This is the current release of the guideline.

This guideline updates a previous version: American College of Emergency Physicians (ACEP). Clinical policy for the management and risk stratification of community-acquired pneumonia in adults in the emergency department. Ann Emerg Med 2001 Jul;38(1):107-13. [38 references]

Community-acquired pneumonia (CAP)

Patients 18 years of age or older with signs and symptoms of community-acquired pneumonia (CAP) and radiographic evidence of pneumonia

Note: These guideline is not intended for patients who are pregnant, or immunocompromised (including patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), organ transplant, or recipients of corticosteroids, antineoplastic therapy, or other immunosuppressive agents), or have been hospitalized within the last 30 days.

Diagnosis/Evaluation

Obtaining blood cultures in higher-risk patients (e.g., patients with severe pneumonia, those immunocompromised, or with other significant comorbidities)

Note: Routine blood cultures are not recommended.

Treatment

Administration of antibiotic therapy as soon as feasible once the diagnosis of community-acquired pneumonia (CAP) is established

Multiple searches of MEDLINE, MEDLINE In-Process, and the Cochrane database were performed. Specific key words/phrases used in the searches are identified under each critical question. All searches were limited to English-language sources, human studies, and adults. Additional articles were reviewed from the bibliography of articles cited and from published textbooks and review articles. Subcommittee members supplied articles from their own files, and more recent articles identified during the process were also included.

See the original guideline document for words/phrases for literature searches associated with each clinical question reproduced in the "Guideline Objectives" field.

Not stated

Strength of Evidence

Literature Classification Schema^

^Some designs (e.g., surveys) will not fit this schema and should be assessed individually.

*Objective is to measure therapeutic efficacy comparing ≥2 interventions.

**Objective is to determine the sensitivity and specificity of diagnostic tests.

***Objective is to predict outcome including mortality and morbidity.

Approach to Downgrading Strength of Evidence*

*See "Description of Methods Used to Analyze the Evidence" field for more information.

This clinical policy was created after careful review and critical analysis of the medical literature.

All articles used in the formulation of this clinical policy were graded by at least 2 subcommittee members for strength of evidence and classified by the subcommittee members into 3 classes of evidence on the basis of the design of the study, with design 1 representing the strongest evidence and design 3 representing the weakest evidence for therapeutic, diagnostic, and prognostic clinical reports, respectively (see the "Rating Scheme for the Strength of Evidence" field). Articles were then graded on 6 dimensions thought to be most relevant to the development of a clinical guideline: blinded versus nonblinded outcome assessment, blinded or randomized allocation, direct or indirect outcome measures (reliability and validity), biases (e.g., selection, detection, transfer), external validity (i.e., generalizability), and sufficient sample size. Articles received a final grade (Class I, II, III) on the basis of a predetermined formula, taking into account design and quality of study (see the "Rating Scheme for the Strength of Evidence" field). Articles with fatal flaws were given an "X" grade and not used in formulating recommendations in this policy. Evidence grading was done with respect to the specific data being extracted and the specific critical question being reviewed. Thus, the level of evidence for any one study may vary according to the question, and it is possible for a single article to receive different levels of grading as different critical questions are answered. Question-specific level of evidence grading may be found in the Evidentiary Table included at the end of original guideline document.

This policy is a product of the American College of Emergency Physicians (ACEP) clinical policy development process, including expert review, and is based on the existing literature; when literature was not available, consensus of emergency physicians was used.

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence Class I" or overwhelming evidence from "strength of evidence Class II" studies that directly address all the issues).

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on "strength of evidence Class II" studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of "strength of evidence Class III" studies).

Level C recommendations. Other strategies for patient management based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus.

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Expert review comments were received from individual emergency physicians and from individual members of the American College of Chest Physicians, the American College of Physicians, the Infectious Diseases Society of America, the Institute for Clinical Systems Improvement, the Society for Academic Emergency Medicine, and American College of Emergency Physicians' (ACEP’s) Section on Critical Care Medicine. Their responses were used to further refine and enhance this policy.

The American College of Emergency Physicians Board of Directors approved this guideline on June 23, 2009.

Supported by the Emergency Nurses Association, July 21, 2009.

Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are repeated at the end of the Major Recommendations.

1. Are routine blood cultures indicated in patients admitted with community-acquired pneumonia (CAP)?

   Patient Management Recommendations

   Level A recommendations. None specified.

   Level B recommendations. Do not routinely obtain blood cultures in patients admitted with CAP.

   Level C recommendations. Consider obtaining blood cultures in higher-risk patients admitted with CAP (e.g., severe disease, immunocompromise, significant comorbidities, or other risk factors for infection with resistant organisms).

2. In adult patients with CAP without severe sepsis, is there a benefit in mortality or morbidity from the administration of antibiotics within a specific time course?

   Patient Management Recommendations

   Level A recommendations. None specified.

   Level B recommendations. There is insufficient evidence to establish a benefit in mortality or morbidity from antibiotics administered in less than 4, 6, or 8 hours from emergency department (ED) arrival.

   Level C recommendations. Administer antibiotics as soon as feasible once the diagnosis of CAP is established; there is insufficient evidence to establish a benefit in morbidity or mortality from antibiotics administered within any specific time course.

Definitions:

Strength of Evidence

Literature Classification Schema^

^Some designs (e.g., surveys) will not fit this schema and should be assessed individually.

*Objective is to measure therapeutic efficacy comparing ≥2 interventions.

**Objective is to determine the sensitivity and specificity of diagnostic tests.

***Objective is to predict outcome including mortality and morbidity.

Approach to Downgrading Strength of Evidence*

*See "Description of Methods Used to Analyze the Evidence" field for more information.

Grades of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence Class I" or overwhelming evidence from "strength of evidence Class II" studies that directly address all the issues).

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on "strength of evidence Class II" studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of "strength of evidence Class III" studies).

Level C recommendations. Other strategies for patient management based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus.

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Blood culture results may be misleading and may cause unintended consequences. False-positive or contaminated specimens are common, and in some studies, rates of false-positive blood cultures approach those of true-positive. Treatment based on preliminary false-positive blood culture results may lead to unnecessary antibiotic coverage and increased length of stay, pending final identification of the organism.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

American College of Emergency Physicians

American College of Emergency Physicians (ACEP) Clinical Policies Subcommittee on Community-acquired Pneumonia

ACEP Clinical Policies Committee

Members of the Clinical Policies Subcommittee on Community-acquired Pneumonia (Writing Committee): Devorah J. Nazarian, MD, Chair; Orin L. Eddy, MD; Thomas W. Lukens, MD, PhD; Scott D. Weingart, MD; Wyatt W. Decker, MD

Members of the Clinical Policies Committee (Oversight Committee): Wyatt W. Decker, MD (Co-Chair 2006-2007, Chair 2007-2009); Andy S. Jagoda, MD (Chair 2003-2006, Co-Chair 2006-2007); Deborah B. Diercks, MD; Barry M. Diner, MD (Methodologist); Jonathan A. Edlow, MD; Francis M. Fesmire, MD; John T. Finnell, II, MD, MSc (Liaison for Emergency Medical Informatics Section 2004-2006); Steven A. Godwin, MD; Sigrid A. Hahn, MD; John M. Howell, MD; J. Stephen Huff, MD; Eric J. Lavonas, MD; Thomas W. Lukens, MD, PhD; Donna L. Mason, RN, MS, CEN (ENA Representative 2004-2006); Edward Melnick, MD (EMRA Representative 2007-2008); Anthony M. Napoli, MD (EMRA Representative 2004-2006); Devorah Nazarian, MD; AnnMarie Papa, RN, MSN, CEN, FAEN (ENA Representative 2007-2009); Jim Richmann, RN, BS, MA(c), CEN (ENA Representative 2006-2007); Scott M. Silvers, MD; Edward P. Sloan, MD, MPH; Molly E. W. Thiessen, MD (EMRA Representative 2006-2008); Robert L. Wears, MD, MS (Methodologist); Stephen J. Wolf, MD; Cherri D. Hobgood, MD (Board Liaison 2004-2006); David C. Seaberg, MD, CPE (Board Liaison 2006-2009); Rhonda R. Whitson, RHIA, Staff Liaison, Clinical Policies Committee and Subcommittees

Relevant industry relationships of subcommittee members: There were no relevant industry relationships disclosed by the subcommittee members.

Relevant industry relationships are those relationships with companies associated with products or services that significantly impact the specific aspect of disease addressed in the critical question.

This is the current release of the guideline.

This guideline updates a previous version: American College of Emergency Physicians (ACEP). Clinical policy for the management and risk stratification of community-acquired pneumonia in adults in the emergency department. Ann Emerg Med 2001 Jul;38(1):107-13. [38 references]

Electronic copies: Available in Portable Document Format (PDF) from the American College of Emergency Physicians Web site .

American College of Emergency Physician clinical policies are available for mobile applications at the American College of Emergency Physicians Web site .

None available

None available

This NGC summary was completed by ECRI on January 29, 2003. The information was verified by the guideline developer on March 13, 2003. This NGC summary was updated by ECRI Institute on January 19, 2010. The information was verified by the guideline developer on February 9, 2010.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information, please refer to the American College of Emergency Physicians (ACEP) Web site .