Insights – Community-Acquired Pneumonia in Urgent Care Medicine – Q2 2023

Controversies and Cutting Edge

While antibiotics remain the mainstay of treatment for CAP, more recent data have evaluated the use of adjunctive medications.

Corticosteroids

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

1. “I thought the tachycardia and hypoxemia were due to pneumonia.” When CAP is not the most likely diagnosis, consider using clinical decision tools such as the PERC rule (available at www.mdcalc.com/calc/347/perc-rule-pulmonary-embolism) and Wells criteria (available at www. mdcalc.com/calc/115/wells-criteria-pulmonary-embolism) to evaluate for pulmonary embolism. Patients with atypical signs and symptoms of CAP (sudden onset of shortness of breath; multiple risk factors for pulmonary embolism) or with findings on imaging that could be consistent with pulmonary infarctions should be evaluated further.
2. “Azithromycin seemed like a good choice for her.” The choice of antibiotic therapy should be made in coordination with the most up-to-date recommendations. The choice of antibiotic therapy varies, depending on treatment as an outpatient, inpatient, or ICU, and the local and community antibiograms. In North America, resistance to azithromycin is high, and thus, azithromycin should only be prescribed as an adjunct treatment when coverage for atypical pathogens is desired.
3. “I was sure he had pneumonia, but the X-ray was normal.” Chest radiography is beneficial in the diagnosis of CAP but cannot rule out the disease process. Chest X-ray should be used in conjunction with a thorough history and complete clinical picture to make the diagnosis. If a patient has a high pretest probability of CAP and a negative chest X-ray, it would be reasonable to either treat for presumed pneumonia or refer the patient for further imaging, such as CT or ultrasound.
4. “I just gave her a dose of IV antibiotics to get things started.” For patients who are able to tolerate oral medications, there are essentially no data to suggest that patients need a dose of IV or intramuscular antibiotics prior to outpatient treatment.⁶⁴
5. “Would you send a 70-year-old patient home with pneumonia?” Scoring systems that incorporate age or medical comorbidities may increase the patient’s score while not accurately reflecting the actual risk to the patient. Clinicians should consider the influence that age and other historical elements have in the development of these scores and use these in conjunction with their overall clinical impression to avoid overestimating the patient’s actual risk of adverse events.
6. “The patient had been having nasal congestion and coughing for several days; it seemed like they should get antibiotics just in case.” Healthy patients with upper respiratory tract complaints have high rates of viral pathogens. Unless a clear clinical suspicion of pneumonia is present based on vital signs, lung findings, or chest X-ray findings, antibiotics should not be prescribed.
7. “Is it really that bad to give a short course of moxifloxacin or levofloxacin?” While commonly prescribed and recommended, fluoroquinolones have several FDA black box warnings and should be used with caution. Patients taking quinolones are thought to have an increased risk of tendon rupture, neuropathy, and aortic aneurysm/dissection. Clinicians should consider the risk for these complications in all patients before using these agents.⁶⁵
8. “The rapid COVID-19 test was positive and the chest X-ray was positive for pneumonia. I assumed the pneumonia was from COVID-19.” To date there is no way to differentiate co-infection with COVID-19 and bacterial pathogens. For this reason, it is recommended that bacterial co-infection be assumed in most cases and patients treated with antibiotics accordingly.⁷