Suspected CAP
Acute respiratory symptoms + new infiltrate on imaging
All Pathways
Infectious DiseaseManagement
Community-Acquired Pneumonia Management (ATS 2025)
Community-Acquired Pneumonia Management (ATS 2025): Suspected CAP → Confirm Diagnosis → Assess Severity → Outpatient Treatment → Duration of Therapy.
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Confirm Diagnosis
Clinical presentation + imaging
- Symptoms: Cough, fever, dyspnea, pleuritic chest pain
- Physical: Crackles, bronchial breath sounds, egophony
- Chest X-ray or CT showing infiltrate
- Consider point-of-care ultrasound
03Decision Assess Severity
Determine site of care
- CURB-65: Confusion, Urea >7, RR ≥30, BP <90/60, Age ≥65
- 0-1: Outpatient, 2: Consider admission, 3-5: Inpatient/ICU
- PSI: Alternative severity score
- Clinical judgment for social/compliance factors
04Action Outpatient Treatment
CURB-65 0-1, no comorbidities
- Previously healthy, no risk factors:
- Amoxicillin 1g PO TID x5 days, OR
- Doxycycline 100mg PO BID x5 days, OR
- Azithromycin 500mg day 1, then 250mg days 2-5
- With comorbidities: Augmentin + macrolide OR respiratory FQ
05Action Duration of Therapy
Shorter courses recommended
- Minimum 5 days for uncomplicated CAP
- Continue until afebrile ≥48h and clinically stable
- Severe/complicated: 7 days minimum
- Procalcitonin can guide de-escalation
- Longer if: S. aureus bacteremia, lung abscess, empyema
06Decision Consider Corticosteroids?
For severe CAP
- Suggested for severe CAP with high inflammatory markers
- Hydrocortisone 200mg/day or Methylprednisolone 40mg/day
- May reduce mortality and need for mechanical ventilation
- Avoid in influenza without bacterial coinfection
07Decision Clinical Response by 72h?
Assess for improvement
- Expect improvement in 48-72 hours
- Fever, WBC, respiratory status should trend down
- CRP/procalcitonin should decrease
08Outcome Improving - Continue Course
Switch to oral when stable
- IV to PO when: Tolerating PO, improving, no GI absorption issues
- Complete course as outpatient if appropriate
- Follow-up imaging at 6-8 weeks if indicated
09Warning Not Improving
Evaluate for complications or alternative diagnoses
- Repeat imaging (CT chest)
- Consider bronchoscopy with BAL
- Rule out: Empyema, abscess, resistant organism
- Evaluate for non-infectious causes
- Expand antimicrobial coverage
10Action Inpatient Non-ICU
CURB-65 2-3, not critically ill
- Ampicillin-sulbactam 3g IV q6h + Azithromycin 500mg IV daily, OR
- Ceftriaxone 1-2g IV daily + Azithromycin 500mg IV daily, OR
- Respiratory fluoroquinolone monotherapy:
- Levofloxacin 750mg IV/PO daily OR Moxifloxacin 400mg IV/PO daily
11Decision Pseudomonas Risk Factors?
Assess need for antipseudomonal coverage
- Structural lung disease (bronchiectasis, CF)
- Frequent antibiotics or prior Pseudomonas
- Recent hospitalization/IV antibiotics
12Action Add Antipseudomonal Coverage
Use antipseudomonal beta-lactam
- Piperacillin-tazobactam 4.5g IV q6h, OR
- Cefepime 2g IV q8h, OR
- Meropenem 1g IV q8h
- PLUS respiratory fluoroquinolone or aminoglycoside
- Path rejoins step 05Shared downstream outcome
- Path rejoins step 05Shared downstream outcome
13Action ICU/Severe CAP
CURB-65 4-5, major criteria, or shock/ventilation
- Beta-lactam (Ceftriaxone 2g daily or Ampicillin-sulbactam 3g q6h)
- PLUS Azithromycin 500mg daily OR Respiratory fluoroquinolone
- Major criteria: Septic shock, mechanical ventilation
- Minor criteria: RR ≥30, PaO2/FiO2 ≤250, multilobar, confusion, BUN ≥20, WBC <4000, platelets <100K, hypothermia, hypotension
14Decision MRSA Risk Factors?
Assess need for MRSA coverage
- Prior MRSA infection/colonization
- Recent hospitalization with IV antibiotics
- Influenza with rapid cavitation
- Gram stain with GPC in clusters
15Action Add MRSA Coverage
Vancomycin or Linezolid
- Vancomycin 15-20 mg/kg IV q8-12h (target trough 15-20), OR
- Linezolid 600mg IV/PO q12h (preferred for necrotizing)
- De-escalate if nasal swab negative and cultures negative at 48h
- Path rejoins step 05Shared downstream outcome
- Path rejoins step 05Shared downstream outcome
- Path rejoins step 11Shared downstream outcome
Guideline Source
Diagnosis and Management of Community-Acquired Pneumonia: An Official ATS Clinical Practice Guideline 2025
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not replace clinical judgment - patient factors may require deviation
- Antibiotic choices should consider local resistance patterns and antibiograms
- Risk stratification tools (PSI, CURB-65) should guide disposition
- Does not address healthcare-associated pneumonia (HCAP) category
- Immunocompromised patients require broader coverage
Applicable Regions
USEUInternational
EU: Similar approach; penicillin-based regimens may be preferred in some countries
US: Consider macrolide resistance in regions >25% resistance; fluoroquinolone alternative
International: Adapt empiric coverage to local pathogen epidemiology
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Community-Acquired Pneumonia Management (ATS 2025)?
The Community-Acquired Pneumonia Management (ATS 2025) is a management clinical algorithm for Infectious Disease. It provides a structured decision tree to guide clinical decision-making, based on Diagnosis and Management of Community-Acquired Pneumonia: An Official ATS Clinical Practice Guideline 2025.
What guideline is the Community-Acquired Pneumonia Management (ATS 2025) based on?
This algorithm is based on Diagnosis and Management of Community-Acquired Pneumonia: An Official ATS Clinical Practice Guideline 2025 (DOI: 10.1164/rccm.202507-1692ST).
What are the limitations of the Community-Acquired Pneumonia Management (ATS 2025)?
Known limitations include: Does not replace clinical judgment - patient factors may require deviation; Antibiotic choices should consider local resistance patterns and antibiograms; Risk stratification tools (PSI, CURB-65) should guide disposition; Does not address healthcare-associated pneumonia (HCAP) category; Immunocompromised patients require broader coverage. Individual patient factors may require deviation from these recommendations.
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