Community-acquired pneumonia develops in people with limited or no contact with medical

institutions or settings. The most commonly identified pathogens are

Streptococcus pneumoniae, Haemophilus influenzae, atypical bacteria (ie,
Chlamydiapneumoniae, Mycoplasma pneumoniae, Legionella sp), and viruses.
Assessment of severity
Illness severity in CAP is used as an indicator of prognosis and to guide management. Many
different severity assessments are available. Currently, the British Thoracic Society (BTS)
recommends the CURB-65 score in conjunction with clinical judgement (Fig 1).2 CURB-65
stratifies patients based on the presence of confusion, urea above 7 mmol/l, respiratory rate over
30/min, blood pressure (BP) below 60/90 mmHg and age above 65 years. Mortality at 30 days
increases with the number of criteria met.
Patients scoring 01 (low severity) have a mortality below 3% and can be treated in the
community. Patients scoring 2 (moderate severity) have a mortality of 9% and require close
observation, possibly with a short hospital admission. Patients scoring 3 or more (high severity)
have a mortality of 1540% and require urgent hospital admission, possibly with high
dependency care.
CURB-65 uses five prognostic variables [11]:
Confusion (based upon a specific mental test or disorientation to person, place, or time)
Urea (blood urea nitrogen in the United States) >7 mmol/L (20 mg/dL)
Respiratory rate 30 breaths/minute
Blood pressure (BP) (systolic <90 mmHg or diastolic 60 mmHg)
Age 65 years

Diagnosis
PHYSICAL EXAMINATION
Physical examination may reveal dullness to percussion of the chest, crackles or rales on
auscultation, bronchial breath sounds, tactile fremitus, and egophony (E to A changes). The
patient also may be tachypneic. A prospective study7 showed that patients with typical

pneumonia were more likely than not to present with dyspnea and bronchial breath sounds on
auscultation.
Diagnosis

Chest x-ray

Consideration of alternative diagnoses (eg, heart failure, pulmonary embolism)

Sometimes identification of pathogen

Symptoms and Signs

Symptoms include malaise, chills, rigor, fever, cough, dyspnea, and chest pain. Cough typically
is productive in older children and adults and dry in infants, young children, and the elderly.
Dyspnea usually is mild and exertional and is rarely present at rest. Chest pain is pleuritic and is
adjacent to the infected area. Pneumonia may manifest as upper abdominal pain when lower lobe
infection irritates the diaphragm. GI symptoms (nausea, vomiting, diarrhea) are also common.
Symptoms become variable at the extremes of age. Infection in infants may manifest as
nonspecific irritability and restlessness; in the elderly, as confusion and obtundation.
Signs include fever, tachypnea, tachycardia, crackles, bronchial breath sounds, egophony (E to A
changesaid to occur when, during auscultation, a patient says the letter E and the examiner
hears the letter A), and dullness to percussion. Signs of pleural effusion may also be present
(see Pleural Effusion : Symptoms and Signs). Nasal flaring, use of accessory muscles, and
cyanosis are common among infants. Fever is frequently absent in the elderly.

Cough that brings up bloody or rust-colored mucus.

Breathing (respiratory) symptoms that get worse.

Chest pain that gets worse when you cough or breathe in.

Fast or painful breathing.

Night sweats or unexplained weight loss.

Shortness of breath, shaking chills, or persistent fevers.

Causes
Over 100 microorganisms can cause CAP, with most cases caused by Streptococcus pneumoniae.
Certain groups of people are more susceptible to CAP-causing pathogens; for example, infants,
adults with chronic conditions (such as chronic obstructive pulmonary disease), senior
citizens, alcoholics and others with compromised immune systems are more likely to develop
CAP from Haemophilus influenzae or Pneumocystis carinii.[5] A definitive cause is identified in
only half the cases.

Management
A number of international guidelines for the management of CAP are available but their
magnitude makes them difficult to implement and there is evidence of marked variation in
clinical practice.11,12
The care bundle approach
Care bundles act as an aide-memoire for essential clinical interventions. The aim is to complete
the entire bundle as a single intervention, rather than undertaking individual components. Bundle
compliance supports improved patient outcomes and efficient use of resources.13 CAP care
bundles are typically based around BTS guidance2 and include:

oxygen assessment and appropriate treatment

severity assessment based on CURB-65, with treatment according to severity

antibiotic dosing within four hours of presentation

patient information leaflets.

Treatment
Initial treatment of CAP is based on physical examination findings, laboratory results, and
patient characteristics (e.g., age, chronic illnesses, history of smoking, history of the illness).15
Physicians should begin their treatment decisions by assessing the need for hospitalization using
a prediction tool for increased mortality, such as the Pneumonia Severity Index (Table 315),
combined with clinical judgment.9

Treatment

Risk stratification for determination of site of care

Antibiotics

Antivirals for influenza or varicella

Supportive measures

Prevention
Some forms of community-acquired pneumonia are preventable with vaccination. Pneumococcal
conjugate vaccine (PCV13) is recommended for children age 2 mo to 2 yr and for adults 19 yr
with certain comorbid (including immunocompromising) conditions. Pneumococcal
polysaccharide vaccine (PPSV23) is given to all adults 65 yr and to any patient 2 yr who has
risk factors for pneumococcal infections,