DO GUIDELINES HELP IN SEVERE COMMUNITY ACQUIRED PNEUMONIA ?

In the face of shifting antimicrobial resistance trends, introduction of new therapeutic options & wide variations in disease severity, the management of severe community acquired pneumonia (SCAP) often requires uncommonly adaptive & customized approaches to patient care(1). With so many changes on the anti-infective landscape, it is not surprising that the diagnosis, risk stratification and antibiotic selection in patients with SCAP continue to challenge clinicians even today(2).

From an institutional & community perspective the therapeutic equation is even more complex. The mandate to both cure patients acutely while preserving long term antimicrobial efficacy in the future represents one of the most important missions that clinicians face when developing protocols & pathways for SCAP (3).

In recent years, treatment strategies for SCAP have evolved significantly, in large part because of changing aetiologic patterns, availability of new agents and increasing antimicrobial resistance especially among strep.pneumoniae which is the leading cause of community acquired pneumonia & bacteremia (4).

Most experts agree that optimizing hospital based management of SCAP requires implementation of process of care strategies that emphasize patient risk stratification according to illness severity followed by appropriate timing, selection and administration of empiric antibiotic therapy & when necessary use of supportive measures (5). The details of various pneumonia severity scores to assess disease severity in SCAP shall be discussed in my presentation. The various professional societies who have issued treatment guidelines for community acquired pneumonia include: American Thoracic Society(ATS), Infectious Disease Society of America (IDSA), American College of Emergency Physicians (ACEP), Centers for Disease Control & Prevention (CDC), British Thoracic Society, Canadian Society of Infectious disease & European Task Force of European Respiratory Society & European Society for Clinical Microbiology & Infectious Diseases (ESCMID) (6-12). These guidelines attempt to identify risk factors associated with drug resistance, poor patient outcomes or infection with specific pathogens requiring modifications in standard therapy. I shall discuss these issues in detail during my talk. While each organization provides treatment recommendations for CAP that are similar & consistent in many ways, there are also subtle differences among them (2). Availability of an extensive armamentorium of antibiotics shown to be effective for CAP – including macrolides, azalides, ketolides, cephalosporins, fluroquinolones, betalactams, carbapenems – further complicates the clinical decision making process(13). Understanding the various risk factors for drug resistance as well as the possible advantages & disadvantages with available therapeutic options endorsed by expert panels & various organizations will best equip busy clinicians to improve clinical outcomes & maximize patient care for SCAP. I shall deal with most of these issues in my talk this afternoon.

REFERENCES :

1. Niederman MS Review of treatment guidelines for community acquired pneumonia. Am J. Med 2004;117:51S –57S
2. Bartlett JG, Mundy M. Community acquired pneumonia NEJM 1995;333:1618-24.
3. Battleman DS, Callahan M, Thaler HT. Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community acquired pneumonia: link between quality of care & resource utilization. Arch. Intern Med. 2002;162:682-88.
4. Heffelfinger JD, Dowell SF et al. Management of community acquired pneumonia in the era of pneumococal resistance. A report from the drug resistant strep.pneumoniae therapeutic working group. Arch. Intern.Med. 2000;160:1399 – 1408.
5. Hanck CD, Adler LM, Mulla ZD. Clinical pathway care improves outcomes among patients hospitalized for community acquired pneumonia. Ann Epidemol 2004;14:669-75.
6. Guidelines for management of adults with community acquired pneumonia. Diagnosis, Assessment of severity, Antimicrobial therapy and Prevention. Official statement of ATS Am J Respir Crit Care Med 2001;163:1730 – 54.
7. Mandell LA, Bartlett JG, Dowell SF, File TM, Musher DM & Whitney C on behalf of IDSA.Update of practice guidelines for the management of community acquired pneumonia in immuno competent adults. Clin Infect. Diseases 2003;37:1405-33.
8. American College of Emergency Physicians clinical policy for management & risk stratification of community acquired pneumonia in adult in emergency department. Ann Emerg. Med 2001;38:107-13.
9. Mandell LA, Marrie TJ, Grossman RF, Chow AW & Hyland RH. Canadian guidelines for initial management of community acquired pneumonia: an evidence based update by the Canadian infectious diseases society and the Canadian thoracic society. Clin Infect. Dis. 2000; 31:383-421.
10. ERS Task force report: Guidelines for management of adult community acquired lower respiratory tract infections. Eur. Respir J. 1998;11:986-91.
11. British Thoracic society, standards of care committee. BTS guidelines for the management of community acquired pneumonia in adults. Thorax 2001;56:Suppl 4, 1-64.
12. Woodhead M, Blasi F, Ewig S et al. guidelines for the management of adult lower respiratory tract infections. ERS Task force & ESCMID Eur Resp. J 2005;26:1138-80.
13. Moellering RC Jr. The continuing challenge of lower respiratory tract infections. Clin Infect Dis. 2004;38:S319-S321.
FURTHER READING:

1. Feeminghan D, Gruneberg RN The Alexander project 1996-97: latest susceptibility data from international study of bacterial pathogens from community acquired lower respiratory tract infections. J Antimicrob Chemother 2000;45:191-203.
2. Song JH, Lee NJ, Ichiyama S et al. Spread of drug resistant streptococcus pneumoniae in Asian countries: Asian network for surveillance of resistant pathogens (ANSORP) study. Clin Infect Dis 1999;28:1206-11
3. Doern GV, Pfaller MA, Kugler K et al. Prevalence of antimicrobial resistance among respiratory tract isolates of strep. pneumonia in North America: 1997 results from SENTRY antimicrobial surveillance programme. Clin Infect. Dis 1998;27:764-70.
4. Powis J, Mc Geer A, Green K et al. In vitro antimicrobial susceptibilities of strep. pneumoniae clinical isolates obtained in Canada. Canadian bacterial surveillance network. Antimicrob Agents Chemother 2004;48:3305-11.
5. Niederman MS, Feldman C & Richards GA. Combining information from prognostic scoring tools for CAP: an American view on how to get the best of all worlds. Eur Resp. J 2006;27:9-11.
6. Ewig S, Torres A & Woodhead M. Assessment of pneumonia severity: A European perspective. Eur Respir J 2006; 27:6-8.



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