Beginner•6 min read•High Yield

Community-Acquired Pneumonia - CCS Case Guide

Key Takeaway: Community-acquired pneumonia is one of the most common infectious causes of hospitalization. Risk stratification with CURB-65 or PSI guides the decision to admit.

Community-acquired pneumonia is one of the most common infectious causes of hospitalization. Risk stratification with CURB-65 or PSI guides the decision to admit. Timely antibiotics with appropriate coverage are the cornerstone of management.

Recognizing the Pneumonia Presentation

  • History: Cough (productive or dry), fever, chills, dyspnea, pleuritic chest pain, and malaise over days
  • Physical Exam: Crackles or bronchial breath sounds on auscultation, dullness to percussion, increased tactile fremitus, egophony over the affected lobe
  • Vital Signs: Fever, tachycardia, tachypnea, possible hypoxia (SpO2 < 94%)

Immediate Actions (First 5 Minutes)

These orders should be placed immediately — timing is scored:

Critical First Orders

  • ✓ Supplemental oxygen to maintain SpO2 > 92%
  • ✓ Chest X-ray (PA and lateral)
  • ✓ Blood cultures x2 if moderate-to-severe
  • ✓ Start empiric antibiotics promptly
  • ✓ IV access if ill-appearing

Complete Workup

After initial stabilization, complete the diagnostic workup:

  • Chest X-ray PA and lateral
  • CBC with differential
  • BMP
  • Blood cultures x2 (if admitted)
  • Sputum culture and Gram stain (if productive cough)
  • Procalcitonin
  • Legionella and pneumococcal urinary antigens (if severe)
  • ABG or VBG if hypoxic or tachypneic
  • CT chest if X-ray inconclusive or complications suspected

Treatment

Outpatient (low risk)

  • Amoxicillin 1 g TID for 5 days
  • OR doxycycline 100 mg BID for 5 days
  • Add azithromycin if comorbidities present

Inpatient (non-ICU)

  • Ceftriaxone 1 g IV daily + azithromycin 500 mg IV daily
  • OR respiratory fluoroquinolone (levofloxacin 750 mg IV daily) as monotherapy

ICU (severe)

  • Ceftriaxone 1 g IV daily + azithromycin 500 mg IV daily
  • Add vancomycin or linezolid if MRSA risk factors
  • Add antipseudomonal beta-lactam if risk factors for Pseudomonas

Supportive Care

  • Supplemental oxygen via nasal cannula or high-flow
  • IV fluids if dehydrated
  • Incentive spirometry
  • DVT prophylaxis

Common Pitfalls

Scoring Tip: These are the most commonly missed actions for Pneumonia cases.

  • Failing to obtain chest X-ray
  • Not risk-stratifying with CURB-65 or PSI before deciding disposition
  • Using fluoroquinolone monotherapy when dual therapy is more appropriate for ICU patients
  • Forgetting blood cultures before antibiotics in admitted patients
  • Missing parapneumonic effusion or empyema on imaging

Disposition

  • Outpatient if CURB-65 score 0-1 and stable
  • Inpatient ward if CURB-65 2 or significant comorbidities
  • ICU if CURB-65 3-5, requiring vasopressors, or mechanical ventilation
  • Discharge when afebrile 48 hours, tolerating PO, and improving clinically

Key Orders Checklist

  • ☐ Chest X-ray
  • ☐ Blood cultures x2
  • ☐ Sputum culture
  • ☐ Ceftriaxone + azithromycin
  • ☐ Supplemental oxygen
  • ☐ Incentive spirometry

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