Written by Clay Smith
Spoon Feed
ACEP has released a new clinical policy statement for the care of community-acquired pneumonia (CAP) in the ED.
Why does this matter?
This policy statement updates the last one, which was in 2009. It answers three critical questions for the ED management of CAP.
CAP:RAP
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“In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition?”
– Level B: PSI and CURB-65 are recommended, but PSI is favored and also recommended by the IDSA/ATS 2019 CAP guidelines.
– Level C: In patients not on the ventilator and not on vasopressors, ≥3 of the 2007 IDSA/ATS minor criteria* may help determine which patients would benefit from a stay in the ICU vs regular hospital bed. You could also use SCAP or SMART-COP.
– Level C: Biomarkers don’t augment these clinical decision tools. Also, clinical judgment always wins over decision rules. -
“In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy?”
– Level C: Don’t rely on biomarkers like procalcitonin or CRP to determine viral from bacterial pneumonia in ED patients with CAP. -
“In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes?”
– Level C: There really is no good evidence. Make decisions based on risk profile and your preference – says the statement.
*2007 IDSA/ATS Criteria for Defining Severe Community-Acquired Pneumonia
Minor Criteria
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Respiratory rate ≥ 30 breaths/min
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PaO2/FiO2 ratio ≤ 250
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Multilobar infiltrates
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Confusion/disorientation
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Uremia (blood urea nitrogen level ≥ 20 mg/dl)
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Leukopenia (not from chemotherapy) (WBC < 4,000 cells/μl)
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Thrombocytopenia (platelet count < 100,000/μl)
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Hypothermia (core temperature < 36°C)
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Hypotension requiring aggressive fluid resuscitation
Major Criteria
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Septic shock with need for vasopressors
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Respiratory failure requiring mechanical ventilation
Source
Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. doi: 10.1016/j.annemergmed.2020.10.024.
