Key Points
ÎCommunity-acquired pneumonia (CAP) is an acute infection of the pulmonary parenchyma associated with a constellation of suggestive features and accompanied by the presence of an acute infiltrate demonstrable on chest radiograph—with or without supporting microbiological data—in a patient not hospitalized or residing in a long-term care facility.
> Clinical features include cough, fever, sputum production and pleuritic chest pain
ÎInitial site of treatment—outpatient, or inpatient in a ward or intensive care unit (ICU)—is one of the most important clinical decisions in managing patients with CAP, often determining:
> Selection and route of administering antimicrobial agents > Intensity of medical observation, and > Use of medical resources
ÎSignificant variation in admission rates among hospitals and among individual physicians is well documented. Physicians often overestimate severity and hospitalize a significant number of patients at low risk for death.
ÎThe decision to admit the patient is the most costly issue in the management of CAP, because the cost of inpatient care for pneumonia is up to 25 times greater than that of outpatient care and consumes the majority of the estimated $8.4-$10 billion spent yearly on treatment.
ÎOther reasons for avoiding unnecessary admissions are that patients at low risk for death who are treated in the outpatient setting are able to resume normal activity sooner than those who are hospitalized, and 80% are reported to prefer outpatient therapy.
ÎHospitalization also increases the risk of thromboembolic events and superinfection by more-virulent or resistant hospital bacteria.
ÎAlmost all major decisions in the management of CAP depend on initial assessment of severity.
ÎPrognostic models such as the Pneumonia PORT Severity Index (PSI) (see Table 1A) or the severity of illness scores CURB-65 (confusion, urea nitrogen, respiratory rate, low blood pressure, age ≥ 65 years) (see Table 1)
can be used to help determine the site of care.
ÎSuch scores should be supplemented by physician determination of subjective factors, including:
> Ability to safely and reliably take oral medication > Availability of outpatient support resources
