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Community-Acquired Pneumonia Management (ATS 2025)

Community-Acquired Pneumonia Management (ATS 2025): START: Community-Acquired Pneumonia → Confirm Diagnosis → Severity Assessment → Outpatient Treatment...

Pathway Overview

18 steps

Algorithm Steps

18 total

  1. 01Start

    START: Community-Acquired Pneumonia

    Acute lower respiratory infection with pulmonary infiltrate

  2. 02Action

    Confirm Diagnosis

    Clinical + radiographic

    • Acute onset cough + at least one of:
    • - Fever/hypothermia
    • - Dyspnea, tachypnea
    • - New focal chest findings
    • PLUS new pulmonary infiltrate on imaging
    • Consider COVID-19, influenza testing
  3. 03Decision

    Severity Assessment

    Use validated scoring system

    • PSI (Pneumonia Severity Index): Class I-III = low risk
    • CURB-65: 0-1 = low risk, 2 = intermediate, 3-5 = high risk
    • Clinical judgment always required
  4. 04Action

    Outpatient Treatment

    Low severity, no comorbidities

    • PSI Class I-II OR CURB-65 0-1
    • No hypoxemia (SpO2 ≥92%)
    • Able to take oral medications
    • Adequate home support
  5. 05Decision

    Comorbidities or Risk Factors?

    Determine antibiotic regimen

    • Comorbidities: CHF, COPD, CKD, DM, liver disease, alcoholism, malignancy, asplenia
    • Risk factors: Antibiotic use in prior 90 days, MRSA/Pseudomonas risk
  6. 06Action

    Healthy Outpatient

    No comorbidities, no risk factors

    • PREFERRED: Amoxicillin 1g PO TID x 5 days
    • OR Doxycycline 100mg PO BID x 5 days
    • Azithromycin 500mg day 1, 250mg days 2-5 (if local resistance <25%)
  7. 07Outcome

    Discharge

    Complete course and follow-up

    • Complete antibiotic course (5-7 days typical)
    • Smoking cessation counseling
    • Pneumococcal and influenza vaccines if indicated
    • Chest X-ray at 6 weeks for smokers/age >50
    • Return if worsening
  8. 08Action

    Outpatient with Comorbidities

    Need broader coverage

    • Amoxicillin-clavulanate 875/125 PO BID
    • PLUS Azithromycin 500mg day 1, 250mg days 2-5
    • OR Respiratory fluoroquinolone monotherapy:
    • - Levofloxacin 750mg PO daily x 5 days
    • - Moxifloxacin 400mg PO daily x 5 days
  9. Path rejoins step 07Shared downstream outcome
  10. 09Action

    Inpatient (Non-ICU)

    Moderate severity

    • PSI Class III-IV OR CURB-65 2
    • Hypoxemia requiring O2
    • Unable to take oral medications
    • Significant comorbidities
  11. 10Action

    Inpatient Non-ICU Antibiotics

    IV therapy

    • PREFERRED: Beta-lactam + Macrolide
    • - Ceftriaxone 1-2g IV daily + Azithromycin 500mg IV/PO daily
    • - Ampicillin-sulbactam 3g IV q6h + Azithromycin
    • ALTERNATIVE: Respiratory fluoroquinolone alone
    • - Levofloxacin 750mg IV daily
    • Duration: Minimum 5 days, afebrile ≥48h before stop
  12. 11Decision

    Reassess at 48-72 Hours

    Evaluate response

    • IMPROVING: Afebrile, hemodynamically stable, improving respiratory status, able to eat
    • NOT IMPROVING: Persistent fever, worsening hypoxemia, new infiltrates
  13. 12Action

    IV to PO Switch

    Transition and discharge planning

    • Switch to oral when: Clinically improving, GI tract functional, no other IV needs
    • Total duration: 5 days minimum (may extend if slow response)
    • Discharge when stable on oral therapy
  14. Path rejoins step 07Shared downstream outcome
  15. 13Warning

    Treatment Failure

    No improvement at 48-72h

    • Consider complications: Empyema, abscess, ARDS
    • Broaden antibiotics
    • CT chest
    • Consider bronchoscopy
    • Rule out non-infectious causes
  16. 14Warning

    ICU Admission

    Severe CAP

    • MAJOR CRITERIA (1 required): Septic shock, mechanical ventilation
    • MINOR CRITERIA (≥3 required): RR ≥30, PaO2/FiO2 ≤250, multilobar infiltrates, confusion, BUN ≥20, WBC <4K, platelets <100K, hypothermia, hypotension needing fluids
  17. 15Action

    ICU Antibiotics

    Aggressive coverage

    • Beta-lactam + Macrolide or Fluoroquinolone:
    • - Ceftriaxone 2g IV daily + Azithromycin 500mg IV
    • - OR Ceftriaxone + Levofloxacin 750mg IV
    • Add Vancomycin if MRSA risk factors
    • Add anti-pseudomonal if risk factors
  18. 16Decision

    MRSA or Pseudomonas Risk?

    Determine if additional coverage needed

    • MRSA risks: Prior MRSA infection/colonization, recent hospitalization, hemodialysis, IV drug use
    • Pseudomonas risks: Structural lung disease, frequent antibiotics, prior Pseudomonas
  19. 17Action

    Add MRSA Coverage

    If risk factors present

    • Vancomycin 15-20 mg/kg IV q8-12h (target trough 15-20)
    • OR Linezolid 600mg IV/PO q12h
    • De-escalate if cultures negative at 48-72h
  20. Path rejoins step 11Shared downstream outcome
  21. 18Action

    Add Pseudomonas Coverage

    If risk factors present

    • Piperacillin-tazobactam 4.5g IV q6h
    • OR Cefepime 2g IV q8h
    • OR Meropenem 1g IV q8h
    • De-escalate based on cultures
  22. Path rejoins step 11Shared downstream outcome
  23. Path rejoins step 11Shared downstream outcome

Guideline Source

ATS Clinical Practice Guideline: Community-Acquired Pneumonia 2025

DOI: 10.1164/rccm.202507-1692stView Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Local resistance patterns may differ - check antibiogram
  • Does not address hospital-acquired or ventilator-associated pneumonia
  • Immunocompromised patients need broader coverage
  • Severity scores should be calculated formally
  • Aspiration pneumonia may need anaerobic coverage

Applicable Regions

USEUGlobal

EU: ERS/ESICM guidelines may differ slightly

US: ATS 2025 is latest US guideline

Version 1Next review: 2028-01-01

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Frequently Asked Questions

What is the Community-Acquired Pneumonia Management (ATS 2025)?

The Community-Acquired Pneumonia Management (ATS 2025) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on ATS Clinical Practice Guideline: Community-Acquired Pneumonia 2025.

What guideline is the Community-Acquired Pneumonia Management (ATS 2025) based on?

This algorithm is based on ATS Clinical Practice Guideline: Community-Acquired Pneumonia 2025 (DOI: 10.1164/rccm.202507-1692st).

What are the limitations of the Community-Acquired Pneumonia Management (ATS 2025)?

Known limitations include: Local resistance patterns may differ - check antibiogram; Does not address hospital-acquired or ventilator-associated pneumonia; Immunocompromised patients need broader coverage; Severity scores should be calculated formally; Aspiration pneumonia may need anaerobic coverage. Individual patient factors may require deviation from these recommendations.

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