Background: More than a decade has passed since the last CAP guidelines. Since then there have been new trials and epidemiological studies. There have also been changes to the process for guideline development. This guideline has moved away from the narrative style of guidelines to the GRADE format and PICO framework with hopes of answering specific questions by looking at the quality of evidence.
Dr. Devin J. Horton
Study design: Multidisciplinary panel conducted pragmatic systemic reviews of high-quality studies.
Setting: The panel revised and built upon the 2007 guidelines, addressing 16 clinical questions to be used in immunocompetent patients with radiographic evidence of CAP in the United States with no recent foreign travel.
Synopsis: Changes from the 2007 guidelines are as follows: Sputum and blood cultures, previously recommended only in patients with severe CAP, are now also recommended for inpatients being empirically treated for Pseudomonas or methicillin-resistant Staphylococcus aureus (MRSA) and for those who have received IV antibiotics in the previous 90 days; use of procalcitonin is not recommended to decide whether to withhold antibiotics; steroids are not recommended unless being used for shock; HCAP categorization should be abandoned and need for empiric coverage of MRSA and Pseudomonas should be based on local epidemiology and local validated risk factors; B-lactam/macrolide is favored over fluoroquinolone for severe CAP therapy; and routine follow-up chest x-ray is not recommended.
Other recommendations include not routinely testing for urine pneumococcal or legionella antigens in nonsevere CAP; using PSI over CURB-65, in addition to clinical judgment, to determine need for inpatient care; using severe CAP criteria and clinical judgment for determining ICU need; not adding anaerobic coverage for aspiration pneumonia; and treating most cases of CAP that are clinically stable and uncomplicated for 5-7 days.
Bottom line: Given new data, updated recommendations have been made to help optimize CAP therapy.
Citation: Metlay JP et al. Diagnosis and treatment of adults with community-acquired pneumonia: An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67.
Dr. Horton is a hospitalist and clinical instructor of medicine at the University of Utah, Salt Lake City.