5
Treatment
5. Procalcitonin
➤ We recommend that empiric antibiotic therapy should be initiated
in adults with clinically suspected and radiographically confirmed
CAP regardless of initial serum procalcitonin level (strong
recommendation, moderate quality of evidence).
6. Inpatient Versus Outpatient
➤ In addition to clinical judgment, we recommend that
clinicians use a validated clinical prediction rule for
prognosis, preferentially the Pneumonia Severity Index (PSI
[www.guidelinecentral.com/calculators/psi-port]) (strong
recommendation, moderate quality of evidence) over the CURB-
65 (tool based on confusion, urea level, respiratory rate, blood
pressure, and age ≥65) (conditional recommendation, low quality
of evidence), to determine the need for hospitalization in adults
diagnosed with CAP.
7. Treatment Intensity
➤ We recommend direct admission to an ICU for patients with
hypotension requiring vasopressors or respiratory failure
requiring mechanical ventilation (strong recommendation, low
quality of evidence).
➤ For patients not requiring vasopressors or mechanical ventilator
support, we suggest using the IDSA/ATS 2007 minor severity
criteria (see Table 1) together with clinical judgment to guide
the need for higher levels of treatment intensity (conditional
recommendation, low quality of evidence).
8. Empiric Antibiotics – Outpatient
➤ For healthy outpatient adults without comorbidities listed below
or risk factors for antibiotic resistant pathogens (see Table 2),
we recommend:
• Amoxicillin 1 g three times daily (strong recommendation, moderate quality of
evidence), or
• Doxycycline 100 mg twice daily (conditional recommendation, low quality of
evidence), or
• A macrolide (azithromycin 500 mg on first day then 250 mg daily or
clarithromycin 500 mg twice daily or clarithromycin extended release
1,000 mg daily) only in areas with pneumococcal resistance to macrolides
<25% (conditional recommendation, moderate quality of evidence).
