The American Thoracic Society and the Infectious Diseases Society of America have published a clinical guideline on the diagnosis and treatment of adults with community acquired pneumonia (CAP) in the Oct. 1 issue of the American Journal of Respiratory and Critical Care Medicine.

Some key recommendations include:

• Avoid obtaining sputum Gram stain and culture routinely in adults with CAP managed as OPD cases.
• Obtain pretreatment Gram stain and culture of respiratory secretions in adults with CAP managed in the hospital setting for those who have severe CAP, or were previously infected with MRSA or P. aeruginosa or are being empirically treated for methicillin-resistant Staphylococcus aureus (MRSA) or P. aeruginosa 
• For healthy outpatients, amoxicillin 1 gram tid, or doxycycline 100 mg bd or a macrolide (azithromycin 500 mg on first day then 250 mg daily or clarithromycin 500 mg twice daily or clarithromycin ER 1000 mg daily) only in areas with macrolide resistance < 25% may be used as empiric treatment. 
• In inpatient adults with non-severe CAP without risk factors for MRSA or P. aeruginosa, empiric antibiotic therapy involves use of combination therapy with a beta-lactam (ampicillin+sulbactam 1.5 to 3 g every 6 hours, cefotaxime 1 to 2 g every 8 hours, ceftriaxone 1 to 2 g daily, or ceftaroline 600 mg every 12 hours) + a macrolide (azithromycin 500 mg daily or clarithromycin 500 mg twice daily) or monotherapy with a respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily)
• For adults with CAP and risk factors for MRSA or P. aeruginosa, cover empirically only for MRSA or P. aeruginosa in adults with CAP if locally validated risk factors for either pathogen are present.

o    Empiric treatment options for MRSA include vancomycin (15 mg/kg every 12 hours, adjust based on levels), or linezolid (600 mg every 12 hours). 

o    Empiric treatment options for P. aeruginosa include piperacillin-tazobactam (4.5 g every 6 hours), cefepime (2 g every 8 hours), ceftazidime (2 g every 8 hours), aztreonam (2 g every 8 hours), meropenem (1 g every 8 hours) or imipenem (500 mg every 6 hours).

(Source: American Thoracic Society, Oct. 1, 2019)

Dr KK Aggarwal

Padma Shri Awardee

President Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA