Community-acquired Pneumonia

Diagnosis

Metlay JP, Kapoor WN, Fine MJ. Does this patient have CAP? Diagnosing pneumonia by history and physical examination. JAMA 1997;278:1440-5. Systematic review found H & P do not reliably predict the presence of pneumonia in acutely symptomatic, ambulatory patients. Physicians' interobserver agreement on exam findings is poor. Article highlights the importance of chest x-rays in diagnosis of pneumonia but the optimal strategy for their use remains unclear.
PMID:  9356004

Treatment

Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.  Clin Infect Dis. 2007;44 Suppl 2:S27-72. An influential new consensus statement from two major societies.
PMID:  17278083
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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;336:243-50. This oft-cited prediction rule, the Pneumonia Severity Index (PSI), incorporates patient demographics, co-morbidities, vitals, labs, and chest film to identify patients likely to do well with outpatient treatment of CAP. 
PMID:  8995086
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Lim WS, Lewis S, Macfarlane JT.  Severity prediction rules in community acquired pneumonia:  a validation study.  Thorax 2000;55:219-23.  The CURB-65 (also validated as the CRB-65 when BUN is unavailable) is simpler to use than the PSI but is not as sensitive for predicting mortality.
PMID: 10679541
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Bartlett JG, Gorbach SL. The triple threat of aspiration pneumonia. Chest 1975;68:560-6. Classic review of the presentation, pathophysiology, and natural history of chemical pneumonitis, bacterial pneumonia, and airway obstruction resulting from aspiration of toxic fluids, bacteria, and inert matter respectively.
PMID:  1175415
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Mittl RL, Schwab RJ, Duchin JS et al. Radiographic resolution of community-acquired pneumonia.  Am J Respir Crit Care Med 1994;149:630-5. Prospective follow-up of both inpatients and outpatients with diagnosis of CAP is cited as a guide for when to look for endobronchial lesions in the setting of slowly clearing pneumonia.  The study found age and multilobar disease were independent predictors of delayed resolution.  Radiographic resolution seen in 51% at 2 weeks, 67% at 4 weeks, and 90% at 12 weeks. 
PMID:  8118630

Schuetz P, Christ-Crain M, Thomann R.  Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial.  JAMA 2009;302:1059-66. 1359 patients with lower respiratory tract infections in 6 Swiss academic hospitals were randomized to a treatment algorithm based on procalcitonin (PCT) levels or to treatment based on current evidence based guidelines.  PCT-guided therapy reduced total antibiotic exposure without any change in adverse outcomes.  Controversy exists regarding the unusually high prevalence of “severe” pneumonia by PSI score, and that reduction in exposure was primarily due to reduced duration of antibiotics rather than avoidance. 
PMID:  19738090
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