Intensive Care Medicine

, Volume 45, Issue 2, pp 159–171 | Cite as

Challenges in severe community-acquired pneumonia: a point-of-view review

  • Antoni TorresEmail author
  • James D. Chalmers
  • Charles S. Dela Cruz
  • Cristina Dominedò
  • Marin Kollef
  • Ignacio Martin-Loeches
  • Michael Niederman
  • Richard G. Wunderink



Severe community-acquired pneumonia (SCAP) is still associated with substantial morbidity and mortality. In this point-of-view review paper, a group of experts discuss the main controversies in SCAP: the role of severity scores to guide patient settings of care and empiric antibiotic therapy; the emergence of pathogens outside the core microorganisms of CAP; viral SCAP; the best empirical treatment; septic shock as the most lethal complication; and the need for new antibiotics.


For all topics, the authors describe current controversies and evidence and provide recommendations and suggestions for future research. Evidence was based on meta-analyses, most recent RCTs and recent interventional or observational studies. Recommendations were reached by consensus of all the authors.

Results and conclusions

The IDSA/ATS criteria remain the most pragmatic tool to predict ICU admission. The authors recommend a combination of a beta-lactam/beta-lactamase inhibitor or a third G cephalosporin plus a macrolide in most SCAP patients, and to empirically cover PES (P. aeruginosa, extended spectrum beta-lactamase producing Enterobacteriaceae, methicillin-resistant S. aureus) pathogens when at least two specific risk factors are present. In patients with influenza CAP, the authors recommend the use of oseltamivir and avoidance of the use of steroids. Corticosteroids can be used in case of refractory shock and high systemic inflammatory response.


Severe community-acquired pneumonia Scoring systems Multidrug resistance Viral pneumonia Antibiotics Septic shock 


Compliance with ethical standards

Conflicts of interest

Professor Torres is consultant for Pfizer, Bayer, Roche, MSD, Polyphor. Professor Chalmers reports grants and personal fees from Glaxosmithkline, grants and personal fees from Boehringer-Ingelheim, grants from Astrazeneca, grants and personal fees from Pfizer, grants and personal fees from Bayer Healthcare, grants and personal fees from Grifols, personal fees from Napp, personal fees from Aradigm corporation, grants and personal fees from Insmed, outside the submitted work. Professor Dela Cruz declares no conflict of interest. Doctor Dominedò declares no conflict of interest. Professor Kollef was supported by the Barnes-Jewish Hospital Foundation. Doctor Martin-Loeches declares no conflict of interest. Professor Niederman is consultant for Pfizer, Merck, Paratek and Melinta. Professor Wunderink is consultant for Nabriva, Melinta, bioMerieux, Curetis, Genmark, Accelerate.

Ethical approval

An approval by an ethics committee was not applicable.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Antoni Torres
    • 1
    • 2
    • 3
    Email author
  • James D. Chalmers
    • 4
  • Charles S. Dela Cruz
    • 5
  • Cristina Dominedò
    • 6
  • Marin Kollef
    • 7
  • Ignacio Martin-Loeches
    • 3
    • 8
  • Michael Niederman
    • 9
  • Richard G. Wunderink
    • 10
  1. 1.Department of Pulmonary MedicineHospital Clinic of BarcelonaBarcelonaSpain
  2. 2.August Pi i Sunyer Biomedical Research Institute, IDIBAPSUniversity of BarcelonaBarcelonaSpain
  3. 3.Biomedical Research Networking Centres in Respiratory Diseases (Ciberes)BarcelonaSpain
  4. 4.Division of Molecular and Clinical MedicineUniversity of DundeeDundeeUK
  5. 5.Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine and Microbial Pathogenesis, Center of Pulmonary Infection Research and TreatmentYale University School of MedicineNew HavenUSA
  6. 6.Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. GemelliUniversità Cattolica del Sacro CuoreRomeItaly
  7. 7.Division of Pulmonary and Critical Care MedicineBarnes-Jewish HospitalSt. LouisUSA
  8. 8.St. James’s Hospital, Multidisciplinary Intensive Care Research Organization (MICRO)DublinIreland
  9. 9.Weill Cornell Medical College and New York Presbyterian/Weill Cornell Medical CenterNew York CityUSA
  10. 10.Pulmonary and Critical Care DivisionNorthwestern University Feinberg School of MedicineChicagoUSA

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