Written by Clay Smith
Reduce blood cultures, ditch procalcitonin, reduce anaerobic coverage for aspiration, no more empiric corticosteroids, no more HCAP and knee jerk broad spectrum antibiotics – these are some of the community acquired pneumonia (CAP) updates since 2007. Read more.
Why does this matter?
The last CAP guidelines were released in 2007. Since then, much has changed. This guideline focuses on adults with community vs hospital-acquired pneumonia who have not traveled and who have a normal immune response. This is an epic guideline and, as such, is a pretty long post. It answers these 16 key questions. Let’s get you up to speed.
Pneumonia guidelines leave me breathless
Question 1: In adults with CAP, should gram stain and culture of lower respiratory secretions be obtained at the time of diagnosis?
Not in outpatients; only if severe inpatient (or intubated), if starting empiric anti-pseudomonal or MRSA coverage, prior history of pseudomonas/MRSA, or prior hospitalization in the past 90-days.
Question 2: In adults with CAP, should blood cultures be obtained at the time of diagnosis?
Not in outpatients or milder severity inpatients; yes if severe inpatient (or intubated), if starting empiric anti-pseudomonal or MRSA coverage, prior history of pseudomonas/MRSA, or prior hospitalization in the past 90-days.
Question 3: In adults with CAP, should legionella and pneumococcal urinary antigen testing be performed at the time of diagnosis?
No pneumococcal testing unless severe; no legionella testing unless an outbreak, travel, or severe disease.
Question 4: In adults with CAP, should a respiratory sample be tested for influenza virus at the time of diagnosis?
Yes at times of high flu prevalence, and they recommend using a molecular assay rather than antigen test.
Question 5: In adults with CAP, should serum procalcitonin plus clinical judgment versus clinical judgment alone be used to withhold Initiation of antibiotic treatment?
If clinically suspected and radiographically confirmed, forget about procalcitonin.
Question 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?
Question 7: Should a clinical prediction rule for prognosis plus clinical judgment versus clinical judgment alone be used to determine inpatient general medical versus higher levels of inpatient treatment intensity (ICU, step-down, or telemetry unit) for adults with CAP?
Of course, hypotension on vasopressors and intubated patients need the ICU. Otherwise, they recommend clinical judgment plus the 2007 IDSA/ATS minor severity criteria.
Question 8: In the outpatient setting, which antibiotics are recommended for empiric treatment of CAP in adults?
Previously healthy with low risk for resistance: amoxicillin 1g TID; doxycycline 100mg BID; or azithromycin (macrolides assuming low community pneumococcal resistance, <25%).
With comorbid diseases of heart, lung, liver, kidney, malignancy, or asplenia: amoxicillin/clavulanate + macrolide or doxycycline; another option is cepodoxime or cefuroxime + macrolide or doxycycline; OR monotherapy with a respiratory fluoroquinolone. See dangers of fluoroquinolones.
Question 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?
See Inpatient Treatment of CAP table below.
Question 10: In the inpatient setting, should patients with suspected aspiration pneumonia receive additional anaerobic coverage beyond standard empiric treatment for CAP?
Not unless lung abscess or empyema is suspected
Question 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?
Healthcare associated pneumonia (HCAP) should be abandoned. Use of broader spectrum antibiotics for supposed HCAP did not improve outcomes. Only treat with extended spectrum antibiotics as above if locally validated risk factors for MRSA or pseudomonas are present.
Question 12: In the inpatient setting, should adults with CAP be treated with corticosteroids?
Do not use steroids in non-severe, severe, or influenza PNA. The literature has been back and forth on this. Steroids probably don’t help.
Question 13: In adults with CAP who test positive for influenza, should the treatment regimen include antiviral therapy?
Yes, oseltamivir should be used in outpatients or inpatients with CAP who test positive for influenza regardless of duration of illness.
Question 14: In adults with CAP who test positive for influenza, should the treatment regimen include antibacterial therapy?
Yes, bacterial pneumonia may exist along with viral pneumonia.
Question 15: In outpatient and inpatient adults with CAP who are improving, what is the appropriate duration of antibiotic treatment?
Antibiotics should be continued until vitals stabilize, oral intake is good, mental status normal, and no less than 5 days.
Question 16: In adults with CAP who are improving, should follow-up chest imaging be obtained?
If improving within 5-7 days, there is no need.
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. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST.
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