Thread by @ericschul

Key recommendations from the new IDSA guidelines for community-acquired pneumonia (thread) atsjournals.org/doi/full/10.11…

1) gram stain/sputum culture at time of CAP diagnosis not routinely recommended unless severe CAP, intubated, or suspicion for MRSA/pseudomonas, or IV abx prev

2) rec against routine blood cx except in severe CAP or suspicion for MRSA/pseudomonad

3) rec against routine urine strep/legionella testing except in severe CAP, or if epidemiology heightens legionella suspicion (outbreak, travel)

4) rec flu testing w/ CAP when flu prevalent

5) recommend against witholding abx in pts w/ clinical suspicion for CAP, even if procalcitonin low

6) recommend use of PSI over CURB-65 for prognostication

7) Rec using IDSA major/minor severity criteria to determine need for higher level of care rather than PSI/CURB

8) empiric tx of CAP in outpatient setting:
If no comorbidities: amox 1g TID, doxy 100 BID, or azithromycin 250 daily (if local resistance to macrolides <25%).

Empiric tx if comorbidities (HF, liver dz, renal dz, DM, EtOH, CA, asplenic):
Combination therapy
amox/clavulanate 500/125 TID or 875/125 BID or cephalosporin (cefpodoxime 200 BID or cefuroxime 500 BID) + macrolide (azithro) or doxy

Monotherapy
Resp quinolone (levo, moxi, gemi

9) empiric inpatient tx for non-severe CAP (w/o risk factors for MRSA/pseudomonas):
Combo therapy w/ beta lactam (amp-sulbactam, ceftriaxone, cefoxatine, ceftaroline) + macrolide
Monotherapy w/ resp quinolone

Beta-lactam + doxy combo therapy also acceptable if contraindication to macrolide or quinolone

Recs for inpatient severe CAP (w/ low suspicion for MRSA/pseudomonas):
Beta-lactam + macrolide
or
Beta-lactam + respiratory quinolone

10) Inpatient anaerobic coverage for suspected aspiration pneumonia? Not recommended, unless lung abscess or empyema are suspected.
Risk of c diff by adding clinda may outweigh benefits of anaerobic coverage.

11) Still recommending against usage of HCAP concept to guide antibiotic coverage. Only cover for MRSA/pseudomonas empirically if local risk factors are present.

12) recommend against use of steroids for non-severe CAP, severe CAP, or severe flu pneumonia

13) recommend anti-influenza for pts with CAP who also test positive for flu in inpatient or outpatient setting, regardless of duration of illness prior to dx

14) rec antibacterial treatment in pts w/ clinical and radiographic evidence of CAP who test positive for flu

15) Duration of antibiotic treatment recommended:
use validated measure of clinical stability (resolution of vital sign abnormalities), treat for no less than 5 days and until pt achieves clinical stability

16) Rec against followup chest imaging in adults w/ resolved CAP

Here's the high-yield table that shows the changes from the previous (2007) guidelines. And with that, good night all! I hope you impress your teams tomorrow by citing these new guidelines (ping me if you do).