Who actually needs antibiotics for pneumonia? Rethinking diagnosis in the era of molecular diagnostics and bedside imaging

Background Community-acquired pneumonia (CAP) remains a major cause of morbidity and mortality, with empirical antibiotics still the standard of care. However, advances in molecular diagnostics and imaging have challenged the assumption that all patients with pneumonia require antibacterial therapy. Objectives To review current evidence on which patients with CAP are most likely to benefit from antibiotics and how modern diagnostics can support more targeted antimicrobial use. Sources A narrative review of recent international guidelines, expert position statements, clinical studies, and reviews addressing viral diagnostics, imaging, biomarkers, host-response profiling, and antimicrobial stewardship in CAP. Content Rapid multiplex polymerase chain reaction (PCR), lung ultrasound, and computed tomography have improved the detection and characterization of pneumonia, while the increasing recognition of viral etiologies has highlighted the limitations of universal empirical antibiotic prescribing. Although bacterial co-infection remains a concern, emerging evidence suggests that selected patients with CAP and a confirmed respiratory viral infection may derive limited benefit from prolonged antibiotic therapy. Novel approaches, including host-response biomarkers, machine learning, and inflammatory endotyping, may further improve diagnostic accuracy and guide individualized treatment. Implications Antibiotic decision-making in CAP should increasingly integrate clinical assessment with molecular diagnostics, imaging, and host-response markers. This approach may reduce unnecessary antibiotic exposure, strengthen antimicrobial stewardship, and support patient-centred care without compromising safety.