Canadian Guidelines for the Initial Management of Community-Acquired Pneumonia: An Evidence-Based Update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society

Community-acquired pneumonia (CAP) remains a serious illness with a significant impact not only on individual patients but also on society as a whole. Guidelines for the initial antibiotic management of CAP were developed in Canada in 1993 and subsequently by the American Thoracic Society (ATS) that same year and by the Infectious Diseases Society of America (IDSA) in 1998 [1–3]. Each of these sets of guidelines has its own strengths and weaknesses, but individually and collectively they have helped to organize and codify our approach to the patient with CAP. Perhaps most important, they have highlighted the weaknesses and deficiencies in this area and have raised important questions for present and future research. As a result of developments in the past several years, it became clear that our guidelines should be updated and revised. This document is a joint effort by the Canadian Infectious Disease Society (CIDS) and the Canadian Thoracic Society (CTS) and we hope that it will be the first of many such collaborations. A committee was established that was composed of members from both the CIDS and CTS, plus additional colleagues from the United States with strong interests in CAP. The members were divided into 3 teams, each of which was responsible for 1 of 3 sections. These were (1) epidemiology, risk factors, and etiology; (2) diagnosis; and (3) treatment. The committee met for 2 days in Toronto in January 1999, and then each team proceeded to develop a draft of its section. These drafts were then circulated among the committee members, and a revised version was sent to colleagues in the United States, Europe, and Israel for review. This document was then finalized on the basis of their input. Relevant articles published during 1966 to the present were retrieved from MEDLINE with use of the MeSH terms “exp pneumonia/,” “community-acquired,” “nursing home,” “human, “random,” “clinical trial,” “exp antibiotics/,” and “English language.” In addition, abstracts from the annual International Conference on Antimicrobial Agents and Chemotherapy and IDSA meetings held in 1997, 1998, and 1999 were reviewed. For the section on epidemiology and etiology, we searched the terms “community-acquired pneumonia” and “etiology” (simultaneously) and found 968 citations. We applied a hierarchical evaluation of the strength of evidence modified from the Canadian Task Force on the Periodic Health Examination [4]. Well-conducted randomized, controlled trials constitute strong or level I evidence; well-designed controlled trials without randomization (including cohort and case-control studies) constitute level II or fair evidence; and expert opinion, case studies, and before-and-after studies are level III (weak) evidence. Throughout these guidelines, ratings appear as roman numerals in parentheses after each recommendation. None of these categories are readily applied to studies of the etiology of pneumonia. Instead, we applied the categories defined by Marston et al. [5] to indicate the degree of certainty that a given etiologic agent has caused the pneumonia: definite, probable, or possible. Unfortunately, most of the studies examined for this document were reported before publication of Marston's article. An examination of the articles on etiology of pneumonia led to a decision to use a small number of articles (for the group of patients requiring admission to the hospital—the largest group) in which the authors used comprehensive methods to try to establish an etiologic diagnosis. It was felt to be important to present the data in tables that allow the reader to see the range of various pathogens identified in each to use a of the of patients on an in or in small of studies, which are reported in their For the section on a of for and were applied for articles used for the of this section. that each on patients with CAP and that the a in the of CAP be in the of the article. articles with patients years, the or individual case studies or studies in this section were in the or in a For the published articles or abstracts on trials CAP were It was that of that were on in data and the of from be to be on level III evidence. with is the of in the United States, and an It for and of each year The for pneumonia are the of In the annual of pneumonia was year were in the group years, In the group years, the was In a of in et al. reported that the of pneumonia for each year of and the was as as year among patients It was also in this that in with A pneumonia for in In 2 in Marston et al. [5] found that the of CAP requiring among was The was among and among The was for years, for of and for In a of in a et al. found that pneumonia an annual of of the developed pneumonia a of the of pneumonia were of of were with a and were have on the of pneumonia in the et al. found that year developed in in the annual was for studies of in and Israel of and found several risk for pneumonia in in a and with A that examined risk for found that and were risk for this A number of these risk the of which is a in the of pneumonia. studies of in the United States have risk and have the of pneumonia among patients with risk for pneumonia in of pneumonia in a to but An of in a for the and 3 in the United States reported of for pneumonia in patients data from the of the for Disease and Marston et al. defined of the risk for this by patients with were reported to the from to with the of the United States with to and of of were in the and during the A risk of was identified for with or for were as of and For the to questions and are in the evaluation of the individual and the to the etiologic diagnosis. We of the that we for but be in our not the evaluation of a patient with pneumonia important not only for the management of that but also for the of the in which the 1 a of that should a patient with pneumonia. to the epidemiology and etiology of on the of the most of the epidemiology of pneumonia is its It is for the to not only the epidemiology of pneumonia but also the epidemiology of The be of the of of and in the and the that to such in the An approach to the etiology of pneumonia is are of and have from The is that the on of or and the of to an etiologic diagnosis. are for only of patients with and is only from patients in a is is for from of patients with pneumonia and a from this only be to be a of pneumonia. In have these and have the etiology of pneumonia as definite, probable, or Marston et al. [5] defined these categories as was defined as of or from or a in of to or or a in or of or from or an for 1 with a of was defined as of or from with or of on in which a was in or on was defined as of pathogens in a of on a of (1) of with (2) in of with or (3) of with a of to in the or a of to or an or an to These for of the etiology of pneumonia the of by should be in future CAP is not to the etiology of CAP is to group patients to the of This in in and of of pneumonia. in this be the and a This illness and in this be and to In this of the etiology of it is important to that the and of used in the various studies that the basis for our the etiology of pneumonia such as are and have not in it is not a etiologic pneumonia a of pneumonia that be to or to It is that many have not or not the as a of pneumonia. the etiology of pneumonia it is that et al. in a reported on patients from for of these The most etiology was for of the were patients and in this most patients pneumonia of of pneumonia on an to of patients with pneumonia are on an Unfortunately, the etiology of pneumonia in this group of patients has not 2 a of the studies that have examined the etiology of pneumonia in is in patients in patients admission to the in studies in was the most etiology, for of the In these studies the of pathogens is many of the not have of the etiology of pneumonia (CAP) on an of pneumonia that admission to the 3 on studies of CAP that These studies were from in the United States, and the The methods used to an etiologic from to but were be from these the most of CAP that is and the with which CAP from to studies the etiology of pneumonia (CAP) that The 3 studies that used various methods to to or its of pneumonia In these studies for and of the of pneumonia. the data are then of of CAP are to et al. found that for of the of pneumonia among with CAP in the same 3 studies of CAP. In the first during was from the of of the patients patients were and pneumonia In the of pneumonia are several for the of of from of the patients in the of et al. antibiotic before It is that after only 1 or of an antibiotic to which is the be from of for in studies but not in It is that in studies in was the most of in of of pneumonia. for of of pneumonia This is evidence that is the most of CAP. The most of from to in various studies of CAP that is The by et al. in which of the were to was during an of it is not of the of this agent as of the etiology of CAP. et al. from 1 of patients with and was for an additional met the for of these are not in their these patients are then the of of in the of et al. was of studies have on methods for of pneumonia is the most of CAP that studies have a of pneumonia among patients with the by et al. which on patients with and found that was the most of pneumonia in this group of for of the for of of CAP that of these are to 1 and and for most of the of the of The for the of 1 in will of the number of to but not of the of CAP. This will the of The use of this has that a used for that of a or should not be used to such as and are of CAP but they are important pathogens in patients are to admission to an of the with with and with These are from of patients with the is to from et al. patients with CAP. pneumonia in 1 et al. patients with CAP were to the of pneumonia: 3 were to 1 was to 1 was to and 1 was to a et al. found that of patients with CAP were to the pneumonia. is a of CAP it is of CAP that to the that is A of in with CAP that of the the the pneumonia and a in the of pneumonia. The of pneumonia during is an This also both the number of of and the number of of pneumonia during a of is as an important in The data in 3 a in this In have many of in and the number of the is was an of pneumonia in the studies in is an important of for of Unfortunately, this is not in many studies of the epidemiology of pneumonia. of these patients have a but pneumonia with both and of the of of CAP that are to pneumonia to an et al. to to the in patients with this of pneumonia. were from of patients and 2 of were and be as a of CAP. is that pneumonia result in many the data reported in 3 it is that for of of CAP that also be in of the etiology of CAP. The data in 3 indicate that caused of of CAP that in the et al. divided the patients into 2 the were not with given in and the were with of the group pneumonia. be for for it is the which has a have pneumonia that is to be caused by be identified on the basis of their and examination These patients are to during of to the or the of the risk of and are of with are not as a of in and are these be important of and CAP. these of they not in their diagnosis. In this it is that 3 of the patients in the of et al. pneumonia caused by This the of to with is the etiologic agent of the and are the for this In these to the and to the is during in the and the of the is the pneumonia and also with which to the of a of pneumonia 2 of or from an is in most In the studies in for of the of pneumonia in of in an and 1 of in the is to pneumonia in in pneumonia in both and with only are In patients with are with and and develop The or or with This is in patients are is a of patients with pneumonia of in a in which was on patients with CAP in to for an etiologic be for only of the It is that of these of etiology are to an has found to pneumonia In most studies of a small of patients have identified as the of the pneumonia. the studies in this from in the to in the et al. and et al. reported that and of their patients pneumonia of In such it is not clear both pathogens or 1 of the which then the agent to of studies of the etiology of pneumonia. is the most the of of the by an important is of pneumonia in patients is caused by these is in it is that this group of is important in pneumonia. A of studies of pneumonia is on to an etiologic as by the of in the of et al. This with the in studies in and the of on to an etiologic diagnosis. of pneumonia. of pneumonia in patients with to et al. patients with and pneumonia. were and with a of An etiologic was for The most were of and was 1 each of of which was The as a group for of the CAP. The of of CAP are on an the of patients for a significant and for the of for CAP and risk of are for patients with CAP that management in the The was for patients with CAP in in the by et al. of the for but in it not result in an in among patients admission to the is the most identified in patients in an The identified pathogens are and agent that pneumonia to and in patients in the in of pneumonia that admission to an a is identified in CAP patients in an an etiologic agent is identified for only of the the of and with or by of the are for patients has also used in patients with CAP The of of patients with CAP has among and The range of from the by the guidelines and the on to the by the IDSA We will for the of illness of the the of illness is by the of by the these will be as A of CAP is on the basis of the initial of a of and these are the then and a number of for and have to it is that are for for patients to be on an basis are from for patients to in a or in the for the of pneumonia and and in not the it should be that the of the and for of patients of CAP has it is studies have examined the of this the studies reported to are in that used as a to pneumonia was in these studies on or to the or of CAP. present with and and on examination should be of pneumonia. An important in the of this is the of a to the of but to it has not studies of in the of in patients with CAP have not reported significant has in several studies of has in the of for but such are for in The of in the of CAP is also but in has and to In on patients with of pneumonia. the was with to the or of and with to and the examination the of pneumonia was by of the In to the of to on the basis of was in only of and this to the of was of examination to which patients be as and which to be also has not The the of examination was reported by et al. It was to CAP patients were risk of days of that patients be for treatment. This both and In the a number of were identified by and on the basis of these were given for the of and on examination and and the basis of this patients were into 1 of and such as of for and were The examination used in this were as an or and The was then in of CAP The of such a for should be remains to be but that the number of patients for CAP be the of for CAP was that among patients The and is the which is and is for these are patients are of pneumonia. or in with and has as a to patients with pneumonia. A is in a etiology, and it also for a of illness or it is that a number of and present with a from the for pneumonia. has the use of and for patients with that a be for patients of but are not the use of to pneumonia has with to patients only has its to in patients of CAP This patients were in the or as and with of CAP. The was the of on was with an The or a The in patients in these patients and in an additional patients and among the patients in were on additional in was as as to in the and Unfortunately, the of the of the was not this a in the management or of the remains to be from is in an are 2 additional questions the of in the of patients of are of and should be The of of of patients with of CAP has by 3 studies and were in studies of various and the was an or These studies that the of of from to but or the same The only the of and found that the was and In only 2 studies was and it was reported as and of These are to of studies in of for patients with pneumonia. in of of patients with pneumonia In an to the use of several authors have developed for for patients with In the 1 and studies that have the of in patients with was felt to CAP and The among the studies, but 2 studies a and a and In of the studies, were developed with but In et al. that was as as the for not to of for patients with pneumonia and of for not to of for patients with pneumonia for a for patients with pneumonia The of decision developed by the studies was reported by et al. In this et al. the of each of the with a cohort of patients to an or the of pneumonia in this was The of the decision from to and from to was and most is for the evaluation of a patient of pneumonia The of is that the of pneumonia is not by the of an etiology and be and be the that in a not be for the patient is in a or to is The that these a of without of the is a approach the is the of it is in but the of this remains to be in among of from to but in to several have developed to in for these appear to be studies to have identified which to for patients with CAP. The only of the of was reported by et al. The in this were as and or risk for of patients of CAP is a patient has to the for the basis of initial and of the and are identified by these have as risk for a or have used in the developed by et al. and have for risk The that these be for patients to the as a of the of illness and the for is evidence to that these are in the of patients in a or a In addition, the that be for patients with an will not the of a patient not have risk for a or and are for the will and the patient from the are many to a the to the to antibiotic in terms of and and to that have such as and Unfortunately, the of is that and in in the epidemiology of a etiologic agent will not be found in to of the of the only after the most significant have studies the impact of on have not a of evidence is that of the not found to be the are with but the of the has on of the after the initial of and of to the not appear to et al. found that in to pathogens are found in of and the of these to a in in of that of to the was not and was and is examined for the of In many a be from the a be the of the is by to the is and of an is in the of and many have the of the of this remains its have that of patients not be is in A the and of of in of pneumonia The found articles that met for the to a 2 2 of and that were and were and were the result of was the and of the that the of from to in that was the for the of from to The among studies and on the as as the of or be and the authors that its use in be own of the the to these and In the for and not be from the published to the additional data were from the authors of these studies and not be from the data in the These were used in of studies of the of for patients with pneumonia of studies of the of for patients with pneumonia the studies in the were patients a to a In many the was a or that the patient was but not of the risk of CAP. In the studies, the not for the of In of the studies the was to the In most the was a the was a of of or a was the in only 1 in which patients pneumonia. A clear of a was given in only of the In of the studies, the a of that of patients a only a the the was from to The 2 studies that and of used or as et al. examined of patients with pneumonia and found that for a the The from to on the For the of of defined the of then the was for the diagnosis. the a of were the to The from to on the of a As in most as the the of for patients with pneumonia to Perhaps the and is that of et al. In a and a for each of of pneumonia to the the The of the etiologic agent the basis of their of the the subsequently identified from or was the of the of the as the but only in terms of of evaluation as the the to was a for The of the the of in the initial cohort of patients not and not have a by the the of this a was for of patients and was for only 1 was the antibiotic in the a of in their own the that of is to use this a be that the of its These studies have examined the of for patients of pneumonia. The of the the of of the strong of these The studies examined in this for the most not to the of in In the of for the of is but is that for of It is important to that a such as or was not used in the of In most studies, a of a was not the and of an have not are from most patients with CAP are to the and the with their use on 3 (1) of patients with CAP have (2) is are most (3) the of have for antibiotic or of CAP patients have on a of patients with CAP the of In a of that of patients will have and that a for of the of and of CAP and reported that of patients to the with for of the studies, the of are is among patients and patients not before of in studies of pneumonia In the of was examined for patients of admission for CAP that was by in the of risk such as or or the but in only of the were the not to be the with these was from and from the of to an in antibiotic for only of the studies have examined the of among with but the number of patients with this is In of patients to an the of to among patients was and only of patients with their management by the data the the and the of antibiotic In of in and were of and for of these The same reported a of with in of the largest CAP studies was the evaluation of CAP patients to in 2 a of and with of were The number of patients with was only of the patients a The of was among not before admission and among to in an of the of was but it to among not before admission and was only among the of admission In a United States of the of was with for of patients with United States a result for of patients with CAP to the both and In each group the of was the same for and for In both for of the but of In 2 studies, the of was In of admission and these patients were found to have a was found in of these patients In of of CAP in patients and were CAP patients to the have the of has For in a group of such with present in of these in and in In of patients with were for and were with the for and for In of of patients with the for of is are most the it is clear that the most identified in patients with CAP is but of be significant in patients to the The of in patients 2 (1) is the most agent with CAP with this should also be or (2) a of CAP patients with are patients with CAP to The is to be are as to but for are not with In most studies have found that a of patients with pneumonia have patients with CAP caused by pathogens In the of Marston et al. [5] were patients with or and were in was in of patients with of patients with and of patients with et al. reported that in of patients with a to et al. found to in of patients and in of patients on the only of patients with were In an pneumonia was by as as by and in this group only of patients with present in patients with of pneumonia. In the are a of patients with pneumonia have patients with CAP of In of patients with were of with and of with were In was present in of patients with pneumonia and in of with CAP caused by is the reported a of in among this

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