Posted on February 11, 2020 in: Professional Practice
By Joan Zhang, Pharm.D.; Christina Sudyk, Pharm.D.; Laura McKeown, Pharm.D., PGY1 residents at Spectrum Health, Grand Rapids
Per the Centers for Disease Control and Prevention (CDC), pneumonia accounts for roughly 1.7 million emergency department visits a year.1 It affects over 5.6 million patients annually and results in over $12 million in healthcare costs.2
In October 2019, the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) released updated guidelines for the diagnosis and treatment of community-acquired pneumonia (CAP). A summary of the major differences between the new and old guidelines can be found in Table 1.
One of the most notable changes is the removal of the healthcare-associated pneumonia (HCAP) designation. The concept of HCAP was originally introduced in the 2005 ATS/IDSA hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) guidelines due to concerns that patients meeting criteria for HCP were at an increased risk of multi-drug resistant organisms (MDRO). However, increasing evidence since then has found that those factors were not very predictive of MDRO.3 This term was also abandoned earlier in the 2016 ATS/IDSA HAP/VAP Guidelines.
Other changes include the recommendation to not add anaerobic coverage for suspected aspiration pneumonia unless lung abscess or empyema is suspected.3 It is now recommended to cover for MRSA and P. aeruginosa only if the patient has a prior history of the pathogen and/or they have severe CAP with recent hospitalization requiring IV antibiotics and locally validated risk factors for either pathogen.3
Summaries of the recommended empiric therapies for patients in the outpatient setting and inpatient setting are provided in Table 2 and Table 3 respectively.
Overall, these guidelines address the recent shift in health care regarding the diagnosis and treatment of pneumonia and the common causative community acquired pathogens. To note, HCAP is no longer a commonly utilized diagnosis given findings from recent literature. Additionally, empiric coverage of P. aeruginosa or MRSA in a patient diagnosed with CAP is not indicated for all patients just like the recommendation to no longer cover for anaerobic organisms in patients with aspiration pneumonia. Much of the driving force behind antibiotic selection will also be dependent on the local resistance rates and institution specific antibiogram patterns. It is important to keep these new recommendations in mind in order to assist with antimicrobial stewardship efforts to reduce antimicrobial resistance, decrease undesirable patient outcomes and side effects to mediations, and reduce the burden of cost to patients and institutions. As the medication experts on the patient care team, it is our duty to ensure that the selected therapies are not only appropriate, but also the gold standard for our patients as determined by the available guidelines.
1. Pneumonia. Centers for Disease Control and Prevention. https://www.cdc.gov/pneumonia/index.html. Published Oct. 22, 2018.
2. Brar NK, Niederman MS. Management of community-acquired pneumonia: a review and update. Ther Adv Respir Dis. 2011;5(1):61-78. doi:10.1177/1753465810381518.
3. Metlay JP, Waterer GW, Long AC, et al. 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;200(7):e45-e67. doi:10.1164/rccm.201908-1581st.
4. 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. doi:10.1086/511159.