Pneumonia (main) - Revision history

Danbot: Embed PSI Calculator on clinical page

2026-03-22T09:56:04Z

Embed PSI Calculator on clinical page

← Older revision		Revision as of 09:56, 22 March 2026
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	== Calculators ==		== Calculators ==
			{{PSI Calculator}}
	{{PORT Score Calculator}}		{{PORT Score Calculator}}
	{{CURB65_Calculator}}		{{CURB65_Calculator}}

Danbot: Embed PORT Score Calculator on clinical page

2026-03-22T09:55:57Z

Embed PORT Score Calculator on clinical page

← Older revision		Revision as of 09:55, 22 March 2026
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	== Calculators ==		== Calculators ==
			{{PORT Score Calculator}}
	{{CURB65_Calculator}}		{{CURB65_Calculator}}

Danbot: Expand Disposition section with actionable admit/discharge criteria

2026-03-22T09:40:16Z

Expand Disposition section with actionable admit/discharge criteria

← Older revision		Revision as of 09:40, 22 March 2026
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	==Disposition==		==Disposition==
			*Use clinical judgment plus [[PORT Score]] (PSI) to guide disposition per IDSA 2019 guidelines<ref name="ATS2019"/>
			*Discharge (PSI class I-II):
			**Able to tolerate oral medications
			**No hypoxia, hemodynamic instability, or significant comorbidities
			**Reliable follow-up in 48-72 hours
			*Admit to floor (PSI class III-IV):
			**Hypoxia requiring supplemental O2
			**Inability to tolerate oral medications
			**Significant comorbidity (immunocompromised, decompensated CHF, etc.)
			*Admit to ICU (PSI class V, or meeting major/minor criteria):
			**Requiring vasopressors or mechanical ventilation (major criteria)
			**3 or more minor criteria: RR >30, PaO2/FiO2 <250, multilobar infiltrates, confusion, BUN >20, WBC <4, platelets <100, hypothermia, hypotension requiring aggressive fluids

	~~IDSA 2019 guidelines recommend clinical judgement plus PSI over CURB-65. <ref name="ATS2019"/>~~

	~~{{Port score}}~~

	==Prognosis==		==Prognosis==

Danbot: Strip excess bold

2026-03-22T09:28:47Z

Strip excess bold

Danbot: Add PSI_PORT_Calculator to page

2026-03-21T16:31:45Z

Add PSI_PORT_Calculator to page

← Older revision		Revision as of 16:31, 21 March 2026
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	== Calculators ==		== Calculators ==
	{{CURB65_Calculator}}		{{CURB65_Calculator}}

			{{PSI_PORT_Calculator}}

	==External Links==		==External Links==

Danbot: Move calculators to own section with header (visible in TOC), expanded, before External Links

2026-03-21T15:05:40Z

Move calculators to own section with header (visible in TOC), expanded, before External Links

← Older revision		Revision as of 15:05, 21 March 2026
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	*[[CURB-65]]		*[[CURB-65]]
	*[[Sepsis (Main)]]		*[[Sepsis (Main)]]

			== Calculators ==
			{{CURB65_Calculator}}

	==External Links==		==External Links==
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	==References==		==References==
	{{reflist\|2}}		{{reflist\|2}}


	~~<div class="mw-collapsible mw-collapsed" style="border:1px solid #aaa; padding:5px; margin-top:10px;">~~
	~~<div style="font-weight:bold;">📊 CURB-65 Calculator [show]</div>~~
	~~<div class="mw-collapsible-content">~~
	~~{{CURB65_Calculator}}~~
	~~</div>~~
	~~</div>~~
	[[Category:ID]]		[[Category:ID]]
	[[Category:Pulmonary]]		[[Category:Pulmonary]]

Danbot: Add CURB-65 calculator (collapsible)

2026-03-21T13:50:04Z

Add CURB-65 calculator (collapsible)

← Older revision		Revision as of 13:50, 21 March 2026
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	{{reflist\|2}}		{{reflist\|2}}


			<div class="mw-collapsible mw-collapsed" style="border:1px solid #aaa; padding:5px; margin-top:10px;">
			<div style="font-weight:bold;">📊 CURB-65 Calculator [show]</div>
			<div class="mw-collapsible-content">
			{{CURB65_Calculator}}
			</div>
			</div>
	[[Category:ID]]		[[Category:ID]]
	[[Category:Pulmonary]]		[[Category:Pulmonary]]

Ostermayer at 16:00, 8 March 2026

2026-03-08T16:00:43Z

Show changes

Ostermayer at 00:39, 16 January 2026

2026-01-16T00:39:40Z

← Older revision		Revision as of 00:39, 16 January 2026
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	{{~~Adult top}} [[~~pneumonia (peds)~~]]''~~		{{AdultPage\|pneumonia (peds)}}
	==Background==		==Background==
	[[File:Lung and diaphragm.jpg\|thumb\|Lobes of the lung with related anatomy.]]		[[File:Lung and diaphragm.jpg\|thumb\|Lobes of the lung with related anatomy.]]

Rossdonaldson1: /* Evaluation */

2023-12-13T22:07:25Z

Evaluation

← Older revision		Revision as of 22:07, 13 December 2023
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	[[File:PneumonisWedge09.jpg\|thumb\|[[CXR]] showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial [[pneumonia]].]]		[[File:PneumonisWedge09.jpg\|thumb\|[[CXR]] showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial [[pneumonia]].]]
	[[File:RLLpneumonia.png\|thumb\|Right lower lobe pneumonia as seen on lateral CXR.]]		[[File:RLLpneumonia.png\|thumb\|Right lower lobe pneumonia as seen on lateral CXR.]]
	[[File:XR chest - pneumonia with abscess and caverns - d0.jpg \|thumb\|[[CXR]] showing pneumonia with abscess.]]		[[File:XR chest - pneumonia with abscess and caverns - d0.jpg \|thumb\|[[CXR]] showing pneumonia with [[lung abscess]].]]
	[[File:CT scan of the chest, demonstrating right-sided pneumonia.jpg\|thumb\|CT chest showing right sided pneumonia]]		[[File:CT scan of the chest, demonstrating right-sided pneumonia.jpg\|thumb\|CT chest showing right sided pneumonia]]
	[[File:PNA_US.gif\|thumb\|Hepatization of the lung and dynamic air bronchograms present in patient with LLL pneumonia. Source: POCUS Atlas]]		[[File:PNA_US.gif\|thumb\|Hepatization of the lung and dynamic air bronchograms present in patient with LLL pneumonia. Source: POCUS Atlas]]

← Older revision		Revision as of 22:07, 13 December 2023
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	[[File:PneumonisWedge09.jpg\|thumb\|[[CXR]] showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial [[pneumonia]].]]		[[File:PneumonisWedge09.jpg\|thumb\|[[CXR]] showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial [[pneumonia]].]]
	[[File:RLLpneumonia.png\|thumb\|Right lower lobe pneumonia as seen on lateral CXR.]]		[[File:RLLpneumonia.png\|thumb\|Right lower lobe pneumonia as seen on lateral CXR.]]
	[[File:XR chest - pneumonia with abscess and caverns - d0.jpg \|thumb\|[[CXR]] showing pneumonia with abscess.]]		[[File:XR chest - pneumonia with abscess and caverns - d0.jpg \|thumb\|[[CXR]] showing pneumonia with [[lung abscess]].]]
	[[File:CT scan of the chest, demonstrating right-sided pneumonia.jpg\|thumb\|CT chest showing right sided pneumonia]]		[[File:CT scan of the chest, demonstrating right-sided pneumonia.jpg\|thumb\|CT chest showing right sided pneumonia]]
	[[File:PNA_US.gif\|thumb\|Hepatization of the lung and dynamic air bronchograms present in patient with LLL pneumonia. Source: POCUS Atlas]]		[[File:PNA_US.gif\|thumb\|Hepatization of the lung and dynamic air bronchograms present in patient with LLL pneumonia. Source: POCUS Atlas]]

← Older revision		Revision as of 09:28, 22 March 2026
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	If patient will be admitted:		If patient will be admitted:

	*[[Blood Cultures]] are ~~'''~~ONLY~~'''~~ indicated for CAP patients with:<ref name="ATS2019"/>		*[[Blood Cultures]] are ONLY indicated for CAP patients with:<ref name="ATS2019"/>
	**ICU admission (required)		**ICU admission (required)
	**Empiric treatment for [[MRSA]] or ''[[Pseudomonas aeruginosa\|P. aeruginosa]]'' (required)		**Empiric treatment for [[MRSA]] or ''[[Pseudomonas aeruginosa\|P. aeruginosa]]'' (required)
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	**Leukopenia		**Leukopenia
	**The yield of blood cultures is low (2% to 9%) in adults without severe CAP, and empiric therapy is rarely changed based on these results<ref name="AAFP2020"/>		**The yield of blood cultures is low (2% to 9%) in adults without severe CAP, and empiric therapy is rarely changed based on these results<ref name="AAFP2020"/>
	*~~'''~~Sputum Gram stain and culture:~~'''~~ recommended for the same indications as blood cultures above<ref name="ATS2019"/>		*Sputum Gram stain and culture: recommended for the same indications as blood cultures above<ref name="ATS2019"/>
	**Lower respiratory tract samples from intubated patients should be sent for Gram stain and culture shortly after intubation (higher yield than sputum)		**Lower respiratory tract samples from intubated patients should be sent for Gram stain and culture shortly after intubation (higher yield than sputum)
	*~~'''~~MRSA nasal PCR~~'''~~ (if available): High negative predictive value (~95%) for ruling out MRSA pneumonia; useful for de-escalation of empiric MRSA coverage<ref name="Parente2018">Parente DM, Cunha CB, Engemann AM, et al. The Clinical Utility of Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Screening to Rule Out MRSA Pneumonia: A Diagnostic Meta-analysis With Antimicrobial Stewardship Implications. Clin Infect Dis. 2018;67(1):1-7.</ref>		*MRSA nasal PCR (if available): High negative predictive value (~95%) for ruling out MRSA pneumonia; useful for de-escalation of empiric MRSA coverage<ref name="Parente2018">Parente DM, Cunha CB, Engemann AM, et al. The Clinical Utility of Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Screening to Rule Out MRSA Pneumonia: A Diagnostic Meta-analysis With Antimicrobial Stewardship Implications. Clin Infect Dis. 2018;67(1):1-7.</ref>
	*~~'''~~Legionella and Pneumococcal urinary antigen testing:~~'''~~ Not routinely recommended; consider for:<ref name="ATS2019"/>		*Legionella and Pneumococcal urinary antigen testing: Not routinely recommended; consider for:<ref name="ATS2019"/>
	**Severe CAP (ICU patients)		**Severe CAP (ICU patients)
	**Legionella antigen in alcoholics, outbreaks, or recent (within 2 weeks) travel history		**Legionella antigen in alcoholics, outbreaks, or recent (within 2 weeks) travel history
	*~~'''~~Influenza testing:~~'''~~ Recommended when influenza is circulating in the community; molecular testing (PCR) preferred over rapid antigen<ref name="ATS2019"/>		*Influenza testing: Recommended when influenza is circulating in the community; molecular testing (PCR) preferred over rapid antigen<ref name="ATS2019"/>

	===Chest X-Ray Mimics===		===Chest X-Ray Mimics===
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	===IDSA Severe Pneumonia Criteria===		===IDSA Severe Pneumonia Criteria===
	Severe pneumonia can be diagnosed with either ~~'''~~one major criterion~~'''~~ or ~~'''~~three or more minor criteria.~~'''~~<ref name="Severity">Severe pneumonia can be diagnosed with either one major criterion or three or more minor criteria. Neth J Med. 1999 Sep;55(3):110-7 10.1016/s0300-2977(99)00071-6</ref> These criteria have a pooled sensitivity of 84% and specificity of 78% for predicting ICU admission.<ref name="ATS2019"/>		Severe pneumonia can be diagnosed with either one major criterion or three or more minor criteria.<ref name="Severity">Severe pneumonia can be diagnosed with either one major criterion or three or more minor criteria. Neth J Med. 1999 Sep;55(3):110-7 10.1016/s0300-2977(99)00071-6</ref> These criteria have a pooled sensitivity of 84% and specificity of 78% for predicting ICU admission.<ref name="ATS2019"/>
	====Minor criteria====		====Minor criteria====
	*Respiratory rate > 30 breaths/min		*Respiratory rate > 30 breaths/min
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	===Adjunctive Corticosteroids===		===Adjunctive Corticosteroids===
	~~'''~~''Updated guidance based on CAPE COD trial (2023) and SCCM 2024 Focused Update:~~'''~~''		''Updated guidance based on CAPE COD trial (2023) and SCCM 2024 Focused Update:''

	*The ~~'''~~SCCM 2024 Focused Update~~''' '''~~strongly recommends~~'''~~ corticosteroids for adult patients hospitalized with ~~'''~~severe~~'''~~ bacterial CAP (strong recommendation, moderate certainty of evidence)<ref name="SCCM2024">Chaudhuri D, Nei AM, Rochwerg B, et al. 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Med. 2024;52(5):e219-e233.</ref>		*The SCCM 2024 Focused Update strongly recommends corticosteroids for adult patients hospitalized with severe bacterial CAP (strong recommendation, moderate certainty of evidence)<ref name="SCCM2024">Chaudhuri D, Nei AM, Rochwerg B, et al. 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Med. 2024;52(5):e219-e233.</ref>
	**No recommendation for or against steroids in ~~'''~~less severe~~'''~~ CAP		**No recommendation for or against steroids in less severe CAP
	*The ~~'''~~CAPE COD trial~~'''~~ (NEJM 2023): IV hydrocortisone 200 mg/day in severe CAP requiring ICU/intermediate care admission showed:<ref name="CAPECOD">Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med. 2023;388(21):1931-1941.</ref>		*The CAPE COD trial (NEJM 2023): IV hydrocortisone 200 mg/day in severe CAP requiring ICU/intermediate care admission showed:<ref name="CAPECOD">Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med. 2023;388(21):1931-1941.</ref>
	**↓ 28-day mortality (6.2% vs 11.9%; absolute difference 5.6%; NNT ~18)		**↓ 28-day mortality (6.2% vs 11.9%; absolute difference 5.6%; NNT ~18)
	**↓ Need for intubation		**↓ Need for intubation
	**↓ Need for vasopressors		**↓ Need for vasopressors
	**Duration: hydrocortisone 200 mg/day for 4 or 7 days based on clinical improvement, then tapered (total 8 or 14 days)		**Duration: hydrocortisone 200 mg/day for 4 or 7 days based on clinical improvement, then tapered (total 8 or 14 days)
	**~~'''~~Excluded~~'''~~ patients already in [[sepsis\|septic shock]]		**Excluded patients already in [[sepsis\|septic shock]]
	*~~'''~~REMAP-CAP~~'''~~ (2025): Fixed-dose hydrocortisone 200 mg/day x 7 days in severe CAP triggered a futility stopping rule for 90-day mortality; however, this trial enrolled a more severely ill population with higher rates of septic shock than CAPE COD<ref name="REMAPCAP">REMAP-CAP Investigators. Effect of hydrocortisone on mortality in patients with severe community-acquired pneumonia. Intensive Care Med. 2025.</ref>		*REMAP-CAP (2025): Fixed-dose hydrocortisone 200 mg/day x 7 days in severe CAP triggered a futility stopping rule for 90-day mortality; however, this trial enrolled a more severely ill population with higher rates of septic shock than CAPE COD<ref name="REMAPCAP">REMAP-CAP Investigators. Effect of hydrocortisone on mortality in patients with severe community-acquired pneumonia. Intensive Care Med. 2025.</ref>
	*~~'''~~Practical approach for the ED:~~'''~~		*Practical approach for the ED:
	**If patient has ~~'''~~severe CAP~~'''~~ (meets IDSA/ATS severity criteria, hypoxic, or being admitted to the ICU), consider hydrocortisone 200 mg IV daily (50 mg q6h) or methylprednisolone 40 mg IV daily		**If patient has severe CAP (meets IDSA/ATS severity criteria, hypoxic, or being admitted to the ICU), consider hydrocortisone 200 mg IV daily (50 mg q6h) or methylprednisolone 40 mg IV daily
	**No clear benefit in non-severe CAP		**No clear benefit in non-severe CAP
	**Avoid in active influenza pneumonia (without bacterial superinfection) per 2019 ATS/IDSA<ref name="ATS2019"/>		**Avoid in active influenza pneumonia (without bacterial superinfection) per 2019 ATS/IDSA<ref name="ATS2019"/>
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	===Aspiration Pneumonia===		===Aspiration Pneumonia===
	''See also: [[Aspiration pneumonia and pneumonitis]]''		''See also: [[Aspiration pneumonia and pneumonitis]]''
	*2019 ATS/IDSA guidelines recommend ~~'''~~against~~'''~~ routinely adding anaerobic coverage beyond standard CAP empiric antibiotics in suspected aspiration pneumonia (conditional recommendation, very low quality of evidence)<ref name="ATS2019"/>		*2019 ATS/IDSA guidelines recommend against routinely adding anaerobic coverage beyond standard CAP empiric antibiotics in suspected aspiration pneumonia (conditional recommendation, very low quality of evidence)<ref name="ATS2019"/>
	**~~'''~~Exception:~~'''~~ Add anaerobic coverage (e.g. [[ampicillin-sulbactam]], [[clindamycin]], or carbapenem) if [[lung abscess]] or [[empyema]] is suspected		**Exception: Add anaerobic coverage (e.g. [[ampicillin-sulbactam]], [[clindamycin]], or carbapenem) if [[lung abscess]] or [[empyema]] is suspected
	*Rationale: More recent studies show anaerobes are uncommon causes of aspiration pneumonia; unnecessary anaerobic coverage increases risk of ''[[Clostridioides difficile]]'' infection without mortality benefit<ref name="Tessier2024">Tessier L, Bhatt M, Engert JC, et al. Anaerobic Antibiotic Coverage in Aspiration Pneumonia and the Associated Benefits and Harms: A Retrospective Cohort Study. Chest. 2024;166(3):488-497.</ref>		*Rationale: More recent studies show anaerobes are uncommon causes of aspiration pneumonia; unnecessary anaerobic coverage increases risk of ''[[Clostridioides difficile]]'' infection without mortality benefit<ref name="Tessier2024">Tessier L, Bhatt M, Engert JC, et al. Anaerobic Antibiotic Coverage in Aspiration Pneumonia and the Associated Benefits and Harms: A Retrospective Cohort Study. Chest. 2024;166(3):488-497.</ref>
	*~~'''~~Aspiration pneumonitis~~'''~~ (chemical/inflammatory reaction without infection): supportive care only; antibiotics are not indicated unless infection develops		*Aspiration pneumonitis (chemical/inflammatory reaction without infection): supportive care only; antibiotics are not indicated unless infection develops

	===Influenza-Associated Pneumonia===		===Influenza-Associated Pneumonia===
	*'''Anti-influenza treatment''' (e.g. [[oseltamivir]]) should be prescribed to all adults with CAP who test positive for influenza, regardless of duration of illness or hospitalization status<ref name="ATS2019"/>		*'''Anti-influenza treatment''' (e.g. [[oseltamivir]]) should be prescribed to all adults with CAP who test positive for influenza, regardless of duration of illness or hospitalization status<ref name="ATS2019"/>
	*Standard antibacterial treatment should also be initially prescribed alongside antivirals in patients with clinical and radiographic evidence of CAP who test positive for influenza<ref name="ATS2019"/>		*Standard antibacterial treatment should also be initially prescribed alongside antivirals in patients with clinical and radiographic evidence of CAP who test positive for influenza<ref name="ATS2019"/>
	*~~'''~~Avoid routine corticosteroids~~'''~~ in influenza pneumonia<ref name="ATS2019"/>		*Avoid routine corticosteroids in influenza pneumonia<ref name="ATS2019"/>

	===Treatment Duration and De-escalation===		===Treatment Duration and De-escalation===
	*~~'''~~Minimum 5 days~~'''~~ of antibiotics<ref name="ATS2019"/>		*Minimum 5 days of antibiotics<ref name="ATS2019"/>
	*Continue until the patient achieves clinical stability, defined as:		*Continue until the patient achieves clinical stability, defined as:
	**Temperature ≤37.8°C		**Temperature ≤37.8°C
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	**Able to take oral intake		**Able to take oral intake
	**Normal mental status (back to baseline)		**Normal mental status (back to baseline)
	*~~'''~~De-escalation:~~'''~~ If empiric MRSA or ''Pseudomonas'' coverage was started, de-escalate to standard CAP therapy within 48 hours if cultures and MRSA nasal PCR are negative and the patient is improving<ref name="ATS2019"/>		*De-escalation: If empiric MRSA or ''Pseudomonas'' coverage was started, de-escalate to standard CAP therapy within 48 hours if cultures and MRSA nasal PCR are negative and the patient is improving<ref name="ATS2019"/>

	===Treatment Failure===		===Treatment Failure===
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	==Disposition==		==Disposition==

	~~'''~~IDSA 2019 guidelines recommend clinical judgement plus PSI over CURB-65.~~'''~~ <ref name="ATS2019"/>		IDSA 2019 guidelines recommend clinical judgement plus PSI over CURB-65. <ref name="ATS2019"/>

	{{Port score}}		{{Port score}}
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	==Prognosis==		==Prognosis==
	*Half of patients are still symptomatic at 30 days, with a significant minority experiencing chest pain, malaise or mild dyspnea even 2 to 3 months after treatment		*Half of patients are still symptomatic at 30 days, with a significant minority experiencing chest pain, malaise or mild dyspnea even 2 to 3 months after treatment
	*In adults with CAP whose symptoms have resolved within 5-7 days, it is ~~'''~~not~~'''~~ recommended to routinely obtain follow-up chest imaging<ref name="ATS2019"/>		*In adults with CAP whose symptoms have resolved within 5-7 days, it is not recommended to routinely obtain follow-up chest imaging<ref name="ATS2019"/>
	*Consider follow-up imaging in 7-12 weeks for patients at higher risk for malignancy (e.g. smokers >50 years) to ensure resolution and exclude underlying malignancy		*Consider follow-up imaging in 7-12 weeks for patients at higher risk for malignancy (e.g. smokers >50 years) to ensure resolution and exclude underlying malignancy