ACEP COVID-19 Field Guide

Authors: ACEP Clinical Policies Committee and Clinical Policies Subcommittee (Writing Committee) on Community-Acquired Pneumonia: Michael D. Smith, MD, MBA (Subcommittee Chair); Christopher Fee, MD; Sharon E. Mace, MD; Brandon Maughan, MD, MHS, MSHP; John C. Perkins Jr, MD; Amy Kaji, MD, MPH, PhD (Methodologist); and Stephen J. Wolf, MD (Committee Chair)

Background

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of adult patients presenting to the emergency department with community-acquired pneumonia. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the below critical questions. For each question, a systematic literature search was performed, evidence was graded and synthesized, and recommendations were made based on the strength of the available data. The background text, systematic review, and critical analysis of the literature are published in the January 2021 issue of Annals of Emergency Medicine.

1. In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? 

Patient Management Recommendations

• Level A recommendations. None specified.
• Level B recommendations. The Pneumonia Severity Index (PSI) and CURB-65 decision aids can support clinical judgment by identifying patients at low risk of mortality who may be appropriate for outpatient treatment. Although both decision aids are acceptable, the PSI is supported by a larger body of evidence and is preferred by other society guidelines (ATS/IDSA 2019 guidelines).
• Level C recommendations. Among patients not receiving vasopressors or mechanical ventilation, use the 2007 IDSA/ATS Minor Criteria rather than mortality prediction aids such as the PSI or CURB-65 to help establish which patients are most appropriate for care based in an ICU setting (Consensus recommendation).
• Do not routinely use biomarkers to augment the performance of clinical decision aids to guide the disposition of emergency department patients with community-acquired pneumonia (Consensus recommendation).
• Use community-acquired pneumonia clinical decision aids in conjunction with physician clinical judgment in the context of each patient’s circumstances when making disposition decisions (Consensus recommendation).

2. In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? 

Patient Management Recommendations

• Level A recommendations. None specified.
• Level B recommendations. None specified.
• Level C recommendations. Do not rely upon any current laboratory test(s), such as procalcitonin and/or C-reactive protein, to distinguish a viral pathogen from a bacterial pathogen when deciding on administration of antimicrobials in emergency department patients who have community-acquired pneumonia.

3. In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? 

Patient Management Recommendations

• Level A recommendations. None specified.
• Level B recommendations. None specified.
• Level C recommendations. Given the lack of evidence, the decision to administer a single dose of parenteral antibiotics prior to oral therapy should be guided by patient risk profile and preferences (Consensus recommendation).

Translation of classes of evidence to recommendation levels

Based on the strength of evidence grading for each critical question, the subcommittee drafted the recommendations and the supporting text synthesizing the evidence, using the following guidelines:

• Level A recommendations. Generally accepted principles for patient care that reflect a high degree of scientific clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies demonstrating consistent effects or estimates).
• Level B recommendations. Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate scientific certainty (eg, based on evidence from 1 or more Class of Evidence II studies or multiple Class of Evidence III studies demonstrating consistent effects or estimates).
• Level C recommendations. Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of any adequate published literature, based on expert consensus. In instances where consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.

References

1. 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 Respir Crit Care Med. 2019;200:e45-e67. 
2. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S27-S72.