IDSA/ATS guidelines for community acquired pneumonia

Joshua P. Metlay, Grant W. Waterer, Ann C. Long et el published the official IDSA /ATS guidelines for treatment of community-acquired pneumonia.

BACKGROUND

Last IDSA/ATS Guidelines for community-acquired pneumonia were updated in 2007 . In 2016,  IDSA/ATS updated guidelines on  ventilator-associated pneumonia as well as Hospital-acquired pneumonia which were discussed in comparison with European guidelines here. The new guidelines are based on  changing evidence and clinical picture of community-acquired pneumonia. Especially recognition of increased incidence of viral pathogens as a cause for pneumonia. Guidelines are in form of question answers  dwelling on several points. 

APPLICATION

These guideline focus on patients in the United States who have not recently completed foreign travel, especially to regions with emerging respiratory pathogens, who are not immunocompromized. 

MAIN DIFFERENCES FROM 2007 GUIDELINES

  1.  Routine sputum and blood cultures not recommended unless severe CAP.
  2. Use of procalcitonin not recommended to tailor therapy
  3. Use of steroids not recommended
  4. Routine use of follow up chest imaging not recommended
  5. Not using the term HCAP(health care associated pneumonia)
  6. Stronger evidence in favor of b-lactam/macrolide combination in severe CAP

SUMMARY

 

QUESTION ANSWER
1 Should Gram Stain and Culture of Lower Respiratory Secretions Be Obtained at the Time of Diagnosis? Not for patients treated as outpatient. Should be for Severe CAP, suspected to have MRSA or pseudomonas
2 Should Blood Cultures Be Obtained at the Time of Diagnosis? Not for patients treated as outpatient. Should be for Severe CAP, suspected to have MRSA or pseudomonas
3 Should Legionella and Pneumococcal Urinary Antigen Testing Be Performed at the Time of Diagnosis? Not unless have severe CAP
4 Should a Respiratory Sample Be Tested for Influenza Virus at the Time of Diagnosis? Yes during season.
5 Should Serum Procalcitonin Be Used to Withhold Initiation of Antibiotic Treatment? No
6 Should a Clinical Prediction Rule for Prognosis plus Clinical Judgment versus Clinical Judgment Alone Be Used to Determine Inpatient versus Outpatient Treatment Location for Adults with CAP? A validated clinical prediction rule such as PSI (Pneumonia Severity Index ) should be used. 
7 Which rules to determine Inpatient General Medical versus Higher Levels of Inpatient Treatment Intensity (ICU, Step- Down, or Telemetry Unit) for Adults with CAP? Patients with hypotension requiring vasopressors or respiratory failure requiring mechanical ventilation need ICU. For others, use Severe CAP criteria (from IDSA 2007 )
8 In the Outpatient Setting, Which Antibiotics Are Recommended for Empiric Treatment of CAP in Adults? Please see below. 
9 In the Inpatient Setting, Which Antibiotic Regimens Are Recommended for Empiric Treatment of CAP in Adults without Risk Factors for MRSA and P. aeruginosa? Please see below. 
10 Should Patients with Suspected Aspiration Pneumonia Receive Additional Anaerobic Coverage beyond Standard Empiric Treatment for CAP? No
11 In the Inpatient Setting, Should Adults with CAP and Risk Factors for MRSA or P. aeruginosa Be Treated with Extended-Spectrum Antibiotic Therapy Instead of Standard CAP Regimens? No, and the term HCAP(health care associated pneumonia) should not be used.
12 In the Inpatient Setting, Should Adults with CAP Be Treated with Corticosteroids? No
13 In Adults with CAP Who Test Positive for Influenza, Should the Treatment Regimen Include Antiviral Therapy? Yes
14 In Adults with CAP Who Test Positive for Influenza, Should the Treatment Regimen Include Antibacterial Therapy? Yes
15 In Outpatient and Inpatient Adults with CAP Who Are Improving, What Is the Appropriate Duration of Antibiotic Treatment? 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
16 In Adults with CAP Who Are Improving, Should Follow-up Chest Imaging Be Obtained? No

 

CRITERIA FOR SEVERE CAP

PSI (Pneumonia severity index)

OUTPATIENT ANTIBIOTICS FOR CAP

 

INPATIENT ANTIBIOTICS FOR CAP