The American Thoracic Society and the Infectious Diseases Society of America have published an official clinical guideline on the diagnosis and treatment of adults with community acquired pneumonia (CAP) in the ATS’s American Journal of Respiratory and Critical Care Medicine.
By definition, CAP is pneumonia acquired outside a hospital setting. Many things can cause pneumonia, which causes the air sacs in the lung to become inflamed, though most often bacteria or viruses are to blame.
The guideline makes recommendations in response to key decisions facing clinicians caring for patients with CAP, including diagnostic testing, site of care, selection of initial empiric antibiotic therapy and subsequent disease management. The guideline focuses on adults who are not immunocompromised.
The latest guideline replaces one from 2007, which was produced by the two societies. Although some of the recommendations made in the earlier guideline remain unchanged, the 2019 version revises recommendations for empiric treatment strategies and makes additional recommendations for disease management.
One important difference between the latest guideline and the 2007 guideline is that it recommends more microscopic studies of respiratory tract samples in some subgroups of patients to avoid unnecessarily prescribing therapies for drug-resistant bacteria.
“CAP remains one of the leading causes of deaths in the world,” said Grant Waterer, MBBS, PhD, co-chair of the guideline committee and a professor of medicine at the University of Western Australia. “Not only has there been new data in the past decade, but there is now a strong national and international focus on antibiotic stewardship. It was time to update the guideline so that clinicians could be certain they were still practicing evidence-based care.”
The 15-member panel that produced the guideline included experts in infectious diseases, pulmonology and evaluating medical studies. Using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework, the panel made recommendations in response to 16 clinical questions.
They produced a series of questions and the recommendations made in answering the questions. All the questions and recommendations can be found here.
The authors of the guideline wrote that it is “disappointing how few key clinical questions have been studied adequately enough to allow for strong recommendations regarding the standard of care.” The guideline highlighted many areas where further research would likely improve care.
Research could lead to new rapid diagnostic tests to identify the organisms causing CAP, help determine the intensity of treatment that would be best for each patient, compare the best therapies for treating CAP on an outpatient basis, guide treatment of those patients at highest risk of dying from pneumonia and identify the subsets of patients, if any, who would benefit or be harmed by corticosteroid therapy.
“Given that CAP is such a significant cause of morbidity, mortality and health care utilization, a much larger research focus is needed,” said Joshua Metlay, MD, PhD, the other co-chair of the guideline committee and chief of the Division of General Internal Medicine at Massachusetts General Hospital. “Still, we believe that there is a sufficient body of evidence supporting most of our recommendations and therefore adhering to them will result in better care and better outcomes for patients.”
Dr. Metlay added that the guideline “cannot replace experienced clinical judgement and that clinicians must have knowledge of their local etiological agents to provide high-quality care to patients with CAP.”
American Thoracic Society has the release.
