SPECIAL ARTICLES: GUIDELINES SECTION
GUIDELINES FOR THE MANAGEMENT OF ADULTS WITH COMMUNITY-ACQUIRED PNEUMONIA [Official Statement of the American Thoracic Society. Am J Respir Crit Care Med 2001;163:1730]:
This represents the updated guidelines from the ATS for the management of CAP. Highlights are the following:
Diagnostic tests: Routine tests should include a chest roentgenogram and, for hospitalized patients, two blood cultures. Sputum culture and gram stain are not required. For severe CAP, Legionella urinary antigen should be done and there should be “aggressive efforts at establishing an etiologic diagnosis including the collection of bronchoscopic samples.”
Criteria for admission to the intensive care unit:
- Need for mechanical ventilation or
- Septic shock or
- Two of the following: BP <90 mmHg, multilobar disease, and PaO 2 /FIO 2 ratio <250
Alternative criteria (British Thoracic Society): two of the following four: RR >30/min, diastolic BP <60, BUN >19 mg/dL, confusion
IV therapy switch to oral treatment:
- Improvement in cough and dyspnea
- Temperature <100°F ×2 (8 hours apart)
- WBC decreasing
- Functioning GI tract
Discharge criteria (independent of co-morbidities):
- Clinical stability—time of IV–>oral switch
- Chest roentgenogram at 4–6 weeks
- Pen resistant S. pneumo
- Age >65 years
- Betalactam abx within 3 months
- Immune suppression
- Multiple medical co-morbidities
- Exposure to child in day care
- Gram-negative bacilli
- Residence in nursing home
- Cardiopulmonary disease
- Multiple medical co-morbidities
- Recent antibiotics
- P. aeruginosa
- Structural disease of lung
- Steroid Rx (>10 mg prednisone/day)
- Broad-spectrum abx for >7 days in past month
Treatment guidelines: Patients are divided into four groups, the first two for outpatients and the second two for hospitalized patients. The specifics are provided in table 1:
These guidelines have many similarities with those published nearly 1 year ago by the IDSA. There are also some important differences:
- The IDSA guidelines seem to have placed much more emphasis on an etiologic diagnosis.
- The ATS guidelines emphasize the frequency of atypical pathogens and the frequency of co-infection. This document also stresses a substantial role for gram-negative bacilli, but this was at least in part explained by the inclusion of patients with nursing home pneumonia, which was not part of the IDSA guidelines.
- The treatment recommendations of the ATS are substantially more complicated than those of the IDSA with six sub-groups compared with three in the IDSA guidelines.
- There are some modest differences in antibiotic recommendations: erythromycin is not included as an option in the ATS guidelines; IV azithromycin is accepted as an appropriate option for hospitalized patients and outpatients. Management includes a combination of a betalactam with a macrolide or doxycycline.
- There is better definition of criteria for admission to the ICU in the ATS guidelines.
- In the category of prevention, smoking cessation is included, which was an oversight in the IDSA guidelines.
- The ATS guidelines judged their recommendations on the basis of “levels 1–3” according to scientific support; the IDSA guidelines provide a different rating scheme which has letters to indicate the strength of the recommendation and roman numerals to indicate the quality of supporting evidence.
Both sets of guidelines are long and scholarly and are in general agreement on major points, although there are some important differences that the physician audience will find confusing. The CDC guidelines are similar, but also show some substantial differences in important places such as recommendations for antibiotics. In fact, many of the same people are on two or even three of these panels. The hope is that the ATS, IDSA, and the CDC will be able to join forces to write a single document for the benefit of the physicians who struggle with three guidelines to make management decisions.
This section represents a summary of recently published guidelines from authoritative sources (reprinted from The Johns Hopkins University AIDS website, http://www.hopkins-aids.edu, with permission).