Management of high-severity CAP in adults
Empirical therapy for community-acquired pneumonia (CAP) in adults is stratified according to disease severity – see Severity assessment of CAP in adults.
High-severity CAP refers to patients with the highest risk of mortality. These patients are usually managed in an intensive care unit because they are more likely to require intensive respiratory or vasopressor support. Always assess the patient’s preferences, goals of care and suitability for intensive care management to determine whether intensive care support is appropriate.
For adults with high-severity CAP, identify the pathogen if possible – see Investigations for CAP in adults. For adults with immune compromise, consider performing investigations for a broader range of pathogens (see Considerations in managing CAP in adults with immune compromise), and seek expert advice on whether to adjust empirical antibiotic therapy while awaiting the results.
For adults with high-severity CAP who have sepsis or septic shock, start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock. Antibiotics should be administered immediately after 2 sets of blood samples are taken for culture. Collect sputum samples (or lower respiratory tract samples for intubated patients) as soon as possible; however, do not delay antibiotic administration to do so. For nonantibiotic management of sepsis or septic shock, see Resuscitation of patients with sepsis or septic shock.
Penicillin-susceptible Streptococcus pneumoniae is the most common cause of high-severity CAP in adults. However, until the results of investigations are available, the empirical antibiotic regimens for high-severity CAP in these guidelines treat a broad range of pathogens (S. pneumoniae, Legionella pneumophila and gram-negative Enterobacterales), because patients with high-severity CAP have a high risk of adverse outcomes if they do not receive appropriate initial treatment.
In tropical regions of Australia1, Burkholderia pseudomallei and Acinetobacter baumannii are important causes of high-severity CAP – see Empirical therapy for high-severity CAP in adults in tropical regions of Australia.
For adults with chronic obstructive pulmonary disease (COPD) or bronchiectasis who have high-severity CAP, the standard empirical regimen may need to be adjusted for patients who are colonised with multidrug-resistant gram-negative pathogens (eg Pseudomonas aeruginosa) – for more information, see Considerations in managing CAP in adults with chronic obstructive pulmonary disease (COPD) or bronchiectasis.
Antibiotic regimens for CAP in these guidelines can be used for initial treatment of aspiration pneumonia – see Management of a patient who has had an aspiration event.
Additional considerations for patients with high-severity CAP include:
- adjunctive corticosteroid therapy
- empirical therapy for suspected infection with a viral respiratory pathogen, Staphylococcus aureus or Pseudomonas aeruginosa
- considerations for adults with CAP during pregnancy.
Patients with palliative care needs who have frailty and advanced disease have an increased incidence of pneumonia – for an approach to management, see Pneumonia in palliative care.