REVIEW

CURRENT
OPINION Update in adult community-acquired pneumonia:
key points from the new American Thoracic
Society/Infectious Diseases Society of America
2019 guideline
Joshua P. Metlay a and Grant W. Waterer b

Purpose of review
The American Thoracic Society and Infectious Diseases Society of America recently released their joint
guideline for the diagnosis and treatment of adults with community-acquired pneumonia (CAP). The
Downloaded from http://journals.lww.com/co-pulmonarymedicine by BhDMf5ePHKbH4TTImqenVICwrFV2Grwd/qivXEP+Qo7Z2KzgX8sCoToXrdFmco8AgwDhf7JAwKM= on 04/11/2020

co-chairs of the guideline committee provide a summary of the guideline process, key recommendations
from the new guideline and future directions for CAP research.
Recent findings
The guideline committee included 14 experts from the two societies. Sixteen questions for the guideline
were selected using the PICO format. The GRADE approach was utilized to review the available evidence
and generate recommendations. The recommendations included expanded microbiological testing for
patients suspected of drug-resistant infections, empiric first-line therapy recommendations for outpatients and
inpatients including use of beta-lactam monotherapy for uncomplicated outpatients, elimination of
healthcare-associated pneumonia as a treatment category, and not recommending corticosteroids as
routine adjunct therapy.

Summary
CAP is a major cause of morbidity and mortality. Effective antibiotic therapy is available and remains
largely empirical. New diagnostic tests and treatment options are emerging and will lead to guideline
updates in the future.
Keywords
antibiotic guidelines, community-acquired pneumonia, microbiological testing

INTRODUCTION of interactions with industry that would exclude

Community-acquired pneumonia (CAP) is one of
the most common and serious infections managed
in both the outpatient and inpatient settings. Opti-
mal management of CAP has been the subject of
numerous professional society guidelines over the
years. In the United States, the American Thoracic
Society and Infectious Diseases Society of America
each produced widely disseminated guidelines and
combined efforts to produce a joint adult CAP guide-
line published in 2007 [1].
In 2013, both societies initiated a revision to the
CAP guideline for adults and we were asked to co-
chair the guideline committee. Several key changes
were implemented in the guideline process that
significantly impacted the process.
First, the professional societies adopted stricter
conflict of interest (COI) rules that identified a range
someone from participating on the committee or,
at a minimum, exclude someone from voting on
specific recommendations within the guideline. The
COI policies did prevent several experts in the field
from participating on the guideline committee but
we recognized the important experience and
a
Division of General Internal Medicine, Department of Medicine, Massa-
chusetts General Hospital and Harvard Medical School, Boston, Mas-
sachusetts, USA and bRoyal Perth Hospital and University of Western
Australia, Perth, Australia
Correspondence to Joshua P. Metlay, MD, PhD, Division of General
Internal Medicine, Department of Medicine, Massachusetts General
Hospital, 100 Cambridge Street, 16th Floor, Boston, MA 02114,
USA. E-mail: jmetlay@mgh.harvard.edu
Curr Opin Pulm Med 2020, 26:203–207
DOI:10.1097/MCP.0000000000000671

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Infectious diseases
KEY POINTS
 The new guidelines abandon the category of HCAP.
 The circumstances under which sputum and blood
culture testing are recommended have been increased
compared with prior guidelines.
 Corticosteroids are not recommended as part of routine
care of patients with CAP.
knowledge they bring to the field and relied on the
review process to solicit their feedback. Overall, we
support the stricter COI policies though also recog-
nize that COI is about more than just industry
interactions and, ultimately, guidelines should
reflect the full input of experts in the field.
Second, the professional societies endorsed the
more rigorous Grading of Recommendations
Assessment, Development and Evaluation
(GRADE) approach towards evidence review and
guideline generation [2]. The process is arduous
and clearly contributed to the multiyear process
required to complete the guideline. Unfortunately,
numerous key questions addressed by the guideline
were not supported by the highest level evidence
emphasized by GRADE. As a result, review of lower
quality evidence and expert opinion were neces-
sary to address the core guideline questions. Thus,
whether the rigorous steps required by GRADE
truly resulted in a different set of guideline recom-
mendations is unclear. What is clear is that the
multiyear process is difficult to sustain and, given
the pace of new research, a faster paced process is
required to update the guideline as new informa-
tion is available. Indeed, even as the guideline was
being finalized, new antibiotics were approved for
use in CAP and ongoing experience with these
agents should be incorporated into updates to
the guideline.
In this article, we summarize five key areas of
focus of the guideline, representing important
changes from the past guideline and/or emerging
areas of research that are likely to continue to evolve
&&
in the next several years [3 ]. We maintain the
conventions of the published adult CAP guideline.
Specifically, we focus on adults (>18 years) without
immunosuppressing conditions who have radio-
graphic confirmation of pneumonia. We recognize
that many physicians will diagnose and manage
adults with CAP without requiring chest radiogra-
phy but substantial evidence highlights the inaccu-
racy of clinical examination to diagnose pneumonia
[4], and the guideline was not developed to manage
patients with biomarker evidence of bacterial
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infection and respiratory complaints, but no defini-
tive evidence of a lung infection.
In this article, we provide a high-level summary
of some of the recommendations from the guide-
line. For a full discussion of the evidence with rele-
vant citations, readers should review the online
version of the guideline or the recently published
&&
executive summary [3 ].
KEY UPDATES
Diagnostic test utilization including
microbiological tests and biomarkers
CAP is caused by a range of infectious agents, includ-
ing both common bacteria and viruses. Like many
other infectious illnesses, it would be helpful to be
able to accurately and rapidly identify the causal
organism to choose appropriate antiinfective ther-
apy. Historically, the two main microbiological tests
available to identify an etiological agent in CAP are
sputum and blood cultures. In addition, urine anti-
gen tests for Streptococcus pneumoniae and Legionella
pneumophila are available and have high level of
specificity in adults. More recently, there has been
an expansion of molecular assays using respiratory
samples to test for a range of viral and bacterial
pathogens. Yet, even with the availability of these
extensive diagnostic testing strategies, the causal
pathogen remains undetected in the majority of
adults with CAP [5]. Moreover, high-level evidence
does not exist that testing strategies result in
improved outcomes for adults with CAP compared
with empiric treatment strategies without testing.
We do acknowledge that there is a strong desire
to limit antibiotic use, or at least utilize the narrow-
est spectrum possible, based on sound antibiotic
stewardship principles as discussed below. However,
there is also no evidence that existing diagnostic
tests achieve this outcome and some evidence
clearly showing that they do not.
Thus, the adult CAP guideline does not endorse
routine use of any current diagnostic testing strate-
gies in the majority of adults with CAP. However, we
did identify two major exceptions when testing is
recommended. First, adults with severe CAP
[defined as 1 major or 3 minor ATS/IDSA criteria
(see Table 1)], are the most likely to benefit from
microbiological testing as they are more likely to
have drug-resistant pathogens and may need
expanded therapy beyond the standard empiric rec-
ommendations. Second, adults with suspected drug-
resistant pathogens, especially methicillin-resistant
Staphylococcus aureus (MRSA) or Pseudomonas aerugi-
nosa, should have testing to either identify
the pathogen and target therapy accordingly or
Volume 26  Number 3  May 2020

Table 1. 2007 IDSA/ATS criteria for defining severe CAP
Minor criteria
Respiratory rate 30 breaths/min
PaO2/FiO2 ratio 250
Multilobar infiltrates
Confusion/disorientation
Uremia (blood urea nitrogen level 20 mg/dl)
Leukopeniaa (white blood cell count <4000 cells/ml)
Thrombocytopenia (platelet count <100 000 /ml)
Hypothermia (core temperature <36 8C)
Hypotension requiring aggressive fluid resuscitation
Major criteria
Septic shock with need for vasopressors
Respiratory failure requiring mechanical ventilation
Validated definition includes either one major criterion or three or more minor
criteria.
a
Due to infection alone (i.e. not chemotherapy-induced).
de-escalate therapy if cultures do not reveal
these pathogens.
We recognize that newer molecular diagnostic
platforms are creating the possibility of rapid, accu-
rate pathogen identification including both bacte-
rial and viral pathogens. We strongly encourage
evaluation of these testing strategies to determine
if the routine use of such tests improves antimicro-
bial drug selection, and, especially, patient out-
comes.
Empiric treatment recommendations
As with past versions of the adult CAP guideline,
empiric treatment recommendations were based on
severity of illness and site of care. As noted above,
while we would prefer to be able to make pathogen-
directed treatment recommendations, the reality is
that pathogen identification is too uncommon and
empiric treatment strategies are needed. We also
recognized that the microbial pathogenesis of CAP
is changing. In particular, the introduction of the
pneumococcal conjugate vaccine in the early 2000s
has resulted in a significant decline in the frequency
of Strep. pneumoniae as a respiratory pathogen in
both children and adults [6]. Indeed, it is likely that
an increasing proportion of adult cases of CAP are
because of viral pathogens alone, eliminating the
need for any antibacterial therapy. Unfortunately,
we did not identify any high-level studies that sup-
ported a strategy of withholding antibiotic therapy
at the time of CAP diagnosis. We acknowledge that
the combination of positive findings with rapid viral
testing and negative findings with a biomarker,
such as procalcitonin that predicts bacterial infec-
tion could ultimately support, such a nonantibiotic
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Update in adult CAP Metlay and Waterer
treatment strategy for adults with CAP; however,
there is currently insufficient data to currently sup-
port such an approach.
Thus, recommendations for empiric antibiotic
therapy focus on the typical bacterial pathogens
identified in CAP patients, with broader coverage
recommended for outpatients with co-morbidities
or inpatients, especially those with severe CAP.
Some key changes in the current guideline included:
(1) Recommending monotherapy with beta-lac-
tams (e.g. amoxicillin) for uncomplicated out-
patients, largely based on the results of inpatient
trials.
(2) Reducing the strength of recommendation for
monotherapy with macrolides for uncompli-
cated outpatients, largely based on the contin-
ued emergence of macrolide resistance among
clinical isolates of Strep. pneumoniae.
(3) Acknowledging the rising number of reports of
adverse drug events associated with certain clas-
ses of antibiotics, especially fluoroquinolones
(vascular injury, tendinopathy, Clostridium dif-
ficile infection) and emphasizing that when
multiple treatment options are presented, the
final choice should reflect a risk–benefit assess-
ment for each individual patient.
Notably, although newer antimicrobial agents
were recently approved for CAP (omadacycline,
lefamulin), experience with these agents was
too limited to have them listed as first-line
agents in the current adult CAP guideline. Still,
we believe that ongoing monitoring and evaluation
is critical and could support updates to these
empiric treatment recommendations in the next
few years.
Accounting for drug-resistant pathogens
One of the major strategies endorsed as part of the
last adult CAP guideline was the recognition of
healthcare-associated pneumonia (HCAP) as a dis-
tinct entity that would warrant broader spectrum
empiric antibiotic treatment to cover for drug-resis-
tant pathogens, especially MRSA and P. aeruginosa.
HCAP risk factors included nursing home or long-
term care residence, recent hospitalization, and
hemodialysis. Unfortunately, the HCAP strategy
failed for several reasons: HCAP poorly predicted
the presence of these drug-resistant pathogens in
most settings, HCAP criteria were widely prevalent
and led to extensive and inappropriate use of
broader agents (e.g. vancomycin, piperacillin–tazo-
bactam, carbapenems) for CAP patients, and out-
comes for patients meeting HCAP criteria were
www.co-pulmonarymedicine.com 205
Infectious diseases
worse when they received broader treatment com-
pared with standard guideline recommended treat-
&
ment [7,8,9 ].
Therefore, the guideline committee recom-
mended that clinicians abandon the use of HCAP
as a strategy for prescribing broader spectrum antibi-
otic therapy. The challenge, however, was identifying
an alternative strategy, as we also recognized that a
small proportion of adults with CAP are infected with
these drug-resistant pathogens and are likely to suffer
worse outcomes if treatment does not cover for them.
Although a few clinical prediction rules have been
developed and likely outperform HCAP as tools to
identify CAP patients at higher risk of drug-resistant
pathogens, none of these rules has been tested in
clinical settings and demonstrated to lead to
improved patient outcomes. In addition, we recog-
nize that the risk of drug-resistant pathogens varies
enormously by clinical site and as the ultimate per-
formance of any prediction rule relates to the baseline
prevalence of the different pathogens, it is critically
important for sites to measure their own local rates of
these pathogens. Thus, some sites may adopt more
aggressive strategies for the use of broader spectrum
empiric treatments, especially in patients with severe
CAP, whereas other sites may be able to withhold
such therapies even in the face of known risk factors.
Therefore, although the guideline committee was
very sympathetic to the desire for a simple rule guid-
ing the use of anti-MRSA and anti-P. aeruginosa ther-
apy, the reality is that there is no substitute for
clinicians having knowledge of their local etiological
data to determine if these are needed.
In part to help support such local data gathering,
as noted above, the committee recommended rou-
tinely obtaining sputum and blood culture data
whenever drug-resistant pathogens are suspected,
especially when broader spectrum empiric therapy
is initiated. In addition, routinely collecting such
diagnostic tests when broader spectrum empiric
therapy is initiated would allow for de-escalation
of therapy at 24–48 h if culture results do not indi-
cate the presence of drug-resistant pathogens requir-
ing the broader therapy.
Antibiotic stewardship
Antibiotic-prescribing decisions have both individ-
ual and societal consequences. Appropriately,
increasing attention is being paid to the unintended
harms that are caused by these prescriptions. At the
individual level, these harms include dose-depen-
dent and idiosyncratic adverse events as well as an
increased individual risk of subsequent antibiotic-
resistant infections. At the societal level, studies
have demonstrated a clear link between per capita
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or per patient utilization of antibiotic classes and
resistance to those classes in the community or
hospital, respectively. Thus, as highlighted earlier,
every antibiotic prescription decision must be
framed as a risk-benefit decision.
The guideline committee spent considerable time
discussing how best to incorporate these concerns
over individual and community-level risk associated
with antibiotic prescribing. Ultimately, the adult CAP
guideline emphasized evidence demonstrating equiv-
alence of different antibiotic treatment strategies as we
did not feel that adverse events reported for individual
classes of drugs should invalidate existing data that
demonstrated therapeutic equivalence across drug
classes. For example, while increasing reports high-
light individual risks of fluoroquinolones and fluoro-
quinolone drug resistance among multiple pathogens
(especially Gram-negative pathogens) is a rising prob-
lem, such evidence did not change the available ran-
domized trial evidence demonstrating therapeutic
equivalence of respiratory fluoroquinolones to other
empiric treatment regimens. However, the continued
inclusion of these different treatment options does not
mean that they should be treated equally in all sit-
uations. Moreover, local infection control strategies
may particularly influence the relative favoring of one
strategy over another.
Similarly, the guideline committee endorsed the
goal of limiting antibacterial drug exposure to those
patients who have susceptible bacterial infections.
We strongly endorsed de-escalation strategies that
narrow or perhaps even stop all antibacterial drugs
depending on the available laboratory and clinical
evidence. Moreover, we called for future studies to
test empiric strategies that withhold antibiotics in
selected groups of patients with CAP.
However, it is worth highlighting that relative to
the total amount of antibiotic prescribing, especially
in the outpatient setting, the amount prescribed to
treat adult patients with CAP is relatively small and
is likely not the major driver of the drug toxicities
and resistance patterns that are being reported.
Thus, although antimicrobial stewardship is an
important perspective to consider in developing
CAP treatment guidelines, it is also important to
highlight that the major efforts to reduce inappro-
priate and unnecessary antibiotic-prescribing pat-
terns should focus on other patient populations,
especially those with acute bronchitis and upper
respiratory tract infections that are not responsive
to antibiotic therapies.
Role of corticosteroids
One of the major new therapeutic drug classes to be
evaluated since the release of the last CAP guideline
Volume 26  Number 3  May 2020

was corticosteroids. Several randomized trials have
now been published and meta-analyses have sum-
marized these data [10,11]. Although some of
these analyses have highlighted the potential for
clinical benefit in the use of corticosteroids in
patients with severe CAP, the guideline committee
did not endorse routine use of corticosteroids in
patients with CAP, including severe CAP. This deci-
sion reflected several considerations including:
important weaknesses in some of the trials that
drove the positive results of the meta-analyses,
appreciation of risks associated with widespread
use of corticosteroids in patients with CAP, and
knowledge of ongoing major trials designed to pro-
vide more definitive evidence on the use of steroids
for adults with CAP, including one strongly nega-
tive randomized controlled trial published after
the guidelines had been finalized and accepted
&
for publication [12 ]. Notably, we did emphasize
settings in which corticosteroid use is recom-
mended and could co-exist in adults with CAP,
including reactive airway diseases, other steroid-
dependent chronic conditions, and sepsis with
refractory shock.
CONCLUSION
Appropriate management of patients with pneumo-
nia has been the focus of debate for over 100 years.
Indeed, despite the discovery and wide-spread use of
antibiotics and vaccines, pneumonia remains a
major source of morbidity and mortality worldwide.
In the United States, acute cough illness is one of the
leading causes of urgent and emergency care visits
and although pneumonia is the underlying diagno-
sis in only a minority of these patients, it drives
much of the management strategy for this patient
population. Given the magnitude of the problem, it
is disappointing that the development of new and
effective preventive, diagnostic and therapeutic
strategies has been relatively slow. Notable excep-
tions include the introduction of the pneumococcal
conjugate vaccine, improved universal uptake of
influenza vaccination, and the relatively recent
introduction of new antimicrobial drug options.
Moreover, emerging molecular diagnostic assays
hold the potential to support rapid, point-of-care
testing strategies that could transform treatment
strategies from purely empiric to more pathogen-
directed. However, for such strategies to be recom-
mended in future iterations of the adult CAP
guideline will require evidence that such strategies
improve patient outcomes. As new evidence
becomes available, we support a process that
will allow more frequent updates to the adult CAP
guideline.
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Update in adult CAP Metlay and Waterer
Acknowledgements
The authors are indebted to the outstanding other mem-
bers of the ATS/IDSA Adult CAP guideline committee:
Ann C. Long, Antonio Anzueto, Jan Brozek, Kristina
Crothers, Laura A. Cooley, Nathan C. Dean, Michael J.
Fine, Scott A. Flanders, Marie R. Griffin, Mark L. Meter-
sky, Daniel M. Musher, Marcos I. Restrepo, and Cynthia
G. Whitney.
Financial support and sponsorship
Administrative support for the guideline committee was
provided by the American Thoracic Society.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
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&& with community-acquired pneumonia. An official clinical practice guideline of
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This study provides more recent evidence that routine corticosteroid use in CAP
does not provide benefit for adult patients and helped inform the decision to not
routinely recommend corticosteroids in the new adult CAP guideline.
www.co-pulmonarymedicine.com 207