APRIL 2023 | VOLUME 2 | ISSUE 4

Evidence-Based Urgent Care High-Yield Clinical Education • Practical Application

CLINICAL CHALLENGES:
• Which risk stratification tools for
CAP are most useful in the urgent
care setting?
• What are the safest and most
effective antibiotic regimens for CAP
in outpatients?
• Which adjunctive therapies, if
any, are helpful in outpatient
management of CAP?

Urgent Care Update Author

Tracey Quail Davidoff, MD, FCUCM
Attending Physician, BayCare Urgent Care,
Tampa, FL

Peer Reviewer
Nichele Nivens, MD, FAAFP, FCUCM
Assistant Professor, Family Medicine; GoFollow
After Care Physician; Clinical Quality Analyst;
Telemedicine Physician; Donald and Barbara
Zucker School of Medicine at Hofstra/Northwell,
Hempstead, NY
Charting & Coding Author
Brad Laymon, PA-C, CPC, CEMC
Certified Physician Assistant, Winston-Salem, NC
Prior to beginning this activity, see
“CME Information” on page 2.
Community-Acquired Pneumonia
in Urgent Care Medicine
 Abstract
Recommendations for the diagnosis, treatment, and disposition
of patients with community-acquired pneumonia continue to
evolve. This issue reviews the current evidence and guidelines
for managing these patients in the urgent care setting, including
key physical examination findings, diagnostic studies, and
treatment options. Various clinical decision aids are compared
in the context of their utility in outpatient facilities. A clinical
pathway for urgent care management of community-acquired
pneumonia is provided to help guide disposition decision making
and delineate optimal antibiotic regimens based on patient
comorbidities and risk factors.

This issue is eligible for CME credit. See page 2. EBMEDICINE.NET

 CME Information
Date of Original Release: April 1, 2023. Date of most
recent review: March 10, 2023. Termination date:
April 1, 2026.
Accreditation: EB Medicine is accredited by the
Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical
education for physicians.
Credit Designation: EB Medicine designates this
enduring material for a maximum of 4 AMA PRA
Category 1 CreditsTM. Physicians should claim only
the credit commensurate with the extent of their
participation in the activity.
Specialty CME: Included as part of the 4 credits, this
CME activity is eligible for 4 Infectious Disease and 1
Pharmacology CME credits, subject to your state and
institutional approval.
AOA Accreditation: Evidence-Based Urgent Care is
eligible for 4 Category 2-A or 2-B credit hours per issue
by the American Osteopathic Association.
Needs Assessment: The need for this educational
activity was determined by a practice gap analysis;
a survey of medical staff; review of morbidity and
mortality data from the CDC, AHA, NCHS, and ACEP;
and evaluation responses from prior educational
activities for urgent care and emergency medicine
physicians.
Target Audience: This internet enduring material is
designed for physicians, physician assistants, nurse
practitioners, and residents in the urgent care and
family practice settings.
Goals: Upon completion of this activity, you should
be able to: (1) identify areas in practice that require
modification to be consistent with current evidence in
order to improve competence and performance; (2)
develop strategies to accurately diagnose and treat
both common and critical urgent care presentations;
and (3) demonstrate informed medical decision-
making based on the strongest clinical evidence.
CME Objectives: Upon completion of this activity,
you should be able to: (1) Develop an evidence-
based approach to risk stratifying urgent care patients
with community-acquired pneumonia (CAP); (2)
order appropriate imaging and laboratory testing
of patients with CAP, based on clinical utility; (3)
prescribe the safest and most effective outpatient
antibiotic regimens for patients with CAP; and (4)
evaluate the evidence behind adjunctive therapy and
medications used to treat CAP.
APRIL 2023 • www.ebmedicine.net
Discussion of Investigational Information: As part of
the activity, faculty may be presenting investigational
information about pharmaceutical products that is
outside Food and Drug Administration approved
labeling. Information presented as part of this activity
is intended solely as continuing medical education
and is not intended to promote off-label use of any
pharmaceutical product.
Disclosure: It is the policy of EB Medicine to ensure
objectivity, balance, independence, transparency,
and scientific rigor in all CME activities. All individu-
als in a position to control content have disclosed all
financial relationships with ACCME-defined ineligible
companies. EB Medicine has assessed all relation-
ships with ineligible companies disclosed, identified
those financial relationships deemed relevant, and
appropriately mitigated all relevant financial relation-
ships based on each individual’s role(s). Please find
disclosure information for this activity below:
Planners
• Keith Pochick, MD (Editor-in-Chief): Nothing to
Disclose
Faculty
• Tracey Quail Davidoff, MD (Author):
◦ Gebauer Corporation (consultant/advisor)
• Bradley Laymon, PA-C (Charting & Coding
Author): Nothing to Disclose
• Nichele Nivens, MD (Peer Reviewer): Nothing
to Disclose
• Angie Wallace (Content Editor): Nothing to
Disclose
Commercial Support: This issue of Evidence-Based
Urgent Care did not receive any commercial support.
Earning Credit: Go online to https://www.
ebmedicine.net/CME and click on the title of the test
you wish to take. When completed, a CME certificate
will be emailed to you.
Additional Policies: For additional policies,
including our statement of conflict of interest, source
of funding, statement of informed consent, and
statement of human and animal rights, visit https://
www.ebmedicine.net/policies
2 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 Points & Pearls
QUICK READ
APRIL 2023 | VOLUME 2 | ISSUE 4
Points
• CAP is an acute infection of the lung parenchyma
in patients who have not been hospitalized or
had recent exposure to the healthcare system.
• Though the most commonly identified pathogen
in CAP is Streptococcus pneumoniae, it is
responsible for only 5% to 15% of hospitalized
cases.13
• High-risk CAP mimics include congestive heart
failure exacerbations, acute coronary syndromes,
pulmonary embolism, neoplastic lesions, and
pulmonary abscess/empyema.
• Identification of sepsis related to pneumonia is
imperative and includes an assessment of the
patient’s vital signs and the clinical signs and
symptoms of severe sepsis and septic shock.
• The most frequently reported symptom in
patients with CAP is cough, observed in 80%
to 90% of patients.24 Antitussives are not very
effective,56 and patients should be counseled on
the risks of opioid agents and assured that the
cough will improve as the pneumonia resolves.
• The clinical utility of biomarkers in the workup of
CAP remains unclear,36 and they currently have no
role in the outpatient setting.
• While blood cultures have a limited role in the
diagnosis and treatment of CAP, they are still
recommended for hospitalized patients with CAP
and for those with MRSA, P aeruginosa isolates,
or other risk factors. Blood cultures should not be
used in the outpatient setting.
• In general, for the vast majority of patients with
CAP, there is almost no role for routine sputum
cultures42 except in cases of severe CAP and in
patients where there is concern for MRSA or
P aeruginosa.
• If use of either the PSI or CURB-65 score to
determine the severity of CAP is not feasible due
to limited availability of data, the CRB-65 score is
a useful alternative in outpatient settings such as
urgent care.50 (See Tables 1 and 2, and Figure 1.)
APRIL 2023 • www.ebmedicine.net
Community-Acquired Pneumonia
in Urgent Care Medicine
Pearls
• Elderly patients are more likely to present
with atypical symptoms, including altered
mental status and fatigue. Typical symptoms
may not even be present.
• Chest x-ray cannot definitively exclude the
diagnosis of CAP, but it can point the clinician
to other disease processes, such as heart
failure, malignancy, effusion, and pulmonary
infarction.
• Risk stratification tools can help determine
the patient's disposition to outpatient or
inpatient therapy; these determinations will
also guide antibiotic therapy.
• Appropriate disposition has been shown to
improve mortality and lower overall costs.66
• The key to risk stratification in urgent care clinics is
to consider the decision to treat as an outpatient,
or to refer to the ED for evaluation and admission.
• The 2019 ATS/IDSA guidelines recommend using
corticosteroids in CAP patients with refractory
septic shock only. There is little to no role in
outpatient use of steroids for CAP except when
other comorbidities, such as asthma, chronic
obstructive pulmonary disease, or adrenal
insufficiency are present.3 The risk of side effects
and complications of corticosteroid use need to be
balanced against the benefits of use and should be
determined on a case-by-case basis.
• In the era of COVID-19, the presence of the
COVID-19 virus in patients with suspected CAP
must be considered. There are no historical or
physical examination findings that can reliably
differentiate between COVID-19 pneumonia and
bacterial pneumonia. If suspected, antibiotics
should be prescribed to cover secondary bacterial
pneumonia in the presence of COVID-19 (or other
viral) pneumonia.
3 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 Clinical Pathway for Urgent Care Management
of Community-Acquired Pneumonia

Patient presents with high probability of having CAP

Determine whether outpatient treatment is appropriate using

PSI, CURB-65 score, or CRB-65 score, in addition to clinical judgment

Outpatient treatment is appropriate Outpatient treatment is not appropriate

Significant comorbidities present?a Transfer to the ED

NO YES

Use Rx 1 Use Rx 2

Recheck in 3 to 5 days

Rx 1: Rx 2:
• Amoxicillin 1 g orally 3 times daily (Class II) or 1. Combination therapy (oral) (Class III)
• Doxycycline 100 mg orally 2 times daily (Class III) or • Amoxicillin/clavulanate:
• A macrolide (azithromycin 500 mg orally on the first day, then ◦ 500 mg/125 mg 3 times daily
250 mg orally daily; or clarithromycin 500 mg orally 2 times daily or ◦ 875 mg/125 mg 2 times daily
clarithromycin extended release 1000 mg orally daily) only in areas ◦ 2000 mg/125 mg 2 times daily
with pneumococcal resistance to macrolides <25% (in most areas of or
North America resistance is >30%; should not use as monotherapy) • Cephalosporin (cefpodoxime 200 mg 2 times daily or
(Class II) cefuroxime 500 mg 2 times daily)
PLUS
• One of 2 macrolides:
◦ Azithromycin 500 mg on the first day then 250 mg daily or
◦ Clarithromycin 500 mg 2 times daily or extended release
1000 mg 1 time daily
OR
2. Respiratory fluoroquinolone (oral) (Class II)
• Levofloxacin 750 mg daily
• Moxifloxacin 400 mg daily
• Gemifloxacin 320 mg daily

Significant comorbidities include but are not limited to: asthma or chronic obstructive pulmonary disease; diabetes; congestive heart failure;
a

immunosuppressive disorders or therapy; chronic kidney disease; active cancer or chemotherapy; degenerative neurologic disorders; and advanced age.
Abbreviations: CAP, community-acquired pneumonia; ED, emergency department; PSI, pneumonia severity index.

Class of Evidence Definitions

Recommendations in the clinical pathways section of Evidence-Based Urgent Care receive a score based on the following definitions.
Class I Class II
• Always acceptable, safe • Safe, acceptable Class III Indeterminate
• Definitely useful • Probably useful • May be acceptable • Continuing area of research
• Proven in both efficacy and effectiveness • Possibly useful • No recommendations until further
Level of Evidence: • Considered optional or alternative research
Level of Evidence: • Generally higher levels of evidence treatments
• One or more large prospective studies • Nonrandomized or retrospective stud- Level of Evidence:
are present (with rare exceptions) ies: historic, cohort, or case control Level of Evidence: • Evidence not available
• High-quality meta-analyses studies • Generally lower or intermediate levels • Higher studies in progress
• Study results consistently positive and • Less robust randomized controlled trials of evidence • Results inconsistent, contradictory
compelling • Results consistently positive • Case series, animal studies, • Results not compelling
consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2023 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

APRIL 2023 • www.ebmedicine.net 4 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

 Case Presentations
A 30-year-old man with no significant past medical history presents to the urgent care clinic with 2
days of fever, cough productive of green sputum, and malaise...
• Physical examination reveals left-sided rhonchi that do not clear with coughing.
• The patient has a heart rate of 105 beats/min and a temperature of 39.1°C. He is normotensive, has
CASE 1

a respiratory rate of 22 breaths/min, is speaking in full sentences, and has 95% oxygen saturation on
room air.
• COVID-19 rapid PCR, influenza A virus, and influenza B virus testing are all negative.
• X-rays show a left-sided retrocardiac opacity concerning for pneumonia.
• When you suggest to the patient that he may require treatment in a hospital, he states he would prefer
to go home…

An 82-year-old woman with a history of mild COPD presents from an assisted-living facility with 3
days of mild cough productive of yellow sputum...
• She reports no fever, chills, chest pain, shortness of breath, orthopnea, or paroxysmal nocturnal
CASE 2

dyspnea.
• Her physical examination reveals normal vital signs and slightly diminished breath sounds in the right
lung fields. X-rays show a right-sided infiltrate consistent with pneumonia.
• The patient’s daughter is concerned about the risk for an adverse outcome, but the patient says she
would like to return to her assisted living facility...

A 55-year-old man with a history of diabetes mellitus and chronic kidney disease presents with 3 days
of a nonproductive cough, fever, and lethargy...
• He is in moderate distress, is breathing with accessory muscles, and has rhonchi and rales in all lung
fields.
CASE 3

• The patient is febrile and has a heart rate of 130 beats/min. His initial blood pressure is 88/50 mm Hg
and his respiratory rate is 26 breaths/min. His oxygen saturation is at 88% on room air.
• X-ray findings include bilateral infiltrates concerning for multifocal pneumonia and a left-sided pleural
effusion.
• The patient’s wife states she will bring him to the hospital after she goes home, packs the patient a bag,
and lets the dog outside...

on management of HAP and VAP.4 HCAP referred

 Introduction
Community-acquired pneumonia (CAP) is a relatively
common disease that is seen frequently in urgent
care clinics. CAP results from an acute infection of
the lung parenchyma in patients who have not been
hospitalized recently or have had recent exposure to
the healthcare system. CAP accounts for the largest
group of sepsis-triggering events and is responsible
for significant morbidity and mortality.1
The American Thoracic Society (ATS)/Infectious
Diseases Society of America (IDSA) guidelines de-
scribe 2 types of pneumonia in addition to CAP: (1)
hospital-acquired pneumonia (HAP) (also called noso-
comial pneumonia), pneumonia that occurs ≥48 hours
after admission to a healthcare facility and that did
not appear to be present at the time of admission;
and (2) ventilator-associated pneumonia (VAP), a type
of HAP that develops ≥48 hours after endotracheal
intubation.2,3
The term healthcare-associated pneumonia
(HCAP) was included in the 2005 ATS/IDSA guidelines
to pneumonia acquired in healthcare facilities such
as hemodialysis centers, nursing homes, outpatient
clinics, or during inpatient hospitalization within the
prior 3 months.5 This category was used to identify
patients at risk for infection with multidrug-resistant
organisms, but it was found to be overly sensitive,
which increased rates of inappropriate antibiotic use.6
Although patients with recent contact with healthcare
facilities are at an increased risk for infection with mul-
tidrug-resistant organisms, this risk is small for most
patients, and the overall prevalence is low;3 thus, the
category of HCAP was removed from the ATS/IDSA
2016 guidelines on HAP and VAP,2 as well as the 2019
ATS/IDSA guidelines on CAP.3
This issue of Evidence-Based Urgent Care reviews
various aspects of the diagnosis and management of
CAP, including its epidemiology, pathophysiology,
urgent care evaluation, utility of various diagnostic
studies, treatment modalities (including antibiotic op-
tions), and evidence-based disposition of patients.

APRIL 2023 • www.ebmedicine.net 5 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

 Community-Acquired Pneumonia in
the Era of COVID-19
Since December 2019, when the SARS-CoV-2 virus
began to spread worldwide, the presence of this
novel viral pathogen has become a consideration in
any patient with possible CAP. In 2020, the co-chairs
of the 2019 ATS/IDSA CAP guidelines issued a series
of recommendations on the management of CAP in
the era of COVID-19.7
From a diagnostic standpoint, historical or
physical examination findings cannot differentiate
reliably between CAP and COVID-19, and the
utility of chest x-ray for patients with COVID-19
also remains unclear. In a review of more than 600
patients seen in urgent care, Weinstock et al found
that the chest x-ray was normal in approximately
58% of patients with COVID-19 and normal or
only mildly abnormal in 89% of patients.8 Thus, in
a patient with a high pretest probability of having
COVID-19, a normal chest x-ray does not rule out
underlying disease.
In terms of treatment, Metlay et al recommend
empiric antibiotic coverage for patients with CAP
who do not have confirmed COVID-19, but states
that antibiotics should not be required for all
patients with confirmed COVID-19.7 Worldwide,
there is variable access to rapid COVID-19 tests,
making differentiation between CAP and COVID-19
even more challenging. In this situation, Metlay
and colleagues recommend the use of antibiotics
to cover bacterial pathogens according to the ATS/
IDSA guidelines, patient demographics, treatment
setting, and severity of illness.7
No clear evidence exists to guide the use of
antibiotics in patients with confirmed COVID-19.
Theoretically, the pulmonary manifestations of
COVID-19 should be strictly viral or attributable to
a host-related immunologic response, yet Du et al
reported high rates of bacterial co-infection, with
Mycoplasma IgM antibodies detected in 9 of 34
(26.5%) patients that were tested, and Chlamydia
was positive in 12 out of 35 (34.1%) patients
tested.9 Retrospective data from the initial New
York COVID-19 surge in 2020 showed lower rates
of co-infection but also illustrated the difficulty
of differentiating between bacterial and viral
pathogens. In a review of patients admitted with
COVID-19, Nori et al found that only 2% of patients
had a confirmed respiratory bacterial co-infection,
while >98% of patients had received at least 1 dose
of antibiotics.10
COVID-19 has presented a dynamic, rapidly
changing clinical situation. In patients with possible
CAP, clinicians need to consider the possibility of
COVID-19. When available, rapid testing may help
confirm the presence of the pathogen, but it does
not rule out the possibility of a coexisting bacterial
pathogen. Urgent care clinicians should be aware
APRIL 2023 • www.ebmedicine.net
of this and consider treatment based on severity
of illness, pre-existing comorbidities, and rates of
COVID-19 infection in the area.
 Epidemiology
In 2018, CAP was the leading cause of infectious
disease-related death and the ninth most common
cause of death in the United States,11 and the rate
of CAP increases with age.12 Of the many pathogens
responsible for CAP, Streptococcus pneumoniae
is the most commonly identified bacterial cause.
However, the incidence of cases of S pneumoniae
has decreased significantly in recent years, and
while it is still the most commonly isolated bacterial
pathogen, it is now responsible for only 5% to 15%
of hospitalized cases of CAP in the United States.13
This decline is thought to be due largely to the
development of the pneumococcal vaccine, as rates
of S pneumoniae are notably higher in areas where
there is not widespread use of this vaccine. While the
pneumococcal vaccine has been shown to reduce
rates of invasive pneumococcal pneumonia, it has not
been shown to reduce mortality.14
Other common CAP pathogens include Hae-
mophilus influenzae, Pseudomonas aeruginosa, and
Moraxella catarrhalis. Certain patient populations
have a higher incidence of specific pathogens, such
as increased rates of P aeruginosa in patients with
underlying lung disease, including chronic obstructive
pulmonary disease. The incidence of atypical bac-
terial causes of CAP (including Mycoplasma pneu-
moniae and Chlamydophila pneumoniae) is some-
what unclear, but likely underreported. Patients with
atypical pathogens generally have a more benign
disease course and may be less likely to seek medical
care. Current testing for atypical pathogens is subop-
timal, making it difficult to quantify the true burden of
disease. Pathogens such as Legionella pneumophila
may occur in geographic clusters related to specific
exposures but are not typically seen in isolation in
the general population. Viral causes of CAP include
influenza, parainfluenza, adenovirus, coronavirus, and
human respiratory syncytial virus. Viral causes include
influenza, parainfluenza, adenovirus, coronavirus, and
human respiratory syncytial virus (RSV). Viruses cause
approximately 20% of cases of CAP, with a higher in-
cidence seen year-round in children and in all patients
during seasonal influenza outbreaks.15
Historically, patients who have had frequent or
recent interactions with the healthcare system were
thought to have an increased risk of developing
pneumonia from multidrug-resistant organisms; in
these cases, patients were categorized as having
HCAP. In a meta-analysis that included 24 studies
and more than 22,000 patients, Chalmers et al found
no increase in the incidence of multidrug-resistant
organisms in patients with HCAP compared to
6 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
patients with CAP,16 and the most recent ATS/IDSA
guidelines have moved away from this classification
and categorize nosocomial pneumonia as either HAP
or VAP.2
In a notable number of cases diagnosed as CAP,
the etiology remains either unclear or is found to
be noninfectious. In an observational study of 259
patients who were hospitalized with a diagnosis of
CAP, Musher et al found a causative bacterium in
only 23.2% of cases. A viral pathogen was identified
in 16.2% of cases, and 26.6% of patients were
diagnosed with a noninfectious syndrome. Despite
extensive testing, no cause for CAP was found in
45.9% of patients.17 It can be nearly impossible to
identify the exact pathogens in a patient presenting
with CAP, and the available data suggest that this
diagnostic uncertainty persists throughout the
patient’s course.
 Pathophysiology
Pneumonia is an infectious process that results from
the infiltration of pathogens into the lung parenchy-
ma, provoking the production of intra-alveolar exu-
dates. The development of pneumonia requires that a
pathogen reach the alveoli and that host defenses are
overwhelmed by either the micro-organism’s virulence
or by the inoculum’s size. The introduction of a patho-
gen into the lower respiratory tract is typically the
result of aspiration from the upper respiratory tract.
Although the outcome of a lower respiratory tract
infection can depend on the virulence of the organ-
ism, an individual may experience a wide spectrum of
symptom severity due to the inflammatory response
in the lung.18
Immune defenses include mucociliary clearance
(often referred to as the mucociliary escalator), anti-
microbial proteins in airway surfactant, and alveolar
macrophages. Younger or healthier patients can typi-
cally mount an effective immune response when small
numbers of low-virulence microbes are deposited in
the lungs. Older patients, patients with underlying
lung disease, and immunocompromised patients may
have a more difficult time clearing even small numbers
of microbes. In contrast, numerous or more virulent
microbes often result in the development of a large
inflammatory response in most patients. Although this
response is essential to clear the respiratory tract of
microbes, it contributes directly to the development of
more severe symptoms and to lung injury.19
The pathogens that cause pneumonia can be
transmitted from person to person by airborne drop-
lets but may already be present in native oral and
nasal flora. The most common way that pathogens
reach the lower respiratory tract is by micro-aspira-
tion. Many conditions can predispose patients to the
development of pneumonia. Specifically, chronic lung
disease (chronic obstructive pulmonary disease, bron-
APRIL 2023 • www.ebmedicine.net
chiectasis), smoking, older age, and immunocompro-
mise are significant risk factors.20 Some studies have
suggested that long-term use of certain medications,
including proton-pump inhibitors, H2 blockers, and
antipsychotic agents may be linked to an increased
risk of pneumonia, but these studies have shown only
observational associations that have not been dem-
onstrated in any randomized controlled trials.21,22
 Differential Diagnosis
Given the broad range of disease severity,
patients with CAP can present with a wide range
of symptoms, and urgent care clinicians must have
a broad differential when evaluating any patient
who may have CAP. This is because commonly
reported symptoms can often be caused by other
medical conditions. High-risk CAP mimics include
congestive heart failure, acute coronary syndromes,
pulmonary embolism, neoplastic lesions, and
pulmonary abscess/empyema. Pulmonary embolism
can be particularly easy to miss if there is pulmonary
infarct resulting in a CAP-like radiographic infiltrate.
Neoplasia should be suspected in a patient with CAP
who does not improve with antimicrobials over weeks
or has other ominous constitutional signs.
These disease processes should be ruled out clin-
ically or diagnostically prior to the definitive diagnosis
of CAP. In some cases, a detailed history and physical
examination may be enough to rule out these causes.
In others, a more thorough workup including an elec-
trocardiogram, laboratory testing, radiographs, and
advanced imaging modalities may be required.
Lower-risk CAP mimics include uncomplicated
bronchitis, viral upper respiratory infections, and mi-
nor asthma exacerbations. Although these conditions
are generally not as severe as CAP, it is important to
make an accurate diagnosis to prevent overtreatment
with antibiotic therapy.
 Urgent Care Evaluation
Patients with severe symptoms such as shortness of
breath, tachypnea, high fever, or chest pain should
be quickly assessed for hypoxemia using a pulse
oximeter. In patients found to have an oxygen
saturation of <90% to 93%, supplemental oxygen
should be provided as soon as possible. Oxygen may
be provided by nasal cannula or face mask. Fluid
resuscitation via intravenous (IV) access is beneficial
in patients with hypotension or other signs of shock.
All patients should be considered to potentially have
COVID-19, so all staff should use personal protective
equipment when encountering any patient with
possible CAP.
Prior to obtaining any imaging or laboratory
studies, a thorough history and physical examination
will help rule out other disease processes and assist
7 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
in the diagnosis of pneumonia. Although not often
thought of in urgent care, identification of sepsis
related to pneumonia is imperative and includes an
assessment of the patient’s vital signs and the clinical
signs and symptoms of severe sepsis and septic
shock. If sepsis is suspected, transport to the nearest
emergency department (ED) by emergency medical
services should occur as soon as possible.
The presence of fever, hypoxia, tachycardia, and
crackles on auscultation are suggestive of CAP. All 4
variables are noted to be specific independent predic-
tors of radiograph-proven pneumonia in a clinical set-
ting. In contrast, demographic information and histori-
cal factors are less likely to provide predictive informa-
tion for the diagnosis of CAP. Although CAP is more
common in the elderly population, age, sex, smoking
history, and past medical history provide no predictive
information for a pneumonia diagnosis.23 Although it
will likely not change management, patients should be
asked about any recent hospitalizations.
Although the classic history for CAP often includes
the presence of productive cough, fever, shortness of
breath, and pleuritic chest pain, these signs do not
reliably confirm or rule out an underlying pneumonia.
The most frequently reported clinical symptom in
patients with CAP is cough, which is observed in 80%
to 90% of patients with the disease.24 Shortness of
breath is also a frequently reported symptom and is
found in up to 70% of patients with CAP.25 In patients
confirmed to have CAP, sputum production and
pleuritic pain are reported in roughly 50% of cases.
The urgent care clinician should not mentally eliminate
the possibility of pneumonia if any of these symptoms
are absent. From a clinical standpoint, these signs and
symptoms are most useful in making the diagnosis of
CAP when they present concurrently, as a constellation
of symptoms.
Diagnosing CAP in elderly patients can present a
challenge, as classic features such as fever, cough, and
shortness of breath may be less prevalent in elderly
patients ultimately diagnosed with pneumonia.26
Elderly patients are more likely to present with atypical
symptoms, including altered mental status, anorexia,
lethargy, and fatigue.
There is limited diagnostic efficacy of auscultation
of the lungs for pneumonia. The presence of crackles
on physical examination can help make the diagnosis
of CAP, but in general, crackles and decreased breath
sounds have relatively low predictive values for pneu-
monia. On the other hand, egophony and dullness to
percussion have higher predictive values.24 For these
reasons, the diagnosis of pneumonia cannot be reliably
confirmed or excluded by the presence or absence of
a particular finding on physical examination. However,
the clinical examination can be useful in creating a dif-
ferential diagnosis.27
Because of the limited utility of the physical
examination in diagnosis CAP, clinical decision rules
APRIL 2023 • www.ebmedicine.net
have incorporated the likelihood of CAP based
on multiple signs and symptoms, and not physical
findings. For more information on the use of clinical
decision rules in diagnosis of CAP, see the “Using
Severity and Risk Scoring Systems for Treatment and
Disposition” section, beginning on page 10.
 Diagnostic Studies
Chest Radiography
Chest x-ray remains a hallmark of the diagnosis of
CAP despite a fairly low sensitivity for detection.
Chest x-ray is an important tool in the evaluation of
patients with cough, shortness of breath, and chest
pain, and can assist with, but not exclude, the diag-
nosis of CAP. Numerous studies have been performed
to assess the utility of chest x-ray in the diagnosis
of CAP. Using CT as the gold standard, chest x-ray
has moderate specificity (93%) but fairly low sensitiv-
ity (range of 46%-77%).28 Based on these sensitivi-
ties, the exclusive use of chest x-ray would result in
missing the diagnosis of CAP in one-third to one-half
of presenting patients. For this reason, chest x-ray
should not be relied upon for the exclusion of pneu-
monia. Despite this low sensitivity, chest x-ray remains
a strong recommendation for all patients in whom
CAP is suspected, as it can point the clinician to other
disease processes, including congestive heart failure,
malignancy, effusion, and pulmonary infarction.29
Computed Tomography
CT of the chest is a much more sensitive test for
pulmonary infiltrates (approaching 100%) than chest
x-ray, but it is associated with increased radiation
exposure and cost.30 Most urgent care clinics do not
have timely access to CT scanning. For these reasons,
chest x-ray remains the initial testing modality for
patients in whom there is suspicion for CAP. CT
may be a useful diagnostic tool for patients without
pulmonary infiltrate on chest x-ray but who present
with clinical suspicion of pneumonia and complicating
factors. Immunocompromised patients, patients with
multiple comorbid conditions, and elderly patients
may particularly benefit from further characterization
with CT,31 if available. Patients with undifferentiated
sepsis or septic shock may also benefit from urgent
CT scanning; however, in the urgent care setting,
hospital evaluation should not be delayed for an
outpatient CT scan and these patients should be
evaluated in the ED as soon as possible.
Ultrasound
With decreasing costs and easier portability, point of
care ultrasound is making its way into urgent care as a
complementary testing modality. Although relatively
few urgent care clinics currently have this technology,
it is slowly disseminating throughout the industry.32
A commonly used modality to asses for deep vein
8 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
thrombosis, gallbladder disease, and bladder volume,
ultrasound is also a useful modality for the diagnosis
of CAP.33 Meta-analysis on the use of lung ultrasound
has demonstrated a pooled sensitivity and sensitivity
for the diagnosis of pneumonia of 94% and 96%,
respectively.34 Unfortunately sensitivity and specificity
depend greatly on the skill level and experience of
the sonographer, making it a less than ideal first-line
test for clinicians who are not highly skilled in its use.
Laboratory Testing
Tests such as white blood cell (WBC) count and
erythrocyte sedimentation rate have erratic sensitivity
and poor specificity, and do not appear to offer
reliable diagnostic or prognostic information in the
evaluation of patients with suspected CAP. While
laboratory tests may identify other possible medical
issues in terms of how CAP is diagnosed and
managed, they have limited utility.
Biomarkers
Over the past several decades, various biomarkers
have been used to evaluate patients with CAP. More
recently, biomarkers such as C-reactive protein (CRP)
and procalcitonin (PCT) have been studied in patients
with suspected pneumonia. CRP is released primarily
from the liver in response to elevated inflammatory
mediators generated by the body’s response to
pathogens. PCT is produced in the thyroid and
becomes detectable after 2 to 4 hours of infection.
Early studies across a wide variety of settings have
reported that PCT is able to predict the presence of a
bacterial infection and, when trended, can illustrate a
response to antibiotics.35
The clinical utility of these biomarkers remains
somewhat unclear, especially in urgent care settings
that may not have a rapid turn-around-time on these
results. Müller et al evaluated the use of PCT and CRP
alongside traditional clinical features (fever, cough,
sputum production, abnormal chest auscultation,
and dyspnea) and WBC count. When added to the
traditional examination findings, PCT and CRP were
more accurate than physical examination features but
were not statistically superior to WBC count.36
The 2019 ATS/IDSA guidelines give a strong
recommendation, based on a moderate quality of
evidence, that patients with clinical and radiographic
findings of CAP should be started on empiric
antibiotics regardless of initial PCT results.3 Currently,
despite more widespread use across a variety of
settings, PCT should not be part of the standard
workup of patients with suspected CAP, and is not
recommended for use in the urgent care setting.
Mycoplasma pneumoniae Testing
M pneumoniae is among the common causes of
CAP, with the highest rates occurring in children
and young adults. Cases of mycoplasma pneumonia
APRIL 2023 • www.ebmedicine.net
typically occur during winter months, are thought
to be highly contagious, and can lead to clusters
of outbreaks. Making the diagnosis of mycoplasma
pneumonia can be a challenge, as patients typically
have lower rates of abnormal pulmonary findings on
examination and chest radiography. IgM and IgG
antibody titers and PCR testing are available, but
may not have meaningful clinical impact, as patients
have a high rate of asymptomatic carriage. In a study
of healthy volunteers, 13.5% of patients without
symptoms were found to harbor M pneumoniae in
the oropharynx during the season of peak prevalence
of mycoplasma pneumonia. The overall incidence
of M pneumoniae detection in healthy volunteers
was approximately 5%.37 Given that pneumonia
caused by M pneumoniae typically has a benign
disease course and rarely results in hospitalization or
significant morbidity, there is little clinical imperative
for clinicians to utilize M pneumoniae testing when
evaluating patients.
Urine Antigen Testing
Urine antigen testing is available for both S
pneumoniae and L pneumophila. Initial studies
reported test characteristics that were comparable
to those seen with blood and sputum cultures,
though the clinical impact of urine antigen testing
remains somewhat unclear. In a trial of 194 patients
who were hospitalized with CAP, Falguera et al
randomized patients to either empiric treatment
based on available guidelines or targeted therapy
based on the results of urine antigen testing. Antigen
testing influenced antibiotic choice in 28.4% of
patients; however, despite this additional data, there
was no difference between the groups in terms of
overall treatment cost, exposure to broad-spectrum
antibiotics, or the incidence of adverse events.38
The 2019 ATS/IDSA guidelines do not
recommend routine pneumococcal antigen testing
other than in cases of severe pneumonia; however,
this is a conditional recommendation based on a low
overall quality of evidence. Similarly, patients should
not be tested routinely for Legionella antigen other
than in cases of severe CAP or if there is an elevated
clinical concern based on recent outbreaks.3
Blood Cultures
Blood cultures have a limited role in the diagnosis
and treatment of CAP because they have a low
sensitivity, a high rate of false-positives, and rarely
offer data that positively alters a patient’s clinical
course. A prospective study of 414 patients with
CAP in an ED reported true-positive cultures in only
7% of patients. Overall, blood cultures altered the
treatment plan in only 3.6% of cases and, in most
instances, the data were used to narrow rather than
broaden antibiotic coverage (2.7% vs 1%).39 A similar
retrospective review of ED patients with CAP found
9 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
a false-positive culture rate of 7.9% versus a true-
positive rate of only 3.4%.40
The 2019 ATS/IDSA guidelines strongly recom-
mend that blood cultures not be obtained for any
outpatients. The guidelines also give a conditional
recommendation that blood cultures should not be
routinely ordered for inpatients with CAP. However,
blood cultures are recommended for hospitalized pa-
tients with severe CAP and also for patients who have
been or are being treated for methicillin-resistant
Staphylococcus aureus (MRSA) or P aeruginosa. Blood
cultures are also recommended for patients who have
been hospitalized and given IV antibiotics within the
past 90 days. Thus, rather than empirically ordering
blood cultures on all patients with CAP, clinicians
should first try to risk stratify patients for the potential
for drug-resistant pathogens.3
Sputum Cultures
The diagnostic performance of sputum cultures is
variable. Gram staining and culture of sputum before
providing antibiotics may be positive in 80% of
cases of pneumococcal pneumonia.41 From a practi-
cal standpoint, sputum cultures are difficult to obtain
and rarely affect patient management. In a prospec-
tive analysis of 116 immunocompetent patients with
CAP, Ewig et al found that sputum cultures could
be obtained in only 36% of patients. Even when
obtained, 69% were not obtained until at least a
day after admission and the samples were “micro-
scopically valid” in only 50% of cases. In terms of
diagnostic yield, 50% of the cultures showed mixed
flora, and only 20% had an isolated positive Gram
stain. Culture results changed the treatment course
in only 1 patient who had failed to clinically respond
to initial antibiotic therapy.42
In the 2019 guidelines, the ATS/IDSA recom-
mended against obtaining sputum cultures in out-
patients. For inpatients, the authors acknowledge
the overall low quality of evidence but recommend
that sputum cultures be used in cases of severe CAP
and for patients in whom there is concern for MRSA
or P aeruginosa. Sputum cultures should also be
considered in patients who have been hospitalized
and given IV antibiotics during the previous 90 days.
The authors acknowledge that previously published
risk factors for MRSA and P aeruginosa largely show
weak associations and suggest that for patients with
these risk factors, negative sputum cultures may help
clinicians de-escalate therapy.3 In general, for the vast
majority of patients with CAP, there is little role for
routine sputum cultures.42
Viral Respiratory Panel
Recently, multiplex viral respiratory panels have
been developed that can help identify various viral
pathogens with rapid turnaround times. Some of
these multiplex panels are being marketed to and
APRIL 2023 • www.ebmedicine.net
are available in some urgent care centers. In terms
of accuracy, most commercially available tests can
reliably identify viral pathogens, most frequently RSV.
However, the clinical utility of these panels remains
unproven. In a randomized controlled trial comparing
a rapid multipathogen viral respiratory panel to
usual care, May et al found that the viral respiratory
panels identified a viral pathogen at the time of the
ED visit in 57% of cases, yet there was no statistically
significant difference in antibiotic use between the
2 groups.43 The widespread use of rapid testing for
influenza has been shown to reliably identify cases
of influenza and is endorsed by the ATS/IDSA;44
nonetheless, it has not been shown to have an impact
on patient-oriented outcomes. Of note, standard
care would now recommend molecular testing for
COVID-19 in all patients suspected of having CAP.
 Using Severity and Risk Scoring
Systems for Disposition
When evaluating a patient with pneumonia in the
urgent care setting, disposition is either outpatient
treatment or ED referral. Determining which patients
can be safely treated as outpatients and which should
be sent for further evaluation can be challenging.
Scoring systems have been developed to risk stratify
patients in terms of their disposition.
Pneumonia Severity Index
The pneumonia severity index (PSI) was developed
to help determine disposition in patients with CAP
from an ED setting. Outcomes include outpatient
treatment, hospital admission, and intensive care unit
(ICU) admission. This tool has been well accepted and
validated in the hospital setting.45,46 Unfortunately,
the PSI requires 20 data points, including venous and
arterial blood testing; this may not be practical in
urgent care or other outpatient settings, so use of the
PSI in these settings may be limited. (See Figure 1,
page 11.)
An online calculator for the pneumonia severity
index score is available at: www.mdcalc.com/psi-port-
score-pneumonia-severity-index-cap
CURB-65 Score
The CURB-65 score is also a clinically validated tool,
using a 5-point scoring system. This tool is less cum-
bersome and more appropriate for the outpatient
or urgent care setting. However, CURB-65 requires a
blood urea nitrogen (BUN) level, which may not be
available in all settings. Patients with scores of 0 or 1
are safe for discharge, patients with a score of 2 can
be observed or admitted, and patients with scores ≥3
should be admitted. Also, if the score is ≥3, patients
may require ICU admission. (See Table 1, page 11.)
10 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 An online calculator for the CURB-65 score is Table 1. CURB-65 Scoring46
available at: https://www.mdcalc.com/calc/324/curb-
65-score-pneumonia-severity Symptom Points

Confusion 1
CRB-65 Score Urea: BUN >19 mg/dL (>7 mmol/L) 1
The CRB-65 score was designed primarily for use by
Respiratory rate ≥30 breaths/min 1
clinicians in an outpatient setting to aid in determin-
ing outpatient versus ED disposition. It is identical to Systolic BP <90 mm Hg or diastolic BP ≤60 mm Hg 1

the CURB-65 score except that it does not require a Age ≥65 years 1
BUN measurement. (See Table 2, page 12.) CRB-65 Total ______
has been well validated in the primary care setting.
One study found no statistical difference in mortal- Score Risk Disposition
ity in outpatients using CRB-65 versus CURB-65.48
0 or 1 1.5% mortality Outpatient care
A recent meta-analysis of urgent under the receiver
operating characteristic curve of 0.74 (good discrimi- 2 9.2% mortality Inpatient versus observation admission
nation); a ratio of observed-to-expected mortality ≥3 22% mortality Inpatient admission; consider ICU
of 1.04 (good calibration); and likelihood ratios for admission with score of 4 or 5

mortality of 0.13, 1.3, and 5.6 for low-, moderate-, Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; ICU,
and high-risk groups, respectively. The meta-analysis intensive care unit.

Figure 1. Pneumonia Severity Index45

Step 1 Step 2: Assign patient to risk class II-V based on points

Is ≥1 of the following characteristics assigned
present? Finding Points
• Age >50 years
Age
• Neoplastic disease
• Congestive heart failure • Men Age (yr)
• Cerebrovascular disease • Women Age (yr)-10
• Renal disease YES
Nursing Home Resident 10
• Liver disease
• Altered mental status Coexisting Illness
• Pulse ≥125 beats/min • Neoplastic disease 30
• Respiratory rate ≥30 breaths/min
• Liver disease 20
• Systolic blood pressure <90 mm Hg
• Temperature <35°C or ≥40°C • Congestive heart failure 10
• Cerebrovascular disease 10
NO • Renal disease 10
Physical Examination Findings
• Altered mental status 20
Assign patient to risk class I
• Respiratory rate ≥30 breaths/min 20
• Systolic blood pressure <90 mm Hg 20
• Temperature <35°C or ≥40°C 15

Points assignment corresponds to the • Pulse ≥125 beats/min 10

following risk classes: ≤70 class II, 71-90 Laboratory and Radiographic Findings
class III, 91-130 class IV, >130 class V • Arterial pH <7.35 30
• BUN ≥30 mg/dL (11 mmol/L) 20
• Sodium <130 mmol/L 20

Score/Class Risk Disposition • Glucose ≥250 mg/dL (14 mmol/L) 10

≤70, class II Low Outpatient care • Hematocrit <30% 10

71-90, class III Low Outpatient versus observation admission PaO2 <60 mm Hg or oxygen saturation <90% 10
on pulse oximetry
91-130, class IV Moderate Inpatient admission
Pleural effusion 10
>130, class V High Inpatient admission
Total _________

Abbreviations: BUN, blood urea nitrogen; PaO2, partial pressure of oxygen, arterial.

APRIL 2023 • www.ebmedicine.net 11 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

was limited to 8 studies judged to be at low risk of
bias in which patients could be treated as outpatients
or inpatients.49 Thus, for otherwise healthy adults, the
CRB-65 is a better tool than the PSI or CURB-65 for
risk stratifying patients with pneumonia in the urgent
care setting.
It should be noted that the CRB-65 rule puts
all patients aged ≥65 years in the “moderate” risk
category, which suggests that all patients with CAP in
that age group should be considered for admission
to the hospital. There are other factors that clinicians
should consider when making disposition decisions,
as variables not included in decision tools may affect
outcomes. For examples, comorbidities such as HIV,
chronic obstructive pulmonary disease, diabetes mel-
litus, and chronic renal failure are not included in the
clinical decision tools. In addition, none of the tools
address previous failure of outpatient oral antibiotic
therapy or social factors such as a patient's inability to
obtain or reliably take medication.50 Clinical decision
rules cannot be used independently without consider-
ing these factors.
 Treatment
Antibiotic Selection
The overall quality of evidence evaluating ideal out-
patient antibiotic choice is poor. In 2014, a Cochrane
meta-analysis evaluated 11 trials including over 3000
patients and concluded, “there were not enough tri-
als to compare the effects of different antibiotics for
pneumonia acquired and treated in the community.”51
The authors of the 2019 ATS/IDSA CAP guidelines
took a broader look at the available data and reviewed
Table 2. CRB-65 Rule to Predict Mortality in Patients With Community-Acquired Pneumonia
Step 1: Calculate the score (range 0-4 points)
Sign or symptom
Confusion (new onset with this illness)
Respiratory rate ≥30 breaths per minute
Blood pressure <90 mm Hg systolic or ≤60 mm Hg diastolic
65 years or older
Total
Step 2: Apply the score to a patient with community-acquired pneumonia
Likelihood ratio for
Risk group (points) mortality Mortality rate (%)a
Low (0) 0.13 0.5
Moderate (1 or 2) 1.3 5.1
High (3 or 4) 5.6 18.9
a
Assuming an overall mortality rate of 4%.
Reprinted from Mark H. Ebell. Community-acquired pneumonia: determining safe treatment in the outpatient setting. American Family Physician.
2019;99(12). Used with permission of the American Academy of Family Physicians.
APRIL 2023 • www.ebmedicine.net
studies involving inpatients who were treated with
oral antibiotics, based on the theory that the majority
of inpatients typically suffer from similar pathogens.3
Due in part to the inclusion of this inpatient data, there
were some notable changes in the updated guidelines
in terms of first-line antibiotic choice.
Due to increasing rates of macrolide-resistant
pneumococcus, these agents are now recommended
only in areas where known resistance is <25%.
Worldwide incidence of macrolide resistance varies
widely, but recent studies in North America have
shown widespread resistance rates >30%, making
macrolides a poor choice for patients in the United
States and Canada.3
The 2019 ATS/IDSA recommendation for the use
of high-dose amoxicillin (1 g orally 3 times a day) as
a treatment for CAP in otherwise healthy outpatient
adults comes from a handful of inpatient studies that
showed similar outcomes when comparing amoxicillin
to various fluoroquinolones.3 One potential limitation
of amoxicillin is that it does not cover atypical patho-
gens sufficiently. Despite this limitation, the ATS/
IDSA authors based their recommendation on the
handful of studies showing the efficacy of amoxicil-
lin even with this likely lack of coverage for atypical
pathogens.3 Similarly, the overall quality of evidence
behind the use of doxycycline is limited to mostly
small studies of inpatients receiving IV formulations.52
The ATS/IDSA authors recognize this limited base of
evidence, yet still recommend the use of doxycycline
as a first-line agent based largely on its “broad spec-
trum of action.”3
Unfortunately, there are no studies evaluating the
effect of these new recommendations. In terms of
Points
1
1
1
1
______
Clinical recommendation
Outpatient treatment unless otherwise contraindicated
Hospitalize in most cases
Hospitalize, and consider intensive care unit
12 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
potential monotherapy per these recommendations,
we are left with using amoxicillin and undertreating
atypical pathogens, using a macrolide and risking
inadequate treatment of Streptococcus, or using
doxycycline, which has largely theoretical efficacy.
Without prospective data, it would be reasonable to
use a combination of amoxicillin and a macrolide to
ensure adequate coverage, leaving doxycycline as
the only potential monotherapy.
For healthy outpatient adults without risk factors
for drug-resistant organisms, the following treatment
regimens are recommended by the 2019 ATS/IDSA
guidelines3:
• Amoxicillin 1 g orally 3 times daily
OR
• Doxycycline 100 mg orally 2 times daily
OR
• A macrolide (only in areas with pneumococcal
resistance to macrolides <25%)
◦ Azithromycin 500 mg orally on the first day,
then 250 mg orally daily
◦ Clarithromycin 500 mg orally 2 times daily
or clarithromycin extended release 1000 mg
orally daily
For outpatients with comorbidities (chronic
heart, lung, liver, or renal disease; diabetes mellitus;
alcoholism; malignancy; or asplenia) either of the
following 2 regimens are recommended3:
1. Combination therapy
• Amoxicillin/clavulanate
◦ 500 mg/125 mg orally 3 times daily
◦ 875 mg/125 mg orally 2 times daily
◦ 2000 mg/125 mg orally 2 times daily
OR
• Cephalosporin
◦ Cefpodoxime 200 mg orally 2 times daily
◦ Cefuroxime 500 mg orally 2 times daily
PLUS
• Macrolide
◦ Azithromycin 500 mg orally on the first
day, then 250 mg orally daily
◦ Clarithromycin 500 mg orally 2 times
daily or extended release 1000 mg orally
once daily
2. Monotherapy
• Doxycycline 100 mg orally 2 times daily
OR
• Respiratory fluoroquinolone
◦ Levofloxacin 750 mg orally daily
◦ Moxifloxacin 400 mg orally daily
◦ Gemifloxacin 320 mg orally daily
Antibiotic Duration
There is limited evidence to identify an ideal duration
of antibiotic therapy, but recent studies have sug-
gested that abbreviated courses are both safe and ef-
fective. Dunbar et al found no difference in outcomes
APRIL 2023 • www.ebmedicine.net
when comparing 5 days of levofloxacin 750 mg daily
to a 10-day course of levofloxacin 500 mg daily.53 In
a meta-analysis, Tansarli et al found that patients who
took <6 days of antibiotics had fewer adverse events
and lower reported mortality when compared with
patients who took antibiotics for >7 days.54 Recent
guidelines recommend a minimum of 5 days of antibi-
otic therapy even if the patient is improving clinically.3
Because not all patients may respond to
treatment as expected, or have other complications,
it is recommended that the patient be re-assessed
on day 5 by either returning to urgent care or seeing
their primary care clinician. If there is improvement,
then antibiotics may be discontinued. If the patient
has not improved or is worsening, evaluation for other
possible diagnoses should be considered, including
empyema, lung abscess, pulmonary embolus,
congestive heart failure, or other concerns. A change
in antibiotic may be warranted if no complications are
found.
Antitussives
Treatment of cough in patients with pneumonia is
somewhat controversial, as many of the proposed
treatments are relatively ineffective and can have
side effects. Because cough is typically self-limited,
treatment aimed at the underlying pneumonia is suc-
cessful in the majority of cases. Specific treatments
for cough include centrally active antitussive agents
(opioid and nonopioid), peripherally acting antitussive
agents (eg, benzonatate), inhaled glucocorticoids,
and inhaled bronchodilators. Codeine has been used
extensively in the treatment of cough, often in combi-
nation with other agents, but it has not been found to
have a statistically significant effect on cough sup-
pression.55 Although morphine has proven somewhat
more effective, it is not recommended for routine
treatment of cough, given its side-effect profile and
its addictive properties. Benzonatate, a peripherally
acting antitussive, acts by anesthetizing stretch recep-
tors in the lungs, which decreases the drive to cough.
Its efficacy has not been proven, but it is often used
as an alternative to opioids. Studies on antitussive
agents, inhaled glucocorticoids, and inhaled broncho-
dilators have shown limited, if any, effect on cough
from pneumonia.56
Given the lack of efficacy of antitussives, patient
education and effective discharge instructions are
very important in the treatment of CAP. Patients
should be counseled that the majority of antitussive
treatments are often ineffective and that the cough
from pneumonia is usually self-limited and improves
with resolution of the infection. Patients should be ad-
vised to return to the ED if they are unable to control
their secretions or if their cough is causing shortness
of breath. If the patient is prescribed an opioid anti-
tussive, they should be counseled on the side effects
and risks, which include respiratory depression.
13 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 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 sec-
ondary infection in patients who are given short-term
doses of corticosteroids.58 In cases of severe CAP, the
available evidence supporting the use of corticoste-
roids 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
APRIL 2023 • www.ebmedicine.net
IDSA guideline on seasonal influenza, which similarly
advocated for the use of these medications.61
There are several potential issues with these rec-
ommendations. First, none of the studies cited spe-
cifically evaluated patients who have both pneumonia
and influenza. The authors asserted that, given the re-
ported 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 is-
sue with these recommendations involves the ongo-
ing debate regarding the efficacy and tolerability of
oseltamivir. While multiple large meta-analyses and
systematic reviews concluded that oseltamivir can
5 Things That Will
Change Your Practice
1. Consider use of 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.
2. 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
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.
4. Do not routinely prescribe corticosteroids ex-
cept 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 cor-
ticosteroid use must be balanced against the
benefits of use and should be determined on
a case-by-case basis.
5. Counsel patients that most antitussive treat-
ments are ineffective; the cough from pneu-
monia is usually self-limited and will improve
with resolution of the infection.
14 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 Case Conclusions
For the 30-year-old man with no significant medical history who presented with 2 days of fever,
cough productive of green sputum, and malaise…
CASE 1

You noted that the patient was otherwise well-appearing and did not have any risk factors for drug-resistant
organisms. His CRB-65 score was 0. You prescribed amoxicillin 1 g orally, 3 times a day for 5 days. The
patient returned to the clinic on day 5, had improved clinically, and was essentially asymptomatic. No
further treatment was recommended.

For the 82-year-old woman with a history of mild COPD who presented from an assisted-living
facility with 3 days of mild cough productive of yellow sputum…
Although she had a mild, productive cough, the patient was overall well appearing and had a CRB-65 score
CASE 2

of 1. Although this would point to hospitalization, you used your clinical judgement to determine that her
age may have falsely elevated her risk, and that outpatient treatment in this case could be reasonable.
You discussed with her the potential risks and benefits of inpatient versus outpatient treatment, and she
stated very clearly that she wanted to go back to the assisted-living facility. Given her history of COPD, you
prescribed amoxicillin/clavulanate 875/125 mg orally 2 times a daily and azithromycin 500 mg day 1 and 250
mg days 2 through 5. The patient returned to her assisted-living facility and had an uneventful recovery.

For the 55-year-old man with a history of diabetes and chronic kidney disease who presented with 3
days of nonproductive cough, fever, and lethargy…
You determined that this patient needed to be transferred to the ED immediately due to a likelihood of
CASE 3

sepsis. The patient had initial objections, but once you pointed out the need for immediate treatment and
the risk of serious complications, including death, he and his wife consented to EMS transfer to the nearest
ED. He was admitted to the ICU where he was diagnosed with COVID-19 pneumonia. His was treated with
supportive care, the latest COVID-19 therapy, and broad-spectrum antibiotics. The patient did well and was
discharged to a rehabilitation facility after 7 days in the hospital.

reduce symptoms and downstream complications,
most of these publications have significant methodo-
logic 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
does not cover atypical causes of CAP and is not suit-
able for patients with comorbidities or risk factors for
antibiotic-resistant pathogens. Coverage with either
amoxicillin/clavulanic acid or a cephalosporin AND a
macrolide OR doxycycline OR a respiratory fluoroqui-
nolone for a minimum of 5 days is recommended for
adults with comorbidities.

 Summary  Time- and Cost-Effective Strategies

CAP is a common pathology seen across a wide
range of patient populations. From a diagnostic
standpoint, recent innovations such as PCT and
rapid viral panel testing show some promise but are
not ready for widespread use. Tools such as the PSI,
CURB-65, and CRB-65 scores can be used to risk
stratify patients and allow for the outpatient treat-
ment of larger subsets of patients.
Macrolide monotherapy for CAP is no longer
recommended as a first-line outpatient agent in most
geographic areas, especially North America, due to
increasing rates of resistance. First-line outpatient
therapies for otherwise healthy adults include mono-
therapy with doxycycline or high-dose amoxicillin.
However, monotherapy with high-dose amoxicillin
• Other than testing for influenza and/or COVID-19
when clinically indicated, do not routinely order
viral testing panels. While viral panel testing
may help identify specific underlying pathogens,
these tests often carry a significant cost and
have not been shown to reliably improve patient
outcomes.
• Do not order routine follow-up imaging for
patients after completion of antibiotic therapy.
The latest ATS/IDSA guidelines recommend
against follow-up imaging unless there is a
suspicion for underlying malignancy, or the
patient has not improved.3

APRIL 2023 • www.ebmedicine.net 15 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

 Charting & Coding: What You Need to Know
•
Medical Decision Making
The criteria for at least 2 of the 3 categories of
the elements of medical decision must be met to
select the evaluation and management service
code for any patient encounter. For patients with
CAP, individual patient factors can be critical to
determining the correct level within each category.
Clinicians must carefully evaluate and consider all
relevant information to make an accurate diagno-
sis and develop an effective treatment plan for the
patient.
Problems Addressed Category
When a patient presents to urgent care with symp-
toms of CAP, the clinician’s understanding of the
distinctions between an “acute, uncomplicated
illness/injury” and an “acute illness with systemic
symptoms” are crucial for accurate selection of
an evaluation and management service code. By
comparing the following 2 case scenarios, we can
explore those distinctions:
Case 1: A 22-year-old man presents with
complaints of fatigue, frequent dry cough,
and body aches. He has no medical history
and does not smoke. His vital signs include
a temperature of 99.3°F, blood pressure of
129/76 mm Hg, heart rate of 87 beats/min,
respiratory rate of 14 breaths/min, and oxy-
gen saturation of 98%.
Case 2: A 77-year-old man presents with a
chief complaint of fatigue, dry cough, and
body aches. He has a past medical history of
congestive heart failure, obesity, and hyper-
tension, and he is a heavy smoker (1.5 packs
per day for 60 years). His vital signs include
a temperature of 101.4°F, blood pressure
of 156/98 mm Hg, heart rate of 118 beats/
min, respiratory rate of 18 breaths/min, and
oxygen saturation of 95%.
These 2 patients present with similar com-
plaints but exhibit different features. Case 1
involves a healthy young man with no comorbidi-
ties and normal vital signs, indicating an “acute,
uncomplicated illness,” which would meet the
criteria for Level 3 in the category of Problems
Addressed. Case 2 is more complex due to the
patient's comorbidities and abnormal vital signs.
The presence of a fever >100.4°F and a heart rate
APRIL 2023 • www.ebmedicine.net
of >90 beats/min meets the criteria for systemic
inflammatory response syndrome (SIRS). His co-
morbidities also put the Case 2 patient at a higher
risk for an unfavorable outcome; this presentation
fits the definition of “acute illness with systemic
symptoms” and meets the criteria for Level 4 in the
Problems Addressed category.
Complexity of Data Category
When a patient presents with symptoms such as
fever, cough, body aches, and fatigue, the clinician
may order point-of-care influenza and COVID-19
tests to determine if the patient has contracted
either (or both) of these viral illnesses. A point-of-
care complete blood count may also be performed
if there is concern for abnormalities. In addition, a
chest x-ray is typically ordered to detect the pres-
ence of pneumonia or other lung-related pathol-
ogy. Decisions about diagnostic testing will be
dependent on various factors such as the patient's
medical history, comorbidities, and the degree of
uncertainty involved in the diagnosis.
If 3 or more tests are ordered, the complexity is
Level 4. However, it is important to note that some
healthcare systems or facilities may bill for the tech-
nical or professional component of the radiographs
separately, as this is considered a separate service
from the medical decision making process.
Risk of Complications Category
The level of risk is determined by evaluating vari-
ous factors such as the severity of the patient's
illness, the potential for complications, and the
likelihood of adverse outcomes. When a patient is
diagnosed with CAP, antibiotics are typically pre-
scribed to address primary or secondary bacterial
infection. An antitussive may also be prescribed for
symptom relief. These treatments are not without
risk and may result in adverse effects such as drug
interactions, allergic reactions, or other complica-
tions. Clinicians must weigh the benefits and risks
of treatment options to determine the most appro-
priate course of action for each patient, taking into
consideration a patient’s medical history and any
underlying health conditions. Due to the moderate
level of risk involved in prescribing medications for
patients with pneumonia, most patient encounters
for CAP will meet the criteria for Level 4 in this
category.
16 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 Critical Appraisal of the Literature
A literature search was performed in PubMed using
the terms community-acquired pneumonia, pneumo-
nia, cough, and related terms. Given the extensive
body of literature concerning CAP, the search focused
on the presentation and management of CAP in
settings relevant to emergency practice, ambulatory
clinics, and urgent care. Forty systematic reviews from
the Cochrane Database of Systematic Reviews were
relevant. The focus was on studies that specifically
evaluated the risk stratification and management of
CAP with particular attention to patient-oriented out-
comes. In addition to the literature search, available
guidelines from the ATS, IDSA, American College of
Emergency Physicians, and American Academy of
Family Physicians were reviewed.
 References
Evidence-based medicine requires a critical appraisal
of the literature based upon study methodology
and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
randomized, and blinded trial should carry more
weight than a case report.
To help the reader judge the strength of each
reference, pertinent information about the study
is included in bold type following the reference,
where available. In addition, the most informative
references cited in this paper, as determined by
the authors, are noted by an asterisk (*) next to the
number of the reference.
1. Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis.
Virulence. 2014;5(1):4-11. (Review)
2. Kalil AC, Metersky ML, Klompas M, et al. Executive summary:
management of adults with hospital-acquired and ventilator-
associated pneumonia: 2016 Clinical Practice Guidelines by
the Infectious Diseases Society of America and the American
Thoracic Society. Clin Infect Dis. 2016;63(5):575-582.
(Guideline)
3*. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and
treatment of adults with community-acquired pneumonia. An
official clinical practice guideline of the American Thoracic
Society and Infectious Diseases Society of America. Am J
Respir Crit Care Med. 2019;200(7):e45-e67. (Guideline)
DOI: 10.1164/rccm.201908-1581ST
4. Guidelines for the management of adults with hospital-
acquired, ventilator-associated, and healthcare-associated
pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.
(Guideline)
5. Roch A, Thomas G, Hraiech S, et al. Hospital-acquired,
healthcare-associated and ventilator-associated pneumonia.
In: Cohen J, Powderly WG, Opal SM, eds. Infectious Diseases.
4th ed: Elsevier; 2016:258-262. (Textbook)
6. Seymann GB, Di Francesco L, Sharpe B, et al. The HCAP
gap: differences between self-reported practice patterns and
published guidelines for health care-associated pneumonia.
Clin Infect Dis. 2009;49(12):1868-1874. (Survey; 855
participants)
7.* Metlay JP, Waterer GW. Treatment of community-acquired
pneumonia during the coronavirus disease 2019 (COVID-19)
APRIL 2023 • www.ebmedicine.net
pandemic. Ann Intern Med. 2020;173(4):304-305. (Guideline)
DOI: 10.7326/M20-2189
8. Weinstock MB, Echenique A, Russell JW, et al. Chest x-ray
findings in 636 ambulatory patients with COVID-19 presenting
to an urgent care center: a normal chest x-ray is no guarantee.
Journal of Urgent Care Medicine. 2020;14(7):13-18.
(Retrospective review; 636 patients)
9. Du Y, Tu L, Zhu P, et al. Clinical features of 85 fatal cases of
COVID-19 from Wuhan. A retrospective observational study.
Am J Respir Crit Care Med. 2020;201(11):1372-1379. (Case
series; 85 patients)
10. Nori P, Cowman K, Chen V, et al. Bacterial and fungal
coinfections in COVID-19 patients hospitalized during
the New York City pandemic surge. Infect Control Hosp
Epidemiol. 2021;42(1):84-88. (Retrospective review; 4627
patients)
11. Xu J, Murphy SL, Kochanek KD, et al. Deaths: final data for
2019. Natl Vital Stat Rep. 2021;70(8):1-87. (Summary of
statistical data)
12. Ramirez JA, Wiemken TL, Peyrani P, et al. Adults
hospitalized with pneumonia in the United States:
incidence, epidemiology, and mortality. Clin Infect Dis.
2017;65(11):1806-1812. (Prospective population-based
cohort study; 7449 patients)
13.* Jain S, Self WH, Wunderink RG, et al. Community-acquired
peumonia requiring hopitalization among U.S. adults. N Engl
J Med. 2015;373(5):415-427. (Prospective; 2400 patients)
DOI: 10.1056/NEJMoa1405870
14. Moberley SA, Holden J, Tatham DP, et al. Vaccines for
preventing pneumococcal infection in adults. Cochrane
Database Syst Rev. 2008(1):CD000422. (Systematic review)
15. de Roux A, Marcos MA, Garcia E, et al. Viral community-
acquired pneumonia in nonimmunocompromised adults.
Chest. 2004;125(4):1343-1351. (Prospective; 338 patients)
16. Chalmers JD, Rother C, Salih W, et al. Healthcare-associated
pneumonia does not accurately identify potentially resistant
pathogens: a systematic review and meta-analysis. Clin Infect
Dis. 2014;58(3):330-339. (Review)
17. Musher DM, Roig IL, Cazares G, et al. Can an etiologic agent
be identified in adults who are hospitalized for community-
acquired pneumonia: results of a one-year study. J Infect.
2013;67(1):11-18. (Retrospective; 259 patients)
18. Alcón A, Fàbregas N, Torres A. Pathophysiology of
pneumonia. Clin Chest Med. 2005;26(1):39-46. (Review)
19. Mizgerd JP. Acute lower respiratory tract infection. N Engl J
Med. 2008;358(7):716-727. (Review)
20. Almirall J, Bolíbar I, Balanzó X, et al. Risk factors for
community-acquired pneumonia in adults: a population-based
case-control study. Eur Respir J. 1999;13(2):349-355. (Case
control study; 280 patients)
21. Gulmez SE, Holm A, Frederiksen H, et al. Use of proton pump
inhibitors and the risk of community-acquired pneumonia:
a population-based case-control study. Arch Intern Med.
2007;167(9):950-955. (Case-control study; 49,460 patients)
22. Xun X, Yin Q, Fu Y, et al. Proton pump inhibitors and the
risk of community-acquired pneumonia: an updated meta-
analysis. Ann Pharmacother. 2022;56(5):524-532. (Meta-
analysis; 13 studies. 2,098,804 patients)
23.* Moore M, Stuart B, Little P, et al. Predictors of pneumonia
in lower respiratory tract infections: 3C prospective cough
complication cohort study. Eur Respir J. 2017;50(5).
(Prospective; 28,883 patients)
DOI: 10.1183/13993003.00434-2017
24. Gennis P, Gallagher J, Falvo C, et al. Clinical criteria for the
detection of pneumonia in adults: guidelines for ordering
chest roentgenograms in the emergency department. J Emerg
Med. 1989;7(3):263-268. (Retrospective; 308 patients)
17 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
25. Spiteri MA, Cook DG, Clarke SW. Reliability of eliciting
physical signs in examination of the chest. Lancet.
1988;1(8590):873-875. (Prospective; 24 physicians)
26. Muder RR, Brennen C, Swenson DL, et al. Pneumonia in a
long-term care facility. A prospective study of outcome. Arch
Intern Med. 1996;156(20):2365-2370. (Prospective; 108
patients)
27. Metlay JP, Kapoor WN, Fine MJ. Does this patient have
Risk Management Pitfalls for Community-Acquired
Pneumonia in Urgent Care
1. “I thought the tachycardia and hypoxemia
were due to the 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 nega-
tive 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
APRIL 2023 • www.ebmedicine.net
community-acquired pneumonia? Diagnosing pneumonia by
history and physical examination. JAMA. 1997;278(17):1440-
1445. (Review)
28. Self WH, Courtney DM, McNaughton CD, et al. High
discordance of chest x-ray and computed tomography for
detection of pulmonary opacities in ED patients: implications
for diagnosing pneumonia. Am J Emerg Med. 2013;31(2):401-
405. (Prospective; 3423 patients)
5. “Would you send a 70-year-old patient home
with pneumonia?” Scoring systems that incorpo-
rate 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/dissec-
tion. 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
18 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
29. Wunderink RG, Waterer GW. Clinical practice. Community-
acquired pneumonia. N Engl J Med. 2014;370(6):543-551.
(Review)
30. Wheeler JH, Fishman EK. Computed tomography in the
management of chest infections: current status. Clin Infect Dis.
1996;23(2):232-240. (Review)
31. Hayden GE, Wrenn KW. Chest radiograph vs. computed
tomography scan in the evaluation for pneumonia. J Emerg
Med. 2009;36(3):266-270. (Retrospective; 1057 patients)
32. Hicks J. Point of care ultrasound (POCUS) in urgent care. The
Journal of Urgent Care Medicine. Accessed March 10, 2023.
Available at: https://www.jucm.com/point-of-care-ultrasound-
pocus-in-urgent-care/ (Online review article)
33. Bourcier JE, Paquet J, Seinger M, et al. Performance
comparison of lung ultrasound and chest x-ray for the
diagnosis of pneumonia in the ED. Am J Emerg Med.
2014;32(2):115-118. (Prospective; 144 patients)
34. Chavez MA, Shams N, Ellington LE, et al. Lung ultrasound for
the diagnosis of pneumonia in adults: a systematic review and
meta-analysis. Respir Res. 2014;15(1):50. (Systematic review;
1172 patients)
35. Shaddock EJ. How and when to use common biomarkers
in community-acquired pneumonia. Pneumonia (Nathan).
2016;8:17. (Review)
36. Müller B, Harbarth S, Stolz D, et al. Diagnostic and
prognostic accuracy of clinical and laboratory parameters in
community-acquired pneumonia. BMC Infect Dis. 2007;7:10.
(Prospective; 545 patients)
37. Foshaug M, Vandbakk-Rüther M, Skaare D, et al. Mycoplasma
pneumoniae detection causes excess antibiotic use in
Norwegian general practice: a retrospective case-control
study. Br J Gen Pract. 2015;65(631):e82-88. (Retrospective
case control; 414 patients)
38. Falguera M, Ruiz-González A, Schoenenberger JA, et
al. Prospective, randomised study to compare empirical
treatment versus targeted treatment on the basis of the urine
antigen results in hospitalised patients with community-
acquired pneumonia. Thorax. 2010;65(2):101-106.
(Prospective randomized; 194 patients)
39. Kennedy M, Bates DW, Wright SB, et al. Do emergency
department blood cultures change practice in patients
with pneumonia? Ann Emerg Med. 2005;46(5):393-400.
(Prospective; 3926 patients)
40. Benenson RS, Kepner AM, Pyle DN, 2nd, et al. Selective
use of blood cultures in emergency department pneumonia
patients. J Emerg Med. 2007;33(1):1-8. (Retrospective; 684
patients)
41. Musher DM, Montoya R, Wanahita A. Diagnostic value
of microscopic examination of Gram-stained sputum and
sputum cultures in patients with bacteremic pneumococcal
pneumonia. Clin Infect Dis. 2004;39(2):165-169.
(Retrospective; 105 patients)
42. Ewig S, Schlochtermeier M, Göke N, et al. Applying sputum
as a diagnostic tool in pneumonia: limited yield, minimal
impact on treatment decisions. Chest. 2002;121(5):1486-1492.
(Prospective; 116 patients)
43. May L, Tatro G, Poltavskiy E, et al. Rapid multiplex testing for
upper respiratory pathogens in the emergency department:
a randomized controlled trial. Open Forum Infect Dis.
2019;6(12):ofz481. (Prospective randomized controlled trial;
191 patients)
44. Uyeki TM, Bernstein HH, Bradley JS, et al. Clinical practice
guidelines by the Infectious Diseases Society of America:
2018 update on diagnosis, treatment, chemoprophylaxis, and
institutional outbreak management of seasonal influenza. Clin
Infect Dis. 2019;68(6):e1-e47. (Guideline)
45. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule
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to identify low-risk patients with community-acquired
pneumonia. N Engl J Med. 1997;336(4):243-250.
(Retrospective; 14,199 patients)
46. Aujesky D, Fine MJ. The pneumonia severity index: a decade
after the initial derivation and validation. Clin Infect Dis.
2008;47 Suppl 3:S133-139. (Review)
47. Lim WS, van der Eerden MM, Laing R, et al. Defining
community acquired pneumonia severity on presentation
to hospital: an international derivation and validation study.
Thorax. 2003;58(5):377-382. (Review; 1068 patients)
48.* Bauer TT, Ewig S, Marre R, et al. CRB-65 predicts death
from community-acquired pneumonia. J Intern Med.
2006;260(1):93-101. (Multicenter prospective study; 1343
patients)
DOI: 10.1111/j.1365-2796.2006.01657.x
49.* Ebell MH, Walsh ME, Fahey T, et al. Meta-analysis
of calibration, discrimination, and stratum-specific
likelihood ratios for the CRB-65 score. J Gen Intern Med.
2019;34(7):1304-1313. (Meta-analysis; 29 studies) DOI:
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safe treatment in the outpatient setting. Am Fam Physician.
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community-acquired pneumonia in adult outpatients.
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 institutional outbreak management of seasonal influenzaa.
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Acknowledgments
Portions of this content were previously published
in: DeLaney M, Khoury C. Community-acquired
pneumonia in the emergency department. Emerg
Med Pract. 2021;23(2):1-24. Used with permission of
EB Medicine.

APRIL 2023 • www.ebmedicine.net 20 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

 CME Questions
Current Evidence-Based Urgent Care
subscribers receive CME credit absolutely
free by completing the following test. Each
issue includes 4 AMA PRA Category 1
CreditsTM. To receive CME credits for this issue, scan
the QR code below or visit https://www.ebmedicine.
net/UC0423
1. The most commonly identified bacterial cause
of CAP in the United States is:
a. Staphylococcus aureus
b. Streptococcus pneumoniae
c. Pseudomonas aeruginosa
d. Haemophilus influenzae
2. Which of the following statements regarding
mycoplasma pneumonia is CORRECT?
a. Mycoplasma pneumoniae is a rare cause of
CAP.
b. Cases of mycoplasma pneumonia typically
occur during summer months.
c. IgM and IgG antibody titers are helpful in
making a definitive diagnosis of mycoplasma
pneumonia.
d. Mycoplasma pneumonia typically has a
benign disease course and rarely results in
hospitalization or significant morbidity.
5. Which tool can be used to identify patients
who can be safely treated on an outpatient
basis?
a. PSI
b. CRB-65
c. CURB-65
d. All of the above
6. In an otherwise healthy adult man with CAP,
no comorbidities, and without risk factors
for drug-resistant organisms, which antibiotic
regimen would be the most appropriate initial
treatment, according to the 2019 ATS/IDSA
guidelines?
a. Amoxicillin 1 g 3 times a day for 5 days
b. Amoxicillin/clavulanate 875 mg/125 mg 2
times a day for 10 days
c. Levofloxacin 750 mg 1 time a day for 7 days
d. Azithromycin 500 mg on the first day, and
then 250 mg 1 time a day
7. Corticosteroids should be used routinely in
which of the following cases?
a. Outpatient CAP in an otherwise healthy adult
b. Outpatient CAP in a nursing home patient
with diabetes mellitus
c. Outpatient CAP in a patient who has
COVID-19 and suspected bacterial
pneumonia
d. None of the above

3. Blood cultures should be obtained in which of

the following patients?
a. 22-year-old woman with diabetes being
treated as an outpatient for CAP
b. 80-year-old woman who is in an assisted
living facility with CAP
c. 40-year-old man who has received IV
antibiotics within the past 90 days with CAP
d. 60-year-old man being admitted for non-
severe CAP

4. The 2019 ATS/IDSA guidelines support routine

testing for which viral pathogen in patients
with possible CAP?
a. Influenza
b. Rhinovirus
c. Adenovirus
d. Respiratory syncytial virus

APRIL 2023 • www.ebmedicine.net 21 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

Evidence-Based Urgent Care Editorial Board
EDITOR-IN-CHIEF
Keith Pochick, MD
Attending Physician, Urgent
Care, Charlotte, NC
EDITORIAL BOARD
Margaret Carman, DNP, RN,
ACNP-BC, ENP-BC, FAEN
Associate Professor, University
of North Carolina at Chapel
Hill School of Nursing, Chapel
Hill, NC; Emergency/Acute
Care Nurse Practitioner,
Martha's Vineyard Hospital,
Oak Bluffs, MA
Chrysa Charno, PA-C, MBA,
FCUCM
Chief Executive Officer
and Clinical Director, Acute
Kids Pediatric Urgent Care,
Rochester, NY
Tracey Quail Davidoff, MD,
FCUCM
Attending Physician, BayCare
Urgent Care, Tampa, FL
Mindy Johnson, DNP, FNP-
BC, AGACNP-BC, ENP-C
Assistant Professor of Nursing,
Vanderbilt University School of
Nursing, Nashville, TN
Emily Montgomery, MD,
MHPE, FAAP
Director of Education, Division
of Urgent Care, Children's
Mercy Kansas City, Kansas
City, MO; Assistant Dean of
Career Services, Associate
Professor of Pediatrics,
University of Missouri-Kansas
City School of Medicine,
Kansas City, MO; Clinical
Assistant Professor of
Pediatrics, University of Kansas
School of Medicine, Kansas
City, KS
Cesar Mora Jaramillo, MD,
FAAFP, FCUCM
Associate Medical Director,
Express at Providence
Community Health Centers;
Clinical Assistant Professor,
Department of Family
Medicine, Warren Alpert
Medical School, Brown
University, Providence, RI
Patrick O'Malley, MD
Attending Physician,
Emergency Department,
Newberry County Memorial
Hospital, Newberry, SC
Claude E. Shackelford, MD Joseph Toscano, MD
Assistant Professor of Urgent Care Physician, John
Clinical Medicine, Vanderbilt Muir Urgent Care, Walnut
University Medical Center; Creek, CA; Emergency
Assistant Medical Director, Physician, San Ramon
Walk-In Clinics, Vanderbilt Regional Medical Center, San
University Medical Center, Ramon, CA
Nashville, TN
James B. Short, Jr., MD,
FAAFP, FCUCM
Director, Piedmont Urgent
Care, Atlanta, GA
Benjamin Silverberg, MD,
MSc, FAAFP, FCUCM
Associate Professor,
Department of Emergency
Medicine; Medical Director,
Division of Physician Assistant
Studies, Department of
Human Performance,
West Virginia University,
Morgantown, WV

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