Thread by @ASPphysician

After 12 yrs of waiting, and 5 years of development, the @atscommunity @IDSAInfo community-acquired pneumonia guidelines have come out atsjournals.org/doi/suppl/10.1…. I have been asked repeatedly for my take and it has taken a while to fully dig my teeth into everything w/ a #tweetorial

Summary:
Minimize microbiology (no sputum/BC unless severe of MDRO Rx)
Don't base initial Rx on PCT
Don't use steroids
Macrolides for outpts ONLY if low resistance
Stop using "HCAP"
Severe CAP: BL+macrolide OR FQ
No routine F/U CXR

Process:
prepared by an ad hoc committee (15)
COI wasn't an exclusion; 2 members recused themselves because of ++ COI
M:F 10:5 (@geetamehta0)
Cauc 13, Hisp 2, Other 0 (@DrJRMarcelin)
ER 0, GIM 4, ID 3, Resp 7, Pharm 0 (@EMCases @Kerry_LaPlante)
0 patients (@SolidFooting)

Focus: adult pts in US
Used GRADE and PICO frameworks--they chose questions (remarkably, no Q on need for Legionella/atypical coverage)
Lit. search carried out from 2015-2017 w/monthly searches in between
2 papers from 2019: LEAP 1 (iv-to-po lefamulin) and omadacycline vs. moxi)

I looked back at my own top 4 questions from earlier this year and they answered 2/4:
❌ how much of CAP is non-bacterial
❌do we need to routinely cover for atypical CAP
✅ can we use biomarkers to determine treatment for CAP
✅ how long do we have to treat with ABx

1st face-to-face meeting 2014; 2nd 2016
Independent of industry funding
Subgroups met, drafted guidelines, based on available evidence +/- meta-analysis

They discourage routine micro testing unless SEVERE CAP or embarking on Rx for MRSA or Pseudo.
They use 2007 IDSA/ATS severity criteria. In fact, one of the co-chairs said as much in 2017.atsjournals.org/doi/full/10.11…

They also discourage routine urinary testing for Pneumococcal and Legionella Ag. Tough to argue with this.
Similarly, they discourage routine procalcitonin measurements for deciding Rx, and I would agree with that, too.

They argue for testing for influenza during flu season, based on "the benefits of antiviral therapy". However, the evidence really only supports hospitalized patients ... and don't tell @bmj_latest.
doi.org/10.1136/bmj.j2… bmj.com/tamiflu

When deciding whether to send pt. home or admit, they favour the PSI (10.1056/NEJM199701233360402), but also encourage @BTSrespiratory CURB-65 and others. They do not mention the evidence that an SaO2<92% has a poor prognosis for CAP outpatients (10.1093/cid/ciq076).

In deciding about ICU care the authors, again, favour the @atscommunity criteria "because they are composed of readily available severity parameters and are more accurate than the other scores described above. Their conclusions are reasonable, but based on poor quality data.

For oupt. low-risk CAP they recommend amox 1g tid >> doxy 100mg bid > macrolide IF resistance <25%.
The amazing thing: nowhere in continental US is macrolide resistance <25%.

https://twitter.com/mikeempharmd/status/1180204749943128066?s=21

.

For outpt. high-risk CAP (i.e. comorbidities) they recommend (amox-clav or cefpodoxime or cefuroxime) PLUS a macrolide OR FQ monotherapy. They justified this with the following which, I must admit, don't really explain the added macrolide/atypical coverage.

Finally, and perhaps the most controversial of recommendations, for inpatient CAP they stuck with the 2007 guidelines and recommended:
beta-lactam (including amp/sulbactam, 3o ceph or + CEFTAROLINE) + macrolide
OR
FQ monotherapy
(and I they managed to mention omadacycline)

In my opinion, this is the most problematic of all their recommendations. Primarily because there is fairly solid evidence that BL monotherapy suffices, and that FQs are unnecessarily harmful/dangerous. It is as if they had never had a conversation with an antimicrobial steward

I also cant believe they went back to old IDSA ways of recommending new drugs a) w/ no safety track record and b) cost a fair bit.
Further, they mention that these regimens should "cover the most likely pathogens causing CAP", but don't even cite Jain et al 10.1056/NEJMoa1500245

If one was to read these guidelines in isolation, you wouldn't know that viruses are by far and away the most common causes of CAP, nor that pretty well everything you need to treat is S. pneumoniae

For severe inpt CAP (however you define it), they emphasize combo therapy: beta-lactam + macrolide or BL+FQ. Both recommendations are STRONG, even though the evidence is quite poor (esp. BL+FQ). It is tough to understand how they got to the BL+FQ, even with their explanation.

Thankfully, they abandon HCAP. Thank heavens! It never should have been introduced.

They also don't recommend routine corticosteroids. I support this, although @RSiemieniuk surely has a differing opinion on this. ncbi.nlm.nih.gov/pubmed/26258555.

The last thing I will touch on is duration. They reasonably set the low end of the bar at 5 days, and state that this should suffice for most patients. I think this is fair, and is backed by enough evidence.

In conclusion
This seems an impossible task: to come up with CAP guidelines that most would agree with. I think if they could have a) overcome process and time issues, b) were disciplined in how they used evidence, and c) included stewards, these CPGs would have been better.