New guidelines for treating community-acquired pneumonia in adults released

March 2007

New guidelines for the treatment of community-acquired pneumonia in adults have been released by the Infectious Diseases Society of America and the American Thoracic Society.

The new consensus guidelines, developed by leaders from both organizations, are an important update because, previously, the two medical organizations had separate guidelines for the treatment of community-acquired pneumonia in adults. The recommendations in these guidelines did not always concur, thus creating confusion for physicians.

“Differences, both real and imagined, between the American Thoracic Society and IDSA guidelines have led to confusion for individual physicians, as well as for other groups who use these published guidelines rather than promulgating their own,” the committee that developed the new guidelines wrote. “In response to this concern, the IDSA and the American Thoracic Society convened a joint committee to develop a unified community-acquired pneumonia guideline document. This document represents a consensus of members of both societies, and both governing councils have approved the statement.”

The goal of the new guidelines is to help reduce the mortality rate associated with community-acquired pneumonia in adults. Currently, community-acquired pneumonia, together with influenza, is the seventh leading cause of death in the United States. According to one estimate, an average of 915,900 episodes of community-acquired pneumonia occur in adults aged 65 and older in the United States each year. “Despite advances in antimicrobial therapy, rates of mortality due to pneumonia have not decreased significantly since penicillin became routinely available,” the committee wrote.

Many of the changes in the updated guidelines revolve around the initial assessment of severity of the patient’s condition. “The initial management decision after diagnosis is to determine the site of care: outpatient, hospitalization in a medical ward or admission to an ICU,” the guidelines state. “The decision to admit the patient is the most costly issue in the management of community-acquired pneumonia, because the cost of inpatient care for pneumonia is up to 25 times greater than that of outpatient care and consumes the majority of the estimated $8.4 billion to $10 billion spent yearly on treatment.”

The guidelines caution that hospital admission is not always in a patient’s best interest. “[One reason] for avoiding unnecessary admissions is that patients at low risk for death who are treated in the outpatient setting are able to resume normal activity sooner than those who are hospitalized, and 80% are reported to prefer outpatient therapy,” the guidelines state. “Hospitalization also increases the risk of thromboembolic events and superinfection by more-virulent or resistant hospital bacteria.”

Diagnosis and treatment

Lionel Mandell, MD, professor in the division of infectious diseases at McMaster University Medical School in Hamilton, Canada, and one of the members of the committee who developed the guidelines, said greater emphasis should be placed on diagnosing community-acquired pneumonia in adults. “It is important to make sure that you are dealing with pneumonia and not some other clinical entity,” Mandell said in an interview. “Physicians should consider carefully the patient’s risk factors and prior antibiotic exposure, as well as the local microbiology/epidemiology data and resistance data and try to institute therapy as quickly and as expeditiously as possible.”

The new guidelines also include some minor changes to diagnostic procedures. “In terms of diagnosis, it is no longer felt to be mandatory to do blood cultures and to obtain sputum samples for gram-stain and culture on all patients admitted to the hospital ward,” Mandell said.

Mandell said that the new guidelines include some important changes in treatment of community-acquired pneumonia in adults. “In terms of treatment, one of the main differences is the emphasis on antibiotics given in the previous three months, which may lead to resistance, particularly the macrolides and the fluoroquinolones,” Mandell said. “There is some discussion of drotrecogin alpha activated for use in select patients. We have also done away with the specific time window in which to begin antibiotic therapy — eg, four hours or eight hours — and we recommend that in certain patients with uncomplicated pneumonia, five days may be an appropriate length of treatment.”

For more information:

• Mandell L, Wunderink R, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44:S27-S72.