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Guidelines updated for treating community-acquired pneumonia

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Expert analysis from IDWeek 2019.

“Ever since we wrote the first CAP [community-acquired pneumonia] guidelines in 1993, we’ve heard good and bad things, and I agree with both,” Michael S. Niederman, MD, FCCP, said in a presentation at IDWeek 2019. “For good or for bad, [guidelines] are a standard against which care can be evaluated.” He discussed how, as guidelines have become more evidence based, they have often become “more wishy washy,” that when the evidence is weak, the recommendation is weak, and the guidelines merely advise doctors: “You figure it out.”

However, he pointed out that, since CAP guidelines were developed, there have been overall improvements in patient care and antibiotic stewardship. But he saw several weaknesses in the new guidelines, including the fact that they did not update minor criteria for determining severe CAP from the 2007 guidelines, despite several studies indicating that there were other criteria to consider. In addition, the updated guidelines held a negative view of the use of serum procalcitonin to guide site-of-care decisions, which Dr. Niederman argued went against an analysis of the Etiology of Pneumonia in the Community (EPIC) study (CHEST. 2016; 150[4]:819-28) and other studies that showed its utility. He referred to his own editorial, in which he discussed the subject extensively (Lancet Resp Med. 2016;4[12]:956).

“Similarly, to me, the macrolide issue is not resolved,” he added, citing several studies that, in contrast to the guideline recommendations, used outpatient macrolide monotherapy to good results, and one study showed that “there was a much better patient outcome for patients who got macrolide monotherapy than for those who got quinolones” (Resp Med. 2012;106[3]:451-8).

Dr. Niederman is clinical director of the division of pulmonary and critical care medicine at New York Presbyterian Hospital/Weill Cornell Medical Center, and professor of clinical medicine at Weill Cornell Medical College, New York. He disclosed that he is a consultant for and has received grants from a variety of pharmaceutical companies, including Bayer and Merck.



An update to the 2007 guidelines on the treatment of community-acquired pneumonia (CAP) was published by two medical societies, based upon the work of a multidisciplinary panel that “conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.”

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The panel addressed 16 questions in the areas including diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Some of their recommendations remained unchanged from the 2007 guideline, but others were updated based upon more-recent clinical trials and epidemiological studies, according to Joshua P. Metlay, MD, of Massachusetts General Hospital, Boston, and colleagues on behalf of the Infectious Diseases Society of America and the American Thoracic Society.

Among the key recommendations differing from the previous guidelines, the 2019 guidelines include the following:

  • Sputum and blood culture samples are recommended in patients with severe disease, as well as in all inpatients empirically treated for methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa.
  • Macrolide monotherapy is only conditionally recommended for outpatients based on resistance levels.
  • Procalcitonin assessment, not covered in the 2007 guidelines, is not recommended in order to determine initial antibiotic therapy.
  • Corticosteroid use, not covered in the 2007 guidelines, is not recommended, though it may be considered in patients with refractory septic shock.
  • The use of health care–associated pneumonia (HCAP) as a category should be dropped, with a switch to an emphasis on local epidemiology and validated risk factors to determine the need for MRSA or P. aeruginosa treatment.
  • Standard empiric therapy for severe CAP should be beta-lactam/macrolide and beta-lactam/fluoroquinolone combinations, but with stronger evidence in favor of the beta-lactam/macrolide combination.

The updated guidelines also include a number of other recommendations, such as those dealing with the management of patients with comorbidities, and were published in the American Journal of Respiratory and Critical Care Medicine.

“A difference between this guideline and previous ones is that we have significantly increased the proportion of patients in whom we recommend routinely obtaining respiratory tract samples for microbiologic studies. This decision is largely based on a desire to correct the overuse of anti-MRSA and antipseudomonal therapy that has occurred since the introduction of the HCAP classification (which we recommend abandoning) rather than high-quality evidence,” the authors stated in their conclusions. They added that they “expect our move against endorsing monotherapy with macrolides, which is based on population resistance data rather than high-quality clinical studies, will generate future outcomes studies comparing different treatment strategies.”

Many of the authors reported relationships with a variety of pharmaceutical companies; full disclosures are detailed at the end of the guideline publication.

SOURCE: Metlay JP et al. Am J Respir Crit Med. 2019;200(7):e45-67.

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