Community-acquired Pneumonia Guidelines Research Articles

Treatment guidelines for community-acquired pneumonia

Published guidelines for community-acquired pneumonia (CAP) have informed management and treatment recommendations for 25 years. Since inception, CAP guidelines have been developed for nearly every region of world, in part owing to improved mortality, clinical outcomes, and costs associated with implementation of guideline based care. This review highlights reasons why guidelines remain useful, overviews the similarities and differences among global CAP guidelines, and focuses on the treatment principles underpinning management recommendations, and addresses treatment issues that should be resolved in future CAP guidelines.

Complicated pneumonia: current concepts and state of the art.

This review aims to provide clinicians engaged in the care of infants and children an update on the current understanding of the epidemiology, etiology, diagnostic evaluation, and clinical management of complicated pneumonia. The review provides timely information surrounding areas of consensus and ongoing research. The epidemiology and etiologies of complicated pneumonia continue to evolve over the past several decades in context of the introduction of new vaccines. We review uncommon and emerging pathogens. Immunocompromised patients are particularly at risk for complications. The 2011 clinical practice guidelines for pediatric community-acquired pneumonia from The Pediatric Infectious Diseases Society/Infectious Diseases Society of America and the British Thoracic Society are changing approaches to evaluation and management. The efficacy of new diagnostic laboratory studies, and imaging techniques, continues to be studied. Antibiotics are the mainstay of treatment, with several new options to consider. Techniques for the drainage of parapneumonic effusions continue to optimize. Although much is known about complicated pneumonia, it remains a significant burden. New diagnostic and therapeutic interventions hold much promise. This review seeks to provide clinicians with evidence that motivates a reasoned approach to the evaluation and management of complicated pneumonia.

Impact of an antimicrobial stewardship program on outcomes in patients with community-acquired pneumonia admitted to a tertiary community hospital.

Results of a study evaluating the impact of an antimicrobial stewardship program (ASP) on clinical outcomes in patients hospitalized for community-acquired pneumonia (CAP) are reported. A retrospective records review was conducted at a 400-bed hospital to identify patients admitted over 3 years with CAP documented as a primary or secondary diagnosis. Clinical and medication-use outcomes during a 1-year baseline period and in the first and second years after ASP implementation (post-ASP years 1 and 2) were analyzed. A local CAP guideline was implemented around the beginning of post-ASP year 2. The mean hospital length of stay declined from 7.24 days in the baseline period to 5.71 days in post-ASP year 1 (p = 0.011) and 5.52 days in post-ASP year 2 (p = 0.008). Mean inpatient antimicrobial days of therapy (DOT) declined from 5.68 days in the baseline period to 5.08 days (p = 0.045) and 4.99 days (p = 0.030) in post-ASP years 1 and 2, respectively. Mean DOT per 100 total days of antimicrobial therapy declined from 9.69 days in the baseline period to 8.85 days in post-ASP year 1 (p = 0.019) and 8.38 days in post-ASP year 2 (p = 0.001). ASP implementation was associated with specific clinical benefits in patients with CAP, including decreased length of stay, decreased durations of antimicrobial therapy, and a shift in utilization to a primary regimen shown to produce superior clinical outcomes.

Is gentamicin safe and effective for severe community-acquired pneumonia? An 8-year retrospective cohort study

Gram-negative bacilli are the causative organisms in a significant proportion of patients with severe community-acquired pneumonia (CAP) admitted to the intensive care unit (ICU). Clinical guidelines recommend broad-spectrum antimicrobials for empirical treatment despite alarming global trends in antimicrobial resistance. In this study, we aimed to assess the safety and efficacy of gentamicin, an aminoglycoside with potent bactericidal activity, for empirical Gram-negative coverage of severe CAP in patients admitted to the ICU. A retrospective cohort study was performed at a university teaching hospital where the severe CAP guideline recommends penicillin, azithromycin and gentamicin as empirical cover. Ceftriaxone plus azithromycin is used as an alternative. Adults with radiologically-confirmed severe CAP were included, comparing those who received gentamicin in the first 72 h of admission with those who did not. Participants were identified using ICD-10 codes for bacterial pneumonia and data manually extracted from electronic medical records. Of 148 patients admitted with severe pneumonia, 117 were given at least one dose of gentamicin whereas the remaining 31 were not. The two groups were well matched in terms of demographics, co-morbidities and disease severity. There were no significant differences between the gentamicin and no-gentamicin groups in the incidence of acute kidney injury [60/117 (51%) vs. 16/31 (52%), respectively], hospital mortality [20/117 (17%) vs. 7/31 (23%)] and secondary outcomes including relapse and length of hospital stay. In conclusion, gentamicin is safe and has similar outcomes to alternative Gram-negative antimicrobial regimens for empirical coverage in severe CAP patients admitted to the ICU.

Editorial introductions

Editorial introductions

Effects of age, comorbidity and adherence to current antimicrobial guidelines on mortality in hospitalized elderly patients with community-acquired pneumonia

BackgroundLimited information exists on the clinical characteristics predictive of mortality in patients aged ≥65 years in many countries. The impact of adherence to current antimicrobial guidelines on the mortality of hospitalized elderly patients with community-acquired pneumonia (CAP) has never been assessed.MethodsA total of 3131 patients aged ≥65 years were enrolled from a multi-center, retrospective, observational study initiated by the CAP-China network. Risk factors for death were screened with multivariable logistic regression analysis, with emphasis on the evaluation of age, comorbidities and antimicrobial treatment regimen with regard to the current Chinese CAP guidelines.ResultsThe mean age of the study population was 77.4 ± 7.4 years. Overall in-hospital and 60-day mortality were 5.7% and 7.6%, respectively; these rates were three-fold higher in those aged ≥85 years than in the 65–74 group (11.9% versus 3.2% for in-hospital mortality and 14.1% versus 4.7% for 60-day mortality, respectively). The mortality was significantly higher among patients with comorbidities compared with those who were otherwise healthy. According to the 2016 Chinese CAP guidelines, 62.1% of patients (1907/3073) received non-adherent treatment. For general-ward patients without risk factors for Pseudomonas aeruginosa (PA) infection (n = 2258), 52.3% (1094/2090) were over-treated, characterized by monotherapy with an anti-pseudomonal β-lactam or combination with fluoroquinolone + β-lactam; while 71.4% of intensive care unit (ICU) patients (120/168) were undertreated, without coverage of atypical bacteria. Among patients with risk factors for PA infection (n = 815), 22.9% (165/722) of those in the general ward and 74.2% of those in the ICU (69/93) were undertreated, using regimens without anti-pseudomonal activity. The independent predictors of 60-day mortality were age, long-term bedridden status, congestive heart failure, CURB-65, glucose, heart rate, arterial oxygen saturation (SaO2) and albumin levels.ConclusionsOvertreatment in general-ward patients and undertreatment in ICU patients were critical problems. Compliance with Chinese guidelines will require fundamental changes in standard-of-care treatment patterns. The data included herein may facilitate early identification of patients at increased risk of mortality.Trial registrationThe study was registered at ClinicalTrials.gov (NCT02489578).

Current status of diagnosis and treatment of community-acquired pneumonia in Shanghai revealed by a questionnaire analysis

Objective: To understand the current status of diagnosis and treatment of community-acquired pneumonia (CAP) among doctors in various hospitals across Shanghai, for the purpose of promoting the 2016 clinical practice guidelines for adult CAP of China. Methods: A questionnaire was designed to address the common questions in CAP management. The responses were collected via WeChat and the data were analyzed. Results: A total of 1 254 valid questionnaires were received, 46.1% from tertiary , 26.4% from secondary and 27.5% from primary care hospitals. Of these valid respondents, 31.4% were respiratory physicians and 68.6% from non-respiratory physicians. When diagnosing CAP, 78.1% of the doctors would use chest CT in more than 50% of the patients. Regarding the tools for evaluating the severity of CAP, 60.3% of the respondents would prefer CURB-65. "Respiratory failure requiring mechanical ventilation and septic shock" were the most common criteria for admission to ICU. Blood culture was not widely used in severe CAP regardless of the level of hospitals (P>0.05). The results of this survey showed that the top 5 pathogenic microorganisms of CAP were Streptococcus pneumoniae, Mycoplasma pneumoniae, Klebsiella pneumoniae, Haemophilus influenza and Chlamydia pneumoniae. For non-severe CAP patients, all the doctors tended to select monotherapy. The most frequently used antimicrobial regimen for severe CAP was third- or fourth-generation cephalosporin monotherapy. As for combination therapy, the most frequently used regimen in tertiary hospitals was "carbapenem plus vancomycin" , while in primary and secondary hospitals it was "β-lactams plus macrolides" . More doctors from primary hospitals and non-respiratory medicine would consider "complete resolution of pulmonary opacity" as the indication to discontinue antimicrobial therapy or to discharge patients, and "prolonged high fever" , "large area consolidation" , "multiple lobe-segment involvement " as the indication for corticosteroid therapy. A significantly lower proportion of doctors in secondary and tertiary hospitals would recommend patients to receive vaccination than in primary hospitals (P<0.05). Conclusions: This questionnaire study showed that there was a gap between the ideal and the real world practice in CAP management. Efforts should be made to popularize the 2016 CAP guideline in hospitals of any level of care, especially primary hospitals, for the purpose of further standardizing CAP management in China.

Editorial introductions

Current Opinion in Infectious Diseases was launched in 1988. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of infectious diseases is divided into 11 sections that are reviewed once a year. Each section is assigned to a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Matteo BassettiMatteo BassettiProfessor Matteo Bassetti is Head of the Infectious Diseases Division of the Santa Maria Misericordia University Hospital, Udine, Italy and Associate-Professor of Infectious Diseases at the University of Udine. He studied at the University of Genoa School of Medicine, Italy and continued his medical education at the Yale University School of Medicine, Connecticut, USA with an infectious diseases fellowship. He also completed a PhD in solid organ transplantation and infectious diseases at the University of Genoa School of Medicine. Professor Bassetti is the chair of the Critically Ill Study Group of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and a member of the executive committee of the Infectious Diseases Group of the European Organisation for Research and Treatment of Cancer (EORTC). Professor Bassetti is also co-chair of the Intra-Abdominal Infections Study Group and secretary of the Bone, Skin and Soft Tissue Infections of the International Society of Chemotherapy (ISC). Professor Bassetti is the vice-president of Italian Society of Anti-Infective Therapy (SITA). He serves on the editorial board of several journals including Intensive Care Medicine (Associate-Section Editor), Journal of Global Antimicrobial Resistance, Journal of Infection and Public Health, Italian Journal of Medicine (Section Editor), Reviews in Medical Microbiology, Journal of Chemotherapy, and Scientific Reports and is reviewer for various international journals. Prof. Bassetti has authored or co-authored over 250 papers published in international peer-reviewed journals with more than 7000 citations (H-index 42). His main interests are bacterial resistance, fungal infections and infections in critically ill patients. Michael S. NiedermanMichael S. NiedermanProfessor Michael S. Niederman is Clinical Director and Associate Chief in the division of Pulmonary and Critical Care Medicine at Weill Cornell Medical Center, New York, and Professor of Clinical Medicine at Weill Cornell Medical College, New York. Prior to this, he was Professor in the Department of Medicine at State University of New York at Stony Brook, and Chairman of the Department of Medicine at Winthrop University Hospital in Mineola, New York for sixteen years. He obtained his medical degree from the Boston University School of Medicine, Massachusetts, and then completed his training in internal medicine at the Northwestern University School of Medicine, Illinois, before undertaking a pulmonary and critical care fellowship at Yale University School of Medicine, Connecticut. His interests lie in respiratory tract infections, and include mechanisms of airway colonization, the management of community- and hospital-acquired pneumonia, the role of guidelines for pneumonia, and the impact of antibiotic resistance on the management and outcomes of respiratory tract infections. He has published over 400 peer-reviewed or review articles, and has lectured widely both nationally and internationally. Prof. Niederman served as co-chairman of the committees that created the American Thoracic Society 1993 and 2001 guidelines for the treatment of community-acquired pneumonia, as well as the 1996 and 2005 committees that wrote guidelines for the treatment of nosocomial pneumonia. In addition, he was a member of the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) committee that published guidelines for community-acquired pneumonia in 2007 and co-lead author of the 2017 European Respiratory Society/European Society of Intensive Care Medicine (ERS/ESICM) guidelines for nosocomial pneumonia. He served for 6 years as a member of the Board of Regents of the American College of Chest Physicians and in 2013 was elected as a Master of the American College of Physicians. He is also Editor-in-Chief of Clinical Pulmonary Medicine, and serves on the editorial boards of Critical Care Medicine, Intensive Care Medicine, Critical Care, and Chest. He has previously served on the editorial board of The American Journal of Respiratory and Critical Care Medicine.

A multicentre stewardship initiative to decrease excessive duration of antibiotic therapy for the treatment of community-acquired pneumonia.

The increased emphasis on pneumonia-related performance measures and patient outcomes has led hospitals to implement multifaceted approaches to quickly identify patients with community-acquired pneumonia (CAP), start timely therapy and reduce readmission. However, there has been minimal focus on duration of therapy (DOT) and patients often receive prolonged antibiotic courses. The IDSA and American Thoracic Society (IDSA/ATS) CAP guidelines recommend 5 days of therapy for clinically stable patients that quickly defervesce and stewardship teams are well positioned to influence prescribing practices. Determine the impact of a prospective stewardship intervention on total antibiotic DOT and associated clinical outcomes in hospitalized patients with CAP. This multicentre, quasi-experimental study evaluated three concurrent interventions over a 6 month period to promote appropriate DOT. All centres updated institutional CAP guidelines to promote IDSA/ATS-concordant DOT, provided education and conducted daily audit and feedback with intervention to provide patient-specific DOT recommendations. A total of 600 patients with CAP were included (307 in the historical control group and 293 in the stewardship intervention group). The stewardship intervention increased compliance with DOT recommendations (42% versus 5.6%, P < 0.001) and reduced the median DOT per patient (6 versus 9 days, P < 0.001). Clinical outcomes, including mortality, readmission with pneumonia, presentation to the emergency centre/clinic with pneumonia and incidence of Clostridium difficile infection within 30 days of discharge, were not different between groups. This multicentre evaluation of a stewardship intervention in hospitalized CAP patients reduced the total antibiotic DOT and increased guideline-concordant DOT without adversely affecting patient outcomes.

Treatment Trends and Outcomes in Healthcare-Associated Pneumonia.

The American Thoracic Society and Infectious Diseases Society of America guidelines for management of healthcare-associated pneumonia (HCAP), first published in 2005, have been controversial regarding the selection of empiric broad-spectrum antibiotics, whether the criteria for HCAP predicts the likelihood of infection with multidrug resistant organisms, and whether HCAP patients have improved outcomes when treated with empiric broad-spectrum antibiotics. A retrospective cohort study at 488 US hospitals from July 2007 to November 2011. Patients who met criteria for HCAP were included. Guideline-concordant antibiotics were assessed based on guideline recommendations. We assessed changes in hospital rates of concordant antibiotic use over time and their correlation with outcomes. Among 149,963 patients with HCAP, 19.6% received fully guideline-concordant antibiotics, 21.7% received partially concordant antibiotics, and 58.9% received discordant antibiotics. Guideline concordance increased over time. Rates of fully or partially concordant antibiotics varied across hospitals (median 36.4%; interquartile range 25.8%-49.1%). Among patients who received discordant antibiotics, 81.5% were treated according to community-acquired pneumonia (CAP) guidelines. On average, the rate of guideline concordance increased by 2.2% per 6-month interval, while hospital level rates of mortality, excess length of stay, and progression to respiratory failure did not change. In this large, nationally representative cohort, only 1 in 5 patients with risk factors for HCAP received treatment that was fully in accordance with guidelines, and many received CAP therapy instead. At the hospital level, increases in the use of concordant antibiotics were not associated with declines in mortality, excess length of stay, or progression to respiratory failure.

A Multicenter Stewardship Initiative to Decrease Excessive Duration of Antibiotic Therapy for the Treatment of Community-Acquired Pneumonia (CAP)

Abstract Background Hospitals have implemented multifaceted approaches to quickly identify CAP, start timely therapy, and reduce hospital readmission, yet there has been minimal focus on providing appropriate duration of therapy. The IDSA CAP guidelines recommend 5 days of antibiotic therapy for patients that are clinically stable and quickly defervesce. However, previous publications suggest duration of therapy for CAP may be unnecessarily prolonged. Methods The objective of this multicenter, quasi-experimental study of hospitalized patients with CAP was to assess the impact of a prospective 6-month stewardship intervention on total duration of antibiotic therapy and associated clinical outcomes. All centers updated institutional CAP guidelines to promote IDSA-concordant durations of therapy and provided education to pharmacists and prescribers. Daily patient-specific prospective audit and feedback was provided by infectious diseases stewardship pharmacists to optimize compliance with guideline recommendations. Results A total of 600 patients were included (307 in the historic control group and 293 in the stewardship intervention group). The stewardship intervention led to significantly increased rates of compliance with IDSA duration of therapy recommendations (5.6% vs. 41.4%, P&amp;lt; &amp;lt; 0.01) and significantly reduced the duration of therapy for CAP (9 vs. 6 days, P &amp;lt; 0.01). Inappropriate days of antibiotic therapy was reduced in the intervention group (4 vs. 1.6 days, P &amp;lt; 0.01), and total avoidance of 720 excessive days of antibiotic therapy. Clinical outcomes, including mortality, length of hospitalization, readmission to hospital with pneumonia, presentation to the ER/clinic with pneumonia within 30 days of discharge, and incidence of C. difficilecolitis, were not different between groups. Conclusion This multicenter evaluation of a prospective stewardship intervention in hospitalized CAP patients reduced the total duration of antibiotic therapy and increased compliance with guideline-concordant duration of therapy without adversely affecting patient outcomes. This project was funded through a competitive stewardship grant provided by Merck &amp; Co. Disclosures A. Huang, Merck: Grant Investigator, Research grant; C. Nguyen, Merck: Grant Investigator, Research grant; J. Grieger, Merck: Grant Investigator, Research grant; S. Revolinski, Merck: Grant Investigator, Research grant; J. Li, Merck: Grant Investigator, Research grant; M. Mack, Merck: Grant Investigator, Research grant; J. N. Wainaina, Merck: Grant Investigator, Research grant; G. Eschenauer, Merck: Grant Investigator, Research grant; T. Patel, Merck: Grant Investigator, Research grant; V. Marshall, Merck: Grant Investigator, Research grant; J. Nagel, Merck: Grant Investigator, Research grant

Diagnosis and treatment of community-acquired pneumonia in adults: 2016 clinical practice guidelines by the Chinese Thoracic Society, Chinese Medical Association.

Community‐acquired pneumonia (CAP) in adults is an infectious disease with high morbidity in China and the rest of the world. With the changing pattern in the etiological profile of CAP and advances in medical techniques in diagnosis and treatment over time, Chinese Thoracic Society of Chinese Medical Association updated its CAP guideline in 2016 to address the standard management of CAP in Chinese adults. Extensive and comprehensive literature search was made to collect the data and evidence for experts to review and evaluate the level of evidence. Corresponding recommendations are provided appropriately based on the level of evidence. This updated guideline covers comprehensive topics on CAP, including aetiology, antimicrobial resistance profile, diagnosis, empirical and targeted treatments, adjunctive and supportive therapies, as well as prophylaxis. The recommendations may help clinicians manage CAP patients more effectively and efficiently. CAP in pediatric patients and immunocompromised adults is beyond the scope of this guideline. This guideline is only applicable for the immunocompetent CAP patients aged 18 years and older. The recommendations on selection of antimicrobial agents and the dosing regimens are not mandatory. The clinicians are recommended to prescribe and adjust antimicrobial therapies primarily based on their local etiological profile and results of susceptibility testing, with reference to this guideline.

Mortality prediction using serum biomarkers and various clinical risk scales in community-acquired pneumonia

We evaluated the predictive value of serum biomarkers and various clinical risk scales for the 28-day mortality of community-acquired pneumonia (CAP). Serum biomarkers including procalcitonin (PCT) and C-reactive protein (CRP) were evaluated in the emergency department. Scores for the pneumonia severity index (PSI); CURB65 (confusion, urea, respiration, blood pressure; age >65 years); Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) guidelines for severe CAP; Acute Physiology, Chronic Health Evaluation (APACHE) II; Sequential Organ Failure Assessment (SOFA); and quick SOFA (qSOFA) were calculated. Receiver-operating characteristic curves for 28-day mortality were calculated for each predictor using cut-off values, and we applied logistic regression models and area under the curve (AUC) analysis to compare the performance of predictors. Of the 125 enrolled patients, 13 died within 28 days. The AUCs of the PCT and CRP were 0.83 and 0.77, respectively. Using a PCT level >5.6 μg/L as the cut-off, the sensitivity and specificity for mortality were 76.9% and 90.2%, respectively. The three pneumonia severity scales showed an AUC of 0.86 (PSI), 0.87 (IDSA/ATS) and 0.77 (CURB65). The AUCs of the APACHE II, SOFA and qSOFA scores were 0.85, 0.83 and 0.81, respectively. The models combining CRP and/or PCT with PSI or the IDSA/ATS guidelines demonstrated superior performance to those of either PSI or the IDAS/ATS guidelines alone. In conclusion, serum PCT is a reliable single predictor for short-term mortality. Inclusion of CRP and/or PCT could significantly improve the performance of the PSI and IDAS/ATS guidelines.

Enablers and barriers to the use of antibiotic guidelines in the assessment and treatment of community-acquired pneumonia-A qualitative study of clinicians' perspectives.

Community-acquired pneumonia (CAP) is a common condition and a number of guidelines have been developed for its assessment and treatment. Adherence to guidelines by clinicians varies and particularly the prescribing of antibiotics often remains suboptimal. The aim of this study was to elucidate potential barriers and enablers to the adherence to antibiotic guidelines by clinicians treating CAP in an Australian hospital. Semi-structured interviews were conducted with purposively recruited senior prescribers who regularly treat CAP in an Australian hospital. Thematic analysis identified a number of themes and subthemes related to their knowledge, attitudes and behaviours associated with the use of CAP guidelines. Thematic saturation was reached after 10 in-depth interviews. Although similar barriers to the use of guidelines as previously described in the literature were confirmed, a number of novel, potential enablers were drawn from the interviews. Clinicians' acceptance and accessibility of guidelines emerged as enabling factors. Generally positive attitudes towards antimicrobial stewardship services invite leveraging what was described as the relationship-based and hierarchical nature of medical practice to provide personalised feedback and updates to clinicians. Adding a social and personalised approach of antimicrobial stewardship to policy- and systems-based strategies may lead to incremental improvements in guideline adherent practice when assessing and treating CAP.

Editorial introductions

Current Opinion in Infectious Diseases was launched in 1988. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of infectious diseases is divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Matteo BassettiMatteo BassettiMatteo Bassetti is Head of the Infectious Diseases Division of the Santa Maria Misericordia University Hospital, Udine, Italy and Associate-Professor of Infectious Diseases of the University of Udine. He studied at the University of Genoa School of Medicine and continued his medical education at the Yale University School of Medicine, New Haven, USA with an Infectious Diseases fellowship. He also completed a PhD in Solid Organ Transplantation and Infectious Diseases at the University of Genoa School of Medicine. Professor Bassetti is the chair of the Critically Ill Study Group of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and member of executive committee of the Infectious Diseases Group of the European Organisation for Research and Treatment of Cancer (EORTC). Professor Bassetti is also co-chair of the Intra-Abdominal Infections Study Group and secretary of the Bone, Skin and Soft Tissue Infections of the International Society of Chemotherapy (ISC). Prof Bassetti is the vice-president of Italian Society of Anti-infective Therapy (SITA). He serves on the editorial board of several journals including Intensive Care Medicine (Associate-Section Editor), Journal of Global Antimicrobial Resistance, Journal of Infection and Public Health, Italian Journal of Medicine (Section Editor), Reviews in Medical Microbiology, Journal of Chemotherapy, Infectious Disease, Scientific Reports and is reviewer for various international journals. Prof Bassetti has authored or co-authored over 250 papers published in international peer-reviewed journals with more than 7000 citations (Hindex 42). The main interest are bacterial resistance, fungal infections and infections in critically ill patients. Michael S. NiedermanMichael S. NiedermanMichael S. Niederman is Clinical Director, and Associate Chief, in the division of Pulmonary and Critical Care Medicine, at Weill Cornell Medical Center, and Professor of Clinical Medicine at Weill Cornell Medical College. Prior to this, he was Professor in the Department of Medicine at the State University of New York at Stony Brook, and Chairman of the Department of Medicine at Winthrop-University Hospital in Mineola, New York for 16 years. He obtained his medical degree from Boston University School of Medicine, and then completed his training in internal medicine at Northwestern University School of Medicine, before undertaking a pulmonary and critical care fellowship at Yale University School of Medicine. His interests lie in respiratory tract infections, and include mechanisms of airway colonization, the management of community- and hospital-acquired pneumonia, the role of guidelines for pneumonia, and the impact of antibiotic resistance on the management and outcomes of respiratory tract infections. He has published over 400 peer reviewed or review articles, and has lectured widely, both nationally and internationally. Dr Niederman served as co-chairman of the committees that created the American Thoracic Society 1993 and 2001 guidelines for the treatment of community-acquired pneumonia and the 1996 and 2005 committees that wrote guidelines for the treatment of nosocomial pneumonia. He was a member of the ATS/IDSA committee that published guidelines for community-acquired pneumonia in 2007. He served for 6 years as a member of the Board of Regents of the American College of Chest Physicians and in 2013 was elected as a Master of the American College of Physicians. He is also Editor-in-Chief of Clinical Pulmonary Medicine, and serves on the editorial boards of Critical Care Medicine, Intensive Care Medicine, Critical Care and Chest. He has previously served on the editorial board of The American Journal of Respiratory and Critical Care Medicine.

Treatment of community-acquired pneumonia in Korean children

Community-acquired pneumonia is the leading cause of pediatric morbidity and mortality. However, there is a lack of data on the epidemiology of pneumonia in Korean children. In this review, we aimed to summarize pneumonia studies in Korea and suggest di agnostic methods and treatment for Korean children who were referred based on the foreign guidelines for pediatric community-acquired pneumonia. A Korean guideline for pediatric pneumonia in tune with domestic circumstances is needed. (Allergy Asthma Respir Dis 2017;5:177-184)

Antibiotic Prescribing for Pediatric Community-Acquired Pneumonia at Children’s Hospitals and General Hospitals Following National Guideline Release

BackgroundThe 2011 IDSA/PIDS guidelines for pediatric community-acquired pneumonia (CAP) recommend penicillin, amoxicillin, or ampicillin (penicillins) as first-line therapy for most children. The use of penicillins increased at children’s hospitals after guideline publication, but trends in antibiotic choice for CAP at general hospitals have not been evaluated.MethodsRetrospective analysis of children 1–17 years admitted from January 2009 through September 2015 to 522 hospitals, captured via the Pediatric Health Information System and Premier Perspective databases. Children with CAP were identified by a validated ICD-9 code algorithm, excluding those with complicated pneumonia, complex chronic conditions, receipt of intensive care, or MRSA infection or colonization. Receipt of penicillins, cephalosporins, and macrolides was assessed, and trends were modeled using segmented logistic regression, adjusting for age, sex, and insurance provider. Standardized probability of antibiotic receipt was compared between children’s and general hospitals.ResultsOf 120,238 children hospitalized with CAP, 54% were admitted to 51 children’s hospitals. After adjustment, penicillin use increased and both cephalosporin and macrolide use decreased in both children’s and general hospitals (Figure). However, in the final study year, children in general hospitals were less likely to receive penicillins (standardized probability 0.23, 95% CI [0.17, 0.29] vs. 0.57 [0.52, 0.62]) and more likely to receive cephalosporins (0.78 [0.73, 0.82] vs. 0.51 [0.45, 0.57]) and macrolides (0.43 [0.38, 0.47] vs. 0.28 [0.25, 0.32]) than children in children’s hospitals.ConclusionPublication of national guidelines was associated with improved antibiotic selection for CAP at both children’s and general hospitals. However, disparities in prescribing between children’s and general hospitals persist.Figure.Trends in standardized probability of receiving select antibiotics for CAPDisclosures All authors: No reported disclosures.

Prevalence of Tuberculosis among Community Acquired Pneumonia Diagnosed Patients

Aim: To evaluate the proportion of pulmonary TB among patients hospitalized with suspected communityacquired pneumonia (CAP). Methods: Consecutive patients diagnosed with community acquired pneumonia (CAP) admitted to a tertiary care centre over a 2 year period was studied prospectively. Systematic investigation of samples of sputum and blood cultures was performed. A subset of patients had urine antigen tests and serum serology. Results: We enrolled 104 CAP suspected patients in the study group according to the BTS guidelines for CAP. Among these patient’s sputum AFB smear positivity was observed in 21 cases (20.19%). 18 (17.30%) patients turned out to be sputum gram stain positive, but their respective cultures didn’t show any growth. 65 (62.50%) of them turned out to be gram stain and culture positive for bacteriological aetiology. The Commonest cause for CAP among sputum and blood culture positive cases was Streptococcus pneumoniae (19/65) followed by, Klebsiella pneumoniae (17/65), Staphylococcus aureus (13/65), Pseudomonas aeruginosa (8/65), Escherichia coli (4/65), Acinetobactor spp. (3/65). Conclusion: Tuberculosis is one of the leading causes of CAP in TB-prevalent areas. Our diagnostic index may help clinicians identify pulmonary TB cases immediately from CAP and initiate appropriate isolation and optimal treatment.

Role of Atypical Pathogens in the Etiology of Community-Acquired Pneumonia.

Atypical pneumonia has been described for over 100 years, but some of the pathogens attributed to it have been identified only in the past decades. The most common pathogens are Chlamydia pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila. The epidemiology and pathophysiology of these three pathogens have been studied since their discovery, and are reviewed herein to provide better insight when evaluating these patients, which hopefully translates into improved care. The incidence of atypical pathogens has been shown to be approximately 22% worldwide, but this probably varies with location. The history and physical exam of a patient with atypical pneumonia reveals how patients share many signs and symptoms with their counterpart patients who have typical pneumonias; therefore, the diagnosis primarily depends on laboratory identification, which is evolving and improving. What started out as simple, but difficult to yield cultures, has progressed to modern molecular-based testing assays. Treatment is missed if an empiric regimen includes only monotherapy with a β-lactam antimicrobial; so, many country guidelines, including the Infectious Diseases Society of America/American Thoracic Society guidelines for community-acquired pneumonia, recommend using a regimen containing either a macrolide or a fluorinated quinolone. Once an atypical pathogen has been identified, evidence trends toward favoring a quinolone, but more data are needed to confirm. The concept of using combination therapy in severe patients is also explored.

IMPACT OF POINT OF CARE CRP TESTING ON THE MANAGEMENT OF PATIENTS WITH SUSPECTED COMMUNITY ACQUIRED PNEUMONIA IN THE ED

Objectives & BackgroundThe World Health Organisation has identified antimicrobial resistance as “an increasingly serious threat to global public health that requires action across all government sectors and society”, and state...