Iberoamerican Journal of Medicine
Iberoamerican Journal of Medicine

Management of Community acquired pneumonia in the Emergency Room

Eduardo Esteban-Zubero, Cristina García-Muro, Moisés A. Alatorre-Jiménez, Alejandro Marín-Medina, Carlos Arturo López-García, Ahmed Youssef, Rocío Villeda-González

Downloads: 2
Views: 822


The incidence of community-acquired pneumonia (CAP) ranges from 2-15 cases/1,000 inhabitants/year, being higher in those over 65 or in patients with comorbidities.
In Emergency Room (ER) it represents up to 1.35% of the care. Approximately 75% of all diagnosed CAPs are treated in ER. The CAP represents the origin of the majority of septic sepsis and shock diagnosed in ER, the leading cause of death and admission to the intensive care unit (ICU) for infectious disease. A global mortality of 10-14% is attributed according to age and associated risk factors. 40-60% of CAPs will require hospital admission, including observation areas (with very variable ranges of 22-65% according to centers, time of year and patient characteristics), and between them 2-10% will be in the ICU. From all that has been said, the importance of CAP in ER is translated, and also of the “impact of emergency care on patients with CAP”, as it is the device where initial, but fundamental, decisions are made for evolution of process.
The great variability among clinicians in the management of diagnostic-therapeutic aspects in the CAP is known, which is one of the reasons that explain the large differences in admission rates, of achieving the microbiological diagnosis, request for complementary studies, the choice of antimicrobial regime or the diversity of care applied. In this sense, the implementation of clinical practice guidelines with the use of prognostic severity scales and the new tools available in HUSs such as biomarkers can improve the care of patients with CAP in ER. Therefore, based on a multidisciplinary group of emergency professionals and specialists participating in the CAP care process, this clinical guide has been designed with various recommendations for decisions and key moments in the process of patient care with NAC in the Emergency Room.


Pneumonia; Emergency Room; Treatment; Diagnosis


1. Julián-Jiménez A, Candel González FJ, Piñera Salmerón P, González del Castillo J, Moya Mir MS, Martínez Ortiz de Zárate M. Recomendaciones INFURG-SEMES: manejo de la infección respiratoria de vías bajas en urgencias. Monografías de Emergencias. 2009;3:1-21.
2. Julián-Jiménez A, Adán Valero I, Beteta López A, Cano Martín LM, Fernández Rodríguez O, Rubio Díaz R, et al. [Recommendations for the care of patients with community-acquired pneumonia in the Emergency Department]. Rev Esp Quimioter.2018;31:186-202.
3. Wunderink RG, Waterer GW. Community-Acquired Pneumonia. N Engl J Med. 2014;370:543-551. DOI: 10.1056/NEJMcp1214869.
4. González-del-Castillo J, Martín-Sánchez FJ, Llinares P, Menéndez R, Mujal A, Navas E, et al. Guidelines for the management of commu­nity-acquired pneumonia in the elderly patient. Rev Esp Quimioter. 2014;27:69-86.
5. Monclús Cols E, Capdevilla Reniu A, Roedberg Ramos D, Pujol Fontrodona G, Ortega Romero M. [Management of severe sepsis and septic shock in a tertiary care urban hospital emergency department: opportunities for improvement].Emergencias. 2016;28:229-234.
6. Julián-Jiménez A, González del Castillo J, Candel González FJ. ¿ When, where and how should a patient with community acquired pneumonia be admitted? Rev Clin Esp. 2013;213:99-107. DOI: 10.1016/j.rce.2012.02.006
7. Tejedor Fernández M, Ferrer Higueras MJ, Tejedor Benítez R. [Patient safety, clinical outcomes, and efficiency in the emergency department]. Emergencias. 2016;28:141-142.
8. Julián-Jiménez A, Palomo MJ, Parejo R, Laín-Terés N, Cuena-Boy R, Lozano-Ancín A. Improved management of community-acquired pneumonia in the emergency department. Arch Bronconeumol. 2013;49:230-240. DOI: 10.1016/j.arbres.2012.12.008
9. Julián-Jiménez A, Parejo R, Cuena-Boy R, Palomo MJ, Laín-Terés N, Lozano-Ancín A. Intervenciones para mejorar el manejo de la neumonía adquirida en la comunidad desde el servicio de urgencias. Emergencias. 2013;25:379-392.
10. Kolditz M, Ewig S, Höffken G. Management-based risk prediction in community-acquired pneumonia by scores and biomarkers. Eur Respir J. 2013;41:974-984. DOI: 10.1183/09031936.00104412
11. Schuetz P, Litke A, Albrich C, Mueller B. Blood biomarkers for perso­nalized treatment and patient management decisions in community-acquired pneumonia. Curr Opin Infect Dis. 2013;26:159-167. DOI: 10.1097/QCO.0b013e32835d0bec
12. Pérez-Díez C, Real-Campaña JM, Noya-Castro MC, Andrés-Aparicio F, Abad-Sazatornil MR, Povar-Marco JB. [Medication errors in a hospital emergency department: study of the current situation and critical points for improving patient safety]. Emergencias. 2017;29:412-415.
13. Johansson N, Kalin M, Tiveljung-Lindell A, Giske CG, Hedlund J. Etiology of Community-Acquired Pneumonia: Increased Micro­biological Yield with New Diagnostic Methods. Clin Infect Dis. 2010;50:202-209. DOI: 10.1086/648678
14. Cillóniz C, Ewing S, Polverino E, Marcos MA, Esquinas C, Gabarrús A, et al. Microbial aetiology of community-acquired pneumonia and its relation to severity. Torax. 2011;66:340-346. DOI: 10.1136/ thx.2010.143982
15. Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med. 2014;371:1619-1628. DOI: 10.1056/NEJMra1312885
16. Long B, Long D, Koyfman A. Emergency Medicine Evaluation of Community-Acquired Pneumonia: History, Examination, Ima­ging and Laboratory Assessment, and Risk Scores. J Emerg Med. 2017;53:642-652. DOI: 10.1016/j.jemermed.2017.05.035
17. Martín-Sánchez FJ, Julián-Jiménez A, Candel González FJ, Llopis Roca F, Martínez Ortiz de Zárate M, González del Castillo J, et al. Profile and initial ma­nagement of infection in elderly patients in an Emergency Department. Rev Esp Geriatr Gerontol. 2017;52:9-14. DOI: 10.1016/j. regg.2016.02.006
18. Chiarella F, González-Del Castillo J, Candel FJ, García-Lamberechts EJ, Núñez-Orantos MJ, Martín-Sánchez FJ; Infectious Disease Group of Spanish Emergency Medicine Society. Key issues in the infected patient care in the Emergency Department.Rev Esp Qui­mioter. 2016;29:318-327.
19. Julián-Jiménez A, Candel-González FJ, González del Castillo J. [Usefulness of inflammation and infection biomarkers in the Emergency Department]. Enferm Infecc Microbiol Clin. 2014;32:177–190.
20. Julián-Jiménez A, González del Castillo J, Candel-González FJ. Usefulness and prognostic value of biomarkers in patients with community-acquired pneumonia in the emergency department. Med Clin (Barc). 2017;148:501–510. DOI: 10.1016/j.med­cli.2017.02.024
21. Trobbiani J. Eops: utilidad de una regla de predicción clínica en pacientes con neumonía adquirida en la comunidad en atención primaria. Evid Act Pract Ambul. 2014:17:104-106.
22. Vila Córcoles A, Ochoa Gondar O, Rodríguez Blanco T. [Usefulness of the CRB-65 scale for prognosis assessment of patients 65 years or older with community-acquired pneumonia]. Med Clin (Barc). 2010;135:97-102. DOI: 10.1016/j.medcli.2009.09.049
23. Julián-Jiménez A, Candel-González FJ, González del Castillo J. [Usefulness of biomarkers to predict bacteraemia in patients with infection in the emergency department]. Rev Esp Quimioter. 2017;30:245- 256.
24. Julián-Jiménez A, Timón Zapata J, Laserna Mendieta EJ, Parejo Miguez R, Flores Chacartegui M, Gallardo Schall P. [Ability of procalcitonin to predict bacteremia in patients with community acquired pneumonia]. Med Clin (Barc). 2014;142:285- 292. DOI: 10.1016/j.medcli.2013.05.046
25. Liu D, Xie L, Zhao H, Liu X, Cao J. Prognostic value of mid-regional pro-adrenodedullin (MR-proADM) in patients with community-acquired pneumonia: A systematic review and meta-analysis. BMC Infect Dis. 2016;16:232. DOI:10.1186/s12879-016-1566-3
26. Jo S, Jeong T, Lee JB, Jin Y, Yoon J, Park B. Validation of modified early warning score using serum lactate level in community-acquired pneumonia patients. The National Early Warning Score- Lactate score. Am J Emerg Med. 2016;34:536–541. DOI: 10.1016/j. ajem.2015.12.067
27. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-adquired pneumonia. N Engl J Med. 1997;336:243-250. DOI: 10.1056/NEJM199701233360402
28. Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, et al. Defining community acquired pneumonia severity on presentation to hospital: An international derivation and validation study. Thorax. 2003;58:377–382.
29. España PP, Capelastegui A, Gorordo I, Esteban C, Oribe M, Ortega M, et al. Development and validation of a clinical prediction rule for severe community- acquired pneumonia. Am J Respir Crit Care Med. 2006;174:1249–1256. DOI: 10.1164/rccm.200602-177OC
30. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003; 31:1250-1256. DOI: 10.1097/01. CCM.0000050454.01978.3B
31. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801-810.
32. Julián-Jiménez A, Laserna-Mendieta EJ, Timón-Zapata J, Cabezas- Martínez A. [Importance of clinical suspicion and confirmation of bacteremia in emergency units]. Med Clin (Barc). 2011;137:424–429.
33. Moran GJ, Rothman RE, Volturo GA. Emergency management of community-acquired bacterial pneumonia: what is new since the 2007 Infectious Diseases Society of America/American Thora­cic Society guidelines. Am J Emerg Med. 2013;31:602-612. DOI: 10.1016/j.ajem.2012.12.002
34. Londoño J, León AL, Rodríguez F, Barrera L, de la Rosa G, Dennis R, et al. [Serum lactate in the emergency department as a prognostic factor in patients with sepsis without hypotension]. Med Clin (Barc). 2013;141:246– 251. DOI: 10.1016/j.medcli.2012.05.033
35. García-Villalba E, Cano-Sánchez A, Alcaraz-García A, Cinesi-Gómez A, Piñera-Salmerón P, Marín I, et al. [Nomogram to predict a poor outcome in emergency patients with sepsis and at low risk of organ damage according to Sepsis-related Organ Failure Assessment (SOFA)]. Emergencias 2017;29:81-86.
36. Eliakim-Raz N, Robenshtok E, Shefet D. Empiric antibiotic coverage of atypical pathogens for community-acquired pneumonia in hos­pitalized adults. Cochrane Database Syst Rev. 2012;9:CD004418. DOI: 10.1002/14651858.CD004418.pub4
37. Lee JS, Giesler DL, Gellad WF, Fine MJ. Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia. A Systematic Review. JAMA. 2016;315:593-602. DOI: 10.1001/jama.2016.0115
38. González del Castillo J, Martín-Sánchez FJ. Microorganismos re­sistentes en urgencias: ¿cómo afrontar el reto? Emergencias 2017;29:303-305.
39. González-Castillo J, Candel FJ, Julián-Jiménez A. Antibióticos y el fac­tor tiempo en la infección en urgencias. Enferm Infecc Microbiol Clin. 2013; 31:173-180. DOI: 10.1016/j.eimc.2012.01.025
40. Vardakas KZ, Trigkidis KK, Apiranthiti KN, Falagas ME. The dilemma of monotherapy or combination therapy in community-acquired pneumonia. Eur J Clin Invest. 2017;e12845. DOI: 10.1111/eci.12845
41. Díaz E, Martín-Loeches I, Vallés J. Neumonía nosocomial. Enferm Infecc Microbiol Clin. 2013;31:692-698.
42. Torres Bonafonte OH, Gil Olivas E, Pérez Macho E, Pacho Pacho C, Meto Roca M, Casademont Pou J, et al. [Predictors of drug-resistant pathogens in community-onset pneumonia: Are factors considered in health-care-associated pneumonia useful in the emergency department?] Emergencias 2017; 29:306-312.
43. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, et al. Management of Adults With Hospital-acquired and Venti­lator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63:e61. DOI: 10.1093/cid/ciw504.
44. Wunderink RG. “How important is methicillin-resistant Sthapylo­coccus aureus as a cause of community-acquired pneumonia and what is best antimicrobial therapy?” Infect Dis Clin North Am. 2013;27:177-188. DOI: 10.1016/j.idc.2012.11.006
45. Aguado García JM, Martín Herrero JE, Lumbreras Bermejo C. [Bacterial resistance and pharmacodynamics as the basis for prescribing antibiotics in respiratory infections].. Enferm Infecc Microbiol Clin 2004;22:230-237.
46. Schaper KJ, Schubert S, Dalhoff A. Kinetics and quantification of antibacterial effects of betalactams, macrolides, and quinolones againts gram-positive and gram-negative RTI pathogens. Infection 2005;33(Suppl 2):3-14. DOI: 10.1007/s15010-005-8202-2
47. Gómez-Guiu A, Azanza JR, Sádaba B, García-Quetglas E. Farmaco­cinética/farmacodinamia de los principales antimicrobianos utilizados por vía oral. Rev Clin Esp 2008;208(Supl 3):22-27.

Submitted date:

Reviewed date:

Accepted date:

Publication date:

5d743ce50e8825264d5a5ddf iberoamericanjm Articles
Links & Downloads

Iberoam J Med

Share this page
Page Sections