November 22, 2019

Understanding the New Pneumonia Guideline

IDSA-ATS has issued update to community-acquired pneumonia guideline

By Mohamed Hagahmed, MD

Much has changed since the last Community Acquired Pneumonia (CAP) guideline was released in 2007. The latest guideline focuses on adults with community or hospital-acquired pneumonia with no recent travel history who have a normal immune response. I will highlight the most important changes to the guideline relevant to our ED practice, but I highly recommend you read the full article listed in my reference at the end of this summary. So, let’s get to it!

Do not order gram stain or culture of lower respiratory secretions in outpatient adults with CAP. Only get them in severe inpatient or intubated adults, if you are starting empiric anti-pseudomonal or MRSA coverage, if there is prior history of pseudomonas/MRSA, and in patients who were hospitalized in the past 90 days. The same strategy applies when deciding when to obtain blood cultures in patients with CAP.

A respiratory sample should be tested for the influenza virus at times of high flu prevalence when an adult is diagnosed with CAP. The guideline recommends using a molecular assay rather than antigen testing. On the other hand, the guideline recommends against testing for the pneumococcal or legionella urinary antigens unless the disease is severe or there is a local legionella outbreak.

Procalcitonin should not be used to withhold initiation of antibiotic treatment when there is clinical and/or radiographic evidence of CAP.

In the outpatient setting, the latest guideline recommends the following antibiotic regimen for empiric treatment of CAP:

  • 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. Clinicians should be cautious when prescribing a fluoroquinolone; especially in older patients.

Do not use steroids in non-severe, severe, or influenza pneumonia. The literature has been back and forth on this. Steroids probably don’t help.

Read the full guideline.

Dr. Hagahmed is an assistant clinical professor in the department of emergency medicine at UT Health San Antonio.

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