The American Thoracic Society has published a new clinical practice guideline (CPG) on pneumonia care, including guidance on lung ultrasound, antibiotics, and corticosteroid use.
Pneumonia, a largely preventable disease, caused more than two million deaths in 2021, according to the Global Burden of Disease report. Evidence-based guidance on its diagnosis and management is, therefore, a priority for clinicians. Now, the American Thoracic Society has published a new clinical practice guideline (CPG), which expands upon its 2019 recommendations.
The treatment duration with antibiotics, for example, is a highlight of the new guideline. “The duration of therapy needs to be tailored to the individual. If the patient does not have severe pneumonia and the symptoms improve within three days of treatment, the patient can be treated with a minimum of three days of therapy,” said Julio Ramirez, MD, co-lead of the guideline panel and emeritus professor of medicine in the Division of Infectious Diseases at the University of Louisville.
The latest guideline, published early online in the American Journal of Respiratory and Critical Care Medicine, provides updates to two questions from the 2019 guideline and addresses two new questions: the use of ultrasound for the diagnosis of pneumonia and the need for antibiotic therapy in patients with a positive test for a viral pathogen.
In addition, “This CPG includes a very important table that provides a framework for individualization of the recommendations since most of them are conditional (without high quality evidence),” noted Barbara Jones, MD, MS, co-lead of the guideline panel. “It should be accompanied by support to clinicians to individualize to specific patients and their circumstances.”
Using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework, the panel made the following recommendations:
1. [New] Should lung ultrasound be considered a reasonable alternative to chest x-ray for diagnosis in adults with suspected community-acquired pneumonia (CAP)?
For adults with suspected CAP, we suggest lung ultrasound is an acceptable alternative to chest x-ray in medical centers where appropriate clinical expertise exists (conditional recommendation, low-quality evidence).
2. [New] Should adults with community-acquired pneumonia who test positive for a respiratory virus be treated with antibacterial therapy?
For adult outpatients without co-morbidities who have clinical and imaging evidence of CAP and who test positive for a respiratory virus, we suggest not prescribing empiric antibiotics (conditional recommendation, very low-quality evidence).
(Note: See the full guideline for recommendations for outpatients with co-morbidities who have clinical and imaging evidence of CAP, inpatients with clinical and imaging evidence of non-severe CAP, and inpatients with clinical and imaging evidence of severe CAP.)
3. [Update from 2019] Should adults with community-acquired pneumonia who reach clinical stability be treated with less than 5 days of antibiotics?
For adult outpatients with CAP who reach clinical stability, we suggest less than five days of antibiotics (minimum of 3 days duration), rather than five or more days of antibiotics (conditional recommendation, low-quality evidence).
(See the full guideline for recommendations for inpatients with non-severe CAP, inpatients with severe CAP, and adults who reach clinical stability.)
4. [Update from 2019] Should adults who are hospitalized with community-acquired pneumonia be treated with corticosteroids?
For adult inpatients with non-severe CAP, we recommend NOT administering systemic corticosteroids (strong recommendation, low-quality evidence).
For adult inpatients with severe CAP, we suggest systemic corticosteroids (conditional recommendation, low-quality evidence).
