T h e Ma n a g e m e n t o f

Infectious Pulmonary
P ro c e s s e s i n t h e E m e r g e n c y
D e p a r t m e n t : Pneumonia
Kasey Dillon, DScPAS, PA-C*, Betsy Garnick, PA-S,
Meghan Fortier, PA-S, Belinda Felicia, PA-S, Alison Fulton, PA-S,
Courtney Dumont, PA-S, Brooke Dorval, PA-S,
Katherine Gardella, PA-S

KEYWORDS
 Pneumonia  Bacterial pneumonia  Community-acquired pneumonia
 COVID-19 pneumonia  Viral pneumonia  Fungal pneumonia

KEY POINTS
 Pneumonia is a common disease process, and emergency medicine providers will be
required to accurately diagnosis and manage pneumonia.
 The 3 primary types of pneumonia are bacterial, viral, and fungal.
 Since 2019, SARS-CoV-2 has greatly increased the percentage of patients being seen in
emergency departments for symptoms consistent with pneumonia.
 Diagnostic and management guidelines have been established for community-acquired
bacterial pneumonia, COVID-19 viral pneumonia, and fungal pneumonia.

INTRODUCTION

In the United States, pneumonia accounts for approximately 2.2% of emergency

department visits per year. A significant percentage of those patients can be safely
managed at home, not requiring admission.1 Age, male gender, and the presence of
complicating comorbidities increase the likelihood of requiring hospitalization, and
therefore, increase the disease burden.1,2 Bacterial, viral, and fungal pathogens can
cause infectious pneumonia. The cause, clinical presentation, and treatment recom-
mendations for each class of pathogens are reviewed. Although nosocomial respira-
tory infections are prevalent, they will not be discussed in this article. In addition, the
revised guidelines established in 2019 for the diagnosis and treatment of community-
acquired pneumonia (CAP) recommend that the nosocomial pneumonia classification,
also known as health care–associated pneumonia or hospital-acquired pneumonia, be

MCPHS University, 1260 Elm Street, Manchester, NH 03110, USA

* Corresponding author.
E-mail address: [email protected]

Physician Assist Clin 8 (2023) 123–137

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2405-7991/23/ª 2022 Elsevier Inc. All rights reserved.
124 Dillon et al

abandoned and that recommendations for management be based on severity and

epidemiologic data alone.3
Community-acquired bacterial pneumonia remains a leading cause of death world-
wide with a mortality as high as 24.8 per 10,000 cases in the United States and be-
tween 1.5 and 14 cases per 1000 people globally.2,4 Prevalence varies based on
season, population characteristics, and geographical factors. Streptococcus pneu-
moniae and Haemophilus influenzae are the leading causes of bacterial pneumonia
worldwide. The most common symptoms of cough, fever, and dyspnea are a result
of pathogens being transmitted to the lower-respiratory tract via the pharynx. There
is, however, significant heterogeneity within the clinical profile of bacterial pneumonia.
Evaluation, treatment recommendations, and guidelines have been established and
are considered the standard of care for emergency medicine providers.2,4
Viral community–acquired pneumonia has an equal prevalence among children and
adults with approximately 100 million cases annually in each group.5 There is
consensus that viral pneumonias are underdiagnosed; however, given the availability
and sensitivity of molecular diagnostic tests, the gap may be closing. One in 3 CAP are
a result of a viral cause, most commonly rhinoviruses, influenza viruses, and corona-
viruses.5 There is risk of bacterial coinfection, making diagnosis and targeted treat-
ment a challenge. In individual circumstances, neuraminidase inhibitors are
recommended for influenza-specific pneumonia; however, a clear consensus does
not exist for algorithmic management when concerned about bacterial overlap.5,6
Although sufficient data exist to support the recommended management of SARS-
CoV-2 pneumonia, a provider must approach COVID-19 pneumonia with caution
given the relative paucity of data and the frequency of iterations in guidelines and sug-
gestions.6 Given current global epidemiologic trends, this article dedicates the discus-
sion of viral pneumonias primarily to SARS-CoV-2.
Pneumonias secondary to a fungal pathology are rare in immunocompetent individ-
uals but pose life-threatening risk to those with a compromised immune response. Pa-
tients with immunodeficiency disorders, such as HIV/AIDS, or patients receiving
immunosuppressive therapy are at higher risk for developing fungal respiratory infec-
tions. In developed countries, opportunistic pathogens, such as Candida or Crypto-
coccus, are increasing in prevalence, as the survival rate of the susceptible
population groups increases. Similar to bacterial resistance to antibiotics, there has
been an emergence of resistant fungal pathogens to typical treatment, making man-
agement of these infections challenging.7,8 Although not nearly as prevalent as viral
or bacterial CAP, it is important that emergency medicine providers consider the pos-
sibility of fungal infection in an at-risk patient population so as to ensure early diag-
nosis and effective treatment.

Community-Acquired Bacterial Pneumonia

Epidemiology
In the United States, CAP accounts for more than 5 million cases of pneumonia per
year. Eighty percent of these cases are treated through outpatient management,
whereas the remaining 20% of individuals require hospitalization. Incidences of CAP
are higher in the male and African American populations. Mortality is greater in
women. The incidence rate of CAP increases with the extremes of age, and in the
United States, CAP carries a mortality of 7.3%.3–5

Cause
CAP is categorized, and treated, based on the cause of “typical” or “atypical” organ-
isms. S pneumoniae, H influenzae, Staphylococcus aureus, and group A streptococci
 The Management of Infectious Pulmonary Processes 125

are 4 of the most common typical organisms causing CAP. Atypical pneumonia can be
caused by organisms such as Legionella, Mycoplasma pneumoniae, and Chlamydia
pneumoniae. S pneumoniae and K pneumoniae are the most common causes of
CAP. Methicillin-resistant Staphylococcus aureus (MRSA) is the most common cause
of health care–associated pneumonia, whereas ventilator-associated pneumonia has
a high prevalence of multidrug-resistant bacteria. In recent years, there has been an
increase in overall antimicrobial resistance by gram-negative bacteria most commonly
found in patients with severe CAP, which substantially increases morbidity, mortality,
and health care–associated cost.4 Bacterial pathogens causing CAP often coexist
with viral pathogens, making initial management challenging at best.3,4

Clinical presentation
Given the heterogeneity of CAP, the clinical presentation of individuals will vary. The
last 10 years, however, have shown substantial expansion of evidence-based data
to support the diagnosis and treatment of CAP based on improved and rapid diag-
nostic testing as well as an increase in understanding of differentiated symptoms
based on type of causative agent.3 The hallmark symptoms of community-acquired
bacterial pneumonia include cough, with or without yellow/green sputum production,
fever, chills, pleuritic chest pain, and potential confusion in the elderly. Patients may
also experience the less-specific symptoms of fatigue, headaches, and feelings of
malaise.9 Progression of bacterial pneumonia can be more rapid than viral or fungal
pathogens and, therefore, may produce symptoms representative of systemic
involvement, including tachycardia, hypotension, and altered mental status. Atypical
pathogens causing CAP are likely to cause extrapulmonary symptoms related to
gastrointestinal upset, including nausea, vomiting, or diarrhea.3,9

Diagnosis/treatment
Early and accurate diagnosis of CAP is crucial in order to initiate targeted therapy while
decreasing unnecessary exposure, and therefore possible resistance or adverse reac-
tion, to antibiotics.9 Following the physical examination, laboratory diagnostic testing,
radiographic imaging, and clinical decision making are crucial components in the
diagnosis of CAP.4,9,10 Clinical decision-making tools are recommended for use in
prognosis and to guide the management of patients with pneumonia. They also assist
in disposition planning from the emergency department, guiding decision making for
individual hospital admission or discharge home. The Pneumonia Severity Index (PSI)
is preferential because of the moderate quality of evidence available to support its ef-
ficacy over the CURB-65 (confusion, urea level, respiratory rate, blood pressure, and
age >65). The PSI demonstrates a higher predictive value as compared with the
CURB-65. Clinician judgment must always be integrated into decision making, as pre-
dictive tools can oversimplify and do not consistently consider patient variables.3,9
In 2019, the Infectious Diseases Society of America (IDSA) and the American
Thoracic Society (ATS) established revised guidelines for the diagnosis and treatment
of CAP. Criteria are outlined for determining severe CAP based on the following minor
and major symptoms and diagnostic findings3,4,11:
 Sputum cultures: Recommended only in patients meeting criteria for severe dis-
ease, especially if requiring mechanical ventilation. There is lack of evidence to
support the use of sputum cultures in outpatient settings.
 Blood cultures: Recommended in patients meeting criteria for severe disease,
those being treated empirically for MRSA or Pseudomonas aeruginosa, those
with a history of MRSA or P aeruginosa, or those hospitalized within the past
90 days. These recommendations do have a low quality of evidence, although
126 Dillon et al

blood cultures continue to remain part of most institutional clinical pathways in

the diagnosis of CAP. Given the overlap of CAP and sepsis, utilization of blood
cultures is appropriate. Data prove that positive blood cultures within 10 hours
of admission have shown an increased risk of mortality; however, only 40% of
blood cultures drawn at initial presentation are positive.
 Molecular diagnostic testing/polymerase chain reaction testing: Recommended
testing for influenza and SARS-CoV-2 based on local transmissibility data and
prevalence. Molecular diagnostic tests have an overall 70% to 80% sensitivity
rate and 99% to 100% specificity rate, therefore isolating cases of viral or atyp-
ical bacterial cause.
 Legionella and pneumococcal urinary antigen testing (UAT): Recommended only
in the patient with severe CAP or in cases of high epidemiologic concern/recent
travel (Legionella).
 Imaging: Chest computed tomography (CT) is considered the gold standard in
detection of both CAP and viral pneumonia; however, cost, accessibility, and ra-
diation continue to be limiting factors. Chest radiograph alone has a sensitivity of
38% to 76%; however, when combined with molecular testing, sensitivity and
specificity increase. Ultrasonography has been shown to have sensitivity rates
of 80% to 90% in the detection of pneumonia. The IDSA/ATS guidelines no
longer recommend routine use of chest radiograph in follow-up after a pneu-
monia diagnosis.
In all patients where community-acquired bacterial pneumonia is likely, empiric
therapy is recommended. Risk assessment should be used to determine if treatment
can be conducted in an outpatient or inpatient setting. As stated, the PSI and CURB-
65 clinical assessment tools are effective and recommended guidelines used in begin-
ning treatment decisions. The CURB-65 and PSI help estimate mortality risk in CAP
based on various risk factors associated with worse outcomes.9 Treatment decisions
vary greatly owing to differences in risk assessment outcomes indicated, comorbid-
ities, and likelihood of MRSA infection. Tables 1 and 2 outline the recommended
outpatient and in-hospital initial treatments for CAP.3

Prognosis
Outcomes of treatment largely depend upon age of onset, hospitalization status with
treatment, and the presence of comorbidities. The overall mortality for pneumonia may
be up to 30% if left untreated. Overall prognosis, however, is tremendous in a healthy
patient. Most individuals respond to treatment within 48 to 72 hours of initial manage-
ment, both in hospital and at home. Respiratory failure, sepsis, organ failure, coagul-
opathy, and exacerbation of comorbidities are complications to consider as a result of
CAP.9

Table 1
Empiric treatment of outpatient community-acquired pneumonia

Recommended Treatment
No comorbidities/risk factors for MRSA or Amoxicillin OR doxycycline OR macrolide
pseudomonas
With comorbidities Augmentin or cephalosporin AND macrolide
or doxycycline OR monotherapy with
respiratory fluoroquinolone

Adapted from Ramirez JA, File, TM, Bond S. UpToDate. Overview of community-acquired pneu-
monia. Sept 7, 2021. Accessed March 1, 2022.
 The Management of Infectious Pulmonary Processes 127

Table 2
Empiric treatment of inpatient community-acquired pneumonia

Standard Prior MRSA Prior Pseudomonas

Nonsevere B-Lactam 1 macrolidea OR Add MRSA coveragec Add pseudo coveraged
inpatient respiratory
fluoroquinoloneb
Severe B-Lactam 1 macrolidea
inpatient
a
Ampicillin and sulbactam, cefotaxime, ceftriaxone, ceftaroline, AND azithromycin or
clarithromycin.
b
Levofloxacin or moxifloxacin.
c
Per 2016 ATS/IDSA guidelines: vancomycin or linezolid.
d
Per 2016 ATS/IDSA guidelines: piperacillin-tazobactam, cefepime, ceftazidime, imipenem, mero-
penem, or aztreonam.
Adapted from Ramirez JA, File, TM, Bond S. UpToDate. Overview of community-acquired pneu-
monia. Sept 7, 2021. Accessed March 1, 2022.

Community-Acquired Viral Pneumonia

Epidemiology
As stated, viral pneumonia is discussed, with reference only to pneumonia caused b
the SARS-CoV-2 virus. At the time of publication, there have been more than 470
million confirmed cases of COVID-19 globally with more than 6 million deaths report-
edy to the World Health Organization (WHO) and to the Centers for Disease Control
and Prevention (CDC).12 Currently, 10 vaccines have been granted an emergency
use listing by the WHO. Worldwide vaccination rates are highest in countries like Can-
ada, Chile, and Australia with countrywide vaccination greater than 90%. Sub-
Saharan Africa has the lowest overall population vaccination rates at less than 10%,
and China does not report vaccination rates. The United States has an overall nation-
wide vaccination rate of 70%.13 Vaccination compliance is determined by factors such
as availability, vaccination hesitancy, and political or religious affiliation.
Before the COVID-19 pandemic, common viral causes of pneumonia included influ-
enza A and B, human boca viruses, coronaviruses NL63 and HKU1, and respiratory
syncytial virus (commonly in children).5 Although these viral illnesses remain, SARS-
CoV-2 pneumonias have contributed to a majority of viral pneumonias worldwide.
Vaccination has been proven to decrease mortality in COVID-19 infections and to
decrease hospitalization rates of infected individuals, both with and without comorbid-
ities.12,14,15 Following the evolution of coronavirus variants, delta and omicron, a third
vaccination for COVID-19 has shown a 94% and 82% (respectively) prevention rate of
an emergency-department encounter following exposure to the virus. Vaccines have
proven to be 94% effective in preventing hospitalization from the delta variant and
90% from the omicron variant.15

Clinical presentation
Although data are lacking in long-term effects of COVID-19 as well as efficacy of
vaccination over time, there is improved understanding within the medical community
regarding presenting symptoms of patients infected by SARS-CoV-2. COVID-19
pneumonia has a virulent pathology and is highly transmissible with the inhalation of
virus infecting the alveolar and endothelial cells in the pulmonary tissue.16 The most
common method of transmission for this virus is person to person via respiratory par-
ticles. Respiratory secretions can spread when one breathes in close proximity to
128 Dillon et al

another individual (<6 ft) or when eliciting any phonatory behavior (ie, coughing,
singing, speaking, and laughing). It is best understood that the airborne transmission
of a viable COVID-19 particle can last up to 16 hours before infecting another host,
although likelihood of infection is affected by things like viral load and vaccination
status.17,18
Current data, including contact tracing, support both asymptomatic and symptom-
atic spread of SARS-CoV-2. This is due to the similar viral loads detected from nasal
and throat swabs from each patient population, with a slightly higher predominance of
virus detected via nasal swab.5,19 COVID-19 infectiousness is highest in the early
course of the illness, during the 2 days before symptom onset. This viral nucleic
acid shedding pattern of SARS-CoV-2 resembles that of influenza and can make it
difficult to control transmission.19 Specific to immunocompetent individuals, an
infected patient is less likely to transmit the virus after day 7.12,20,21
Within an emergent setting, patients with COVID-19 infection can present with
symptoms ranging in severity from mild to severe. Common complaints include fever,
cough, dyspnea, myalgia, loss/alterations of gustatory and olfactory senses, gastroin-
testinal manifestations (most commonly diarrhea), and headaches.22 Severe illness is
more frequent among older individuals and those with multiple comorbidities. Pro-
viders may also note delirium and general health decline especially in the older pop-
ulation, who may have previous neurologic impairments.23 Acute respiratory
distress syndrome (ARDS) is a significant complication of COVID-19 pneumonia and
has a high mortality.16
Current guidelines recommend laboratory and diagnostic testing in the diagnosis of
COVID-19 pneumonia. Recommendations are largely consistent with the initial evalu-
ation of CAP with a few exceptions:
 Procalcitonin: Procalcitonin is a biomarker of bacterial infection. It can be useful
in determining bacterial coinfection. Data suggest that procalcitonin is an effec-
tive diagnostic tool used upon initial presentation as well as for monitoring treat-
ment and guiding management.24
 Laboratory inflammatory markers (erythrocyte sedimentation rate and C-reactive
protein): These may be increased in patients presenting with COVID-19 pneu-
monia, however, are nonspecific and do not assist in specific initial management,
although they may be better used to monitor progress and outcome.23
 Imaging: Chest radiograph is insensitive in accurately detecting early or mild
COVID-19 pneumonia. It is, however, cost-effective and time effective. CT imag-
ing of the chest is more sensitive for early detection as well as for monitoring dis-
ease progression.16 It is common to see ground-glass opacities bilaterally with
COVID-19 pneumonia on imaging studies.

Treatment
The management of COVID-19 pneumonia is based on the severity of the illness at
time of presentation to the emergency department. Minimizing the risk of health
care worker and patient exposure must be considered, and measures such as rapid
triage and risk stratification should be implemented.25 Reliable patients who present
with any upper-respiratory symptoms, such as rhinorrhea, loss of taste or smell, diar-
rhea, and fatigue, and who have minimal to no comorbidities, can be managed at
home and often should be evaluated through a telemedicine or primary care visit.25
With signs of lower-respiratory tract pathologic condition, such as dyspnea or cough,
and with patients having multiple comorbidities, hospitalization should be considered.
Severe illness is defined by an oxygen saturation below 94%, a respiratory rate greater
than 30, and the presence of infiltrates on imaging in greater than 50% of lung tissue.25
 The Management of Infectious Pulmonary Processes 129

These patients will be monitored, admitted, and likely need supplemental oxygen.
Currently, pharmacologic treatments are recommended based on disease severity.26
The American Academy College of Emergency Physicians recommends the
following specific approach based on severity26:
 Mild to moderate signs of COVID-19: These patients may benefit from nonphar-
macologic treatment alone. These options include home oxygen therapy, breath-
ing exercises, continual ambulation, adequate sleep, and a consistent healthy
diet with adequate hydration.
 Severe signs of COVID-19: Recommendations for oxygen support using a nasal
cannula with titration to 6 L, high-flow nasal cannula (HFNC) or high-velocity ther-
apy, noninvasive positive pressure ventilation if HFNC is not available, or a
consideration of prone positioning if patient can be monitored closely. Proning
of patients is contraindicated in the presence of respiratory distress.
 Endotracheal intubation is considered: If a goal of oxygenation at 92% to 96%
cannot be maintained, low-tidal volume, plateau pressures less than 30 cm,
higher positive end-expiratory pressure, or if a patient experiences refractory
hypoxemia with prone ventilation. Currently, sufficient data do not exist to deter-
mine the benefit of extracorporeal membrane oxygenation in the management of
severe COVID-19 pneumonia.
Recommendations for pharmacologic management of COVID-19 are not made
specific to those patients with or without pneumonia. Recommendations are based
on outpatient or inpatient management and therefore on disease severity. Current
recommendations as seen in Tables 3 and 4 and Fig. 1 are summarized as
follows26,27:
 Remdesivir is the only antiviral medication approved by the Food and Drug
Administration (FDA) for the treatment of COVID-19.
 Ritonavir-boosted nirmatrelvir (Paxlovid) and SARS-CoV-2 monoclonal anti-
bodies have been given an Emergency Use Authorization from the FDA.
 Nonhospitalized patients: All patients with confirmed SARS-CoV-2 who are at
risk for progressing to severe disease should receive (in order of preference):
paxlovid, sotrovid, remdesivir, and molnupiravir. Systemic corticosteroids are
not recommended.
 Hospitalized patients: Remdesivir is recommended in all patients requiring
admission for SARS-CoV-2. In addition, dexamethasone is recommended if sup-
plemental oxygen is required. Finally, and dependent on severity of disease and
progression, tocilizumab is recommended.
 The National Institutes of Health and CDC update detailed guidelines regularly,
including the use of heparin.

Prognosis
The prognosis of COVID-19 pneumonia is variable and ranges widely. Mortality is
highest among patients with ARDS. There is no clinical significance in mortalities be-
tween COVID-19–related ARDS or non–COVID-19–related ARDS. Data suggest mor-
talities from 12% to 78% in patients diagnosed with COVID-19 and ARDS. Death from
COVID-19 can result from other complications, such as arrhythmias, cardiac arrest, or
pulmonary embolism.28 Rapid symptom progression does not contribute to worsened
outcomes. Patient prognosis and outcome are affected by individual comorbidities,
patient population and demographics, hospital staffing, and staff experience in treat-
ing COVID-19.28
130 Dillon et al

Community-Acquired Fungal Pneumonia

Cause/epidemiology
Fungal pneumonia affects 2 different patient populations, neutropenic and nonneutro-
penic individuals. Risk factors for neutropenic fungal pneumonia include neutropenia
greater than 10 days typically following chemotherapy or following a hematopoietic
stem cell transplant. Risk factors for nonneutropenic fungal pneumonia include pro-
longed steroid use, which is further broken down into intermediate risk (<0.3 mg/kg/
d prednisone equivalents for >3 weeks) and low risk (<7 days of steroid use). Trans-
plant recipients, and patients with AIDS/HIV infection, chronic obstructive pulmonary
disease, diabetes mellitus, liver failure/cirrhosis, renal failure/hemodialysis, severe im-
munodeficiency (chronic granulomatous disease), and critically ill intensive care unit
(ICU) patients are at increased risk for developing fungal pneumonia.29
There are several common fungal pathogens leading to pneumonia.29 Coccidioido-
mycosis, also known as “valley fever,” is endemic to the Southwestern United States
(primarily Arizona and California), Mexico, Central America, and South America. The
fungal spores of coccidioidomycosis live in soil, which are transmitted via inhalation.7
Histoplasma capsulatum is a dimorphic fungus also transmitted via inhaled spores
from soil but is endemic to the Ohio and Mississippi river valleys. Aspergillus species,
most commonly Aspergillus fumigatus, is a common mold infection found in immuno-
compromised individuals.7 Neutropenia is the most common risk factor for invasive
aspergillosis.4,8 Candida albicans, Cryptococcus neoformans, blastomyces, and Pneu-
mocystis jiroveci are additional fungal pathogens found in at-risk patient populations.2,7

Clinical presentation
Neutropenic and nonneutropenic individuals with fungal pneumonia will present with
varied clinical symptoms. Fever and symptoms consistent with angioinvasion are
more prevalent in a neutropenic host. Angioinvasion leads to a higher susceptibility
of fungal spread to other organs, most commonly the skin, brain, and eyes. Angioin-
vasion is not common in a nonneutropenic host. Most nonneutropenic patients are
asymptomatic until later stages in the disease.4,8
Although variable, patients with fungal pneumonia will typically present with a cough
(79%–91%), fever (up to 75%), dyspnea (70%), increased sputum production (up to
65%), or pleuritic chest pain (up to 50%). Generalized symptoms of lightheadedness,
malaise, weakness, headache, nausea/vomiting, joint pain, and rash can also be asso-
ciated with fungal pneumonia but are less common as an initial complaint. The elderly
population can present with nonspecific complaints as stated, as well as altered
mental status independent of other symptoms. Specifically, coccidioidomycosis can
cause fever, cough, headache, rash, muscle aches, and joint pain.30 H capsulatum
is commonly asymptomatic but can also mimic mild flulike symptoms, fever, head-
ache, chest pain, dry cough, and night sweats. Inoculum size is a major determinant
in the symptomatology of patients.31 It is important to use appropriate history, physical
examination, and laboratory and diagnostic imaging to exclude other disease pro-
cesses, including bacterial or viral pneumonia.

Diagnosis
Because of the limitations in testing availability within emergency departments, the diag-
nosis of fungal pneumonia is often limited to the history and physical examination findings
that are supported with imaging findings and consistent with patient risk factors29,32,33:
 Complete blood Count: Recommended to determine the presence of neutrope-
nia and/or lymphopenia. This allows for a more targeted approach to
management.
 The Management of Infectious Pulmonary Processes 131

Table 3
Nonhospitalized patient guidelines for COVID-1927

Patient Disposition Panel’s Recommendations

Does not require hospitalization or All patients should be offered symptomatic
supplemental oxygen management (AIII)
For patients who are at high risk of
progressing to severe COVID-19a
(treatments are listed in order of
preference based on efficacy and
convenience of use):
 Ritonavir-boosted nirmatrelvir
(Paxlovid)b,c (AIIa)
 Sotrovimabd (AIIa)
 Remdesivirc,e (BIIa)
 Molnupiravirc,f (CIIa)
The panel recommends against the use of
dexamethasone or other systemic
corticosteroids in the absence of another
indication (AIIa)g
Discharged from hospital inpatient setting in The panel recommends against continuing
stable condition and does not require the use of remdesivir (AIIa),
supplemental oxygen dexamethasoneg (AIIa), or baricitinibg
(AIIa) after hospital discharge
Discharged from hospital inpatient setting There is insufficient evidence to recommend
and requires supplemental oxygen either for or against the continued use of
For those who are stable enough for remdesivir or dexamethasone
discharge but who still require oxygenh
Discharged from ED despite new or The panel recommends using
increasing need for supplemental oxygen dexamethasone 6 mg PO once daily for the
When hospital resources are limited, duration of supplemental oxygen
inpatient admission is not possible, and (dexamethasone use should not exceed
close follow-up is ensuredi 10 days) with monitoring of AEs (BIII)
Because remdesivir is recommended for
patients with similar oxygen needs who
are hospitalized,j clinicians may consider
using it in this setting. Given that
remdesivir requires intravenous infusions
for up to 5 consecutive days, there may be
logistical constraints to administering
remdesivir in the outpatient setting

Rating of Recommendations: A 5 strong; B 5 moderate; C 5 Optimal.

Rating of Evidence: I 5 one or more randomized trails without major limitations; IIa 5 other ran-
domized trails or subgroup analyses of randomized trails; IIb 5 nonrandomized trials or observa-
tional cohort studies; III 5 expert opinion.

 Blood and sputum cultures: There are limited data to support the benefit of blood
and sputum cultures in the emergency department. Both cultures are useful for
long-term management of patients and are often obtained upon presentation,
especially if the patient is presenting with signs and symptoms of severe disease.
 Serologic testing: Not commonly recommended in the emergent setting. Both
acute and convalescent serum titers are necessary and are less likely to be avail-
able in this environment. IDSA/ATS guidelines state that serologic testing is only
recommended in certain circumstances, such as ICU admission, failure of outpa-
tient antibiotic management, presence of cavitary infiltrates, active alcohol
 132
Dillon et al
Table 4
Fungal pneumonia—comparison of 2007 American Thoracic Society/Infectious Diseases Society of America guidelines with 2019 guidelines3

Recommendation 2007 ATS/IDSA Guideline 2019 ATS/IDSA Guideline

Sputum culture Primarily recommended in patients with severe Now recommended in patients with severe
disease disease as well as in all inpatients empirically
treated for MRSA or P aeruginosa
Blood culture Primarily recommended in patients with severe Now recommended in patients with severe
disease disease as well as in all inpatients empirically
treated for MRSA or P aeruginosa
Macrolide monotherapy Strong recommendation for outpatients Conditional recommendation for outpatients
based on resistance levels
Use of procalcitonin Not covered Not recommended to determine need for initial
antibacterial therapy
Use of corticosteroids Not covered Recommended not to use. May be considered in
patients with refractory septic shock
Use of health care-associated pneumonia Accepted as introduced in the 2005 ATS/IDSA Recommend abandoning this categorization.
category hospital-acquired and ventilator-associated Emphasis on local epidemiology and validated
pneumonia guidelines risk factors to determine need for MRSA or P
aeruginosa coverage. Increased emphasis on
deescalation of treatment if cultures are
negative
Standard empiric therapy for severe CAP b-Lactam/macrolide and b-lactam/ Both accepted but stronger evidence in favor of
fluoroquinolone combinations given equal b-lactam/macrolide combination
weighting
Routine use of follow-up chest imaging Not addressed Recommended not to obtain. Patients may be
eligible for lung cancer screening, which
should be performed as clinically indicated
 The Management of Infectious Pulmonary Processes 133

Fig. 1. Hospitalized patient guidelines for treating COVID-19.27

134 Dillon et al

abuse, severe or structural lung disease, positive Legionella UAT, positive pneu-
mococcal UAT, and presence of pleural effusion.
 Imaging: Chest radiograph is an appropriate and recommended initial diagnostic
test. Findings may include lobar consolidation, cavitary lesions, or pleural effu-
sions. As with bacterial and viral pneumonia, CT imaging may be required for
further diagnostic accuracy. Bedside ultrasound is sensitive and specific in iden-
tifying pleural pulmonary lesions.

Treatment
For patients that have not been previously treated for pneumonia, empiric antibiotics
are recommended and based on patient’s exposure history, risk factors, and severity
of disease. Severity of disease and short-term risk assessment can be determined us-
ing the CURB-65 and PSI criteria to establish inpatient versus outpatient manage-
ment. Failure to improve with initial antibiotic management should raise suspicion
for fungal infection.29,32–34
Treatment of fungal infection is often targeted and based on blood and/or sputum
culture results:
 Aspergillosis: Initial therapy with voriconazole is recommended for most patients.
The preferred alternative for patients that cannot tolerate the recommended
initial therapy is a combination of posaconazole and isavuconazole.35
 P jiroveci: Initial therapy with trimethoprim/sulfamethoxazole is recommended.30
 H capsulatum: If less than 4 weeks of an acute lung infection, no treatment is rec-
ommended. If greater than 4 weeks of an acute lung infection, a 3-month course
of itraconazole is recommended.31
Because of the rise in cases of COVID-19, and with the increased need for long-term
intubation, there is a concomitant rise in A fumigatus infections.5 Any patient with a
recent COVID-19 infection, particularly in the circumstance of a recent history of hos-
pitalization requiring intubation, has a higher risk of developing fungal pneumonia.3,35
The ATS/IDSA guidelines were revised in 2019 and are accepted as the standard of
care (see Fig. 1).

DISCUSSION

Pneumonia remains a common condition evaluated and treated in the emergency depart-
ment. With the emergence of the SARS-CoV-2 virus and COVID-19–associated pneu-
monia, hospital admission rates for severe pneumonia have increased, leading to
increased overall mortality. It is imperative that emergency medicine providers easily iden-
tify patients displaying signs and symptoms of both typical and atypical pneumonia and
are familiar with the guidelines established for diagnosis and management of pneumonia,
including recommended diagnostic testing. Guidelines for the management of bacterial,
viral, and fungal pneumonias are created collaboratively by organizations like the IDSA,
CDC, and ATS and revised regularly. The prevalence and cause of pneumonia are demo-
graphically and seasonally determined; therefore, providers must be aware of guiding
treatment based on these factors. Individual patient risk factors must also be considered.

CLINICS CARE POINTS

 Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and group A

streptococci are 4 of the most common typical organisms causing community-acquired
 The Management of Infectious Pulmonary Processes 135

bacterial pneumonia. Geographical susceptibility, in addition to current guidelines, must be

considered when selecting the appropriate treatment.
 Empiric therapy is recommended in all patients with suspected community-acquired
bacterial pneumonia.
 Standard empiric therapy for severe community-acquired bacterial pneumonia includes a
B-lactam/macrolide combination.
 Because of the significant overlap in presentation of community-acquired bacterial
pneumonia and sepsis, blood cultures are recommended in patients with severe disease or
in those at risk for methicillin-resistant Staphylococcus aureus and/or pseudomonas.
 Acute respiratory distress syndrome is a significant complication of COVID-19 pneumonia
and has a high mortality, making rapid diagnosis critical.
 Remdesivir is recommended in all patients requiring admission for SARS-CoV-2. In addition,
dexamethasone is recommended if supplemental oxygen is required.
 Failure to improve with initial antibiotic management should raise suspicion for fungal
infection.

DISCLOSURE

These authors declare that they have no conflicts of interest. These authors declare
that they have no competing monetary interests or personal relationships that could
have influenced the work reported here.

REFERENCES

1. Self WH, Grijalva CG, Zhu YZ, et al. Rates of emergency department visits due to
pneumonia in the United States, July 2006-June 2009. Acad Emerg Med 2013;
20(9):957–60.
2. Regunath H, Oba Y. Community-acquired pneumonia. StatPearls. Updated
August 18, 2021. Available at: https://www.ncbi.nlm.nih.gov/books/NBK430749/.
3. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with
community-acquired pneumonia. An official clinical practice guideline of the
American Thoracic Society and Infectious Diseases Society of America. Am J Re-
spir Crit Care 2019;200(7).
4. Martin-Loeches I, Torres A. New guidelines for severe community-acquired pneu-
monia. Curr Opin Pulm Med 2021;27(3):210–5.
5. Ruuskanen O, Lahti E, Jennings LC, et al. Viral pneumonia. Lancet 2011;
377(9773):1264–75.
6. Ng TM, Ong SWX, Loo AYX, et al. Antibiotic therapy in the treatment of COVID-19
pneumonia: who and when? Antibiotics 2022;11(2):184.
7. Arastehfar A, Gabaldon T, Garcia-Rubio R, Jenks JD, Hoenigl M, Salzer HJF,
Ilkit M, Lass-Florl C, Perlin DS. Drug-resistant fungi: an emerging challenge
threatening our limited antifungal armamentarium. Antib 2020;9(12).
8. Li A, Lu G, Meng G. Pathogenic fungal infection in the lung. Front Immunol 2019;
10(1524).
9. Sattar SA, Sharma S. Bacterial pneumonia. StatPearls. Updated December 28,
2021. Available at: https://www.ncbi.nlm.nih.gov/books/NBK513321/
10. Ramirez JA, File, TM, Bond S. UpToDate. Overview of community-acquired pneu-
monia. 2021. Available at: https://www.uptodate.com/contents/overview-of-com-
munity-acquired-pneumonia-in-adults?search5diagnosis%20of%20community
136 Dillon et al

%20acquired%20pneumonia&source5search_result&selectedTitle52-
w150&usage_type5default&display_rank52. Accessed March 1, 2022.
11. Karimi E. Comparing sensitivity of ultrasonography and plain chest radiography
in detection of pneumonia: a diagnostic value study. Arch Acad Emerg Med
2019;7(1):8.
12. McIntosh K, Hirsch MS, Bloom A. UpToDate. COVID-19: Epidemiology, virology,
and prevention. 2022. Available at: https://www.uptodate.com/contents/covid-19-
epidemiology-virology-and-prevention?sear ch5COVID%
20PNA&topicRef5128323&source5. Accessed March 4, 2022.
13. Vaccination rates, approvals, and trials by country. COVID-19 Vaccine Tracker.
2022. Available at: https://covid19.trackvaccines.org/trials-vaccines-by-
country/. Accessed March 18, 2022.
14. 10. CDC. COVID Data Tracker. Updated daily by 8 pm EST. Available at: https://
covid.cdc.gov/covid-data-tracker/#vaccine-effectiveness.
15. CDC. Effectiveness of a third dose of MRNA vaccines against COVID-19–associ-
ated emergency department and urgent care encounters and hospitalizations
among adults during periods of delta and omicron variant predominance —
VISION network, 10 states, August 2021–January 2022. Morbidity Mortality Rep
2022;71(4):139–45. Available at: https://www.cdc.gov/mmwr/volumes/71/wr/
mm7104e3.htm#:w:text5During%20both%20 Delta%2D%20and%
20Omicron,and%2090%25%2C%20respectively.
16. Guarnera A, Podda P, Santini E, Paolantonio P, Laghi A. Differential diagnosis of
COVID-19 pneumonia: the current challenge for the radiologist – a pictorial essay.
In. Img 2021;34.
17. Samet J, Prather K, Benjamin G, et al. Airborne transmission of severe acute res-
piratory syndrome coronavirus 2 (SARS-CoV-2): what we know. Clin Infect Dis
2021;73(10):1924–6. https://doi.org/10.1093/cid/ciab039. Available at: https://
escholarship.org/uc/item/1dx8f89w.
18. Ahn JY, An S, Sohn Y, et al. Environmental contamination in the isolation rooms of
COVID-19 patients with severe pneumonia requiring mechanical ventilation or
high-flow oxygen therapy. J Hosp Infect 2020;106(3). https://doi.org/10.1016/j.
jhin.2020.08.014.
19. Zou L, Ruan F, Huang M, et al. SARS-CoV-2 viral load in upper respiratory spec-
imens of infected patients. N Engl J Med 2020;382(12):1177–9. https://doi.org/10.
1056/NEJMc2001737.
20. He X, Lau EHY, Wu P, et al. Temporal dynamics in viral shedding and transmissi-
bility of COVID-19. Nat Med 2020;26:672–5.
21. Jones TC, Biele G, Muhlemann B. Estimating infectiousness throughout SARS-
CoV-2 infection course. Science 2021;373(655). https://doi.org/10.1126/
science.abi5273.
22. Pagliano P, Sellitto C, Conti V, et al. Characteristics of viral pneumonia in the
COVID-19 era: an update. Infection 2021;49:607–16.
23. McIntosh, K. COVID-19: Clinical Features. UpToDate. Updated Jan 10, 2022.
Available at: https://www.uptodate.com/contents/covid-19-clinical-features. Ac-
cessed March 18, 2022.
24. Wonhee S, Simon MS, Choi JJ, et al. Characteristics of procalcitonin in hospital-
ized COVID-19 patients and clinical outcomes of antibiotic use stratified by pro-
calcitonin levels. Inter Emerg Med 2022;17(5):1405–12.
25. Schalekamp S, Bleeker-Rovers CP, Beenen LFM. Chest CT in the emergency
department for diagnosis of COVID-19 pneumonia: Dutch experience. Radiology
2020;298:2.
 The Management of Infectious Pulmonary Processes 137

26. Pantazopoulos I, Tsikrika S, Kolokytha S, et al. Management of COVID-19 patients

in the emergency department. J Pers Med 2021;11(10):961.
27. Coronavirus Disease 2019 (COVID-19) Treatment guidelines. National Institutes
of Health. 2022. Available at: https://www.covid19treatmentguidelines.nih.gov/.
Accessed March 18, 2022.
28. Emergency department Covid-19 management tool. 2022. Available at: https://
www.acep.org/globalassets/sites/acep/media/covid-19-main/acep-covid-19-ed-
managem ent-tool.pdf. Accessed March 12, 2022.
29. Mertersky Mark. https://www.dynamed.com/condition/community-acquired-
pneumonia-in-adults. Accessed 18 March 2022.
30. Center for Disease Control. Pneumocystis pneumonia: fungal diseases. 2021.
Available at: https://www.cdc.gov/fungal/diseases/pneumocystis-pneumonia/
index.html. Accessed March 6, 2022.
31. Akram SM, Koirala J. Histoplasmosis. StatPearls. Available at: http://www.ncbi.
nlm.nih.gov/books/NBK448185/. Accessed March 6, 2022.
32. Patterson TF, Kauffman CA, Hall KK. UpToDate. Available at: https://www.
uptodate.com/contents/treatment-and-prevention-of-invasive-aspergillosis?
search5aspergillus%20pneumonia&source5search_
result&selectedTitle52w150&usage_type5default&display_rank52#H5. Ac-
cessed March 6, 2022.
33. Woolfrey KGH. Pneumonia in adults: the practical emergency department
perspective. Emerg Med Clin North Am 2012;30(2):249–70.
34. Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Tho-
rax 2015;70(3):270–7.
35. Khan AA, Farooq F, Jain SK, et al. Comparative host-pathogen interaction ana-
lyses of SARS-CoV2 and aspergillus fumigatus, and pathogenesis of COVID-
19-associated aspergillosis. Microb Ecol 2021;(Nov 4):1–9.