Identify severe CAP (ATS/IDSA criteria), start the Indian national empirical regimen within 1 h, add hydrocortisone, and think of Indian tropical mimics.
At the bedside
Timed steps- 1
Recognise and admit to ICU
0 hApply ATS/IDSA criteria; CURB-65 ≥ 3 also flags high risk.
- 2
Samples before antibiotics
Two blood cultures, sputum/tracheal aspirate Gram stain and culture, urinary pneumococcal and Legionella antigens, influenza/SARS-CoV-2 PCR; consider sputum GeneXpert for TB and scrub typhus/leptospira/dengue tests in the Indian monsoon setting.
- 3
Empirical antibiotics within 1 h
≤ 1 hCeftriaxone 2 g IV daily + azithromycin 500 mg daily (or doxycycline 100 mg BD). Pseudomonas risk (bronchiectasis, recent antibiotics/hospital, immunosuppression): piperacillin-tazobactam 4.5 g q6h + azithromycin. Add MRSA cover (vancomycin or linezolid) for necrotising pneumonia or post-influenza.
- 4
Influenza
Oseltamivir 75 mg BD when influenza is suspected in season, without waiting for PCR.
- 5
Hydrocortisone
Severe CAP (ICU, high-flow/NIV/ventilation): hydrocortisone 200 mg/day for 4-8 days with taper (CAPE COD). Not in influenza pneumonia.
- 6
Respiratory support
HFNC or NIV trial with close monitoring (ROX index); lung-protective ventilation if intubated.
- 7
De-escalate and stop
Narrow to culture results; stop macrolide when atypicals excluded; total 5-7 days if clinically stable (longer for S. aureus, Pseudomonas, lung abscess, empyema). If not resolving in 2 weeks, exclude TB.
Severe CAP backbone
Ceftriaxone
- Dose
- 2 g once daily
Atypical cover
Azithromycin
- Dose
- 500 mg once daily
Severe CAP adjunct
Hydrocortisone
- Dose
- 200 mg/day for 4 days (8 if still severe), then taper
- Preparation
- 200 mg in 50 mL NS over 24 h = ~2 mL/h
- Worked example
- Any weight: 200 mg/24 h ≈ 8.3 mg/h
Influenza
Oseltamivir
- Dose
- 75 mg twice daily for 5 days
Empirical ICU CAP regimens (NCDC/ICMR 2025)
| Scenario | First line | Alternative |
|---|---|---|
| ICU, no Pseudomonas risk | Ceftriaxone 2 g OD + azithromycin 500 mg OD (or doxycycline 100 mg q12h) | Cefotaxime 2 g TDS or piperacillin-tazobactam 4.5 g q6h + azithromycin/doxycycline |
| ICU with Pseudomonas risk | Piperacillin-tazobactam 4.5 g q6h + azithromycin or doxycycline | Imipenem/meropenem + azithromycin or doxycycline |
| Necrotising or post-influenza | Add vancomycin 25 mg/kg load then 15 mg/kg q8-12h | Teicoplanin or linezolid 600 mg BD (after TB excluded) |
Calculators for this topic
References
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Severe CAP: first hour
Step 1 of ~3
Decision: Major criterion or ≥ 3 minor criteria?
Based on National Centre for Disease Control (DGHS, MoHFW) and Indian Council of Medical Research; Metlay JP, Waterer GW, Long AC, et al. Educational use; follow local protocol.
Pathophysiology
S. pneumoniae remains the leading cause; H. influenzae, S. aureus, Gram-negative bacilli (Klebsiella), atypicals (Legionella, Mycoplasma) and respiratory viruses (influenza, SARS-CoV-2, RSV) follow. Severe disease reflects dysregulated host response with lung injury and sepsis.
Evidence
- ATS/IDSA 2019 defines severe CAP and empirical regimens [Metlay 2019].
- ERS/ESICM/ESCMID/ALAT 2023 suggest corticosteroids for severe CAP without shock and macrolides in combination [Martin-Loeches 2023].
- CAPE COD: hydrocortisone reduced 28-day mortality (6.2% vs 11.9%) in severe CAP [Dequin 2023].
Controversies
- Steroids in influenza or in patients already in septic shock; macrolide vs doxycycline for atypical cover.
🇮🇳 India notes
- The NCDC/ICMR National Treatment Guidelines (v2.0, 2025) set ceftriaxone + azithromycin/doxycycline as first line for ICU CAP.
- Indian CAP mimics: TB, scrub typhus, leptospirosis (pulmonary haemorrhage), melioidosis, H1N1 influenza and dengue; ask about season, occupation and geography.
References
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