ICU · Resuscitation
Acute severe community-acquired pneumonia: outpatient to ICU care pathway
Also known as CAP care pathway · Pneumonia severity triage · Emergency department to ICU pathway · CAP management algorithm · Door-to-antibiotic pathway · Pneumonia discharge bundle
Severe CAP pathway: PSI preferred over CURB-65 for the admission decision; IDSA/ATS 1 major or 3+ minor for ICU; blood and sputum cultures in severe CAP; beta-lactam plus macrolide or respiratory fluoroquinolone; de-escalate on cultures and nasal PCR; 5-day minimum guided by clinical stability; CAPE COD hydrocortisone mortality benefit in ICU severe CAP.
Checked against its sources on 13 Oct 2026
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- Antimicrobials immediately, ideally within 1 hour of recognition, for possible septic shock or high-likelihood sepsis
- 1 major (shock on vasopressors, respiratory failure needing ventilation) or 3+ minor IDSA/ATS criteria = severe CAP = ICU
- Do not delay antibiotics for procalcitonin — treat clinically suspected, radiographically confirmed CAP regardless of PCT
- Blood cultures in severe CAP, MRSA/Pseudomonas cover, and prior MRSA/Pseudomonas — not routine in all inpatients
- Hydrocortisone in ICU severe CAP cut 28-day death (CAPE COD trial) — know the result and its date
Meet the patient
A 68-year-old arrives with three days of fever and productive cough, now confused, breathing 32 times a minute, blood pressure 92 over 55 and saturating 88 per cent on room air. His CURB-65 is 5 — confusion, urea over 7, RR over 30, low blood pressure, age over 65 — and the registrar asks whether he belongs in the ICU.[5]
The decision that sets the whole pathway is site of care, and it is made with validated prediction rules: clinicians should use PSI preferentially over CURB-65 to determine the need for hospitalisation, and the IDSA/ATS severe-CAP criteria (1 major or 3+ minor) to determine the need for ICU — always alongside clinical judgment.[11]
SAQ — Severe CAP: severity scoring and the site-of-care decision
10 minutes · 10 marks
A 68-year-old man presents to ED with a 3-day history of fever, productive cough and pleuritic chest pain. He is confused, RR 32, BP 92/55, SaO2 88% on room air. Bloods: urea 11 mmol/L. CXR shows right lower-lobe consolidation. The registrar asks whether he should be admitted to ICU.
SAQ — IV-to-oral switch, duration, and follow-up imaging
10 minutes · 10 marks
A 55-year-old woman with right middle-lobe pneumococcal pneumonia has been on IV antibiotics for 5 days. She is now afebrile, RR 18, BP 118/72, SaO2 96% on room air, alert and eating normally. Blood cultures (day 1) grew Streptococcus pneumoniae sensitive to penicillin. The team wishes to switch to oral and plan follow-up.
References14ShowHide
- [1]Niederman MS, Torres A Severe community-acquired pneumonia. European respiratory review : an official journal of the European Respiratory Society, 2022.PMID 36517046
- [2]Watkins RR, Lemonovich TL Diagnosis and management of community-acquired pneumonia in adults. American family physician, 2011.PMID 21661712
- [3]Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA, 1997.PMID 9403422
- [4]Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. The New England journal of medicine, 1997.PMID 8995086
- [5]Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax, 2003.PMID 12728155
- [6]Halm EA, Fine MJ, Marrie TJ, et al. Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines. JAMA, 1998.PMID 9600479
- [7]Garin N, Genné D, Carballo S, et al. β-Lactam monotherapy vs β-lactam-macrolide combination treatment in moderately severe community-acquired pneumonia: a randomized noninferiority trial. JAMA internal medicine, 2014.PMID 25286173
- [8]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 2021.PMID 34599691
- [9]Meehan TP, Weingarten SR, Holmboe ES, et al. A statewide initiative to improve the care of hospitalized pneumonia patients: The Connecticut Pneumonia Pathway Project. The American journal of medicine, 2001.PMID 11530031
- [10]Dharmarajan K, Hsieh AF, Lin Z, et al. Hospital readmission performance and patterns of readmission: retrospective cohort study of Medicare admissions. BMJ (Clinical research ed.), 2013.PMID 24259033
- [11]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. American journal of respiratory and critical care medicine, 2019.PMID 31573350
- [12]Liapikou A, Ferrer M, Polverino E, et al. Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2009.PMID 19140759
- [13]Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in Severe Community-Acquired Pneumonia. The New England journal of medicine, 2023.PMID 36942789
- [14]Lim WS, Woodhead M, British Thoracic Society British Thoracic Society adult community acquired pneumonia audit 2009/10. Thorax, 2011.PMID 21502103