Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults

Guidelines for the management of community-acquired pneumonia were issued on behalf of the Infectious Diseases Society of America in April 1998. The present version represents a revision of these guidelines issued in February 2000; updates at 6- to 12-month intervals are anticipated. A summary of these guidelines follows. Grading system. Recommendations are categorized by the letters A–D, according to the strength of the recommendation: A, good evidence to support the recommendation; B, moderate evidence to support the recommendation; C, poor evidence to support the recommendation; and D, evidence against the recommendation. The recommendations are also graded by the quality of the evidence to support the recommendation, on the basis of categories I–III; I, at least 1 randomized controlled trial supports the recommendation; II, evidence from at least 1 well-designed clinical trial without randomization supports the recommendation; and III, “expert opinion.” Chest radiography. Chest radiography is considered critical for establishing the diagnosis of pneumonia and for distinguishing this condition from acute bronchitis (AB), which is a common cause of antibiotic abuse. Site of care. Recommendations regarding the decision for hospitalization are based on the methodology used in the clinical prediction rule for short-term mortality, from the publications of the Pneumonia Patient Outcome Research Team (Pneumonia PORT). Patients are stratified into 5 severity classes by means of a 2-step process. Class I indicates an age <50 years, with none of 5 comorbid conditions (neoplastic disease, liver disease, congestive heart failure, cerebrovascular disease, or renal disease), normal or only mildly deranged vital signs, and normal mental status. In step 2, patients not assigned to risk class I are stratified in classes II–V on the basis of points assigned for 3 demographic variables (age, sex, and nursing home residency), 5 comorbid conditions (summarized above), 5 physical examination findings, and 7 laboratory and/or radiographic findings. Patients in risk classes I and II do not usually require hospitalization, those in risk class III may require brief hospitalization, and those in risk classes IV and V usually require hospitalization. It should be noted that social factors, such as outpatient support mechanisms and probability of adherence, are not included in this assessment. Laboratory tests. All patients thought to have pneumonia should undergo chest radiography. The following laboratory values should be determined for patients who are hospitalized: complete blood cell count and differential, serum creatinine, blood urea nitrogen, glucose, electrolytes, and liver function tests. HIV serology with informed consent should be considered, especially for persons aged 15–54 years. Oxygen saturation should be assessed. There should be 2 pretreatment blood cultures, as well as Gram staining and culture of expectorated sputum. Selected patients should have microbiological studies for tuberculosis and legionella infection. The preferred tests for detection of Legionella species are the urinary antigen assay for Legionella pneumophila serogroup 1 and culture with selective media. The rationale for performing microbiological studies to establish an etiologic diagnosis is based on attempts to improve care of the individual patient with pathogen-specific treatment; to improve care of other patients and to advance knowledge by detecting epidemiologically important organisms (Legionella, penicillin-resistant Streptococcus pneumoniae, and methicillin-resistant Staphylococcus aureus); to implement contact-tracing and antimicrobial prophylaxis in appropriate settings (such as cases of Neisseria meningitidis infection, Haemophilus influenzae type B infection, and tuberculosis); to prevent antibiotic abuse; and to reduce antibiotic expense. Antimicrobial therapy. Recommendations are provided for pathogen-specific treatment in cases in which an etiologic diagnosis is established or strongly suspected. If this information is not available initially but is subsequently reported, changing to the antimicrobial agent that is most cost-effective, least toxic, and most narrow in spectrum is encouraged. Recommendations for treating patients who require empirical antibiotic selection are based on severity of illness, pathogen probabilities, resistance patterns of S. pneumoniae (the most commonly implicated etiologic agent), and comorbid conditions. The recommendation for outpatients is administration of a macrolide, doxycycline, or fluoroquinolone with enhanced activity against S. pneumoniae. For patients who are hospitalized, the recommendation is administration of a fluoroquinolone alone or an or a Patients in the care should or in with a fluoroquinolone or other those are not may be to the patient is is and is to patients a clinical on chest usually the clinical and chest radiography is not for patients who The to usually indicates an or of or or such as or The most of community-acquired pneumonia are S. pneumoniae and The most for to is of appropriate antibiotic S. pneumoniae, the most common etiologic agent of pneumonia in for of pneumonia and are the most cause of community-acquired in by the of and are as the of pneumonia by may not as as pneumonia by The activity of and or other is good against but with that and are the only with in are against that are or to but resistance in selective that with fluoroquinolone The are of and of according to guidelines of the on of the for and Recommendations for the of blood culture antibiotic treatment and the of antibiotic treatment of hospitalization, are on the basis of are laboratory tests for Legionella in patients in the of an on chest of patients with an of for and of blood or of are the cause of in the and the cause of to in the in the the of pneumoniae and of detection and antimicrobial and are conditions in that are in of Guidelines for management were in by the Society the Society and the Infectious Society as well as the Infectious Diseases Society of America in The present guidelines recommendations of the with these guidelines are to recommendations in and an of guidelines are to community-acquired pneumonia in Recommendations are to strength and a to the quality of evidence is for quality from the It should be that of be to with the of variables that regarding of and selection of these should not good clinical for recommendations in the for recommendations in the is commonly as an acute of the that is with at least of acute infection, by the of an acute on a chest or with pneumonia (such as and/or in a patient not or in a for of of acute may most at least of the or with or without or in of in a patient with chest or the of patients also have such as and Pneumonia is the most common cause of in the the of to pneumonia and by the basis of on in the of this is to a of persons aged also by which that other may have to a changing of a of the with conditions at risk of infection. cases of in and in the The of that hospitalization is to be persons and persons aged from to patients in a of the is is to be for patients not The of is the the of a to patients the of an illness, the of and the probability of the of is of clinical from from without to and The to in cases of a on The decision to a patient or to or as an outpatient is the most important clinical decision by the of illness, which on the and of laboratory antibiotic and The treatment for an of in the is the of outpatient for diagnosis and management of community-acquired and type of or a or or fluoroquinolone with enhanced or complete blood cell care tests for for for diagnosis and management of community-acquired and type of or a or or fluoroquinolone with enhanced or complete blood cell care tests for for studies have risk for in cases of were in the studies of an risk with the of the of and radiographic studies have these with have also for a of comorbid such as congestive heart and and with of mental or and and Laboratory and radiographic with are liver function and to or S. and pneumonia are also with knowledge regarding the of and radiographic and patient mortality, is in for that do not a to the decision to to the In the risk of for patients with and the of is with the decision to the years, at least studies have used to of for patients with The Pneumonia a clinical prediction rule that short-term for patients with this as a this rule may the and of treatment for patients with this of risk in the and of risk in the and The Pneumonia prediction rule with with with with and and outpatients in the Pneumonia this patients are stratified into 5 severity classes by means of a 2-step process. In step patients are as risk class I (the severity are aged years, have none of 5 important comorbid conditions (neoplastic disease, liver disease, congestive heart failure, cerebrovascular disease, or renal disease), and have normal or only mildly deranged vital and normal mental status. In step 2, patients who are not assigned to risk class I on the basis of the and physical examination alone are stratified into classes on the basis of points assigned for 3 demographic variables (age, sex, and nursing home 5 comorbid conditions above), 5 physical examination mental or and 7 laboratory or radiographic blood urea nitrogen, or with the following class class class and class for step 2 of the prediction to risk classes II–V for step 2 of the prediction to risk classes II–V In the and of this for risk classes for class IV and for class V in risk class were also with hospitalization and to for outpatients and with of to the and of for in the Pneumonia the basis of these Pneumonia that patients in risk classes I or II are for outpatient risk class III patients are for outpatient treatment or brief and patients in classes IV and V should be from the Pneumonia that these recommendations reduce the of patients care by and that be a brief for an The and of the Pneumonia prediction rule to the of care for an of patients with have with of a version of the Pneumonia prediction rule were the rule and were to those in risk classes as with and of at to the The for those at home this were with the for from the the the were patients as for short-term classes for with The initially as outpatients the the of hospitalization used as the a outpatient care the but the of those initially in the outpatient the of A controlled trial subsequently the and of the Pneumonia prediction rule for the decision In this were assigned to management of or to implement a critical that included the Pneumonia prediction rule to the were the rule and were to those in risk classes as outpatients with patients with were in this of the prediction rule in an in the of patients of the rule not in an in or and not status. studies support of the Pneumonia prediction rule to patients who be in the outpatient The the of the Pneumonia prediction which for and a for the decision regarding hospitalization. should be that the prediction rule is as a prediction and not as a to patients with studies are to the the of this rule in the that patients as and in the outpatient have to or those of patients who are It is important to that prediction are to to to is that other severity of also be considered in an individual patient is a for outpatient care. Patients as may have important and to outpatient with treatment or poor social support at to of and to of be In patients may have such as or which are not included as in these prediction but the of a poor may also the important For in have the on risk as in clinical a blood of of such the of especially alone not the that an blood of of and of prediction the of in clinical is by the that the of patients with do not have for of care for outpatient care studies the of in have to the cause of of cases of and have in The most common etiologic agent in studies of is S. pneumoniae, which for of cases of pneumonia cases implicated influenzae of which are pneumoniae, pneumoniae, S. Streptococcus pneumoniae and other Legionella on the and other The of other is on factors, as with and and of of of the of pneumonia are by the of and of the tests used for of the that for in tests used for legionella a of and do tests used for the of to the of is or on the and of tests used in of the individual physical findings, or laboratory and such as the of or in pneumonia to or have not the other most have of patients and have not the for by of of and physical findings. In as that patients in a a 5 and laboratory to most patients with from the other patients A type of for patients with If such may be for patients who should undergo tests are to for patients with and be with antimicrobial are cause pneumonia commonly persons with risk For pneumonia is especially to in the and in patients with a of disease, disease, and HIV infection. conditions of such as in or S. pneumoniae is only to as the most common cause of acute pneumonia in patients with Legionella is an legionella pneumonia is in and It is an important cause of pneumonia in and in patients with renal and with in patients with disease, and those with pneumoniae thought to and evidence that pneumonia in of age There are in of of the of Pneumonia to S. pneumoniae, and in pneumoniae to cause pneumonia is a of of disease, cases with studies that is in other that is the and There are other in of of The and severity of as a of as a of For in of may also with pneumonia is in the of from the that with in and in the in of may be a The of pneumonia to that are be to with in conditions. For the of is on the of Legionella species in of the in with the of conditions for to and of in of these variables to in with in the to be the basis for the of in the in Pneumonia should be in patients with and/or especially by and It is that be a and empirical therapy. The of establishing the diagnosis of pneumonia and cause is with the antibiotic studies for of community-acquired studies for of community-acquired The diagnosis of is based on a of clinical and laboratory The diagnosis of is and and as well as disease, congestive heart failure, with pneumonia and cases of and are of do not require and are the of antibiotic antimicrobial is usually for and a chest radiography is usually to establish the diagnosis of examination to or is for detecting pneumonia Chest radiography is considered is for the etiologic the and or conditions. Chest in patients with pneumonia are for to of but this is not for the are in detecting but the clinical of these is and the not the of this of the of the and of the of may to patients for on the basis of without radiographic should be the and of antimicrobial in of and the of pneumonia with that from only in a outpatient to in an The that chest radiography be included in the of patients for pneumonia is considered a diagnosis The on microbiological studies staining and culture of expectorated in the guidelines represents a from the guidelines of the Society against microbiological studies the in and the of in of or A of the is that the quality of microbiological as to with that in an is that of the Laboratory which from to this the or other of attempts to studies to this have not rationale for the of microbiological and is in which with to the individual and The to the etiologic agent is by empirical selection of of the and In the of and microbiological the rationale considered to the of guidelines based on etiologic for establishing an etiologic for establishing an etiologic A may be for a that may to are in have as to of these have not to controlled a of with and infection. and by and are of is with pneumonia to influenzae or or with S. pneumoniae. indicates by studies of have that clinical do not etiologic support the of clinical for an etiologic diagnosis conditions to in patients with community-acquired conditions to in patients with community-acquired the clinical diagnosis of should be to microbiological diagnosis with studies of and blood for and of to common are in require tests for which are in The for is Gram staining of usually expectorated staining of or urinary antigen assay for for in urinary antigen assay for S. pneumoniae, staining for detection of and tests for Recommendations for expectorated and Recommendations for expectorated and studies for of community-acquired studies for of community-acquired such as are in not commonly or not for detection of tuberculosis is the only for detection of a pathogen that by the and but is for only with that on that of a be for therapy. The etiologic diagnosis be for and a diagnosis the to to treatment be with in a based on the and antibiotic by selection of antimicrobial with a or a an appropriate be of blood of for is with a in to studies have that with in patients is the for those with and without an etiologic diagnosis studies were not to the the is based on of cases with and without an etiologic also of that have not are of and do of these studies For and that a diagnosis by Gram staining with of of antimicrobial therapy. by that antibiotic treatment to poor which that the of an etiologic diagnosis is The of microbiological studies for patients is A from the Pneumonia with of patients that the of Gram staining and culture of were and studies were on only of outpatients with in this and most other studies of are at which microbiological studies are in other care The of a pathogen in blood in patients with The with studies is from to for patients and usually for outpatients The studies is by in the quality of microbiological and the patient It is that of an etiologic with of blood of antimicrobial treatment and Gram staining and culture for patients who require hospitalization. The is to establish a diagnosis that be used for and of antimicrobial the other the of studies for of severity is studies are to the of studies in these in the of the diagnosis on the pathogen and on the as follows. a is established by a clinical the of a etiologic agent from an or or the from of a pathogen that not the Legionella or tests are as the are usually not available in a or the are a etiologic diagnosis is established by a clinical with detection staining or of a pathogen in or or the pathogen should be in moderate to of from of from or used for etiologic The following tests or of are used to establish an etiologic blood culture at should be from patients who require hospitalization for acute pneumonia from other and should have Gram staining and culture by the clinical examination and the of Gram staining of expectorated is but this for selection of antimicrobial provided that a is antibiotic and in the laboratory a of with antimicrobial should not be for patients of the in for microbiological laboratory tests should Gram and culture of that for diagnosis and for outpatient and management of community-acquired pneumonia in for diagnosis and for outpatient and management of community-acquired pneumonia in for the of the of and in patients with normal or determined with of a examination the values from to based on of culture with clinical and of a of and Legionella species are may should be the of in is of expectorated should clinical and In may not be to Gram staining in a to antibiotic but a may be and for studies support the of examination of a with of that S. pneumoniae. the of Gram staining for patients with pneumonia to be and the to be In a of patients to the with a with the of and on The of by these a that the blood culture in have appropriate antimicrobial for of patients on the basis of In the Gram is of the of organisms that are The of with in a patient who not by most The of the is to the of the of expectorated are the common of are The most for microbiological is that the not a of from the the patient to a or the care not to such a administration of in the to from or culture and with of the by the of the The may to and the normal the pathogen to especially with such as S. pneumoniae. In cases of S. pneumoniae may be in culture in only of cases are used The of S. pneumoniae is from and of antibiotic may reduce the of common in of from and is with for such as or S. the of these for detecting other or tuberculosis is these tests are usually not in the of patients with but may for in a support the diagnosis of pneumoniae infection, with a of but this poor to pneumoniae require to 1 to for are The to and Legionella species The acute for Legionella in is usually or a have an acute as a for a or but 1 that this a of only If tests are to be an serum be from the of a in a serum be and studies of be to is for that are commonly available tests that be used to for acute by pneumoniae, pneumoniae, or Legionella for of in and in other have for with a of and for of S. in have to and of and on the are The an assay to S. pneumoniae antigen in may be as as of the to the the a of and a of are the with the the for in to to and the of on The this as a to and blood The also is a assay to S. pneumoniae but available are available for detection of and 2, and The of these tests are to are of of the of that be of the of tests of and a detection of on the basis of an The urinary antigen tests have to be and for detection of pneumophila serogroup which for of legionella cases in the other are the with which the is and the of of antibiotic staining of is with and poor and not by only and antigen of and a of A laboratory not the is by organisms other pneumophila serogroup but a culture or antigen assay is The urinary antigen and culture on selective and with to and tests that for the of or serum are especially for and Legionella The for these tests have not by the and is to and If such tests may be in establishing diagnosis and for at the of care. is for the detection of pneumoniae, and that the in the of tests and used to that were for culture for the detection of as well as common is of and the of in the A of of is the of to in the in the of or The of is on pathogen and from the of the are to by the should not be have the as expectorated For of common culture of or of a is considered The for and of for culture are available from is for is and may be to in a in patients with a who require to an or have pneumonia to antimicrobial is especially for the detection of such as and The blood and expectorated Gram staining and culture as the only studies to be considered for patients with and should be for patients and used only with appropriate to recommendations 5 studies for according to severity of S. pneumoniae is the of and for persons who have and the A of of in the from that S. pneumoniae for of cases in which an etiologic diagnosis as well as for of the cases of pneumonia In the is that cases of pneumonia hospitalization A for the most common of S. pneumoniae is and the on that the be to persons aged and patients who have conditions with risk for and is years. in the S. pneumoniae to which to patients with with alone or other commonly used without for of S. pneumoniae to and to other antimicrobial noted in and in the to be a in in the in in and in the In the to the and to be The of S. pneumoniae to is by the for Laboratory as follows. are by the is with as are by and by is against in with that are important with these is from a clinical of the on the A with as a pneumonia but not the basis of present and on the of the as of in the of S. pneumoniae from persons were or to from to and of the or in a the on the of the are based on in in cases of are in blood and in For these in treating pneumonia with of resistance is not resistance may be especially is of resistance are in in the with such as the and in these of antibiotic especially to is only of the the of with to are to such as or by an resistance to these and resistance are In with these to of with also have to these A resistance to other and to is the for pneumonia by or is to to treatment with of or is against S. pneumoniae, and the activity of this or other be by of in tests with or of Streptococcus pneumoniae to commonly used antimicrobial stratified by to of Streptococcus pneumoniae to commonly used antimicrobial stratified by to resistance the the of resistance is organisms have that resistance to other classes of or that are penicillin-resistant are also to other and the most appropriate to is these the in the as of to of these be by the of are an In the most resistance is a of by and to is that this resistance may be by of In most resistance is to a by this in resistance to and resistance to that be It is important to that resistance to such as or resistance to The of resistance to is to that of resistance to but resistance to is and of this is only and are against are against of penicillin-resistant but resistance to these to in are used the the and to be most with for S. pneumoniae those for to the to that to the of outpatient for in which the of cases have to S. pneumoniae, have a good is these studies were not to antibiotic resistance antimicrobial for empirical treatment of pneumonia and or a or in is preferred to of and studies resistance to to is a of of clinical in patients without risk for with S. pneumoniae is of In pneumonia by organisms that are or to to treatment with or Pneumonia to or organisms of these studies have a treatment with of a or a without to pneumonia to or but the of with and a in studies A with pneumonia to be the condition to penicillin-resistant and to for severity of and hospitalization, of which the that be present not the of the treatment in It or may not by of S. pneumoniae for which are and are in with or patients have of or without with a good is to antibiotic is a not to this is to be of of the of or a fluoroquinolone should be used for treatment of pneumonia in patients who are to or are other but with these antimicrobial for pneumonia is pneumonia is as the of of from the or into the The to

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