Updated Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia

Written by Vinay Singh singh Published On 2018-07-12T19:01:20+05:30 | Updated On 12 July 2018 7:01 PM IST

Community-acquired pneumonia is a common infectious disease in adults. The current guideline represents an updated version of the 2009 treatment guideline for community-acquired pneumonia in Korea. The new clinical practice guideline which appears in the journal Infection & Chemotherapy (ic) provides revised recommendations on the appropriate diagnosis, treatment, and prevention of community-acquired pneumonia in adults aged 19 years or older, taking into account the current situation regarding community-acquired pneumonia in Korea.

Recommendation and evidence levels:

The level of recommendation was divided into “Strong, Weak”, and the level of evidence was divided into “High, Moderate, Low, Very low”. A consensus was deemed reached if over 70% of the participating committee members agreed.

Summary of guidelines on antibiotic use for community-acquired pneumonia:

Diagnosis of pneumonia

KQ 1. For adults who may have contracted community-acquired pneumonia, are the tests used to identify causative helpful for selecting therapeutic antibiotics?

Recommendation

Use an appropriate testing method to identify the causative bacteria of pneumonia when a patient is diagnosed with moderate or severe community-acquired pneumonia (level of recommendation: strong, level of evidence: low).

Selectively perform tests according to age, underlying diseases, severity markers, epidemiological factors, and current history of antibiotic use when treating outpatients with community-acquired pneumonia of low severity (level of recommendation: strong, level of evidence: low).

It is advisable to perform blood culture, and sputum Gram smear and culture tests before antibiotic administration for patients with community-acquired pneumonia who require hospitalization (level of recommendation: strong, level of evidence: low).

KQ 2. For adults who may have contracted community-acquired pneumonia, is the urinary S. pneumoniae antigen test useful for selecting therapeutic antibiotics?

Recommendation

Perform an S. pneumoniae urinary antigen test for all patients with community-acquired pneumonia who require hospitalization (level of recommendation: strong, level of evidence: moderate).

KQ 3. Is the Legionella urinary antigen test helpful for selecting therapeutic antibiotics for adults who may have contracted community-acquired pneumonia?

Recommendation

A Legionella urinary antigen test is performed for patients with moderate or severe community-acquired pneumonia (level of recommendation: strong, level of evidence: moderate).

KQ 4. Is a blood culture useful for choosing therapeutic antibiotics for adults who may have contracted community-acquired pneumonia?

Recommendation

A blood culture test is performed before antibiotic administration for all patients with moderate or severe community-acquired pneumonia (level of recommendation: strong, level of evidence: low).

Hospitalization criteria for pneumonia

KQ 5. For adults who may have contracted community-acquired pneumonia, does making a hospitalization decision according to hospitalization criteria produce good prognoses?

Recommendation

Physicians must clinically decide whether a patient with community-acquired pneumonia should be hospitalized or not according to objective criteria (level of recommendation: strong, level of evidence: low).

KQ 6. Of CURB-65 and PSI, which are hospital and intensive care unit (ICU) admission criteria, which one will lead to better prognoses for adults who may have contracted community-acquired pneumonia?

Recommendation

It is recommended to use CRB-65 in clinics or outpatient clinics at the level of a hospital and to use CURB-65 for patients who are in emergency departments or whose blood tests results are available (level of recommendation: strong, level of evidence: low).

KQ 7. For adults who may have contracted community-acquired pneumonia, does making an ICU admission decision according to hospitalization criteria produce good prognoses?

Recommendation

Patients with community-acquired pneumonia who require mechanical ventilation or have septic shock must be hospitalized in ICU (level of recommendation: strong, level of evidence: moderate).

For patients who have CURB-65 ≥3, who exhibit ancillary signs of severe pneumonia as defined by the IDSA/ATS, who have developed pneumonia based on clinical findings, and whose underlying diseases have worsened, the need for ICU admission must be reassessed (level of recommendation: weak, level of evidence: low).

Treatment of pneumonia

KQ 8. What are the first choices of antibiotics in the outpatient treatment of patients who may have contracted community-acquired pneumonia?

Recommendation

β-lactam is recommended for use as an empirical antibiotic (level of recommendation: strong, level of evidence: high).

Respiratory fluoroquinolones are recommended for use as empirical antibiotics (level of recommendation: strong, level of evidence: high).

Use of respiratory fluoroquinolones as empirical antibiotics must be avoided in situations where tuberculosis cannot be excluded (level of recommendation: weak, level of evidence: low).

Recommendation

The therapeutic effects of the β-lactam monotherapy are not inferior to those of the β-lactam + macrolide combination therapy.

β-lactam + macrolide is recommended for suspected atypical pneumonia.

Respiratory fluoroquinolones have excellent antibacterial activities against tuberculosis bacilli. They may thus delay the diagnosis of tuberculosis in patients for whom tuberculosis has been misdiagnosed as another kind of bacterial pneumonia, and may allow tuberculosis bacilli to develop resistance against fluoroquinolones.

KQ 9. For patients who may have contracted community-acquired pneumonia, and are hospitalized in an ICU, does the β-lactam /macrolide (or respiratory fluoroquinolone) combination therapy produce better prognoses than the β-lactam monotherapy?

Recommendation

Use of β-lactam antibiotics or respiratory fluoroquinolones is recommended in the empirical treatment of patients with mild to moderate pneumonia admitted to a general ward (level of recommendation: weak, level of evidence: moderate).

β-lactam and macrolide antibiotics may be administered together in patients suspected of having an atypical bacterial infection or in patients who have moderate pneumonia, under limited circumstances (level of recommendation: weak, level of evidence: moderate).

KQ 10. What is the adequate duration of antibiotic treatment for patients who may have contracted community-acquired pneumonia?

Recommendation

Antibiotics must be administered for at least five days (level of recommendation: strong, level of evidence: low).

KQ 11. For patients who may have contracted community-acquired pneumonia, when is it appropriate to switch from intravenous antibiotics to oral antibiotics?

Recommendation

A patient may switch from intravenous antibiotics to oral antibiotics once he/she is clinically stable, and can take oral medications (level of recommendation: strong, level of evidence: high).

KQ 12. For patients who may have contracted community-acquired pneumonia, when is the appropriate time to be discharged?

Recommendation

If a patient can undergo oral treatment, does not require treatment or diagnostic tests for underlying diseases, and is in a social environment where he/she will be taken care of, discharge may be considered (level of recommendation: strong, level of evidence: high).

KQ 13. For patients who may have contracted community-acquired pneumonia, are oxygen therapy, low-molecular-weight heparin therapy, and early ambulation helpful?

Recommendation:

The level of oxygen is maintained at 94-98% via oxygen therapy in patients with hypoxemia (level of recommendation: weak, level of evidence: low).

Low-molecular-weight heparin is injected into patients at high risk of venous thromboembolism (level of recommendation: strong, level of evidence: high).

Early ambulation is recommended (level of recommendation: strong, level of evidence: high).

KQ 14. For patients who may have contracted community-acquired pneumonia and are admitted to ICU for treatment, does the β-lactam/macrolide (or respiratory fluoroquinolone) combination therapy lead to better prognoses than the β-lactam monotherapy?

Recommendation:

For patients requiring ICU admission, the β-lactam + azithromycin/fluoroquinolone combination therapy is recommended over the β-lactam monotherapy (level of recommendation: strong, level of evidence: moderate).

KQ 15. For patients who may have contracted community-acquired pneumonia and who are in admitted to ICU for treatment, does the β-lactam/macrolide (or respiratory fluoroquinolone) combination therapy lead to better prognoses than the respiratory fluoroquinolone monotherapy?

Recommendation

For patients requiring ICU admission, the β-lactam + azithromycin/fluoroquinolone combination therapy is recommended over the respiratory fluoroquinolone monotherapy (level of recommendation: strong, level of evidence: moderate).

KQ 16. For patients who may have contracted community-acquired pneumonia and who are admitted to ICU for treatment, does a treatment against Legionella lead to better prognoses?

Recommendation

For patients with severe community-acquired pneumonia who require ICU admission, it is necessary to perform treatment against Legionella (level of recommendation: strong, level of evidence: low)

KQ 17. For patients who may have contracted community-acquired pneumonia and who are admitted to ICU for treatment, does steroid therapy lead to good prognoses?

Recommendation

Steroid therapy may be considered for patients with severe community-acquired pneumonia accompanied by shock (level of recommendation: weak, level of evidence: low).

Assessment of the effectiveness of pneumonia treatment

KQ 18. For patients who may have contracted community-acquired pneumonia, are follow-up chest-X-rays useful for assessing treatment response?

Recommendation

For patients with community-acquired pneumonia who do not show clear symptom improvements, or who are at high risk of lung cancer, it is recommended to take follow-up chest X-rays to examine the treatment response (level of recommendation: strong, level of evidence: low).

Recommendation

Lesion improvements manifest themselves more slowly than clinical symptoms on chest-X-rays of patients with pneumonia.

The Lesion loss may radiologically manifest slowly even after 12 weeks after treatment in patients who are aged 50 years or older, who have multilobar pneumonia and have underlying diseases.

For patients who are aged 50 years or older, are male, and are smokers, chest X-rays must be performed to differentiate between underlying lung diseases such as pneumonia 7-12 weeks after treatment, and to confirm complete lesion loss.

KQ 19. For patients who may have contracted community-acquired pneumonia, is the C-reactive protein (CRP) test useful for assessing therapeutic effects?

Recommendation

CRP levels may be repeatedly measured to assess the risk of treatment failure and complications in patients who do not clinically show clear symptom improvements (level of recommendation: weak, level of evidence: low).

KQ 20. For patients who may have contracted community-acquired pneumonia, is the procalcitonin test useful for assessing therapeutic effects?

Recommendation

The procalcitonin test may be used in the process of deciding whether to continue antibiotic treatment or not for patients who show clinical improvements (level of evidence: moderate, level of recommendation: weak).

Adjuvant treatment and prevention of pneumonia

KQ 21. For adults who have contracted community-acquired pneumonia, and have the risk factors of S. pneumoniae infection, can vaccination against S. pneumoniae prevent community-acquired pneumonia?

Recommendation

Old adults and adults who have the risk factors of S. pneumoniae infection are recommended to be vaccinated against S. pneumoniae (level of recommendation: strong, level of evidence: high).

KQ 22. Does smoking cessation education prevent community-acquired pneumonia among adults who have contracted community-acquired pneumonia?

Recommendation

Smoking cessation education is necessary for current smokers who have pneumonia (level of recommendation: strong, level of evidence: high).

For more reference log on to https://doi.org/10.3947/ic.2018.50.2.160

community based pneumoniaDiagnosisfluoroquinolonesguidelineshospitalizedjournal Infection & ChemotherapypneumoniaPreventiverecommendationstherapytreatment

Source : With inputs from the journal Infection �& Chemotherapy

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Vinay Singh singh