Updated clinical guidelines for the diagnosis and treatment of CAP

Reference

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. Am J Respir Crit Care Med 200;7(7):e45-e67.

Synopsis

The ATS and IDSA convened a multidisciplinary panel to conduct systematic reviews of the research and make clinical recommendations on the diagnosis and treatment of adults with CAP, using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. The 2019 guidelines recommend the following: (1) obtain sputum and blood cultures in all patients with severe disease, as well as those being empirically treated for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa; (2) only test for urine Legionella or pneumococcal antigen if there is a severe CAP or legionella outbreak; (3) when influenza is circulating in the community, test for the flu virus using a rapid molecular test; (4) do not use the procalcitonin level to determine the initial need for antibiotics; (5) use a validated clinical prediction rule, preferably the Pneumonia Severity Index, to determine the need for hospitalization; (6) for healthy outpatients, use amoxicillin OR doxycycline—OR use a macrolide but only in areas where pneumococcal resistance is less than 25%; (7) for outpatients with comorbidities, use combination therapy with amoxicillin/clavulanic acid or a cephalosporin plus a macrolide or doxycycline, OR monotherapy with a respiratory fluoroquinolone; (8) for inpatients with nonsevere CAP and no risk factors for MRSA or P. aeruginosa, use combination therapy with a beta-lactam plus a macrolide or doxycycline, OR monotherapy with a respiratory fluoroquinolone; (9) for inpatients with severe CAP and no risk factors for MRSA or P. aeruginosa, use a beta-lactam plus macrolide OR beta-lactam plus respiratory fluroquinolone; (10) cover for MRSA and P. aeruginosa with extended-spectrum antibiotics only in patients with locally validated risk factors for these bacteria; (11) do not routinely add anaerobic coverage for suspected aspiration pneumonia; (12) do not use corticosteroids in patients with nonsevere CAP (strong recommendation, high quality of evidence) or those with severe CAP (conditional recommendation, moderate quality of evidence); (13) use both antibacterial and anti-influenza treatment for patients with CAP who test positive for flu; (14) treat both outpatients and inpatients with no less than 5 days of antibiotics and until clinical stability; and (15) do not obtain routine follow-up chest imaging for patients whose symptoms have resolved within 5 to 7 days.