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American Thoracic SocietyPulmonology2025advanced

Diagnosis and Management of Adults with Community-Acquired Pneumonia

Published by American Thoracic Society · GRADE

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Summary

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Understanding of the diagnosis and treatment of adults with community-acquired pneumonia (CAP) has evolved. This document updates evidence-based clinical practice guidelines on four key questions: LUS versus chest radiography, empiric antibacterial therapy with positive respiratory virus testing, antibiotic duration, and systemic corticosteroids.

community-acquired pneumoniaATSpulmonologyguidelinesantibiotic durationlung ultrasoundsystemic corticosteroidsviral CAP

Key Takeaways

  • 1
    Lung ultrasound is an acceptable alternative to chest radiography for CAP diagnosis if local clinical expertise is available.
  • 2
    For viral CAP, empiric antibiotics are not suggested for outpatients without comorbidities, but are suggested for outpatients with comorbidities and all hospitalized patients.
  • 3
    Antibiotic therapy can safely be reduced to less than 5 days (minimum 3 days) for outpatients and nonsevere inpatients reaching early clinical stability.
  • 4
    Antibiotics for 5 or more days remain recommended for severe CAP.
  • 5
    Systemic corticosteroids are conditionally recommended for patients hospitalized with severe CAP (excluding influenza) but strongly recommended against for nonsevere CAP.

What's New in This Version

Updates the 2019 guidelines by answering two new clinical questions (lung ultrasound vs. chest radiography, and empiric antibiotics for viral pneumonia) and updating two existing clinical questions (duration of antibiotics, and use of systemic corticosteroids).

Key Recommendations

1. Lung ultrasound versus chest radiography to diagnose CAP

  • 1

    For adults with suspected CAP, we suggest lung ultrasound is an acceptable diagnostic alternative to chest radiography in medical centers where appropriate clinical expertise exists.

    conditionalEvidence: lowDiagnosis

2. Empiric antibacterial therapy for CAP with positive respiratory virus testing

  • 2a

    For adult outpatients without comorbidities who have clinical and imaging evidence of CAP and who have a positive test result for a respiratory virus, we suggest not prescribing empiric antibiotics.

    conditionalEvidence: very lowTreatment
  • 2b

    For adult outpatients with comorbidities who have clinical and imaging evidence of CAP and who have a positive test result for a respiratory virus, we suggest prescribing empiric antibiotics because of concern for bacterial-viral coinfection.

    conditionalEvidence: very lowTreatment
  • 2c

    For adult inpatients with clinical and imaging evidence of nonsevere CAP who have a positive test result for a respiratory virus, we suggest prescribing empiric antibiotics because of concern for bacterial-viral coinfection.

    conditionalEvidence: very lowTreatment
  • 2d

    For adult inpatients with clinical and imaging evidence of severe CAP who have a positive test result for a respiratory virus, we suggest prescribing empiric antibiotics because of concern for bacterial-viral coinfection.

    conditionalEvidence: very lowTreatment

3. Antibiotic duration for CAP

  • 3a

    For adult outpatients with CAP who reach clinical stability, we suggest less than 5 days of antibiotics (minimum of 3-d duration) rather than 5 or more days of antibiotics.

    conditionalEvidence: lowTreatment
  • 3b

    For adult inpatients with nonsevere CAP who reach clinical stability, we suggest less than 5 days of antibiotics (minimum of 3-d duration) rather than 5 or more days of antibiotics.

    conditionalEvidence: lowTreatment
  • 3c

    For adult inpatients with severe CAP who reach clinical stability, we suggest 5 or more days of antibiotics rather than less than 5 days of antibiotics.

    strongEvidence: lowTreatment

4. Systemic corticosteroids for CAP

  • 4a

    For adult inpatients with nonsevere CAP, we recommend NOT administering systemic corticosteroids.

    strongEvidence: lowTreatment
  • 4b

    For adult inpatients with severe CAP, we suggest systemic corticosteroids.

    conditionalEvidence: lowTreatment

Scope & Objectives

Clinical Topic

Community-acquired Pneumonia

Objectives

To update evidence-based clinical practice guidelines on four key questions for the diagnosis and management of adult patients with CAP.

Target Patient Population

Adults with suspected or confirmed community-acquired pneumonia (CAP)

Diagnostic Criteria

Clinical signs and symptoms plus chest imaging confirmation to visualize alveolar inflammation

Target Providers

PulmonologistsInfectious Disease SpecialistsInternistsCritical Care PhysiciansHospital Medicine PhysiciansEmergency Medicine Physicians

Patient Criteria & Setting

Therapeutic Area

Respiratory Infections

Guideline Scope

DiagnosisTreatmentManagement

Inclusion Criteria

  • Immunocompetent adult patients
  • Clinical signs and symptoms of pneumonia
  • Chest imaging confirmation

Exclusion Criteria

  • Immunocompromised hosts
  • SARS-CoV-2 pneumonia during the COVID-19 pandemic

Care Settings

OutpatientInpatientIntensive Care Unit

Special Populations

Patients with comorbiditiesPatients with severe CAP

Evidence Grading

System: GRADE

Recommendation Strength

strongThe overwhelming majority of individuals in this situation would want the recommended course of action, and only a small minority would not.
conditionalThe majority of individuals in this situation would want the suggested course of action, but a sizable minority would not. Different choices will be appropriate for different patients.

Safety & Contraindications

Contraindications

  • Systemic corticosteroids in nonsevere CAP
  • Systemic corticosteroids in severe CAP caused by influenza pneumonia
  • Short duration of antibiotics in patients with severe chronic lung disease or necrotizing pneumonia

Monitoring Guidance

Daily evaluations of clinical stability and review of microbiological results to inform deescalation or early discontinuation of antibacterial therapy.

Authors & Contributors

Barbara E. JonesJulio A. RamirezEyal OrenNilam J. SoniLiam R. SullivanMarcos I. RestrepoDaniel M. MusherBrian L. ErstadChiagozie PickensValerie M. VaughnScott A. HelgesonKristina CrothersJoshua P. MetlayBrittany D. Bissell TurpinBin CaoJames D. ChalmersCharles S. Dela CruzInessa GendlinaLeila S. HojatMaryrose Laguio-VilaStephen Y. LiangGrant W. WatererMarilynn PaineConall HawkinsKevin Wilson

Guideline Features

Dosing informationBased on systematic reviewMultidisciplinaryPatient involvement

Learning Context

Difficulty

advanced

Learning Paths

Community-Acquired PneumoniaClinical Practice GuidelinesAntimicrobial StewardshipPoint-of-Care UltrasoundCorticosteroid TherapyInfectious Disease