The American Thoracic Society (ATS) recently published a new practice guideline for the diagnosis and management of community acquired pneumonia (CAP). This guideline addresses changes in testing and treatment that have taken place since the last CAP guideline was published in 2019. The ability to identify potential viral causes of CAP with new rapid molecular pathogen testing was addressed, as well as, newer imaging techniques and the role of corticosteroids.
In this article we will review some of the changes in the recent ATS recommendations for community acquired pneumonia, focusing on how these changes affect nursing practice. In each section we will compare the recommendations from 2019 with the current 2025 recommendations followed by implementation techniques for nursing practice that align with these recommendations. We hope this article will help to incorporate the most recent best evidence clinical practices into nursing interventions and patient education. You are encouraged to review the full guideline found at the links below for more important information on this topic.
Guidelines Referenced
- Diagnosis and Management of Community-acquired Pneumonia. An Official American Thoracic Society Clinical Practice Guideline
- Published: July 2025
Major Changes
Diagnostic Imaging
- The diagnosis of CAP requires the presence of associated symptoms and objective findings of alveolar inflammation. Diagnostic imaging is used to look for objective findings.
- A chest x-ray is most commonly used to diagnose CAP.
- Chest CT(computed tomography) is sometimes used as well.
- New recommendations suggest chest ultrasound is an acceptable alternative to chest x-ray in settings with appropriate expertise.
- This may be beneficial for patients in regions without access to radiology services or when a chest x-ray cannot be performed for other reasons like contraindications to radiation, cost, or patient preference.
- Lung ultrasound does require expertise in technique and interpretation to utilize this method effectively.
Practice Change Chest ultrasound, x-ray, or CT may be used to diagnose CAP. The choice of imagining technique depends on individual patients characteristics and preferences and the availability of imaging services and expertise.
Treatment
Patient Selection for Antibiotic Therapy
- Healthy outpatients with non-severe CAP who test positive for a respiratory virus may no longer need to start empiric antibiotic therapy because newer laboratory technology now allows for rapid identification of more viral pathogens.
- Empiric antibiotic therapy describes the initial antibiotic prescribed before the pathogen has been identified with culture and sensitivity testing.
- The decision to treat patients with a known respiratory virus who have CAP takes into consideration the possibility of a viral-bacterial coinfection and weighs the risk of delayed antibiotic treatment versus the risk associated with antibiotic use.
| Comparison of Recommendations | |
|---|---|
| 2019 Recommendations | 2025 Recommendations |
| For healthy outpatient adults without comorbidities listed below or risk factors for antibiotic resistant pathogens, we recommend: • amoxicillin 1 g three times daily or • doxycycline 100 mg twice daily or • a macrolide (azithromycin 500 mg on first day then 250 mg daily or clarithromycin 500 mg twice daily or clarithromycin extended release 1,000 mg daily) only in areas with pneumococcal resistance to macrolides <25%. | For adult outpatients without co-morbidities who have clinical and imaging evidence of CAP and who test positive for a respiratory virus, we suggest not prescribing empiric antibiotics due to concern for bacterial-viral co-infection. |
| For outpatient adults with comorbidities such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia we recommend (in no particular order of preference): • Combination therapy: ∘ amoxicillin/clavulanate 500 mg/125 mg three times daily, or amoxicillin/clavulanate 875 mg/125 mg twice daily, or 2,000 mg/125 mg twice daily, or a cephalosporin (cefpodoxime 200 mg twice daily or cefuroxime 500 mg twice daily); AND ∘ macrolide (azithromycin 500 mg on first day then 250 mg daily, clarithromycin 500 mg twice daily or extended release 1,000 mg once daily, or doxycycline 100 mg twice daily) OR • Monotherapy: ∘ respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily, or gemifloxacin 320 mg daily). | For adult outpatients with co-morbidities who have clinical and imaging evidence of CAP and who test positive for a respiratory virus, we suggest prescribing empiric antibiotics due to concern for bacterial-viral co-infection. |
| In inpatient adults with nonsevere CAP without risk factors for MRSA or P. aeruginosa, we recommend the following empiric treatment regimens (in no order of preference): • combination therapy with a β-lactam (ampicillin + sulbactam 1.5–3 g every 6 h, cefotaxime 1–2 g every 8 h, ceftriaxone 1–2 g daily, or ceftaroline 600 mg every 12 h) and a macrolide (azithromycin 500 mg daily or clarithromycin 500 mg twice daily), or • monotherapy with a respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily). A third option for adults with CAP who have contraindications to both macrolides and fluoroquinolones is: • combination therapy with a β-lactam (ampicillin + sulbactam, cefotaxime, ceftaroline, or ceftriaxone, doses as above) and doxycycline 100 mg twice daily. | For adult inpatients with clinical and imaging evidence of non-severe CAP who test positive for a respiratory virus, we suggest prescribing empiric antibiotics. |
| In inpatient adults with severe CAP without risk factors for MRSA or P. aeruginosa, we recommend: • a β-lactam plus a macrolide; or • a β-lactam plus a respiratory fluoroquinolone. | For adult inpatients with clinical and imaging evidence of severe CAP who test positive for a respiratory virus, we recommend prescribing empiric antibiotics. |
Practice Change Otherwise healthy outpatient adults with non-severe CAP who test positive for a respiratory virus usually do NOT need to be prescribed empiric antibiotics.
Nursing Interventions Education for patients with a respiratory virus who have CAP should include review of the typical course of CAP and when to seek urgent medical care for worsening, as well as the importance of: Adequate hydration and nutrition. Smoking cessation. Good handwashing and social distancing to prevent disease spread. Physical activity as tolerated. Coughing to help clear secretions. Reassurance that viral illnesses are not affected by antibiotics and should improve without treatment.
Duration of Antibiotics Therapy
- The duration of antibiotic therapy according to the 2025 guidelines was reduced from 5 or more days to less than 5 days for outpatients and inpatients with non-severe CAP who have reached clinical stability.
- Some organisms requiring longer duration of antibiotic treatment are:
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Suspected Legionella suspected
- Legionella pneumophila or
- Other intracellular microorganisms.
- Potential risks of longer antibiotic durations include:
- Side effects
- Clostridioides difficile infection
- Changes to normal flora
- Kidney injury
- Potential antibacterial resistance.
| Comparison of Recommendations | |
|---|---|
| 2019 Recommendation | 2025 Recommendations |
| We recommend that the duration of antibiotic therapy should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities [heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature], ability to eat, and normal mentation), and antibiotic therapy should be continued until the patient achieves stability and for no less than a total of 5 days. | For adult outpatients with CAP who reach clinical stability, we suggest less than five days of antibiotics (minimum of 3 days duration), rather than five or more days of antibiotics. |
| For adults inpatients with non-severe CAP who reach clinical stability, we suggest less than five days of antibiotics (minimum of 3 days duration), rather than five or more days of antibiotics. | |
| For adult inpatients with severe CAP who reach clinical stability, we suggest five or more days of antibiotics, rather than less than five of antibiotics. | |
Practice Change Shorter duration of antibiotic therapy is suggested for adult outpatients with CAP and adult inpatients with non-severe CAP. Duration was decreased to 3-5 days, rather than a minimum of 5 days of treatment.
Nursing Interventions For patients on antibiotics. Review potential side effects—rash, diarrhea, nausea, vomiting, abdominal pain. How and when to take the medication. The importance of finishing the full course of the antibiotic even if they feel better. Maintain adequate hydration and nutrition. Additional interventions for inpatients include: Monitoring vital signs and auscultation of lung sounds to assess for clinical stability. Administering oxygen when appropriate. Administering medical therapies and monitoring for side effects or worsening of symptoms. Clearing secretions with suctioning and encouraging coughing. Positioning to improve oxygenation - Semi-Fowler’s, Fowlers, or in some cases prone positioning. Coaching on and encouragement of incentive spirometry use. Early ambulation.
Corticosteroids
- There is now a recommendation suggesting the use of systemic corticosteroids for inpatients with severe CAP.
- Contraindications to corticosteroids include, but are not limited to:
- Influenza
- Aspergillus
- Uncontrolled diabetes
- History of recent gastrointestinal bleeding.
| Comparison of Recommendations | |
|---|---|
| 2019 Recommendations | 2025 Recommendations |
| We suggest not routinely using corticosteroids in adults with severe CAP. We suggest not routinely using corticosteroids in adults with severe influenza pneumonia. | For adult inpatients with severe CAP, we suggest administering systemic corticosteroids. (This recommendation excludes patients with severe CAP due to influenza pneumonia). |
| We recommend not routinely using corticosteroids in adults with nonsevere CAP. | For adult inpatients with non-severe CAP, we recommend not administering systemic corticosteroids. |
Practice Change Inpatient adults with severe CAP (excludes patients with influenza pneumonia) may be given systemic corticosteroids.
Nursing Interventions Patients with severe CAP on corticosteroids should be educated on the risks, benefits, and potential side effects of treatment. Nurses should: Monitor vital signs and urine output. Watch for signs of secondary infection. Monitor for adverse effects - hyperglycemia, mood and sleep changes, increased appetite and thirst, gastrointestinal bleeding. Corticosteroids should not be stopped abruptly because this can cause adrenal crisis. When discontinuing the dose should be tapered. Take measures to prevent secondary infection.
That’s it for this article on nursing considerations for adults with community acquired pneumonia. We thank you for reading and encourage you to sign up for alerts to stay informed on the latest published guidelines and articles.
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