Community Acquired Pneumonia Guideline Update

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We have been waiting and waiting and waiting for the new community acquired guidelines. And here they are! Infectious Diseases expert Devang Patel,MD joins Matt DeLaney, MD and Neda Frayha, MD for a conversation on CAP in general and the new guidelines in specific.

Pearls:

• The latest guidelines for community acquired pneumonia now includes amoxicillin or doxycycline for 5-7 days as first-line treatment given the rising rates of macrolide resistance and less emphasis on coverage of atypical pneumonia pathogens.

• Review of pathophysiology:
• • Lower respiratory tract often preceded by an upper respiratory tract infection, that inhibits ability to clear mucus and pathogens invade the lungs
  • Other risk factors:
  • • Smoking
    • Elderly
    • Immune compromise (ie: infection, steroids, cancer)
  • Pathogens:
  • • Typical - strep pneumo, haemophilus, staph aureus
    • Atypical (more common) - influenza, parainfluenza, mycoplasma, chlamydia pneumoniae, legionella, coccidioidomycosis (in the southwest)
    • EPIC Study (2015) - study to determine pneumonia pathogens using all the tools we have available (culture, PCR)
    • • 62% no pathogen detected
      • 22% viral - most were rhinovirus which does not cause lower respiratory tract infections but predisposes to pneumonia
      • Strep pneumonia was the number one bacterial pathogen
      • Bottomline: we still don't know what causes most pneumonias but just that our patients get better with antibiotics
    • Differentiating between typical v. atypical pneumonias - there's no good way to know viral versus bacterial → default is to treat as bacterial pneumonia with antibiotics
• Diagnosis:
• • Clinical features (cough, fever, sputum production, pleuritic chest pain, crackles)
  • Guidelines recommend a chest x-ray
  • For outpatient uncomplicated pneumonia, don't get blood or sputum cultures
  • For severe cases (those with risk factors for multidrug resistance, MRSA, or pseudomonas) you still want to get blood and sputum cultures
  • Pearls:
  • • No more healthcare-associated pneumonia
    • Emphasis on CURB-65 to assess severity of who does NOT need to be admitted
    • Procalcitonin is NOT endorsed as a way to determine who gets antibiotics and who doesn't
• Treatment:
• • Increasing strep pneumo resistance to macrolides so no more monotherapy with macrolide (azithromycin) unless resistance is less than 20% in the area
  • First-line in non-hospitalized adult is amoxicillin or doxycycline for 5-7 days
  • Steroids recommended not use but may be considered in septic shock
• Commentary from Dr. Patel (ID specialist):
• • Not a major change in practice other than to consider not covering atypicals in an otherwise healthy person

REFERENCES:

1. Metlay JP, Waterer GW, Long AC, et al on behalf of the American Thoracic Society and Infectious Diseases Society of America. 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-e67. doi: 10.1164/rccm.201908-1581ST. https://www.atsjournals.org/doi/10.1164/rccm.201908-1581ST 
2. Jain S, Self WH, Wunderink RG, et al for the CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med 2015; 373:415-427.
3. Postma DF, van Werkhoven CH, van Elden LJR, et al for the CAP-START Study Group. Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med 2015; 372:1312-1323.