• In community-acquired pneumonia, the need for admission to an intensive care unit (ICU) has been estimated to be between 3 and 5 per cent of total cases.
• The outcome of ICU-admitted patients with community-acquired pneumonia is poor, with most studies reporting a mortality near 50 per cent.
• Severe community-acquired pneumonia shows a characteristic etiological pattern different from that of milder cases. Although Streptococcus pneumoniae remains the most common pathogen, Legionella pneumophila, Hemophilus influenzae, enteric Gram-negative bacilli, and Staphylococcus aureus are not infrequent.
• The initial diagnostic approach to severe pneumonias should include sputum Gram stain and culture, two serial blood cultures, and acute phase serology for Legionella and atypical agents.
• If an invasive approach is considered, a transthoracic needle aspiration with an ultrathin needle is particularly indicated in non-ventilated pneumonias, whereas a bronchoscopic protected specimen brush should be preferred in patients receiving assisted ventilation.
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