The AUC increased from 0. Moreover, there are variations in the strength of association between individual minor criteria and other selected variables identifying the need of ICU admission. The need to identify prediction rules that determine when a patient with severe CAP requires ICU care are limited because they were designed to predict day mortality and therefore, it has been used as marker for the need of a higher level of care. Liapikou et al.
|Published (Last):||6 June 2018|
|PDF File Size:||10.36 Mb|
|ePub File Size:||14.78 Mb|
|Price:||Free* [*Free Regsitration Required]|
Search Menu Executive Summary Improving the care of adult patients with community-acquired pneumonia CAP has been the focus of many different organizations, and several have developed guidelines for management of CAP. The guidelines are intended primarily for use by emergency medicine physicians, hospitalists, and primary care practitioners; however, the extensive literature evaluation suggests that they are also an appropriate starting point for consultation by specialists.
Substantial overlap exists among the patients whom these guidelines address and those discussed in the recently published guidelines for health care-associated pneumonia HCAP.
Pneumonia in nonambulatory residents of nursing homes and other long-term care facilities epidemiologically mirrors hospital-acquired pneumonia and should be treated according to the HCAP guidelines. However, certain other patients whose conditions are included in the designation of HCAP are better served by management in accordance with CAP guidelines with concern for specific pathogens. Implementation of Guideline Recommendations. Locally adapted guidelines should be implemented to improve process of care variables and relevant clinical outcomes.
Strong recommendation; level I evidence. Enthusiasm for developing these guidelines derives, in large part, from evidence that previous CAP guidelines have led to improvement in clinically relevant outcomes. Consistently beneficial effects in clinically relevant parameters listed in table 3 followed the introduction of a comprehensive protocol including a combination of components from table 2 that increased compliance with published guidelines. The first recommendation, therefore, is that CAP management guidelines be locally adapted and implemented.
Documented benefits. CAP guidelines should address a comprehensive set of elements in the process of care rather than a single element in isolation. Strong recommendation; level III evidence. Development of local CAP guidelines should be directed toward improvement in specific and clinically relevant outcomes.
Moderate recommendation; level III evidence. Site-of-Care Decisions Almost all of the major decisions regarding management of CAP, including diagnostic and treatment issues, revolve around the initial assessment of severity. Site-of-care decisions e.
Hospital admission decision 4. Severity-of-illness scores, such as the CURB criteria confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater , or prognostic models, such as the Pneumonia Severity Index PSI , can be used to identify patients with CAP who may be candidates for outpatient treatment.
Objective criteria or scores should always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources.
Strong recommendation; level II evidence. Physicians often admit patients to the hospital who could be well managed as outpatients and who would generally prefer to be treated as outpatients. ICU admission decision. Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation.
Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed in table 4. Moderate recommendation; level II evidence.
In some studies, a significant percentage of patients with CAP are transferred to the ICU in the first 24—48 h after hospitalization. Mortality and morbidity among these patients appears to be greater than those among patients admitted directly to the ICU.
Conversely, ICU resources are often overstretched in many institutions, and the admission of patients with CAP who would not directly benefit from ICU care is also problematic. Unfortunately, none of the published criteria for severe CAP adequately distinguishes these patients from those for whom ICU admission is necessary. In the present set of guidelines, a new set of criteria has been developed on the basis of data on individual risks, although the previous ATS criteria format is retained.
The presence of at least 3 of these criteria suggests the need for ICU care but will require prospective validation. Diagnostic Testing 9. In addition to a constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data, is required for the diagnosis of pneumonia.
Recommended diagnostic tests for etiology Patients with CAP should be investigated for specific pathogens that would significantly alter standard empirical management decisions, when the presence of such pathogens is suspected on the basis of clinical and epidemiologic clues.
Recommendations for diagnostic testing remain controversial. The overall low yield and infrequent positive impact on clinical care argue against the routine use of common tests, such as blood and sputum cultures. Conversely, these cultures may have a major impact on the care of an individual patient and are important for epidemiologic reasons, including the antibiotic susceptibility patterns used to develop treatment guidelines. A list of clinical indications for more extensive diagnostic testing table 5 was, therefore, developed, primarily on the basis of 2 criteria: 1 when the result is likely to change individual antibiotic management and 2 when the test is likely to have the highest yield.
Routine diagnostic tests to identify an etiologic diagnosis are optional for outpatients with CAP. Pretreatment blood samples for culture and an expectorated sputum sample for stain and culture in patients with a productive cough should be obtained from hospitalized patients with the clinical indications listed in table 5 but are optional for patients without these conditions. Moderate recommendation; level I evidence.
Pretreatment Gram stain and culture of expectorated sputum should be performed only if a good-quality specimen can be obtained and quality performance measures for collection, transport, and processing of samples can be met.
Patients with severe CAP, as defined above, should at least have blood samples drawn for culture, urinary antigen tests for Legionella pneumophila and Streptococcus pneumoniae performed, and expectorated sputum samples collected for culture. For intubated patients, an endotracheal aspirate sample should be obtained. The most clear-cut indication for extensive diagnostic testing is in the critically ill CAP patient. Such patients should at least have blood drawn for culture and an endotracheal aspirate obtained if they are intubated; consideration should be given to more extensive testing, including urinary antigen tests for L.
For inpatients without the clinical indications listed in table 5 , diagnostic testing is optional but should not be considered wrong. Antibiotic Treatment Empirical antimicrobial therapy. Empirical antibiotic recommendations table 7 have not changed significantly from those in previous guidelines.
Increasing evidence has strengthened the recommendation for combination empirical therapy for severe CAP. At present, the committee is awaiting further evaluation of the safety of telithromycin by the US Food and Drug Administration before making its final recommendation regarding this drug.
Recommendations are generally for a class of antibiotics rather than for a specific drug, unless outcome data clearly favor one drug. Because overall efficacy remains good for many classes of agents, the more potent drugs are given preference because of their benefit in decreasing the risk of selection for antibiotic resistance. Outpatient treatment Previously healthy and no risk factors for drug-resistant S. Presence of comorbidities, such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; use of antimicrobials within the previous 3 months in which case an alternative from a different class should be selected ; or other risks for DRSP infection: A.
A respiratory fluoroquinolone moxifloxacin, gemifloxacin, or levofloxacin [ mg] strong recommendation; level I evidence B. Inpatient, non-ICU treatment A respiratory fluoroquinolone strong recommendation; level I evidence A respiratory fluoroquinolone should be used for penicillin-allergic patients.
Increasing resistance rates have suggested that empirical therapy with a macrolide alone can be used only for the treatment of carefully selected hospitalized patients with nonsevere disease and without risk factors for infection with drug-resistant pathogens.
However, such monotherapy cannot be routinely recommended. Inpatient, ICU treatment For community-acquired methicillin-resistant Staphylococcus aureus infection, add vancomycin or linezolid.
Infections with the overwhelming majority of CAP pathogens will be adequately treated by use of the recommended empirical regimens. The emergence of methicillin-resistant S. However, diagnostic tests are likely to be of high yield for these pathogens, allowing early discontinuation of empirical treatment if results are negative.
The risk factors are included in the table 5 recommendations for indications for increased diagnostic testing. Pathogens suspected on the basis of epidemiologic considerations. Risk factors for other uncommon etiologies of CAP are listed in table 8 , and recommendations for treatment are included in table 9. Pathogen-directed therapy. Once the etiology of CAP has been identified on the basis of reliable microbiological methods, antimicrobial therapy should be directed at that pathogen.
Early treatment within 48 h of the onset of symptoms with oseltamivir or zanamivir is recommended for influenza A.
Pandemic influenza Patients with an illness compatible with influenza and with known exposure to poultry in areas with previous H5N1 infection should be tested for H5N1 infection. In patients with suspected H5N1 infection, droplet precautions and careful routine infection control measures should be used until an H5N1 infection is ruled out. Patients with suspected H5N1 infection should be treated with oseltamivir level II evidence and antibacterial agents targeting S.
Moderate recommendation. Time to first antibiotic dose. For patients admitted through the emergency department ED , the first antibiotic dose should be administered while still in the ED.
Rather than designating a specific window in which to initiate treatment, the committee felt that hospitalized patients with CAP should receive the first antibiotic dose in the ED. Switch from intravenous to oral therapy.
Patients should be switched from intravenous to oral therapy when they are hemodynamically stable and improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care.
Inpatient observation while receiving oral therapy is not necessary. Duration of antibiotic therapy. Patients with CAP should be treated for a minimum of 5 days level I evidence , should be afebrile for 48—72 h, and should have no more than 1 CAP-associated sign of clinical instability table 10 before discontinuation of therapy level II evidence.
A longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis. Weak recommendation; level III evidence. Other Treatment Considerations Patients with CAP who have persistent septic shock despite adequate fluid resuscitation should be considered for treatment with drotrecogin alfa activated within 24 h of admission.
Weak recommendation; level II evidence. Hypotensive, fluid-resuscitated patients with severe CAP should be screened for occult adrenal insufficiency.
Management of Nonresponding Pneumonia Definitions and classification. The use of a systematic classification of possible causes of failure to respond, based on time of onset and type of failure table 11 , is recommended.
A systematic approach to these patients table 11 will help to determine the cause.
Improving the 2007 IDSA/ATS severe Community-Acquired Pneumonia criteria to predict ICU admission
With several recent studies impacting our diagnostic and therapeutic approach for CAP, the American Journal of Respiratory and Critical Care Medicine just released a set of updated guidelines. This post will take you through the relevant ED recommendations on testing, disposition, and antibiotic therapy. For more, see the open access article at ATS Journals. Do not routinely obtain sputum Gram stain and culture in adults with CAP managed as outpatients strong recommendation, very low quality of evidence. Do not obtain blood cultures for patients with CAP managed as outpatients strong recommendation, very low quality of evidence , and do not routinely obtain blood cultures in those admitted conditional recommendation, very low quality of evidence. Test for Legionella urinary antigen and collect lower respiratory tract secretions for culture or nucleic acid amplification testing NAAT in severe CAP conditional recommendation, low quality of evidence. If influenza is present in the community, test for influenza with rapid influenza molecular assay NAAT , rather than an antigen test strong recommendation, moderate quality of evidence.
Community-Acquired Pneumonia: ATS/IDSA Guidelines Update
Search Menu Executive Summary Improving the care of adult patients with community-acquired pneumonia CAP has been the focus of many different organizations, and several have developed guidelines for management of CAP. The guidelines are intended primarily for use by emergency medicine physicians, hospitalists, and primary care practitioners; however, the extensive literature evaluation suggests that they are also an appropriate starting point for consultation by specialists. Substantial overlap exists among the patients whom these guidelines address and those discussed in the recently published guidelines for health care-associated pneumonia HCAP. Pneumonia in nonambulatory residents of nursing homes and other long-term care facilities epidemiologically mirrors hospital-acquired pneumonia and should be treated according to the HCAP guidelines. However, certain other patients whose conditions are included in the designation of HCAP are better served by management in accordance with CAP guidelines with concern for specific pathogens. Implementation of Guideline Recommendations. Locally adapted guidelines should be implemented to improve process of care variables and relevant clinical outcomes.