ATS, IDSA Update Guidelines on Community-Acquired Pneumonia

The American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) have released updated guidelines on the diagnosis and treatment of adults with community-acquired pneumonia (CAP). 

“Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions,” according to the guideline authors.

The authors developed the guidelines based on 16 clinical questions, which addressed how to best manage patients from the time of clinical diagnosis of pneumonia through the completion of antimicrobial therapy and follow-up chest imaging. The guidelines do not provide recommendations on the initial clinical diagnostic criteria or prevention of pneumonia.

Among the updated recommendations are: 

• Sputum and blood cultures are recommended in patients with severe disease as well as in all inpatients empirically treated for methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa. The cultures were recommended primarily for patients with severe disease in the 2007 guidelines. 
• Though corticosteroid use may be considered in patients with refractory septic shock, the authors recommend against their use. The prior guidelines did not cover corticosteroids.
• In adults with CAP whose symptoms have resolved within 5 to 7 days, it is recommended that follow-up chest imaging not be routinely obtained. The routine use of follow-up chest imaging was not addressed in the 2007 guidelines. 
• The use of macrolide monotherapy among outpatients is now considered a conditional recommendation based on resistance levels. The prior guidelines noted the therapy as a strong recommendation for outpatients.
• While both are accepted as a standard empiric therapy for severe CAP, there is now stronger evidence in favor of β-lactam/macrolide combination therapy compared with β-lactam/fluoroquinolone combination therapy. The 2007 guidelines gave both combinations equal weight.

“It remains disappointing how few key clinical questions have been studied adequately enough to allow for strong recommendations regarding the standard of care,” according to the guideline authors. “We hope that the research priorities outlined in this document will prompt new investigations addressing key knowledge gaps.”

—Colleen Murphy

Reference:

Metlay JP, Waterer GW, Long AC, et al.  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;200(7). doi:10.1164/rccm.201908-1581ST.