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pulm.cap.core.v1PRODUCTION
pulm.cap.core.v1

Community-Acquired Pneumonia

pulmonologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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Onset history confirms community acquisition

Patient inputs (21)

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)

CURB-65 (SBP <90 / DBP ≤60) + sepsis screening (Lim Thorax 2003 PMID 12728155)

CURB-65 (RR ≥30) + IDSA severe-CAP minor criterion (RR ≥30) + qSOFA (Lim Thorax 2003 PMID 12728155; Metlay AJRCCM 2019)

Hypoxemia threshold for admission; P/F ≤250 is an IDSA severe-CAP minor criterion (2025 ATS CAP; Metlay AJRCCM 2019)

Sepsis screening; T <36°C is an IDSA severe-CAP minor criterion; bacterial vs viral pattern (Metlay AJRCCM 2019)

eGFR/CrCl for renal dose adjustment of β-lactams, fluoroquinolones, vancomycin, oseltamivir (2025 ATS CAP)

Confirms pneumonia; lung ultrasound or CT acceptable when CXR equivocal (2025 ATS CAP §Imaging)

CURB-65 (new confusion / AMT ≤8); AMS is an IDSA severe-CAP minor criterion (Lim Thorax 2003 PMID 12728155)

Prior MRSA/Pseudomonas isolation (esp. respiratory, last 1 yr) overrides empiric narrowing (2025 ATS CAP; Metlay AJRCCM 2019)

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)

Bronchiectasis / severe COPD raises Pseudomonas risk and CAP+COPD-exacerbation overlap (2025 ATS CAP)

Immunocompromise broadens differential to PJP/fungal/Nocardia → route to pulm.pcp-pneumonia.core.v1 / id.invasive-aspergillosis.core.v1 (2025 ATS CAP)

Dysphagia, AMS, alcohol, stroke, dementia, tube feeds → aspiration-CAP overlap (Marik NEJM 2001) — see pulm.aspiration-pneumonia.core.v1

Antibiotic safety (avoid doxycycline/fluoroquinolone; β-lactam + macrolide preferred) (2025 ATS CAP; pregnancy labelling)

Macrolide/FQ QT interactions, FQ tendon/aortic risk, β-lactam allergy, chronic corticosteroid (modifies CAPE-COD steroid decision) (2025 ATS CAP)

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)

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 <100×10⁹/L is an IDSA severe-CAP minor criterion (Metlay AJRCCM 2019)

CAP-sepsis severity / SSC 2026 bundle; lactate clearance monitoring (SSC 2026)

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)

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)

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Severity triggers (11)

11 need judgement
  • informationallife_threateningidsa_severe_cap_major_or_3_minor
    IDSA severe CAP: ≥1 MAJOR (septic shock needing vasopressors OR respiratory failure needing mechanical ventilation) OR ≥3 MINOR (RR ≥30, P/F ≤250, multilobar infiltrates, AMS, BUN ≥20 mg/dL, WBC <4×10⁹/L, plt <100×10⁹/L, T <36°C, hypotension needing aggressive fluids)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcap_with_septic_shock_sepsis_overlap
    CAP meeting Sepsis-3 with vasopressor-dependent hypotension / lactate ≥4 — CAP+sepsis co-existence
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecurb65_3_or_more_severe_icu
    CURB-65 ≥3 (any of confusion, urea >7 mmol/L ≈ BUN >19 mg/dL, RR ≥30, SBP <90 / DBP ≤60, age ≥65 — total ≥3) — predicted 30-d mortality ~22% (3 ~17%, 4-5 ~41-57%)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremrsa_risk_pattern_locally_validated
    Prior MRSA respiratory isolation, necrotising/cavitary pneumonia, post-influenza secondary pneumonia with gram-positive cocci, recent IV antibiotics + hospitalisation — with locally validated MRSA prevalence
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepseudomonas_risk_pattern
    Structural lung disease (bronchiectasis, severe COPD), recent IV antibiotics in 90 d + hospitalisation, prior Pseudomonas respiratory isolation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparapneumonic_effusion_empyema
    Parapneumonic effusion >1 cm on decubitus / CT OR loculation OR pleural pH <7.20 OR positive pleural Gram/culture
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereimmunocompromised_broaden_differential
    Significant immunocompromise (transplant, neutropenia, HIV/low CD4, biologics, high-dose chronic steroid) with pneumonia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecurb65_2_intermediate_ward
    CURB-65 2 — predicted 30-d mortality ~9% (PSI III-IV band)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateprocalcitonin_low_with_positive_viral_pcr
    Low procalcitonin (<0.25 ng/mL) WITH positive respiratory viral PCR — bacterial-vs-viral likelihood shifts toward viral, but does NOT exclude bacterial co-infection in confirmed radiographic CAP
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenon_resolving_at_72h
    Lack of clinical improvement at 72 h on adequate empirical therapy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildcurb65_0_1_low_mortality_outpatient
    CURB-65 0-1 — predicted 30-d mortality ~1.5% (0 ~0.6-0.7%, 1 ~2.7-3.2%); PSI I-II equivalent low band
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives disposition
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Recommended regimen

2025 ATS empirical + targeted antibiotic ladder (outpatient → ward → ICU/severe)
axis: cap_empirics_by_settingstep outpatient_no_comorbid - Outpatient — previously healthy, no comorbidity, no resistance risk factors
Selected step "Outpatient — previously healthy, no comorbidity, no resistance risk factors" — CURB-65 0-1 / PSI I-II, SpO2 ≥92%, no comorbidity, no antibiotic in last 90 d, can tolerate PO, no social barrier
  • amoxicillin
    first line
    aminopenicillin
    1 g PO TID • PO • q8h × 5 days (3-5 d acceptable if afebrile ≥48 h and stable per 2025 ATS)
    triggers: no_comorbidity, no_atypical_concern
    2025 ATS / 2019 ATS-IDSA — first-line outpatient when no comorbidity; high dose covers drug-resistant S. pneumoniae (DRSP). RxCUI 723 RxNav-verified IN 2026-05-16
    rxcui 723
  • doxycycline
    first line
    tetracycline
    100 mg PO BID • PO • q12h × 5 days
    triggers: penicillin_allergy, atypical_concern
    Atypical + S. pneumoniae coverage; preferred first-line alternative — macrolide-resistance hedge. Avoid in pregnancy. RxCUI 3640 RxNav-verified IN 2026-05-16
    rxcui 3640
  • azithromycin
    second line
    macrolide
    500 mg PO ×1 then 250 mg PO daily • PO • daily × 5 days total
    triggers: local_pneumococcal_macrolide_resistance_under_25pct
    Use ONLY where local pneumococcal macrolide resistance <25% (2025 ATS / 2019 ATS-IDSA). QTc check. RxCUI 18631 RxNav-verified IN 2026-05-16
    rxcui 18631

outpatient playbook — drug actions (4)

  1. 1. amoxicillin
    1 g PO TID • PO • q8h × 5 d (3-5 d if afebrile ≥48 h and stable)
    trigger: Healthy adult, no comorbidity
    DRSP coverage (2025 ATS CAP)
  2. 2. doxycycline
    100 mg PO BID • PO • q12h × 5 d
    trigger: Penicillin allergy or atypical concern
    Atypical + S. pneumoniae coverage; avoid pregnancy (2025 ATS CAP)
  3. 3. amoxicillin-clavulanate + macrolide/doxycycline
    875/125 mg PO BID + azithromycin 500/250 mg or doxycycline 100 mg BID • PO • q12h × 5 d
    trigger: Comorbidity OR recent abx
    β-lactam + atypical combination for higher-risk outpatient (2025 ATS CAP)
  4. 4. levofloxacin
    750 mg PO daily • PO • daily × 5 d
    trigger: β-lactam + macrolide intolerance
    Respiratory FQ monotherapy alternative (2025 ATS CAP)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cough + fever ± dyspnea ± pleuritic chest pain (2025 ATS CAP §Diagnosis); New infiltrate on CXR / consolidation on lung ultrasound — imaging confirmation required (2025 ATS CAP §Imaging); Tachypnea + tachycardia + temperature derangement → screen CAP-sepsis (Sepsis-3; SSC 2026).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Community-Acquired Pneumonia** (pulm.cap.core.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **2025 ATS empirical + targeted antibiotic ladder (outpatient → ward → ICU/severe)** — step "Outpatient — previously healthy, no comorbidity, no resistance risk factors".
1. amoxicillin 1 g PO TID PO q8h × 5 days (3-5 d acceptable if afebrile ≥48 h and stable per 2025 ATS) (aminopenicillin, first line) — 2025 ATS / 2019 ATS-IDSA — first-line outpatient when no comorbidity; high dose covers drug-resistant S. pneumoniae (DRSP). RxCUI 723 RxNav-verified IN 2026-05-16
2. doxycycline 100 mg PO BID PO q12h × 5 days (tetracycline, first line) — Atypical + S. pneumoniae coverage; preferred first-line alternative — macrolide-resistance hedge. Avoid in pregnancy. RxCUI 3640 RxNav-verified IN 2026-05-16
3. azithromycin 500 mg PO ×1 then 250 mg PO daily PO daily × 5 days total (macrolide, second line) — Use ONLY where local pneumococcal macrolide resistance <25% (2025 ATS / 2019 ATS-IDSA). QTc check. RxCUI 18631 RxNav-verified IN 2026-05-16

Setting playbook (outpatient) — Identify CAP that can be safely managed at home (CURB-65 0-1 / PSI I-II); short-course oral antibiotics with atypical coverage; 48-72 h follow-up (2025 ATS CAP)
4. amoxicillin 1 g PO TID PO q8h × 5 d (3-5 d if afebrile ≥48 h and stable) — Healthy adult, no comorbidity (DRSP coverage (2025 ATS CAP))
5. doxycycline 100 mg PO BID PO q12h × 5 d — Penicillin allergy or atypical concern (Atypical + S. pneumoniae coverage; avoid pregnancy (2025 ATS CAP))
6. amoxicillin-clavulanate + macrolide/doxycycline 875/125 mg PO BID + azithromycin 500/250 mg or doxycycline 100 mg BID PO q12h × 5 d — Comorbidity OR recent abx (β-lactam + atypical combination for higher-risk outpatient (2025 ATS CAP))
7. levofloxacin 750 mg PO daily PO daily × 5 d — β-lactam + macrolide intolerance (Respiratory FQ monotherapy alternative (2025 ATS CAP))

Non-pharmacologic actions:
- Hydration + antipyretic counselling (2025 ATS CAP)
- Smoking cessation pharmacotherapy if applicable (2025 ATS CAP)
- Influenza, pneumococcal (PCV20 or PCV15+PPSV23), COVID vaccination when recovered (ACIP 2025)
- Return precautions — worsening dyspnea, confusion, persistent fever ≥72 h, hemoptysis (2025 ATS CAP)
- Follow-up call/visit at 48-72 h (2025 ATS CAP)

AVOID / contraindication checks:
-  macrolide + fluoroquinolone QTc — baseline ECG and avoid additive QT prolonging drugs (2025 ATS CAP)
-  fluoroquinolone tendon/aortic aneurysm/peripheral neuropathy/dysglycemia/CNS warnings — reserve when alternatives exist (FDA 2018; 2025 ATS CAP)
-  doxycycline contraindicated in pregnancy and children <8 yr (tooth staining) (2025 ATS CAP)
-  fluoroquinolone avoid in pregnancy — use β lactam + macrolide (2025 ATS CAP; pregnancy labelling)
-  linezolid serotonin syndrome with SSRI/SNRI/MAOI; reversible myelosuppression if >14 d (IDSA)
-  hydrocortisone — exclude influenza/uncontrolled viral pneumonia and active untreated fungal/TB before steroid; avoid net benefit unclear if already on chronic corticosteroid (Dequin NEJM 2023 PMID 36942789)
-  vancomycin AUC24 target 400 600, avoid trough only dosing; nephrotoxicity additive with pip tazo — monitor SCr (IDSA/ASHP/SIDP 2020)
- Renal: dose adjust β lactams (pip tazo, cefepime, meropenem, amox clav), levofloxacin, vancomycin, oseltamivir for CrCl; cefepime neurotoxicity in unadjusted renal impairment (2025 ATS CAP)
- Hepatic: azithromycin/macrolide caution in severe hepatic impairment; ceftriaxone biliary sludging — consider cefotaxime if biliary disease (2025 ATS CAP)
-  do NOT add MRSA/antipseudomonal coverage without locally validated risk factors — HCAP construct retired (Metlay AJRCCM 2019)

Monitoring

Regimen monitoring:
- clinical response at 48-72h — defervescence, O2 wean, WBC/CRP trend (2025 ATS CAP)
- IV to PO switch once Halm clinical-stability criteria met (Halm JAMA 1998)
- lactate clearance in severe CAP / CAP-sepsis (SSC 2026)
- culture/antigen/respiratory-PCR de-escalation at 48-72h; nasal-MRSA-PCR negative → stop empiric vancomycin/linezolid (2025 ATS CAP)
- procalcitonin trend may support stopping in equivocal cases but does NOT override clinical judgment in confirmed CAP (ProACT Huang NEJM 2018 PMID 29781385)
- vancomycin Bayesian AUC24 400-600 + SCr if MRSA cover (IDSA/ASHP/SIDP 2020)
- steroid: glucose q6h on hydrocortisone; taper over 8-14 d total; watch superinfection (Dequin NEJM 2023 PMID 36942789)
- duration: stop when ≥5 d AND afebrile ≥48 h AND ≤1 instability sign; 3-5 d in low-risk (Uranga PMID 27455166; 2025 ATS CAP)
- CXR follow-up at ~6 weeks ONLY if smoker or age ≥50 (occult malignancy) — routine repeat imaging not needed if resolved (2025 ATS CAP)

Setting (outpatient) monitoring:
- Symptom check at 48-72 h (2025 ATS CAP)
- CXR at ~6 weeks ONLY if smoker or age ≥50 (occult malignancy) — not routine (2025 ATS CAP)

Follow-up plan: 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)
- Close-out criterion: Follow-up scheduled, duration finalised, prevention addressed

Monitoring phase: 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)

Disposition

Current setting: outpatient — Identify CAP that can be safely managed at home (CURB-65 0-1 / PSI I-II); short-course oral antibiotics with atypical coverage; 48-72 h follow-up (2025 ATS CAP)

Disposition criteria:
- Discharge home: CURB-65 0-1 / PSI I-II, SpO2 ≥92% RA, tolerates PO, no unstable comorbidity / social barrier, follow-up arranged (2025 ATS CAP; Lim Thorax 2003 PMID 12728155)

Escalation triggers (move to higher acuity):
- SpO2 <92% on room air → ED (2025 ATS CAP)
- CURB-65 ≥2 / PSI ≥III → ED (Lim Thorax 2003 PMID 12728155)
- Failure of oral therapy at 48-72 h → ED (2025 ATS CAP)
- Hemoptysis or pleuritic pain with hemodynamic instability → ED (2025 ATS CAP)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] IDSA severe CAP: ≥1 MAJOR (septic shock needing vasopressors OR respiratory failure needing mechanical ventilation) OR ≥3 MINOR (RR ≥30, P/F ≤250, multilobar infiltrates, AMS, BUN ≥20 mg/dL, WBC <4×10⁹/L, plt <100×10⁹/L, T <36°C, hypotension needing aggressive fluids)
- [LIFE_THREATENING] CAP meeting Sepsis-3 with vasopressor-dependent hypotension / lactate ≥4 — CAP+sepsis co-existence
- [SEVERE] CURB-65 ≥3 (any of confusion, urea >7 mmol/L ≈ BUN >19 mg/dL, RR ≥30, SBP <90 / DBP ≤60, age ≥65 — total ≥3) — predicted 30-d mortality ~22% (3 ~17%, 4-5 ~41-57%)

Citations

- 2025/26 ATS "Diagnosis and Management of Community-acquired Pneumonia: An Official ATS Clinical Practice Guideline" (Jones BE, Ramirez JA, Oren E, Soni NJ, et al.; Am J Respir Crit Care Med 2026;212(1):24-44; PMID 40679934; DOI 10.1164/rccm.202507-1692ST; ATS-approved, NOT IDSA-endorsed; updates 4 questions: lung-US, viral-positive empirics, <5-day duration, corticosteroids by severity) + foundational 2019 ATS/IDSA CAP Guideline (Metlay JP, AJRCCM 2019;200(7):e45-e67; PMID 31573350) + CAPE COD severe-CAP hydrocortisone + Surviving Sepsis Campaign 2026 [PMID:40679934](https://pubmed.ncbi.nlm.nih.gov/40679934/)
- Cited evidence (PMID 31573350) [PMID:31573350](https://pubmed.ncbi.nlm.nih.gov/31573350/)
- Cited evidence (PMID 12728155) [PMID:12728155](https://pubmed.ncbi.nlm.nih.gov/12728155/)
- Cited evidence (PMID 8995086) [PMID:8995086](https://pubmed.ncbi.nlm.nih.gov/8995086/)
- Cited evidence (PMID 26172429) [PMID:26172429](https://pubmed.ncbi.nlm.nih.gov/26172429/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2025/26 ATS "Diagnosis and Management of Community-acquired Pneumonia: An Official ATS Clinical Practice Guideline" (Jones BE, Ramirez JA, Oren E, Soni NJ, et al.; Am J Respir Crit Care Med 2026;212(1):24-44; PMID 40679934; DOI 10.1164/rccm.202507-1692ST; ATS-approved, NOT IDSA-endorsed; updates 4 questions: lung-US, viral-positive empirics, <5-day duration, corticosteroids by severity) + foundational 2019 ATS/IDSA CAP Guideline (Metlay JP, AJRCCM 2019;200(7):e45-e67; PMID 31573350) + CAPE COD severe-CAP hydrocortisone + Surviving Sepsis Campaign 2026 — PMID:40679934
  • Cited evidence (PMID 31573350) — PMID:31573350
  • Cited evidence (PMID 12728155) — PMID:12728155
  • Cited evidence (PMID 8995086) — PMID:8995086
  • Cited evidence (PMID 26172429) — PMID:26172429