Community-Acquired Pneumonia in Adults: Guidelines for Management

John G. Bartlett 0 1 2 3 Robert F. Breiman 0 1 2 3 Lionel A. Mandell 0 1 2 3 Thomas M. File 0 1 2 3 Jr. 0 1 2 3 Executive Summary 0 1 2 3 0 Clinical Infectious Diseases 1998;26:811-38 q 1998 by The University of Chicago. All rights reserved. 1058-4838/98/2604-0003$03.00 1 Received 3 July 1997; revised 15 January 1998. This guideline is part of a series of updated or new guidelines from the IDSA that will appear in CID. AIDS Clinical Trials Unit , Baltimore, Maryland 21205 2 From the Johns Hopkins University School of Medicine , Baltimore, Maryland ; the Centers for Disease Control and Prevention , Atlanta, Georgia ; McMaster University , Hamilton, Ontario, Canada ; and the Northeastern Ohio Universities College of Medicine , Akron, Ohio 3 Peter A. Gross, MD , for the IDSA Practice Guidelines Committee This is part of the series of practice guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. The purpose of this guideline is to provide assistance to clinicians in the diagnosis and treatment of community-acquired pneumonia. The targeted providers are internists and family practitioners. The targeted groups are immunocompetent adult patients. Criteria are specified for determining whether the inpatient or outpatient setting is appropriate for treatment. Differences from other guidelines written on this topic include use of laboratory criteria for diagnosis and approach to antimicrobial therapy. Panel members and consultants are experts in adult infectious diseases. The guidelines are evidence based where possible. A standard ranking system is used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary and tables highlight the major recommendations. The guidelines will be listed on the IDSA home page at http://www.idsociety.org. - Recommended diagnostic studies include blood cultures and gram staining and cultures of expectorated sputum for patients who require hospitalization. Caveats in this recommendation address the need for pretreatment specimens that are expeditiously transported and undergo cytologic screening as contingencies for optimal results. Tests for the presence of Legionella species, preferably culture and urinary antigen assay, should be performed for a subset of patients. Other diagnostic tests for specific microbial pathogens are recommended, but these tests are not considered routine. Some organisms are considered diagnostic as the cause of pneumonia when detected in any specimen; most potential pathogens recovered from expectorated sputum represent possible contaminants from the upper airways; thus interpretation of their recovery is dependent on clinical correlations, gram stain findings, and quantification in cultures. Selected topics are discussed individually as well as within the context of the broader perspective of all patients with pneumonia. These topics include pneumococcal pneumonia; aspiration pneumonia; pneumonia caused by anaerobic bacteria, Chlamydia pneumoniae, Legionella species, and Mycoplasma pneumoniae; Hantavirus pulmonary syndrome; Pneumocystis carinii pneumonia; influenza; and empyema. Treatment: Therapeutic recommendations are provided in two categories. The first category includes the recommendations that apply when a pathogen is detected, i.e., pathogendirected therapy based on in vitro susceptibility test results and/or clinical trials. Penicillin or amoxicillin are recommended for strains of Streptococcus pneumoniae that show susceptibility or intermediate resistance (MIC, 1.0 mg/mL). For strains with high-level resistance (MIC, 2 mg/mL), the recommendation is based on results of in vitro testing; for empirical use, a fluoroquinolone with good antipneumococcal activity or vancomycin is recommended. Other microbe-specific recommendations are based on predicted in vitro activity and results of clinical trials or clinical experience. The second category of treatment recommendations applies when no etiologic diagnosis has been made and decisions on empirical antibiotic therapy are required. For this group of patients, the guideline provides multiple options because of the lack of clinical trial data that clearly identify superior regimens and the desire to encourage use of a broad range of drugs. The recommendations for outpatients are a macrolide, a fluoroquinolone with good activity against S. pneumoniae, or doxycycline. The recommendation for hospitalized patients is a blactam (cefotaxime, ceftriaxone, or a b-lactam b-lactamase inhibitor) with or without a macrolide; an equally acceptable option is a fluoroquinolone with good antipneumococcal activity and established efficacy for atypical pneumonia (pneumonia due to Legionella species, C. pneumonia, or M. pneumoniae). For seriously ill patients, emphasis is placed on adequate coverage for S. pneumoniae and, less commonly, Legionella species as the major causes of lethal pneumonia. The recommendations for empirical therapy are for a b-lactam combined with erythromycin, azithromycin, or a fluoroquinolone. However, the Panel recognizes that local factors such as susceptibility patterns and epidemiologically important pathogens may dictate alternative options. Therapy with parenteral agents usually may be changed to oral antimicrobial treatment, and patients can be discharged from the hospital when there is evidence of a clinical response and ability to tolerate oral medications. The recommended duration of treatment for pneumococcal pneumonia is 72 hours after the patient becomes afebrile. Most other forms of pneumonia caused by bacterial pathogens are treated for 1 2 weeks after patients become afebrile. Atypical pneumonia is usually treated for 10 21 days. Response: Failure to respond is ascribed to multiple factors, but most commonly represents inadequate host defense; less Good evidence to support a recommendation for use Moderate evidence to support a recommendation for use Poor evidence to support a recommendation for use Moderate evidence to support a recommendation against use Good evidence to support a recommendation against use NOTE. Data are from [1]. Table 2. Categories indicating the quality of evidence on which recommendations are made. Evidence from at least one randomized, controlled trial Evidence from at least one well-designed clinical trial without randomization Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees NOTE. Data are from [1]. common causes include erroneous drug selection, dosage regimen, or diagnosis; an unusual pathogen; or dual infections or complications such as empyema. Diagnostic options in such cases include CT imaging, bronchoscopy, and diagnostic studies for alte (...truncated)