Controversies and Cutting Edge
While antibiotics remain the mainstay of treatment for CAP, more recent data have evaluated the use of adjunctive medications.
The 2019 ATS/IDSA guidelines recommend using corticosteroids for CAP and refractory septic shock but recommend against the routine use of corticosteroids in all other cases.3 The authors commented that while no study has shown excess mortality in CAP patients who have received corticosteroids, the overall risk for adverse events outweighs any potential benefits.
Despite these recommendations, the available literature regarding the role of corticosteroids suggests that the balance between potential harm and potential benefit may be more subtle. In cases of non-severe CAP, multiple studies have shown an improvement in outcomes that may be clinically significant, including lower rates of mechanical ventilation and decreased inpatient lengths of stay.57 Conversely, other studies have shown increased rates of hyperglycemia and secondary infection in patients who are given short-term doses of corticosteroids.58 In cases of severe CAP, the available evidence supporting the use of corticosteroids seems to be more clear, with a reported number needed to treat of 17 to prevent 1 death. However, in this same subset of patients, the reported number needed to harm is 11. While this number needed to treat is greater than the reported number needed to harm, the relative risks of harm (largely in the form of hyperglycemia) may be justified by the potential mortality benefit.58 Based on these recommendations, Urgent Care clinicians should carefully consider each patient before determining if corticosteroid treatment for CAP would be beneficial or harmful.
Influenza, Antiviral Agents, and Community-Acquired Pneumonia
Based on a moderate quality of evidence, the ATS/ IDSA guidelines advocate for the use of oseltamivir in all patients with CAP who test positive for influenza, regardless of length of illness.2 Despite the lack of studies specifically assessing the use of antiviral agents in patients with CAP and influenza, the authors based their recommendations on observational studies showing an association between the use of oseltamivir and a reduced mortality in patients who are hospitalized with influenza.59
For the outpatient setting, the guideline authors recommend using oseltamivir regardless of a patient’s duration of symptoms.3 The authors cite a paper by Dobson et al60 that reported a decreased rate of lower respiratory complications in patients with influenza (but not necessarily pneumonia) who were treated with antivirals. This recommendation for fairly widespread use of antivirals closely mirrors the 2018 IDSA guideline on seasonal influenza, which similarly advocated for the use of these medications.61
There are several potential issues with these recommendations. First, none of the studies cited specifically evaluated patients who have both pneumonia and influenza. The authors asserted that, given the reported benefits of oseltamivir in patients with isolated influenza, patients with influenza and CAP would similarly benefit from an aggressive use of antiviral agents. While this may prove to be true, the evidence behind this recommendation is lacking. A second issue with these recommendations involves the ongoing debate regarding the efficacy and tolerability of oseltamivir. While multiple large meta-analyses and systematic reviews concluded that oseltamivir can reduce symptoms and downstream complications, most of these publications have significant methodologic limitations that call into question the reported efficacy of these agents.62 Clinicians should know that the ATS/IDSA guidelines call for the widespread use of oseltamivir, but should also understand there is limited quality of available evidence.63
5 Things That Will Change Your Practice
Consider using the CRB-65 clinical decision tool, along with clinical judgment, to help identify the subset of patients in Urgent Care who can safely receive outpatient treatment.
Do not prescribe a macrolide alone for first-line treatment of CAP. Macrolide monotherapy is a poor choice in many areas due to increasing rates of macrolide-resistant pneumococcus.3 The 2019 ATS/ IDSA guidelines recommend amoxicillin or doxycycline as first-line treatment for adult outpatients without comorbidities.3
Limit antibiotic use to 5 days in patients who show signs of improvement. Studies suggest that patients who take longer courses of antibiotics have similar rates of clinical cure but a higher incidence of adverse events. It is reasonable to start all patients on a 5-day course of antibiotics and then reassess if they are not improving by the end of their prescription.
Do not routinely prescribe corticosteroids except for patients with refractory septic shock.3 In patients with comorbidities such as asthma or chronic obstructive pulmonary disease, the risk of side effects and complications of corticosteroid use must be balanced against the benefits of use and should be determined on a case-by-case basis.
Counsel patients that most antitussive treatments are ineffective; the cough from pneumonia is usually self-limited and will improve with resolution of the infection.
Risk Management Pitfalls for Community-Acquired Pneumonia in Urgent Care
7.* Metlay JP, Waterer GW. Treatment of community-acquired pneumonia during the coronavirus disease 2019 (COVID-19) pandemic. Ann Intern Med. 2020;173(4):304-305. (Guidelines)