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

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Abstract

Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia.

Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.

Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions.

Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.

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Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study.

Marco Confalonieri, Rosario Urbino, Alfredo Potena … (2005)

We hypothesize that hydrocortisone infusion in severe community-acquired pneumonia attenuates systemic inflammation and leads to earlier resolution of pneumonia and a reduction in sepsis-related complications. In a multicenter trial, patients admitted to the Intensive Care Unit (ICU) with severe community-acquired pneumonia received protocol-guided antibiotic treatment and were randomly assigned to hydrocortisone infusion or placebo. Hydrocortisone was given as an intravenous 200-mg bolus followed by infusion at a rate of 10 mg/hour for 7 days. Primary end-points of the study were improvement in Pa(O(2)):FI(O(2)) (Pa(O(2)):FI(O(2)) > 300 or >/= 100 increase from study entry) and multiple organ dysfunction syndrome (MODS) score by Study Day 8 and reduction in delayed septic shock. Forty-six patients entered the study. At study entry, the hydrocortisone group had lower Pa(O(2)):FI(O(2)), and higher chest radiograph score and C-reactive protein level. By Study Day 8, treated patients had, compared with control subjects, a significant improvement in Pa(O(2)):FI(O(2)) (p = 0.002) and chest radiograph score (p < 0.0001), and a significant reduction in C-reactive protein levels (p = 0.01), MODS score (p = 0.003), and delayed septic shock (p = 0.001). Hydrocortisone treatment was associated with a significant reduction in length of hospital stay (p = 0.03) and mortality (p = 0.009).

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Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia.

Marin H. Kollef, Andrew R Shorr, Ying P. Tabak … (2005)

Traditionally, pneumonia developing in patients outside the hospital is categorized as community acquired, even if these patients have been receiving health care in an outpatient facility. Accumulating evidence suggests that health-care-associated infections are distinct from those that are truly community acquired. To characterize the microbiology and outcomes among patients with culture-positive community-acquired pneumonia (CAP), health-care-associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). A retrospective cohort study based on a large US inpatient database. A total of 4,543 patients with culture-positive pneumonia admitted into 59 US hospitals between January 1, 2002, and December 31, 2003, and recorded in a large, multi-institutional database of US acute-care hospitals (Cardinal Health-Atlas Research Database; Cardinal Health Clinical Knowledge Services; Marlborough, MA). Culture data (respiratory and blood), in-hospital mortality, length of hospital stay (LOS), and billed hospital charges. Approximately one half of hospitalized patients with pneumonia had CAP, and > 20% had HCAP. Staphylococcus aureus was a major pathogen in all pneumonia types, with its occurrence markedly higher in the non-CAP groups than in the CAP group. Mortality rates associated with HCAP (19.8%) and HAP (18.8%) were comparable (p > 0.05), and both were significantly higher than that for CAP (10%, all p < 0.0001) and lower than that for VAP (29.3%, all p < 0.0001). Mean LOS varied significantly with pneumonia category (in order of ascending values: CAP, HCAP, HAP, and VAP; all p < 0.0001). Similarly, mean hospital charge varied significantly with pneumonia category (in order of ascending value: CAP, HCAP, HAP, and VAP; all p < 0.0001). The present analysis justified HCAP as a new category of pneumonia. S aureus was a major pathogen of all pneumonias with higher rates in non-CAP pneumonias. Compared with CAP, non-CAP was associated with more severe disease, higher mortality rate, greater LOS, and increased cost.

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2009 pandemic influenza A (H1N1): pathology and pathogenesis of 100 fatal cases in the United States.

Wun-Ju Shieh, Dianna M. Blau, Amy M. Denison … (2010)

In the spring of 2009, a novel influenza A (H1N1) virus emerged in North America and spread worldwide to cause the first influenza pandemic since 1968. During the first 4 months, over 500 deaths in the United States had been associated with confirmed 2009 pandemic influenza A (H1N1) [2009 H1N1] virus infection. Pathological evaluation of respiratory specimens from initial influenza-associated deaths suggested marked differences in viral tropism and tissue damage compared with seasonal influenza and prompted further investigation. Available autopsy tissue samples were obtained from 100 US deaths with laboratory-confirmed 2009 H1N1 virus infection. Demographic and clinical data of these case-patients were collected, and the tissues were evaluated by multiple laboratory methods, including histopathological evaluation, special stains, molecular and immunohistochemical assays, viral culture, and electron microscopy. The most prominent histopathological feature observed was diffuse alveolar damage in the lung in all case-patients examined. Alveolar lining cells, including type I and type II pneumocytes, were the primary infected cells. Bacterial co-infections were identified in >25% of the case-patients. Viral pneumonia and immunolocalization of viral antigen in association with diffuse alveolar damage are prominent features of infection with 2009 pandemic influenza A (H1N1) virus. Underlying medical conditions and bacterial co-infections contributed to the fatal outcome of this infection. More studies are needed to understand the multifactorial pathogenesis of this infection.

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Journal

Journal ID (nlm-ta): Am J Respir Crit Care Med

Journal ID (iso-abbrev): Am. J. Respir. Crit. Care Med

Journal ID (publisher-id): ajrccm

Title: American Journal of Respiratory and Critical Care Medicine

Publisher: American Thoracic Society

ISSN (Print): 1073-449X

ISSN (Electronic): 1535-4970

Publication date (Print and electronic): 1 October 2019

Publication date (Electronic): 1 October 2019

Publication date (Print): 1 October 2019

Volume: 200

Issue: 7

Pages: e45-e67

Author notes

[*]

Co–first authors.

Author information

Joshua P. Metlay http://orcid.org/0000-0003-2259-6282

Grant W. Waterer http://orcid.org/0000-0002-7222-8018

Antonio Anzueto http://orcid.org/0000-0002-7007-588X

Jan Brozek http://orcid.org/0000-0002-3122-0773

Kristina Crothers http://orcid.org/0000-0001-9702-0371

Laura A. Cooley http://orcid.org/0000-0002-5127-3442

Nathan C. Dean http://orcid.org/0000-0002-1996-0533

Michael J. Fine http://orcid.org/0000-0003-3470-9846

Scott A. Flanders http://orcid.org/0000-0002-8634-4909

Marie R. Griffin http://orcid.org/0000-0001-7114-7614

Mark L. Metersky http://orcid.org/0000-0003-1968-1400

Daniel M. Musher http://orcid.org/0000-0002-7571-066X

Marcos I. Restrepo http://orcid.org/0000-0001-9107-3405

Article

Publisher-manuscript ID: 201908-1581ST

DOI: 10.1164/rccm.201908-1581ST

PMC ID: 6812437

PubMed ID: 31573350

SO-VID: f13367a6-f680-44ae-aa30-f1c0cc2724e0

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You may print one copy of this document at no charge. However, if you require more than one copy, you must place a reprint order. Domestic reprint orders: amy.schriver@ 123456sheridan.com ; international reprint orders: louisa.mott@ 123456springer.com .

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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

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Pneumonia, sex, and the environment

Most cited references 209

Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study.

Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia.

2009 pandemic influenza A (H1N1): pathology and pathogenesis of 100 fatal cases in the United States.

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