October 16, 2019
2 min read

New CAP guidelines stress de-escalation

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Recently updated guidelines for the diagnosis and treatment of adults with community-associated pneumonia, or CAP, stressed the importance of de-escalation of antibiotic therapy and made stricter recommendations on when to use broad-spectrum antibiotics for the treatment of patients with CAP and risk factors for drug-resistant organisms.

It had been 12 years since the last CAP guidelines were published, and “much … has not changed,” said Joshua P. Metlay, MD, PhD, chief of the division of general internal medicine at Massachusetts General Hospital, who co-chaired the American Thoracic Society/Infectious Diseases Society of America guideline committee.

“Much of our first-line therapy is very similar, which tells you that there hasn’t been a lot more in the pipeline, although there are some new drugs that have been recently released and approved” — such as Xenleta (lefamulin, Nabriva Therapeutics) and Nuzyra (omadacycline, Paratek Pharmaceuticals) — “so I think we’re going to see some updates in the coming years,” Metlay told Infectious Disease News.

He said the new guidelines “sharpened up” recommendations for microbiologic testing to make testing more aligned with treatment decisions, and addressed the widespread use of broad-spectrum antibiotics for health care-associated pneumonia.

“We felt the need to try and address the overuse of the health care-associated pneumonia (HCAP) category by reducing the circumstances under which people used HCAP to justify broad-spectrum treatment and try to point out that when these broader antibiotics are being used, they’re being used inappropriately and may be worsening outcomes,” Metlay explained.

For adults with CAP being treated in the outpatient setting, the guidelines recommend against collecting sputum Gram’s stain and culture or blood cultures or performing urinary pneumococcal or Legionella antigen testing.

The guidelines recommend obtaining pretreatment Gram’s stain and culturing respiratory secretions for adult patients being managed in the hospital setting who have severe CAP, are being empirically treated for MRSA or Pseudomonas aeruginosa, were previously infected with MRSA or P. aeruginosa or were recently hospitalized and received parenteral antibiotics.

The guidelines recommend Legionella antigen testing only in patients with severe CAP or when Legionella is suspected due to an epidemiological factor — for example, because of an outbreak or a recent history of travel — whereas pneumococcal antigen testing should be performed only among patients with severe CAP.

According to the guidelines, corticosteroids should not be routinely used in adults with pneumonia because “there are no data suggesting benefit of corticosteroids in patients with nonsevere CAP with respect to mortality or organ failure and only limited data in patients with severe CAP.”


However, the guidelines do endorse the use of corticosteroids in patients with CAP and refractory septic shock, as recommended in the Surviving Sepsis Campaign.

“We did address some new ideas which have emerged in the last 12 years, most specifically related to the use of corticosteroids as adjunct treatment in patients with pneumonia. Ultimately, we concluded that in most cases of CAP, steroids do not have a frontline role in treatment. But we did continue to endorse the role of steroids in the treatment of refractory shock and sepsis,” Metlay said.

“I think it is increasingly important that local sites have information on the epidemiology of the pathogens that are causing pneumonia,” he said. “We produce national guidelines, but there’s a lot about the treatment plan that needs to be locally tailored. …The other opportunity here is for infectious disease clinicians to help support some of the efforts that we’re trying to promote with the new guidelines to encourage de-escalation of therapy.” – by Marley Ghizzone

Disclosures: Metlay reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.