Mar 1;44 Suppl 2:S America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Keywords: Community-acquired pneumonia, ICU admission, arterial .. The IDSA/ATS CAP Guidelines major criteria including the pH. Pneumonia In Adults Adapted from: IDSA/ATS CONSENSUS GUIDELINES Mandell LA, Wunderlink RG, Anzueto A, et al. Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clin Infect Dis. ;(Suppl 2).
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BUN, blood urea nitrogen; CI, confidence interval; inf.
IDSA CAP Guidelines
Appropriate drug selection is dependent on the causative pathogen and its antibiotic susceptibility. The PSI score is based on a history of diseases that increase risk of death, whereas the CURB score does not directly address underlying disease. Second, an accurate prediction model will minimize delayed ICU admission, which is associated with increased mortality [ 623 ]. For these reasons, blood cultures are optional for all hospitalized patients with CAP but should be performed selectively table 5.
Although influenza remains the predominant viral cause of CAP in adults, other commonly recognized viruses include RSV [ ], adenovirus, and parainfluenza virus, as well as less common viruses, including human metapneumovirus, herpes simplex virus, varicella-zoster virus, SARS-associated coronavirus, and measles virus.
Recommendations for patients in whom routine diagnostic testing is indicated for the above reasons are listed in table 5. Open in a separate window. The 3-tier scale similar to that used in other IDSA guideline documents [ 12 ] and familiar to many of the committee members was therefore chosen. The major issue with urinary bacterial antigen detection is whether the tests allow narrowing of empirical antibiotic therapy to a single specific agent.
Initial therapy should be given intravenously for most admitted patients, but some without risk factors for severe pneumonia could receive oral therapy, especially with highly bioavailable agents such as fluoroquinolones.
Admission decision support derived from the ATS guideline [ 5 ] recommendations, combined with outpatient antibiotic recommendations, reduced the CAP hospitalization rate from The cost of treating community-acquired pneumonia. A randomized, parallel group study introduced a pneumonia guideline in 20 of 36 small Oklahoma hospitals [ 29 ], with the identical protocol implemented in the remaining hospitals in a second phase.
One acknowledged weakness of this document is the lack of representation by primary care, hospitalist, and emergency medicine physicians.
In the United States, the FDA recommended the use of drotrecogin alfa activated for patients at high risk of death. Prompt recognition of a failed NIV trial is critically important, because most studies demonstrate worse outcomes for patients who require intubation after a prolonged NIV trial .
In EDs with sufficient decision support resources either human or computerizedthe benefit of greater experience with the PSI score may favor its use for screening patients who may communit candidates for outpatient management [ 5057—59 ].
Many of the factors predictive of positive blood culture results [ 95 ] overlap with risk factors for severe CAP table 4.
Defining community-acquired pneumonia severity on presentation to hospital: Multiple prospective randomized trials have demonstrated that either regimen results in high cure rates.
For Legionellaseveral urinary antigen assays are available, but all detect only L. Because shortages of antibacterials and antivirals are anticipated during a pandemic, the appropriate use of diagnostic tests will be even more important to help target antibacterial therapy whenever possible, especially for patients admitted to the acqiired. This is borne out by the finding that deviation from guidelines is greatest in the treatment of patients with CAP admitted to the ICU [ 18 ].
Nosocomial tracheal colonization is not an issue if the sample is obtained soon after intubation. The yield of cultures is substantially higher with endotracheal aspirates, bronchoscopic sampling, or transthoracic needle aspirates [ — ], although specimens obtained after initiation of antibiotic therapy are unreliable and must be interpreted carefully [, ].
Community Acquired Pneumonia Guidelines
Although the PSI and CURB criteria are valuable aids in avoiding inappropriate admissions of low-mortality-risk patients, another important role of these criteria may be to help identify patients at high risk who would benefit from hospitalization.
Wunderink, Antonio Anzueto, John G.
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. Patients with severe CAP are more odsa to be infected with pathogens pneumojia than S.
Almost all of the major decisions regarding management of CAP, including diagnostic and treatment issues, revolve around the initial assessment of severity. Issues regarding hospital admission and ICU transfer are discussed above.
Differences, both real and imagined, between the ATS and IDSA guidelines have led to confusion for individual physicians, as well as for other groups who use these published guidelines rather than promulgating their own.
Another study showed that those receiving a macrolide alone had the lowest day mortality but were the least pneumoniq [ ]. Available data on short-course treatment do not suggest any difference in outcome with appropriate therapy in either inpatients or outpatients [ ]. Some who use guidelines suggest that this variability itself is undesirable. Consistently beneficial effects in clinically relevant parameters listed pheumonia table 3 followed the introduction of a comprehensive protocol including a combination of components from table 2 atts increased compliance with published guidelines.
The second-level admission decision is whether to place the patient in the ICU or a high-level monitoring unit rather guiddlines on a general medical floor.
Short-duration therapy may be suboptimal for patients with bacteremic S. Acquited committee cochairs were charged with selection of the rest of the committee. Statistical Analyses Categorical variables were analyzed using the Chi-square test. These studies suggest that therapy with azithromycin alone can be considered for carefully selected patients with CAP with nonsevere disease patients admitted primarily for reasons other than CAP and no risk factors for infection with DRSP or gram-negative pathogens.
These conditions and specific pathogens, with preferred treatment, are listed in tables 8 and 9. Critical to empirical therapy is an understanding of the management of patients who do not follow the normal response pattern.