Guideline

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Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America

Author(s): Metlay JP, Waterer GW, Long AC et al

Am J Respir Crit Care Med 2019; 200: e45–e67

Respiratory infections
General respiratory patient care

Digest Author(s): Stylianos Loukides, e-Learning Director / 17 October, 2019

The document provides evidence-based guidelines on the management of patients with community-acquired pneumonia. The experts panel addressed 16 specific areas for recommendations. Areas that covered diagnostic processes, site of care, treatment strategies and management decisions. As severe CAP validated criteria established in 2007 are still active. One major [septic shock with need of vasopressors or RF requiring MV] or/and 3 or more minor [RR>30 breaths, PaO2/FiO2 ≤250, multilobar infiltrates, confusion, uremia, leukopenia<4000, Thrombocytopenia <1000000, hypothermia<36C, hypotension requiring aggressive fluid]. Considering the differences between 2007 and 2019 blood and sputum cultures are recommended for the severe disease, macrolide monotherapy is a conditional recommendation for outpatients and based on resistance levels, avoid the use of procalsitonin as a biomarker for antibiotic initiation, do not use systemic corticosteroids and consider them only in cases of refractory septic shock, There is a recommendation for abandoning the term health care associated pneumonia, standard empiric therapy for severe CAP β lactam/macrolide or β lactam /fluroquinolone, a routine follow up with chest x ray is not recommended.

Some other aspects involve: use PSI and less CURB65, anaerobic coverage only for suspected aspiration pneumonia only in the presence of lung abscess or empyema, test for influenza virus when virus is circulating in the community, prescribe antibiotics in adults with CAP and positive test for influenza virus, perform pneumoccocal and legionella urinary antigen only in patients with severe CAP.

Comment:

This type of guidelines is quite challenging specially for clinicians. Three are the main messages: We have to correct the overuse of anti MRSA and anti pseudomonal antibiotics, we have to identify with proper criteria the severe CAP and finally apart from the traditional therapeutic approach to consider local spectrum and frequency of resistant pathogens.