in combination with clinical judgment.37

PSI

Criteria Points Scoring

Gender Age ≤50 with no comor- bidities and normal physi- cal exam fi ndings (Class I) • 30-day mortality 0.1% • Low risk • Outpatient care

Score of 51–70 (Class II) • 30-day mortality 0.6% • Low risk • Consider outpatient care

versus short inpatient observation

Score of 71–90 (Class III) • 30-day mortality 0.9% • Low risk • Consider outpatient care

versus short inpatient observation

Score of 91–130 (Class IV) • 30-day mortality 9.3% • Moderate risk • Inpatient care

Score of 131–395 (Class V) • 30-day mortality 27.0% • High risk • Inpatient care

Male 0

Female -10

Demographic factors

Age (one point per year) Age (yr)

Long-term-care facility resident 10

Comorbidities

Malignancy 30

Liver disease 20

Congestive heart failure 10

Cerebrovascular disease 10

Renal disease 10

Physical examination fi ndings

Altered mental status 20

Respiratory rate ≥30/minute 20

Systolic BP <90 mm Hg 20

Temperature <35°C or ≥40°C 15

Pulse ≥125/minute 10

Laboratory and radiographic fi ndings

Arterial pH <7.35 30

BUN ≥30 mg/dL (11 mmol/L) 20

Sodium <130 mEq/L 20

Glucose ≥250 mg/dL (14 mmol/L) 10

Hematocrit <30% 10

Partial pressure of arterial oxygen <60 mm Hg

Pleural effusion on X-ray 10

Adapted from Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336(4):243-250.

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■ Treatment Antibiotic choices. I f the clinician feels that it is rea- sonable to treat a patient with CAP in the outpatient setting, antibiotic therapy should be initiated as soon as possible.7 In nearly half of pneumonia cases, the culprit pathogen is not identifi ed, and due to the sig- nifi cant cost of determining the infecting microor- ganism, patients in the outpatient setting are treated empirically.10,40 The fi rst-line antibiotic choice for CAP in previously healthy individuals with no risk factors for drug-resistant pathogens is amoxicillin 1g three times daily.7 (See ATS/IDSA antibiotic recommenda- tions.) This is a departure from the previous IDSA/ ATS guideline, which placed a macrolide as fi rst-line treatment.40 The new recommendation of amoxicillin aligns with recommendations from current British and European guidelines.41,42

F actors that contributed to this change include the results of several studies indicating that amoxicillin was successful in treating CAP despite lack of coverage for atypical pathogens, the proven safety record of amoxi- cillin when compared with other options, and increas- ing resistance to macrolides, particularly in pneumo- coccal pneumonia.7 A Cochrane Review published in 2009 and then repeated in 2014 compared various antibiotics and antibiotic groups in treatment of adult outpatients with CAP.43,44 In both systematic reviews, the authors were unable to recommend one antibiotic regimen over another as they were similarly effi ca- cious.43,44 A large, recent randomized trial published in the New England Journal of Medicine compared the

use of beta-lactam antibiotics with fl uoroquinolones and with beta-lactam/ macrolide combinations, fi nd- ing that the use of beta-lactam monotherapy was not inferior to the other antibiotic regimens in noncritical patients admitted with CAP.45 In this trial, the main outcome studied was 90-day mortality; however, it was also noted that median length of hospital stay was identical between groups.45

A n alternative choice to the fi rst-line amoxicillin, listed as a conditional recommendation, is doxycycline 100 mg twice daily.7 The ATS/IDSA guideline includes macrolide treatment as a conditional recommendation as well, only to be used in areas where S. pneumoniae resistance to macrolides is under 25%.7

I n patients with chronic conditions such as chronic heart, lung, liver, or renal disease; diabetes; alcohol use disorder; cancer; or asplenia, a broader-spectrum an- tibiotic regimen is recommended due to the patients’ increased risk of harboring pathogens either resistant to or not well covered by beta-lactam antibiotics (such as H. infl uenzae, Moraxella catarrhalis, and S. aureus), and the increased risk for poor outcomes if the initial antibiotic regimen is ineffective.7 In this clinical sce- nario, antibiotic recommendations from the ATS/IDSA include a combination of a beta-lactam plus a macro- lide, or a respiratory fl uoroquinolone.7 When treating with combination therapy, doxycycline is an alternative choice for the macrolide, and this is a conditional rec- ommendation.7 In this subset of patients, a macrolide as monotherapy would not be appropriate as up to 30% of S. pneumoniae strains are resistant to macrolides; how- ever, when used in combinatio n with a beta-lactam, the treatment becomes effective as S. pneumoniae continues to be susceptible to beta-lactam antibiotics.10

Musher and Thorner report that both regimens have been studied extensively and have been shown effi ca- cious in 90% of patients with mild to moderate CAP.10 The guideline makes clear that there is no preference between the two options in this patient subset and that clinicians should weigh the risks and benefi ts of mono- therapy versus combination therapy prior to choosing a treatment plan.7 Several factors to consider include cost, convenience of the regimen, medication allergies, recent usage of one class of antibiotics, and comorbidities or other risk factors that increase the possibility of adverse reactions with particular antibiotic choices.7

Although fl uoroquinolones continue to carry black box warnings to avoid in patients with myasthenia gra- vis and for tendon rupture, peripheral neuropathy, and

CURB-65

Criteria Scoring

Confusion Each positive result worth one point: Score of 0 or 1 • 30-day mortality 1.5% • Outpatient care reasonable Score of 2 • 30-day mortality 9.2% • Inpatient or observation

admission recommended Score of ≥3 • 30-day mortality 22% • Inpatient admission need-

ed with possible ICU place- ment for scores of 4–5

BUN >19 mg/dL (>7 mmol/L)

Respiratory rate ≥30

Systolic BP <90 mm Hg or Diastolic BP ≤60 mm Hg

Age ≥ 65

Adapted from Lim WS, van der Eerden MM, Laing R, et al. Defi ning community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377-382.

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central nervous system effects, which are particularly a concern in patients over age 60, the ATS/IDSA indi- cates that their use is still justifi ed in the treatment of CAP due to their effi cacy and because serious adverse reactions are relatively rare.7,46 It is important to note that the US FDA has recently strengthened warnings on fluoroquinolones due to other possible adverse reactions including hypoglycemia, delirium, disorien- tation, agitation, anxiety, and memory impairment.47

In August, 2019, the FDA approved lefamulin for the treatment of CAP.48 Lefamulin is in the antibiotic subclass of pleuromutilins and works by inhibiting bacterial protein synthesis.49 Lefamulin is available for oral and I.V. administration.49 Two important non- inferiority trials recently reported that lefamulin was not inferior to moxifl oxacin (a fl uoroquinolone).50,51 File and colleagues found similar rates of adverse reactions among the lefamulin group and the moxi- fl oxacin group; however, Alexander and colleagues

reported an increase in mild-to-moderate adverse reactions in the lefamulin group.50,51 Although le- famulin, priced at $275 per day for oral treatment, is signifi cantly more expensive than fl uoroquinolones, it is expected to be an important new option for the treatment of CAP.52,53

Supportive care for outpatients with CAP includes fl uids, antipyretics, and analgesics. Generally, avoid- ing cough suppressants is considered prudent, and a recent systematic review was not able to fi nd evidence to support the use of mucolytics.54

Length of treatment. The recommended length of treatment for all antibiotic regimens is no less than 5 days with generally 5 to 7 days of treatment being con- sidered reasonable in outpatients.7,10,16 Several recent meta-analyses have documented effi cacy in antibiotic courses of 7 days or fewer with no differences when compared with longer courses of therapy.7,10,16 For antibiotic discontinuation, patients must have reached

ATS/IDSA antibiotic recommendations7

Patient group Strong recommendation Conditional recommendations

Healthy outpatient adults with no comorbidities

amoxicillin 1g three times daily doxycycline 100 mg twice daily

A macrolide (only in areas where S. pneu- moniae resistance to macrolides is <25%) • azithromycin 500 mg on the fi rst day,

then 250 mg daily • clarithromycin 500 mg twice daily • clarithromycin ER 1,000 mg daily

Outpatient adults with comorbidities

Combination therapy*

A beta-lactam • amoxicillin/clavulanate 500 mg/125 mg three times daily • amoxicillin/clavulanate 875 mg/125 mg twice daily • amoxicillin/clavulanate 2,000 mg/125 mg twice daily • cefpodoxime 200 mg twice daily • cefuroxime 500 mg twice daily

and

A macrolide • azithromycin 500 mg on the fi rst day, then 250 mg daily • clarithromycin 500 mg twice daily • clarithromycin ER 1,000 mg daily

For patients who are unable to have a macrolide in combination therapy: doxycycline 100 mg twice daily

Monotherapy with a respiratory fl uoroquinolone* • levofl oxacin 750 mg daily • moxifl oxacin 400 mg daily • gemifl oxacin 320 mg daily

Length of treatment for all medication regimens and all patient groups recommended until the patient achieves clinical stability (and for no less than 5 days)

*In no particular order of preference—assess risk/benefi t in each patient case

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clinical stability, which is evidenced by normal vital signs, normal mentation, and the ability to eat.7

■ Follow-up Frequency of follow-up visits will depend on the pa- tient’s individual situation. With proper antibiotic cov- erage, patients with CAP will generally reach clinical stability in the fi rst 48 to 72 hours, and CAP symptoms will resolve within 5 to 7 days.7 If patients do not reach clinical stability within a reasonable period of time or if symptoms worsen, a change in antibiotic therapy may be required.7

Follow-up chest radiography is not recommended routinely for all patients; however, this is a condi- tional recommendation with low quality of evidence.7 The overarching rationale for reevaluating a chest radiograph is to ensure for resolution of a lung in- fi ltrate as an unresolved suspicious area on the ra- diograph may indicate a previously undiagnosed lung malignancy.7 Because this is not common, the guideline only recommends repeat chest radiography in patients for whom symptoms have not resolved adequately.7 In patients with recurrent pneumonia, it is critical that clinicians evaluate for risk factors and consider alternative diagnoses such as lung cancer or tuberculosis.16

■ Conclusion In addition to being a common diagnosis in the pri- mary care setting, pneumonia places a heavy burden on the healthcare system and is a common cause of hospitalization, morbidity, and mortality. Using evidence-based recommendations to guide diag- nostic testing strategies and to choose antimicrobial therapies will help to reduce the future burden of CAP by expanding antibiotic stewardship to avoid increasing microorganism resistance to available treatments.

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Jana Esden is an associate professor at Frontier Nursing University, Hyden, Ky, and a member of The Nurse Practitioner Editorial Advisory Board.

The author and planners have disclosed no potential confl icts of interest, fi nancial or otherwise.

DOI:10.1097/01.NPR.0000653944.99226.25

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