ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia

Abstract

BackgroundSevere community-acquired pneumonia (sCAP) is associated with high morbidity and mortality, and while European and non-European guidelines are available for community-acquired pneumonia, there are no specific guidelines for sCAP.Materials and methodologyThe European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Latin American Thoracic Association (ALAT) launched a task force to develop the first international guidelines for sCAP. The panel comprised a total of 18 European and four non-European experts, as well as two methodologists. Eight clinical questions for sCAP diagnosis and treatment were chosen to be addressed. Systematic literature searches were performed in several databases. Meta-analyses were performed for evidence synthesis, whenever possible. The quality of evidence was assessed with GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Evidence to Decision frameworks were used to decide on the direction and strength of recommendations.ResultsRecommendations issued were related to diagnosis, antibiotics, organ support, biomarkers and co-adjuvant therapy. After considering the confidence in effect estimates, the importance of outcomes studied, desirable and undesirable consequences of treatment, cost, feasibility, acceptability of the intervention and implications to health equity, recommendations were made for or against specific treatment interventions.ConclusionsIn these international guidelines, ERS, ESICM, ESCMID and ALAT provide evidence-based clinical practice recommendations for diagnosis, empirical treatment and antibiotic therapy for sCAP, following the GRADE approach. Furthermore, current knowledge gaps have been highlighted and recommendations for future research have been made.

Antibiotic Strategies for Severe Community-Acquired Pneumonia

“…Recently, the European Respiratory Society (ERS), the European Society of Intensive Care Medicine (ESICM), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), and Asociación Latinoamericana del Tórax (Latin American Thoracic Association; ALAT) launched the first international guidelines for treating patients with sCAP. 5 Nonetheless, some aspects of sCAP management still remain matter of debate. It is well-established that delayed admission to the ICU is a risk factor for higher mortality in patients with CAP.…”

“…[10][11][12][13] However, there is no consensus on the optimal tool to apply in real-life practice, and the decision whether to admit to the ICU should be cautiously pondered. 5 Beyond the choice of the most appropriate site of care, another factor that significantly affects the prognosis of CAP is the timing of antimicrobial treatment. Multiple studies have demonstrated that timely initiation of empiric antibiotic therapy with coverage against the suspected pathogen is associated with better outcomes in severe infections.…”

“…The recommended duration of antibiotic therapy ranges from of 5 to 7 days of therapy up to longer courses, depending on patient's clinical condition and immune status. 5,17 Numerous studies have explored the effectiveness of a biomarker-driven treatment duration. 18 The ERS/ESICM/ ESCMID/ALAT task force recommends utilizing procalcitonin (PCT) as a biomarker to determine the optimal duration of antibiotic therapy in patients with sCAP.…”

“…With regard to respiratory support, in patients presenting with acute respiratory failure the use of high-flow nasal oxygen or noninvasive ventilation is recommended over standard oxygen as a means of preventing the need for intubation. 5 Another important consideration in managing sCAP is whether to administer systemic corticosteroid therapy with anti-inflammatory and immunomodulatory purposes. Several studies have shown promising data regarding the use of steroids in sCAP with regard to mortality, shock, mechanical ventilation, and treatment failure.…”

“…25,26 The ERS/ESICM/ESCMID/ALAT guidelines on the management of sCAP suggest the use of corticosteroids whenever shock is present. 5 However, several questions remain unresolved, such as which corticosteroid should be used, how to identify patients who should receive corticosteroid, and the potential long-term effects of corticosteroids. 5…”