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

The Infectious Diseases Society of America (IDSA) produced guidelines for community-acquired pneumonia (CAP) in immunocompetent adults in 1998 and again in 2000 [1, 2]. Because of evolving resistance to antimicrobials and other advances, it was felt that an update should be provided every few years so that important developments could be highlighted and pressing questions answered. We addressed those issues that the committee believed were important to the practicing physician, including suggestions for initial empiric therapy for CAP. In some cases, only a few paragraphs were needed, whereas, in others, a somewhat more in-depth discussion was provided. Because many physicians focus on the tables rather than on the text of guidelines, it was decided that all of the information dealing with the initial empiric treatment regimens should be in tabular format with footnotes (tables 1–3). The topics selected for updating have been organized according to the headings used in the August 2000 CAP guidelines published in Clinical Infectious Diseases [2]. The major headings were “Epidemiology,” “Diagnostic Evaluation,” “Special Considerations,” “Management,” “Prevention,” and “Performance Indicators,” and each section had a number of subentries. Our current topics are either updates of specific subheadings or are new contributions, and the committee's recommendations are given at the beginning of each section. A summary of prior IDSA recommendations presented in 2000 and the updated and new recommendations can be found in table 4. Ratings of the strength of the supporting evidence and the quality of the data are given in parentheses after each recommendation, and the grading system used to categorize them is in table 5. The next guidelines for the treatment of CAP will be a joint effort by the IDSA and the American Thoracic Society (ATS). A working group representing both societies has been formed and is already at work on the next CAP treatment guidelines. Recommendation 1. The initial site of treatment should be based on a 3-step process: (1) assessment of preexisting conditions that compromise safety of home care; (2) calculation of the pneumonia PORT (Pneumonia Outcomes Research Team) Severity Index (PSI) with recommendation for home care for risk classes I, II, and III; and (3) clinical judgment (A-II). Recommendation 2. For discharge criteria, during the 24 h prior to discharge to the home, the patient should have no more than 1 of the following characteristics (unless this represents the baseline status): temperature, >37.8°C; pulse, >100 beats/min; respiratory rate, >24 breaths/min; systolic blood pressure, <90 mm Hg; blood oxygen saturation, <90%; and inability to maintain oral intake (B-I). Comment. Selection of the initial site of treatment, whether home or hospital, continues to be one of the most important clinical decisions made in the treatment of patients with CAP, often determining the selection and route of administration of antibiotic agents, intensity of medical observation, and use of medical resources. This decision is often made in the emergency department, the portal of entry for 75% of the 1 million annual pneumonia admissions in the United States. Two recent articles suggest that the initial site of treatment decision be selected using a systematic 3-step process [3, 4]. Step 1 involves assessment of any preexisting conditions that compromise the safety of home care, including severe hemodynamic instability, active coexisting conditions that require hospitalization, acute hypoxemia or chronic oxygen dependency, and inability to take oral medications. The second step involves calculation of the pneumonia PSI, with a recommendation for home care for patients in risk classes I, II, or III. A description of how the PSI is derived is shown in Appendix A. The third step involves clinical judgment regarding the overall health of the patient and the suitability for home care. Mitigating factors for step 3 include frail physical condition, severe social or psychiatric problems compromising home care (including a history of substance abuse), and an unstable living situation or homelessness. Clinical judgment should supercede decisions made on the basis of PSI alone. At the present time, 3 North American medical practice guidelines advocate use of the PSI as an objective measure of risk stratification to help determine the initial site of treatment for CAP [2, 5, 6]. Preliminary results from the Emergency Department Triage of Community-Acquired Pneumonia Study indicate that implementation of the PSI significantly increases the proportion of low-risk patients with pneumonia managed in the emergency department who are treated as outpatients without compromising outcomes, as measured by short-term mortality or subsequent hospitalization [7]. In this randomized, controlled study that involved 32 hospital emergency and patients with CAP, implementation of the PSI with and implementation in a significantly proportion of low-risk patients treated in the The committee continues to use of the PSI as a of risk stratification and that this process be with assessment of the patient and use of clinical discharge are of the initial site of treatment are data that use of can mortality The discharge are during the 24 h discharge to the home, the patient should have no more than 1 of the following characteristics (unless this represents the baseline status): temperature, >37.8°C; pulse, >100 beats/min; respiratory rate, >24 breaths/min; systolic blood pressure, <90 mm Hg; blood oxygen saturation, <90%; and inability to maintain oral for are the of a in or a of using a in or a of respiratory using that for Comment. is an important respiratory it has been with chronic as a for the of with this is this for the in the and for a of the of this it is that is with to The IDSA CAP recommendations of the for and in the United and the for in are that include and or For the short-term treatment of patients with CAP, either the of by or the of the by or of respiratory is most to be increases in by and an are to be more in or For only is acute using a in the or an of be of a is Because the by to from to and should be in the on the are important to the of the and to for of a either of the by of subsequent or with the use of are for of in clinical has and only the for a is no that has been by the and is in A of have been used to in including in and The of is that of the to specific and the The is an to the of blood and and with the of results to those for Comment. that has been by the for using a is as a for the of pneumonia in The is an used to is to all are using and results of the are with the results using for pneumonia in the from to and the is on the of The in in adults has been to be In one of the published to on from adults with CAP. was in of patients with of the patients who had pneumonia with no was in that a of that are by can be with of from patients with pneumonia to other were problems with have the of of that the was no more to be with pneumonia than and it was significantly more to be those who were of this is to be for with pneumonia from those who are and the to be for the has been include the of a for patients with to or a to that of and the for of a For the should the of for CAP, and a of this administration of therapy This be for patients therapy at the of it should be a for will be to specific are to the clinical of and to determine in clinical should be that results from of in a patient with pneumonia by the basis of the present the this a to blood and other for pneumonia in The committee at of results in the Recommendation 1. of to and in should be as an of should be as an of and should be as an of Recommendation 2. or are the for treatment of pneumonia without for with to with of or of Recommendation is the antibiotic for oral treatment of pneumonia Comment. of the the for and The new to treatment of by and that with of are to be those with of are and those with of are This is the that the has provided for from and and should more of pneumonia to be treated with for were derived from for Because the of antibiotic in is only a of that in to be an have a The new that by to be and some that were as can be treated with the of or are the for pneumonia the of with an of The could be for use of for The IDSA committee and to the new as for the clinical should be in the to for and other Recommendation 1. care be in of important include the for to including health care and Recommendation 2. include clinical and and include for the for are (1) for (2) of during the acute of or any after or (3) of by second by using a second of the or a of it to the use of Recommendation The major is care Recommendation 4. include in patients with or include of and and of and Comment. is the used to of pneumonia that were in in in and that during of of have been from The of were in and with and severe and A of health care and with patients who had and were by the to most has been from patients to with a of with respiratory and respiratory have been to be the most important of and have been as the of the to in a to to of a and to a number of other without with a has the of whether by or by care a of should take safety and should from an in should include and of and and the patient in a and use of or for all who the are for include many on patients of the evidence for to health care in the use of This include of or and an of that can be to should be for at the of and some be for a of the of information should be from active as those of the and the a number of were in patients with including and it is that a is the an of this in patients with by of respiratory and and of with the with produced a severe respiratory to in The of of of the in and a number of other are and a number of are to the The of the has been the in the and either as a of 1 of the 3 or in a group For using clinical and criteria, has been as or cases, and the working by have been for to the for a a patient have and clinical of respiratory of and as as of to an with of or of with a or of A is one that the for in has either evidence of respiratory or with pneumonia or respiratory without an of have as new information has in the updated of with of should be from the or of the criteria, most in the United and have been using clinical and of the is evidence of the of have had both with results and with of in both the of and in the Because to have been found in the to be a the current and the after the second of to the or are to be is to is or with the Because of the of results of and only the of in a after is by the to be a for are for use in clinical should to other in patients of and and should be for a specific has been and should be from patients the and to and health for at the 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controlled clinical of the of and the of evidence of for any treatment to from a in to an with of this the has in most of the in with health including and on a during the or A second of in and of new the of as the acute of the The of the on and medical care is only beginning to be and the of is that will be an important of pneumonia in the and the of outpatients at risk for of the pneumonia Infectious physicians will to that maintain and that for the and to from Recommendation 1. empiric therapy prior to of data for a patient to require to a hospital can be with a or a respiratory to care and is a a of a either a or a respiratory should be used Recommendation 2. data are and it is that the patient has pneumonia with without evidence to with a treatment will in the is a or be used the is or a respiratory or other by in be used Comment. The mortality for pneumonia is it was that in was The guidelines from the the and the Infectious Diseases Society and Thoracic Society a and or a for empiric treatment of patients to a hospital and a or a for patients to the for has been In the therapy was based on the results of that that a was with a of and mortality For this recommendation was based on a of data as for severe CAP, as as with a have that therapy that a given mortality with pneumonia the that were that had is important to that the of initial empiric therapy the results of blood were of therapy after the results of blood were and the that the results of the of Two for the results with a are the of or and the of A is to determine the without or the A of data patients years with severe pneumonia by the that with a was as as any other a or The were mortality and mortality therapy for patients with CAP to a hospital can be with either a or a respiratory alone. For those to require to the and in is an initial empiric treatment any data are should be with a either a or a blood a as and is no evidence of with a the decision to with therapy or to to a is on an basis to include the and any as as the and to a is to be the committee that pneumonia should be treated with or the is and it should be treated with a respiratory or other by in the is Recommendation 1. are the and of respiratory on (A-II). Recommendation 2. for is for any patient with pneumonia This is in patients with pneumonia severe to require care in the in the of an or is to to a Recommendation for is is evidence of this results Recommendation 4. The treatment for for patients is or a and is only as an oral For patients who require hospitalization, include or a (A-II). should be as as is (A-II). Comment. is in of CAP in most is to and as in risk factors include recent with an of the home, to recent in or and are immunocompetent was 1 of major respiratory in patients with CAP who to the according to of recent that the following of clinical this of or severe have in of from other of CAP on the basis of initial clinical or A clinical system that a of clinical and is specific to a help specific of include and require for and selection of is is and are no The are the and of respiratory The for 1 is and and to of community-acquired of it is for of of other than 1 on all is and for is for any patient with is for patients with pneumonia severe to require hospitalization in an pneumonia in a in the of an and to to treatment with a should be that no for all patients with the In the clinical and therapy for should be given or the results of are The therapy for the of the health of the and patient patients with pneumonia hospitalization be treated with a of agents, including and or a or are for severe is only in an oral A in therapy is with an mortality rate, and treatment should be as as The of treatment should be it should be for of Recommendation 1. are are for in adults and are for adults Recommendation 2. A for is for of this for treatment that A and are Recommendation treatment h after of is in the treatment of A using or and is in the treatment using and (B-I). of is for with a of of h be used to in patients or for pneumonia Recommendation 4. treatment of of should and with as or a respiratory Recommendation 5. Pneumonia by or should be treated with (A-II). Recommendation is no with for the treatment of adults with the or Comment. are of often of in patients with chronic and patients with study of adults found respiratory in on of those for an acute respiratory of or chronic and that or for 75% of A of and for the that was for an of and in the United States. were with and the as years of was in an of with most and with chronic or of respiratory are and is in a section in this is a to be a important respiratory pneumonia in both and adults The clinical of and the of are on patient and of immunocompetent adults with CAP have evidence of this from in A recent from the United evidence of a in of patients with CAP, with and in and of the and other can are in and the has from to in The most of is has been found in to of patients in In the of a no clinical or are to with from with for respiratory for can a the next and are to be in patient at can a in with the specific of and patient is in adults so that results the have to be to based on the of and in the of an some can A and have for are with use of respiratory from for respiratory is in the of a of a specific controlled of treatment of adults have been therapy is for with and other in selected The and are active only for A the are for both A and to be as as the other for A and is it is with of are for and treatment of have been in 1 found that has been by the for was more than oral in of home during A in of of resistance to the treatment of in adults with or oral the of respiratory The use of the of respiratory as by use of in patients with In adults with a of had no was found in one study of treatment Because patients often have after after hospitalization, treatment Because of risk of resistance and of is an for For with therapy with an and this has been shown to clinical in a is for treatment of or treatment of is for other in immunocompetent has been used in has been this for is for use for of in Recommendation 1. should the to and the to health in of Recommendation 2. and guidelines are those of the for and of the as for the specific of for A of for blood and for blood and and of and for of blood and or in 3 Comment. A number of can be by as that can of The most to severe are and and or be with The with was the that or to in in the United Clinical to the of from CAP have been of this a of initial and without and some and on on and were for of h The mortality in this and prior in the antibiotic were The most important are of antibiotic treatment and of selection should be based on the have an resistance to and should be have shown in of in the of of oral or for with should be that the of in the United in so any of or should of health in the United of of in in as a was by by the in the The most of with after is or Clinical include an of and and a often with is the be from blood or only with using or other as or This represents a to and should be only in a are including and are only in or health treatment is is is more can be given and is an and are treatment and are more with is for has been used in and The of treatment is with or more and has a mortality The with during that mortality was is risk of and the recommendation for for is or for is a of it has a in the of antibiotic treatment, and can be from to Clinical of include and that is to and The or that is of is to be present with A of of in the United for that only were of the The is with of or blood often to this is the should be in for at for one and at for the other of the care are at risk of so respiratory should be patients have therapy for The treatment for pneumonia is administration of or in for be given for treatment or resistance has been to be as as in with and be given for treatment or of or for is the has or is selection for patients with CAP is the as for all adults with CAP for and in the are as of the recommendations given in the following on of CAP. Comment. In the United CAP is the of in and an of care a of are at risk of pneumonia the of the of pneumonia in adults is In a study CAP was the in of patients was in in in and respiratory in The of pneumonia in living in the is it is in those with For home data are more The proportion of of pneumonia in care that are to is The of to and were and and were In risk factors for pneumonia risk and of In a study to risk factors for pneumonia in of care and the inability to take oral were found to be Clinical The clinical of CAP has been as more in have been few systematic to A study of patients found that years and years had and than those years The of was most for those to and and and care to hospital with pneumonia were with with CAP, it was that home were to and for the of CAP in the have been in randomized, controlled selection recommendations for patients with CAP are the as for all adults with CAP A discussion of of and is in the following on of CAP. Recommendation 1. at risk for and of should as by the on The is the for most at risk of with for of and for health care The is an for some years without chronic including and chronic medical conditions should be to at hospital discharge or during treatment during the and care in and and care should annual Recommendation 2. by in the United is for according to current guidelines, including use for years and for those with selected be either at hospital discharge or during treatment Comment. and is the of pneumonia for A systematic that 1 and for frail had an of for for hospitalization, and for A recent study of adults years found that was with a in the risk of hospitalization for and pneumonia or as as a in the risk of to all In care of health care with is an important health from have shown to either the of of health care or to no of of health care was with a in patient mortality rate, from to a care in of health care with no of health care significantly mortality who had a of in health care were with were with the are more to the has been in randomized, controlled of one clinical that the provided some pneumonia other pneumonia or without the use of have the to an Two have pneumonia of care including a recent and adults with chronic medical conditions have of for of and for of pneumonia without The overall immunocompetent years is 75% with adults be from of of In a was for use in in the United States. to data from the of pneumonia with and in with baseline by years of and adults years the is only for the safety and have been in patients with CAP should and as by the The for is and in and is for those who were and can be given at the in The should be provided either at hospital discharge or at the of can be used to the process of that patients are recommendations that should be given to all of who are at risk for from for include of any who in a home or other care who have a chronic of the or including or who have a chronic that or hospitalization in the prior as chronic (including or (including by or by and who will be in the second or third of during the health care or work involves any patient including with home should to to In of all and is was in by the guidelines on use were published in The is for use and is as an for of of the new include the to both and and the of administration using the rather than Because it is made from care should be to it to rather than the should be given to years or with with or other chronic of the or with other medical including as and or who have or who are or or other of the of with and Because data are on of from to use of is for health care and who have with can be used as an to for and of and have for treatment and of A and is for and treatment of both A and is for the treatment of both A and is for an to the in be during this for with to who or work in with an and other at risk for in the of a be for with to or be given in to to in the be The use of for treatment or should to the

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