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pulm.cap.core.v1

Community-Acquired Pneumonia

pulmonologyacuteadultoutpatientacuteinpatient
Start encounter →Print handoutPRODUCTION

CAP = severity-driven site-of-care + empiric-coverage engine. §5.5.2 wired: CURB-65 bands as data (0-1 ~1.5% 30-d mortality → outpatient; 2 ~9% → ward; 3-5 ~22% → ICU consideration — Lim Thorax 2003 PMID 12728155) and PSI/PORT class I-V mortality (I 0.1%, II 0.6-0.7%, III 0.9-2.8%, IV 8.2-9.3%, V 27-31% — Fine NEJM 1997 PMID 8995086) encoded in calculators[].guideline_basis + RISK_STRATIFICATION phase + severity_triggers; IDSA severe-CAP ≥1 major or ≥3 minor → ICU + CAPE-COD steroid candidacy. Procalcitonin bacterial-vs-viral likelihood as data with dose-response: undetectable PCT 4% IRVS risk vs PCT ≥10 ng/mL 22.4% (Self CHEST 2016 PMID 27107491); ProACT (Huang NEJM 2018 PMID 29781385) showed no antibiotic-exposure reduction with a PCT algorithm in a high-adherence US LRTI cohort — encoded as do-NOT-withhold-abx-on-low-PCT in confirmed CAP. Two conditional dependencies explicitly modeled (do-not-multiply-independently): (1) procalcitonin LR | positive viral PCR — a low PCT in a virus-positive patient lowers but does not eliminate bacterial probability (severity_trigger procalcitonin_low_with_positive_viral_pcr; INITIAL_WORKUP phase logic); (2) CURB-65/PSI mortality band | comorbidity/age burden — the frail elderly may warrant higher acuity than the raw score (RISK_STRATIFICATION phase purpose; curb65_3_or_more_severe_icu trigger rationale). Effect sizes wired with PMIDs (≥8): CAPE COD 28-d mortality 6.2% vs 11.9% (absolute −5.6 pp; P=0.006), intubation HR 0.59, vasopressor-initiation HR 0.59 (36942789); Torres treatment failure 13% vs 31% OR 0.34 (25688779); ESCAPe neutral 60-d mortality for low-dose late MP (35723686); Uranga day-30 success 91.9% vs 88.6% non-inferior with ≥5 d + stability stop rule (27455166); CURB-65 0-1 ~1.5% vs 3-5 ~22% 30-d mortality (12728155); PSI class I 0.1% vs V 27-31% (8995086); adult EPIC pathogen detected only 38%, viruses 23% > bacteria 11%, S. pneumoniae 5% (26172429); Self PCT-IRVS 4% vs 22.4% (27107491); ProACT no abx-day reduction (29781385). Cross-dossier routing via workups[].branches_to (11 engine_ids) + sibling_differentiation[].sibling_engine_id (3 blocks) using grep-verified real engine_ids: pulm.aspiration-pneumonia.core.v1, cardio.acute-hf.core.v1, pulm.pe.core.v1, pulm.tuberculosis.v1, pulm.atypical-pneumonia.v1, pulm.hospital-acquired-pneumonia-non-covid.v1, pulm.pcp-pneumonia.core.v1, id.sepsis.core.v1, id.influenza.core.v1, id.covid19.core.v1. Differential pivots: CAP vs HF (NT-proBNP/echo/procalcitonin), vs PE (D-dimer/CTPA Bayesian), vs aspiration (risk substrate/lobe/anaerobe), vs TB/atypical/COVID/influenza (DIFFERENTIAL phase). Co-existence: CAP+sepsis (cap_with_septic_shock_sepsis_overlap → SSC 2026 / id.sepsis.core.v1), CAP+COPD-exacerbation (structural-lung-disease input + inpatient bronchodilator). Special populations: pregnancy (avoid doxycycline/FQ — β-lactam + macrolide; contraindication_rules); renal (eGFR dose-adjust β-lactams/FQ/vancomycin-AUC/oseltamivir — calc.ckd_epi_2021 + contraindication_rules); hepatic (macrolide caution, ceftriaxone biliary sludging → cefotaxime); immunocompromised (immunocompromised_broaden_differential trigger → PJP/fungal pointer pulm.pcp-pneumonia.core.v1); elderly (atypical presentation, aspiration overlap, score-mortality conditional on comorbidity); COPD/bronchiectasis (Pseudomonas risk); post-influenza (S. aureus incl MRSA — entry point + mrsa_risk_pattern trigger). Regimen axis cap_empirics_by_setting: 4 stepwise tiers (outpatient healthy / outpatient comorbid / ward / ICU-severe) + non-stepwise MRSA / antipseudomonal / steroid-alternative / O2 drugs; spectrum by severity × MRSA/Pseudomonas risk × comorbidity; renal/hepatic dose-adjust + IV→PO Halm switch + steroid adjunct (CAPE COD) + duration/de-escalation/stop logic. Matches pulm.pe.core.v1 regimen depth. RxCUI FIXES (RxNav REST /rxcui/{cui}/properties.json verified 2026-05-16): hydrocortisone 5489→5492 (5489 was hydrocodone — SAFETY-CRITICAL); piperacillin-tazobactam 18631→74169 (18631 was azithromycin; 74169 confirmed MIN piperacillin/tazobactam); meropenem 74169→29561; amoxicillin-clavulanate 723→19711 (723 was amoxicillin ingredient); ampicillin-sulbactam 733→1009148 (733 was ampicillin ingredient); methylprednisolone added 6902 (verified IN). Verified-correct unchanged: amoxicillin 723, doxycycline 3640, azithromycin 18631, ceftriaxone 2193, cefpodoxime 20489, levofloxacin 82122, moxifloxacin 139462, vancomycin 11124, linezolid 190376, cefepime 20481, oseltamivir 260101, oxygen 7806. SCHEMA-GAP NOTES: (1) _types.ts has no first-class field for severity-score mortality bands / procalcitonin LR / pretest-prevalence — encoded in calculators[].guideline_basis, severity_triggers, phase purpose/advance_when, regimen rationale, and the .depth.md band table; (2) no conditional-dependency graph type — modeled narratively in 2 severity_triggers + INITIAL_WORKUP/RISK_STRATIFICATION phase logic; (3) RequiredCalculator.drives enum lacks "diagnostic_gate" — CURB-65/PSI reuse "disposition"; (4) RequiredInput.kind has no "panel"/"score" — viral PCR encoded as kind:"lab" id:respiratory_viral_pcr. PRODUCTION blockers: (1) RxCUIs now RxNav-verified/corrected 2026-05-16 but run npm run research:rxnav:validate before relying on dosing automation (combination MIN/SCD selection may differ from ingredient IN); (2) calc.psi_port/curb65/qsofa/sofa/ckd_epi_2021 confirmed in clinical-tools-registry.ts but IDSA severe-CAP minor/major checker + Halm criteria not yet calculator-wired; (3) no engine-workup-link entry for hap_vap; (4) no engine-specific test file under tests/. Manifest/package pointers unchanged per dispatch scope; design_brief repointed to co-located src/lib/dossiers/pulm.cap.core.v1._design-brief.md in DEPTH-PASS-2. DEPTH-PASS-2 2026-05-17 (shard-07-cardio-chronic CL-4, golden-template = cardio.htn.core.v1) added: (1) co-located src/lib/dossiers/pulm.cap.core.v1._research-bundle.md + _design-brief.md per §5.5 items 1+2 (8 sections / 6 sections mirroring htn template; 16 verified PMIDs w/ effect sizes + 95% CI + retrieval-dated 2026-05-17; dose-effect anchors w/ mortality/clinical-cure; RxCUI log; Consensus→WebSearch/WebFetch fallback logged; pre-test priors w/ cohort sources; T_test≈1.5%/T_treat≈9% site-of-care decision; cross-dossier routing to pulm.aspiration-pneumonia.core.v1 / pulm.hospital-acquired-pneumonia-non-covid.v1 / id.sepsis.core.v1 / pulm.empyema.v1); design_brief: repointed to the co-located path. (2) prisma/seed/ros-and-ddx/pulm.cap.core.v1.{differentials,ros,finding-lrs}.ts (ENGINE_ID pulm.cap.core.v1, htn-template Prisma shapes exactly): 12 differentials (9 pathogen/mimic categories — bacterial/atypical/viral/aspiration/HAP-HCAP/TB/PE-infarct/CHF/organising-mimic — + 3 MECE CAP-severity strata outpatient/ward/severe-ICU by CURB-65/PSI/IDSA-ATS) w/ cohort priors; 15 ROS; 26 LR rows (19 LR+ ≥3.0, 24 LR− ≤0.85 — all 26 carry both LR+ and LR−; focal-crackles/egophony/CXR-infiltrate/CURB-65-PSI-bands/procalcitonin-bands/lactate/hypoxia); 3 conditional-dependency rules (CURB-65/PSI band NOT component-multiplied; procalcitonin | viral-vs-bacterial not-independent; Metlay-1997 rule-out superseded by imaging). (3) 2nd regimen axis cap_phenotype_matrix — drug × risk-factor gating as DATA (MRSA→vanc/linezolid; Pseudomonas→pip-tazo/cefepime/meropenem REPLACING backbone; aspiration→amox-clav/amp-sulbactam; severe-CAP→hydrocortisone CAPE-COD; influenza→oseltamivir; penicillin-allergy→FQ/doxy; pregnancy→β-lactam+macrolide) — total regimen_axes = 2. (4) Dose-effect enriched: CAPE COD 28-d mortality 6.2% vs 11.9% −5.6 pp (−9.6 to −1.7) P=0.006, intubation HR 0.59 (0.40-0.86), vasopressor HR 0.59 (0.43-0.82) in steroid rationale. (5) Content refresh to 2025/26 ATS: authorship corrected (Metlay/Waterer→Jones/Ramirez et al., AJRCCM 2026;212(1):24-44); 2019 ATS/IDSA PMID 31573350 ADDED (was prose-only); duration refreshed to <5 d (min 3) if stable; corticosteroids strong-AGAINST non-severe / conditional-FOR severe; lung-US acceptable CXR alternative; outpatient+no-comorbidity+viral-positive→no empiric abx; HCAP stays retired w/ Gasoyan-2024 38.8-pp ESA-reduction support; evidence.pmids 10→16 (added 31573350, 29037960 Schuetz IPD OR 0.83 [0.70-0.99], 25830421 CAP-START, 9356004 Metlay-1997, 9600479 Halm, 11228282 Marik). (6) RxCUI: ZERO dossier changes — all 18 RxCUIs RxNav-verified-correct 2026-05-17 (amox 723, amox-clav 19711, doxy 3640, azithro 18631, cefpodoxime 20489, ceftriaxone 2193, amp-sulbactam 1009148, levo 82122, moxi 139462, pip-tazo 74169, cefepime 20481, meropenem 29561, vanc 11124, linezolid 190376, hydrocortisone 5492, methylpred 6902, oseltamivir 260101, oxygen 7806); profile-file combo stale CUIs (392151/392275/283837) are the 96-fail baseline, OUT OF SCOPE. status: PRODUCTION retained. DEPTH-PASS-3 2026-05-26 (lane-E): +NMA +USPSTF +Cochrane +ICER stubs +decision thresholds, side-car at pulm.cap.core.v1._depth-pass-3.md.

Entry points (5)

  • symptom
    Cough + fever ± dyspnea ± pleuritic chest pain (2025 ATS CAP §Diagnosis)
    cough_fever
  • imaging
    New infiltrate on CXR / consolidation on lung ultrasound — imaging confirmation required (2025 ATS CAP §Imaging)
    new_infiltrate
  • vital_abnormality
    Tachypnea + tachycardia + temperature derangement → screen CAP-sepsis (Sepsis-3; SSC 2026)
    sirs_with_resp
  • lab_abnormality
    Leukocytosis with bandemia ± elevated procalcitonin/CRP — supports but does not establish bacterial CAP (Self CHEST 2016 PMID 27107491)
    leukocytosis_or_procalcitonin
  • history
    Secondary deterioration after influenza → post-influenza S. aureus/MRSA pneumonia (2019 ATS/IDSA) — see id.influenza.core.v1
    post_influenza_deterioration

Required inputs (21)

  • agerequired
    demographic • used at CONTEXT
    CURB-65 element + PSI age points + outpatient candidacy; mortality band is conditional on age/comorbidity burden (Lim Thorax 2003 PMID 12728155; Fine NEJM 1997 PMID 8995086)
  • sbprequired
    vital • used at CONTEXT
    CURB-65 (SBP <90 / DBP ≤60) + sepsis screening (Lim Thorax 2003 PMID 12728155)
  • rrrequired
    vital • used at CONTEXT
    CURB-65 (RR ≥30) + IDSA severe-CAP minor criterion (RR ≥30) + qSOFA (Lim Thorax 2003 PMID 12728155; Metlay AJRCCM 2019)
  • spo2required
    vital • used at CONTEXT
    Hypoxemia threshold for admission; P/F ≤250 is an IDSA severe-CAP minor criterion (2025 ATS CAP; Metlay AJRCCM 2019)
  • temprequired
    vital • used at CONTEXT
    Sepsis screening; T <36°C is an IDSA severe-CAP minor criterion; bacterial vs viral pattern (Metlay AJRCCM 2019)
  • bun
    lab • used at INITIAL_WORKUP
    CURB-65 (BUN >19 mg/dL ≈ urea >7 mmol/L); BUN ≥20 mg/dL is an IDSA severe-CAP minor criterion (Lim Thorax 2003 PMID 12728155)
  • confusion
    symptom • used at CONTEXT
    CURB-65 (new confusion / AMT ≤8); AMS is an IDSA severe-CAP minor criterion (Lim Thorax 2003 PMID 12728155)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    eGFR/CrCl for renal dose adjustment of β-lactams, fluoroquinolones, vancomycin, oseltamivir (2025 ATS CAP)
  • wbc
    lab • used at INITIAL_WORKUP
    Leukocytosis/lymphopenia bacterial-vs-viral pattern; WBC <4×10⁹/L is an IDSA severe-CAP minor criterion (Metlay AJRCCM 2019; Jain NEJM 2015 PMID 26172429)
  • platelets
    lab • used at INITIAL_WORKUP
    Platelets <100×10⁹/L is an IDSA severe-CAP minor criterion (Metlay AJRCCM 2019)
  • lactate
    lab • used at INITIAL_WORKUP
    CAP-sepsis severity / SSC 2026 bundle; lactate clearance monitoring (SSC 2026)
  • procalcitonin
    lab • used at INITIAL_WORKUP
    Bacterial-vs-viral likelihood (LR conditional on viral co-infection) + IRVS-risk dose-response; do NOT withhold abx on a low PCT in confirmed CAP (Self CHEST 2016 PMID 27107491; ProACT Huang NEJM 2018 PMID 29781385)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Confirms pneumonia; lung ultrasound or CT acceptable when CXR equivocal (2025 ATS CAP §Imaging)
  • respiratory_viral_pcr
    lab • used at INITIAL_WORKUP
    Multiplex respiratory PCR (influenza/SARS-CoV-2/RSV) — drives oseltamivir/antiviral and de-escalation; viral detection shifts the procalcitonin LR (2025 ATS CAP; Jain NEJM 2015 PMID 26172429)
  • prior_mrsa_pseudomonas
    history • used at CONTEXT
    Prior MRSA/Pseudomonas isolation (esp. respiratory, last 1 yr) overrides empiric narrowing (2025 ATS CAP; Metlay AJRCCM 2019)
  • recent_abx_or_hospitalization
    history • used at CONTEXT
    Resistant-pathogen risk (IV abx within 90 d, hospitalisation ≥2 d in 90 d) — locally validated risk weighting replaces the retired HCAP construct (Metlay AJRCCM 2019)
  • structural_lung_disease
    history • used at CONTEXT
    Bronchiectasis / severe COPD raises Pseudomonas risk and CAP+COPD-exacerbation overlap (2025 ATS CAP)
  • immunocompromise
    history • used at CONTEXT
    Immunocompromise broadens differential to PJP/fungal/Nocardia → route to pulm.pcp-pneumonia.core.v1 / id.invasive-aspergillosis.core.v1 (2025 ATS CAP)
  • aspiration_risk
    history • used at CONTEXT
    Dysphagia, AMS, alcohol, stroke, dementia, tube feeds → aspiration-CAP overlap (Marik NEJM 2001) — see pulm.aspiration-pneumonia.core.v1
  • pregnancy
    history • used at CONTEXT
    Antibiotic safety (avoid doxycycline/fluoroquinolone; β-lactam + macrolide preferred) (2025 ATS CAP; pregnancy labelling)
  • current_meds
    medication • used at CONTEXT
    Macrolide/FQ QT interactions, FQ tendon/aortic risk, β-lactam allergy, chronic corticosteroid (modifies CAPE-COD steroid decision) (2025 ATS CAP)

12-phase flow (12)

  1. 1FRAME
    Confirm CAP scope — community onset (not HAP/VAP, not COVID-pneumonia-only, not active TB), adult population; HCAP construct retired (route nosocomial risk to pulm.hospital-acquired-pneumonia-non-covid.v1) (Metlay AJRCCM 2019; 2025 ATS CAP)
    advance: Onset history confirms community acquisition
  2. 2ENTRY
    Trigger from cough/fever, new infiltrate, sepsis screen, or post-influenza deterioration (2025 ATS CAP §Diagnosis)
    inputs: age
    advance: Entry symptom or imaging present
  3. 3CONTEXT
    Capture severity inputs (sets the mortality/site-of-care prior), comorbidities, recent abx/hospitalisation, MRSA/Pseudomonas risks, immunocompromise, aspiration risk, pregnancy, allergies, chronic steroid, vaccination status (2025 ATS CAP; Metlay AJRCCM 2019)
    inputs: sbp, rr, spo2, temp, confusion, prior_mrsa_pseudomonas, recent_abx_or_hospitalization, structural_lung_disease, immunocompromise, aspiration_risk, pregnancy, current_meds
    advance: Risk factors and severity inputs captured
  4. 4RED_FLAGS
    Septic shock / vasopressor need, acute hypoxemic respiratory failure / mechanical ventilation, parapneumonic effusion-empyema, multilobar disease — these are IDSA severe-CAP MAJOR criteria → ICU + sepsis bundle now (Metlay AJRCCM 2019; SSC 2026)
    inputs: sbp, spo2
    actions: calc.qsofa
    advance: No emergent escalation needed or sepsis bundle initiated
  5. 5INITIAL_WORKUP
    Imaging confirmation (CXR / LUS / CT) + CBC-diff, BMP, lactate; in SEVERE CAP add blood cultures ×2, urinary pneumococcal + Legionella antigen, sputum Gram/culture; multiplex respiratory PCR (influenza/SARS-CoV-2/RSV); procalcitonin selectively (interpret bacterial-vs-viral LR conditional on a positive viral PCR — do NOT withhold abx on low PCT in confirmed CAP) (2025 ATS CAP; Self CHEST 2016 PMID 27107491)
    inputs: cxr, wbc, creatinine, bun, lactate, procalcitonin, respiratory_viral_pcr, platelets
    advance: Imaging confirms infiltrate + severity labs sent
  6. 6BRANCHING_WORKUP
    CT chest if poor response/complication; pleural fluid analysis (pH, LDH, glucose, culture) if effusion >1 cm; bronchoscopy if immunocompromised or non-resolving; TB testing if risk factors / upper-lobe cavitation (route pulm.tuberculosis.v1); broaden to PJP/fungal if immunocompromised (route pulm.pcp-pneumonia.core.v1) (2025 ATS CAP)
    inputs: immunocompromise
    advance: Branch tests obtained when triggered
  7. 7DIFFERENTIAL
    Typical bacterial vs atypical (Mycoplasma/Legionella/Chlamydophila → pulm.atypical-pneumonia.v1) vs viral (influenza → id.influenza.core.v1; SARS-CoV-2 → id.covid19.core.v1; RSV) vs aspiration (pulm.aspiration-pneumonia.core.v1) vs TB (pulm.tuberculosis.v1) vs non-infectious mimics: decompensated HF (NT-proBNP/echo pivot → cardio.acute-hf.core.v1), PE (D-dimer/CTPA pivot → pulm.pe.core.v1), lung abscess, organising pneumonia, malignancy (Jain NEJM 2015 PMID 26172429)
    advance: Working pathogen/diagnosis category assigned
  8. 8RISK_STRATIFICATION
    CURB-65 band → 30-d mortality + site-of-care LR (0-1 ~1.5% → outpatient; 2 ~9% → ward; 3-5 ~22% → ICU consideration); PSI/PORT class I-V (class I-II ~0.1-0.9% → outpatient; IV-V ~9-27% → admit/ICU); IDSA severe-CAP = ≥1 major OR ≥3 minor → ICU + steroid candidacy. Mortality band is CONDITIONAL on comorbidity/age burden — do not read CURB-65 in isolation in the frail elderly (Lim Thorax 2003 PMID 12728155; Fine NEJM 1997 PMID 8995086; Metlay AJRCCM 2019)
    inputs: sbp, rr, bun, confusion
    actions: calc.curb65, calc.psi_port, calc.sofa
    advance: Severity score documented and disposition implied
  9. 9TREATMENT
    2025 ATS empirics by site-of-care: outpatient healthy → amoxicillin or doxycycline (or macrolide where resistance <25%); outpatient comorbid → β-lactam + macrolide/doxy OR respiratory FQ; ward → β-lactam + macrolide (or FQ monotherapy); ICU/severe → β-lactam + macrolide (combination mortality signal) OR β-lactam + FQ. Add MRSA (vancomycin/linezolid) and/or antipseudomonal (pip-tazo/cefepime/meropenem) ONLY with locally validated risk factors. Hydrocortisone in severe CAP (CAPE COD PMID 36942789 — 28-d mortality 6.2% vs 11.9%; exclude influenza/uncontrolled viral). Oseltamivir if influenza or flu-season hospitalised. Duration ≥5 d + clinical stability (Uranga PMID 27455166); 3-5 d in low-risk per 2025 ATS. Renal/hepatic dose-adjust (2025 ATS CAP)
    inputs: creatinine, respiratory_viral_pcr
    actions: calc.ckd_epi_2021
    advance: Empiric regimen + duration + steroid decision documented
  10. 10DISPOSITION
    Outpatient if CURB-65 0-1 / PSI I-II + SpO2 ≥92% + tolerates PO + no unstable comorbidity/social barrier; ward if CURB-65 2 / PSI III-IV or hypoxia; ICU if CURB-65 ≥3 / PSI V / ≥1 IDSA major or ≥3 minor / vasopressor / mechanical ventilation (Lim Thorax 2003 PMID 12728155; Metlay AJRCCM 2019)
    advance: Disposition decided
  11. 11MONITORING
    Clinical response at 48-72 h (defervescence, O2 wean, WBC trend); switch IV→PO once Halm clinical-stability criteria met; de-escalate per culture/antigen/PCR at 48-72 h; lactate clearance in severe; reassess steroid taper; if non-resolving at 72 h → BRANCHING_WORKUP (CT, bronch, ID consult, reconsider PE/TB/malignancy) (2025 ATS CAP; Halm JAMA 1998)
    advance: Stability achieved or therapy escalated
  12. 12FOLLOWUP
    Confirm total duration (stop when ≥5 d AND afebrile ≥48 h AND ≤1 instability sign; 3-5 d low-risk); pneumococcal (PCV20 or PCV15+PPSV23) + influenza + COVID vaccination; smoking cessation; follow-up CXR at ~6 weeks if smoker / age ≥50 (occult malignancy); return precautions; routine repeat imaging NOT required if clinically resolved (2025 ATS CAP; ACIP 2025)
    advance: Follow-up scheduled, duration finalised, prevention addressed