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breathe editorial.

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The IDSA/ATS consensus


guidelines on the management
of CAP in adults
F. Piffer
F. Tardini
R. Cosentini
j In March 2007, the Infectious Diseases
Society of America (IDSA) and the American
Thoracic Society (ATS) issued a consensus
guidelines document on the management of
community-acquired pneumonia (CAP) [1]. The
U.O. Medicina d'Urgenza, document includes important advances and uni-
Gruppo NIV, Fondazione fies the previous guidelines released separately
Ospedale Maggiore Policlinico, by the two societies.
Mangiagalli e Regina Elena,
Milan, Italy. Strength of recommendation and
evidence level
Each recommendation is graded in terms of
Correspondence strength (strong, i.e. most patients should receive
R. Cosentini the intervention; moderate; and weak) together
Gruppo NIV with evidence level (level I: randomised studies;
Fondazione Ospedale Maggiore
level II: nonrandomised studies, case series; and
Policlinico
Mangiagalli e Regina Elena level III: case studies, expert opinions).
U.O. Medicina d'Urgenza
Via F. Sforza, 35 Objective of the guidelines
20122 Milan The declared objective of these guidelines is a
Italy decrease in mortality. The authors believe that
Fax: 39 255033600 the application of guidelines can decrease mor-
E-mail: roberto.cosentini tality and the discussion is primarily focused on
@policlinico.mi.it
this outcome. CAP management guidelines
should be locally adapted and implemented.

The physicians addressed


These guidelines address emergency medicine How to assess severity? Where to
physicians, hospital physicians and primary care treat my patient?
physicians. They could also be an important con- • Clinical judgement is crucial.
sultation tool for specialists involved in the man- • Severity scores are useful and should be
agement of pneumonia. implemented.
The authors suggest using a severity score,
The patients addressed either the Pneumonia Severity Index (PSI) score
Patients addressed by these guidelines are adult or the CURB-65 (Confusion, Urea nitrogen >7
immunocompetent subjects with CAP. This mM, Respiratory rate ≥30 breaths per min, Blood
means that the approach to pneumonia occur- pressure <90 mmHG (systolic) or ≤60 mmHg
ring in nonambulatory residents of nursing (diastolic), age ≥65 years) score (strong recom-
homes is not included in these guidelines mendation, evidence level I).
and should be treated according to published The authors recommend that the decision to
guidelines of healthcare-associated pneumonia admit or discharge a patient is primarily clinical,
[2]. and that physicians should also consider

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IDSA/ATS CAP guidelines

subjective factors, including the ability to take The ICU.


oral medications and family support (strong rec- Image: Norbert Kaiser
ommendation, level II evidence).

Admission versus discharge


The entire management of CAP in terms of diag-
nostics and therapeutic measures depends on
the initial assessment of severity. The authors
encourage the use of severity scores, either the
PSI score or the CURB-65 score, which take into
account objective data. The PSI score relies on
20 objective variables, and has been developed
and validated on a large series of patients. It is antimicrobial treatment is associated with
intended to identify low-risk patients who can increased mortality; and
safely be treated at home. The CURB-65 score is 4.identification of CAP patients who would
based on only five objective variables, is benefit from immunomodulatory treatment.
designed to identify high-risk patients and has The identification of severe CAP is one of the
been validated on a smaller case series of sub- most relevant advances included in these guide-
jects. However, CURB-65 is much simpler and lines. Severe CAP carries a very high mortality
easily remembered, and is focused more on rate. Patients with severe CAP warrant direct ICU
severity of illness rather than on the likelihood of admission if septic shock requiring vasopressor
mortality. Therefore, the PSI score is preferable administration and/or acute respiratory failure
for identifying low-risk patients, especially when necessitating mechanical ventilation are present
the emergency department's decision support (major criteria; strong recommendation, level II
resources are sufficient, whereas CURB-65 is the evidence). However, this definition is too narrow
preferred score for assessing illness severity. One and lacks sensitivity, since many patients with
important limitation of both scores is that they CAP who are not in shock or acute respiratory
are generated at a single point in time, whereas failure are eventually admitted to the ICU. This
patient assessment is better obtained in a observation led the authors to revise the minor
dynamic fashion over several hours of criteria of CAP severity, adding the CURB-65
observation. criteria and signs of sepsis to the previous minor
A CURB-65 score ≥2 generally warrants criteria (see table 1).
more intensive treatment, i.e. hospitalisation or – ICU/HLMU admission is recommended if
when appropriate and available – intensive in- patients present with at least three minor criteria
home healthcare (moderate recommendation, among those in table 1.
level III evidence).
Table 1 Criteria for identifying severe CAP
When should I admit my patient to
the intensive care unit (ICU)? Minor criteria#
• When septic shock is present or mechanical Respiratory rate ≥30 breaths per min
Pa,O2/FI,O2 ratio ≤250¶
ventilation is needed. Multilobar infiltrates
• When severity scores are very high. Confusion/disorientation
• When signs of severe sepsis are present. Uraemia (BUN level ≥20 mg per dL)
ICU admission is a second-level admission Leukopenia+ (WBC count <4,000 cells per mm3)
decision. The rapid and correct identification of Thrombocytopenia (platelet count <100,000 cells per mm3)
patients requiring ICU/high-level monitoring Hypothermia (core temperature <36ºC)
unit (HLMU) admission would allow: Hypotension requiring aggressive fluid resuscitation
1. resource optimisation; Major criteria
Invasive mechanical ventilation
2.avoidance of delay in ICU transfer,
Septic shock with the need for vasopressors
which has been associated with higher
mortality; Pa,O2: arterial oxygen tension; FI,O2: inspired oxygen fraction; BUN: blood urea nitrogen; WBC:
white blood cell. #: Other criteria to consider include hypoglycaemia (in nondiabetic patients),
3.appropriate diagnostic testing and acute alcoholism/alcohol withdrawal, hyponatraemia, unexplained metabolic acidosis or
empirical antimicrobial treatment, since elevated lactate level, cirrhosis and asplenia; ¶: a need for noninvasive ventilation can substi-
microbial aetiologies differ in these tute for a respiratory rate ≥30 breaths per min or Pa,O2/FI,O2 ratio ≤250; +: as a result of infec-
patients and an incorrect initial empiric tion alone. Reproduced from [1], with permission from the publisher.

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IDSA/ATS CAP guidelines

Is microbiological assessment recommendation, level I evidence).


useful? • Gram stain may allow both the identification
• Not in primary care. of unusual pathogens not included in the
• Yes in hospitalised patients, especially in empirical antibiotic treatment and the
severe CAP or when a specific pathogen is confirmation of sputum culture results.
suspected, where microbiological results • Sputum Gram stain and culture are
may positively influence the management warranted, especially in necrotising/
of CAP. cavitary pneumonia, frequently caused by
Microbiological workup is not recommended community-associated Methicillin-resistant
in an outpatient setting (moderate recommen- Streptococcus aureus (MRSA), and in
dation, level III evidence). severe chronic obstructive pulmonary
For in-patients, microbiological assessment is disease (COPD) patients and alcoholics,
suggested, especially when specific pathogens are where Pseudomonas aeruginosa and other
suspected on the basis of clinical and epidemio- Gram-negative pathogens are commonly
logical data (strong recommendation, level II evi- involved. In these patients, a negative
dence), or when the patient is severely ill (table 2). Gram stain and culture should allow a safe
The main reasons to perform microbiological exclusion of empirical antibiotic coverage
work-up in the individual patient are the expected for these pathogens.
likelihood of antibiotic changing and/or improv- • In patients with severe CAP, sputum Gram
ing the likelihood of positive outcomes. stain and culture, blood culture and
The guidelines refer to a very comprehensive urinary antigen tests (UATs) for Legionella
table where microbiological workup is indicated pneumophila and Streptococcus
in specific conditions (table 2). pneumoniae are recommended.
In summary: Endotracheal aspirate is suggested if the
• Sputum Gram stain and culture – if patient is intubated (moderate, level II).
productive sputum is available – and blood • UATs for L. pneumophila and S. pneumoniae
culture are recommended before have been cleared by the US Food and
treatment in patients belonging to one of Drug Administration. Sensitivity is greater
the categories listed in table 2 (moderate for Legionella (only serogroup 1, however)
than for the pneumococcus antigen (70-
90% versus 50–80%, respectively). The
Table 2 When to perform more extensive diagnostic tests
major advantage of pneumococcal antigen
Indication Blood Sputum Legionella Pneumococcal Other use is that it is not influenced by previous
culture culture UAT UAT antibiotic use nor is it influenced in COPD
ICU admission     # patients with pneumococcal colonisation.
Failure of outpatient The diagnostic yield of the UAT is greater
antibiotic therapy    in severe cases, especially in bacteraemic
Cavitary infiltrates   ¶ pneumococcal pneumonia.
Leukopenia  
• Rapid antigen detection for viruses is
Active alcohol abuse     promising. This test provides important
Chronic severe liver   epidemiological information and information
disease on the need for isolation, but sensitivity
Severe obstructive/  and specificity are suboptimal.
structural liver disease • Serology for atypical pathogens has only a
Asplenia (anatomical   retrospective value.
or functional) • PCR testing for atypicals and other bacteria
Recent travel (within  +
(e.g. Mycobacterium species) is not yet
past 2 weeks)
Positive Legionella UAT ƒ NA
standardised for use on a large scale.
result Special circumstances
Positive pneumococcal   NA • Patients with pleural effusion >5 cm
UAT result
should undergo thoracocentesis for fluid
Pleural effusion     §
analysis, Gram stain and culture.
UAT: urinary antigen test; NA: not applicable. #: endotracheal aspirate if intubated, possible • The use of invasive diagnostic techniques
bronchoscopy or nonbronchoscopic bronchoalveolar lavage; ¶: fungal and tuberculosis cultures; (bronchoscopic BAL, protected brushing,
+: see [1] for details; ƒ: special media for Legionella; §: thoracocentesis and pleural cultures.
transthoracic needle aspiration) is

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IDSA/ATS CAP guidelines

suggested in immunocompromised patients aztreonam is suggested (moderate, level III).


or in those who fail to respond to treatment. • Community-associated MRSA: the authors
suggest the use of vancomycin or linezolid
What initial antimicrobial treatment (moderate, level III).
is recommended? • For suspected P. aeruginosa infection, a
• Empirical antibiotic treatment varies combination regimen is suggested, until
according to risk factors and severity of the susceptibility is known.
disease (table 3). • Pneumococcal bacteraemic pneumonia is
General considerations more safely treated with combination
• Current recommendations are similar to therapy especially in the most severe
previous guidelines. patients (ICU).
• The authors highlight the importance of • Patients with influenza A should be treated
combination therapy in severe CAP. with oseltamivir or zanamivir within 48 h
• The recommendations refer to a class of (strong, level I). The authors also suggest
drug, rather than to a specific agent. treating outpatients with influenza with
• Due to the fear of antibiotic resistance inhaled zanamivir or oral oseltamivir in
selection, the more potent drug is order to reduce respiratory tract
preferred. complications.
• Patients presenting with influenza-like
Special circumstances for in-patients syndrome who have been exposed to
• Where there is allergy to penicillin, poultry in H5N1-endemic areas should be
replacement of the β-lactam with tested for H5N1 (moderate, level III),

Table 3 Initial antimicrobial treatment


Patients Drugs Recommendation/
evidence level
Outpatients
Previously healthy, no Macrolide (azithromycin, Strong/I
risk factors for DRSP clarithromycin/erythromycin)
Doxycycline Weak/III
Comorbidities#, antibiotic treatment Respiratory fluoroquinolone Strong/I
in last 3 months or other risk factors (moxifloxacin, levofloxacin 750 mg)
for DRSP¶ β-lactam+ plus a macrolide1ƒ Strong/I
Penicillin-allergic Respiratory fluoroquinolone
(moxifloxacin, levofloxacin 750 mg)
In-patients
Non-ICU admission Respiratory fluoroquinolone Strong/I
(moxifloxacin, levofloxacin 750 mg)
β-lactam§ plus a macrolide##,¶¶ Strong/I
ICU admission β-lactam§ plus fluoroquinolone Strong/I
β-lactam§ plus azithromycin II
ICU admission and P. aeruginosa Antipneumococcal, antipseudomonas Strong/I
an issue β-lactam++ plus either ciprofloxacin
or levofloxacin (750 mg)
Antipneumococcal, antipseudomonas Moderate/III
β-lactam++ plus an aminoglycoside
and azithromycin
Antipneumococcal, antipseudomonas Moderate/III
β-lactam++ plus an aminoglycoside and
antipneumococcal, antipseudomonas
fluoroquinolone

DRSP: drug-resistant S. pneumoniae; #: chronic heart failure, COPD, chronic kidney or liver disease, diabetes mel-
litus, cancer, asplenia or immunosuppression; ¶: also in regions with a high prevalence of macrolide-resistant
S. pneumoniae; +: high-dose amoxicillin (1 g t.i.d.) or amoxi/clavulanate (2 g b.i.d.), ceftriaxone, cefpodoxime,
and cefuroxime (500 mg b.i.d.); ƒ: or doxycycline (level III evidence); §: cefotaxime, ceftriaxone, ampicillin
(ertapenem for selected patients); ##: monotherapy with macrolide is not suggested routinely because of the
increasing resistance rate; ¶¶: macrolides are not recommended if patients have received an antibiotic of this class
in the previous 3 months; ++: piperacillin/tazobactam, cefepime, imipenem, meropenem.

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IDSA/ATS CAP guidelines

treated wth oseltamivir (level II) and Table 4 Criteria defining clinical
covered for S. pneumoniae and S. aureus stability
(level III). Droplet precautions should be
used (moderate, level III). Temperature ≤37.8ºC
Heart rate ≤100 beats per min
Is the recommended empirical Respiratory rate ≤24 breaths per min
Systolic blood pressure ≥90 mmHg
antibiotic treatment a panacea for Sa,O2 ≥90% or PO2 ≥60 mmHg on room air
all patients? Ability to maintain oral intake#
No. The suggested regimens are effective for the Normal mental status#
vast majority of patients, with two important #
: important for discharge or oral switch decision but
exceptions: not necessarily for determination of nonresponse.
• Pneumonia sustained by drug-resistant Reproduced from [1], with permission from the
S. Pneumoniae and MRSA. publisher.
• Pneumonia sustained by P. aeruginosa.
Resistence to empirical antibiotic treatment and has no more than one sign of clinical insta-
depends on geography. The best approach to bility (moderate recommendation).
this important issue is the knowledge of local The authors suggest a longer treatment if
resistance patterns, most reliably by local hospi- the identified pathogen was not covered by
tal antibiograms, and the modifications of guide- empirical antibiotic therapy, or in case of extra-
lines accordingly. pulmonary complications (weak recommenda-
Physicians are encouraged to search for epi- tion, level III evidence).
demiological and clinical risk factors for these Discharge is suggested when patients are
pathogens, as outlined in the guidelines [1]. clinically stable, are able to take oral drugs,
comorbidities have been treated and there is no
When should I administer the first need for additional diagnostic tests, provided
antibiotic dose? that social needs are met.
• As soon as possible.
The authors recommend administering the What additional treatments are
first antibiotic as soon as possible after the diag- important?
nosis of CAP. For patients who present to an • Treat the patient, not only the infected
emergency department, it seems reasonable to lung!
administer the first dose of antibiotic while still • Always search for sepsis; consider a
in the department (moderate recommendation, cautious noninvasive ventilation (NIV) trial
level III evidence). if respiratory distress is present.
The key factor is that the approach to pneu-
When should I switch from i.v. monia is not only the treatment of an infected
to oral antibiotic? For how long lung, but also the management of a patient as a
should I treat my patient with whole, with a special attention to signs and
antibiotic? When should I symptoms of sepsis.
discharge my patient? Treat the patient in septic shock with ade-
• Switch to oral therapy when the patient is quate fluid resuscitation and, if still nonrespon-
clinically stable. sive, consider the use of drotrecogin α within
• Treat until at least 2–3 days after 4 h of admission (weak, level II), and test for
defervescence. occult adrenal insufficiency (moderate, level II).
• Discharge when the patient is clinically If the patient is hypoxaemic or in respiratory
stable, comorbidities are treated and social distress, consider a brief and cautious trial of
needs are met. NIV. However, if improvement in respiratory rate,
The switch to oral antibiotics is suggested for Pa,O2/FI,O2 ratio and/or Pa,CO2 does not occur
all patients who are clinically stable and have within 1–2 h, prompt intubation is warranted,
normal gastrointestinal function (strong recom- since mortality increases when intubation is pre-
mendation, level II evidence). Table 4 shows the ceded by a long NIV trial. Patients with acute res-
criteria defining clinical stability, which are also piratory distress syndrome (ARDS) or a
useful for discharge. Pa,O2/FI,O2 ratio <150 are poor candidates
The authors suggest treating patients with for NIV (moderate recommendation, level I
antibiotics for ≥5 days (level I evidence), evidence).
provided that the patient is afebrile for 48–72 h, Patients intubated for ARDS should be

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IDSA/ATS CAP guidelines

ventilated with low tidal volume strategy risk; pregnancy; long-term facility residence;
(6 mL per kg of ideal body weight; strong aspirin therapy if aged ≤18 years), household
recommendation, level I evidence). contacts of high-risk people and healthcare work-
ers (strong recommendation, level I evidence).
What should I do if my patient The pneumococcal polysaccharide vaccine is
does not respond? recommended for persons aged ≥65 years and
• Identify risk factors for clinical failure and those at high-risk (strong recommendation, level
intensify diagnostic work-up, if present. II evidence).
• Search regularly for clinical failure, either In patients hospitalised with CAP, vaccina-
early (<72 h) or delayed. tion status should be assessed on admission
• Use a systematic approach for possible (moderate recommendation, level III evidence),
causes. and nonvaccinated at-risk patients should be
When a patient shows an inadequate clini- offered vaccination (moderate recommendation,
cal response despite antibiotic treatment, the level III evidence).
authors suggest using a systematic classification Smoking cessation should be offered to
based on the kind of failure (failure to improve patients with pneumonia (moderate recommen-
versus deterioration/progression) and the tim- dation, level III evidence), and pneumococcal
ing of failure (early (<72 h) versus delayed; mod- and influenza vaccination should be performed
erate recommendation, level II evidence) [1]. in those who do not quit (weak recommenda-
Microbiological assessment in nonres- tion, level III evidence).
ponding pneumonia is critical. The causal iden- Other measures to reduce the transmission
tification of failure is easier when initial microbi- of respiratory pathogens include the prompt
ological work-up results are available; therefore, notification of cases of pneumonia of public
it is crucial to recognise the presence of risk fac- health concern to the local health authority
tors for failure [1], in order to maximise initial (strong recommendation, level III evidence), and
diagnostic work-up (table 2). the use of respiratory hygiene measures (hand
washing, masks; strong recommendation, level
Is pneumonia prevention useful III evidence).
and feasible?
• Yes, pneumonia is preventable using How should I monitor/audit
vaccination. outcome?
• Identify vaccination status on admission, • Use performance indicators and modify
and manage accordingly. your approach according to results.
Influenza vaccination has been shown to Quality control plays a crucial role in clinical
reduce pneumonia, hospitalisation and death practice. The authors suggest four performance
rate. Invasive pneumococcal diseases (bacter- indicators.
aemia and meningitis) are effectively reduced by 1. Initial empirical antibiotic treatment
the use of pneumococcal vaccines among the should be consistent with guidelines.
elderly and subjects with certain chronic medical 2. The first treatment dose should be
conditions. administered in the emergency
For these reasons, vaccination represents a department.
key factor for the prevention of pneumonia [1], 3. Data on mortality and severity on
considering also that the use of vaccination in admission should be recorded, including
clinical practice is suboptimal. the number of patients with severe
The US Centers for Disease Control and pneumonia initially admitted to a general
Prevention recommend annual influenza vacci- ward.
nation with an inactivated vaccine for persons 4. Data on actual vaccination rate in the
aged ≥50 years, those at high-risk (e.g. chronic at-risk population should be recorded.
cardiovascular and pulmonary disease; chronic A deviation is expected, and should be
renal and metabolic diseases; haemoglobino- specified in the clinical chart. Compliance of
pathies; immunodeficiency; increased aspiration ~80–95% is considered acceptable.
References
1. Mandell LA, Wunderink RG, 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: Suppl. 2, S27–S72.
[Available free of charge online at www.thoracic.org/sections/publications/statements/pages/mtpi/idsaats-cap.html]
2. American Thoracic Society/Infectious Diseases Society of America. Guidelines for the management of adults with hospital-
acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171: 388–416.

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