Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults | | IDENTITY | | | Citation | | | · Mandell LA, et al. Guidelines for CAP in Adults. CID 2007; 44 Suppl 2S27-S72. | | | Date Released | | | GEM Cut History | |
| | DEVELOPER | | | Developer Name | | | Conflict Of Interest Policy | | | Conflict Of Interest Disclosure | |
| | PURPOSE | | | Objective | | | · update clinicians with regard to important advances and controversies in the management of patients with CAP. | |
| | INTENDED AUDIENCE | | | Intended Users | | | · Primary care doctors | | | Care Setting | |
| | METHOD OF DEVELOPMENT | | | Rating Scheme | | | Evidence Quality Rating Scheme | | | · Level I (high) - Evidence from well-conducted randomized controlled trials; Level II (moderate) - Evidence fromwell designed, controlled trials without randomization (including cohort, patient series, and case control studies.Also include any large case seies in which systematic analysis of disease patterns and/or microbial etiology was conducted, as well as reports of data on new therapies that were not collected in a randomized fashion.Level III (low) Evidence from case studies and expert opinion, in soime instances , therapy recommendations come from antibiotic susceptibility data without clinical observations. | | | Recommendation Strength Rating Scheme | | | · A strong recommendation required .ge.6 members to consider it to be strong and the majority of the others to grade it as moderate. Implication of a strong rec is that most patients should receive that intervention....Conversely moderate or weak recommendations suggest that, even if a majority would follow the recommended management, many practitioners may not. | | | Qualifying Statement | | | Patient And Public Involvement | |
| | TARGET POPULATION | | | Inclusion Criterion | | | Exclusion Criterion | |
| | | | | | KNOWLEDGE COMPONENTS | | | | | | | DEFINITIONS | | | | | | | | RECOMMENDATION: Hospital admission decision. | | Imperative: | Severity-of-illness scores, such as the CURB-65 criteria (confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater), or prognostic models, such as the Pneumonia Severity Index (PSI), can be used to identify patients with CAP who may be candidates for outpatient treatment. {Rec_1:Imp_ 1 } | | | | | Directive: Use Severity-of-illness scores, such as the CURB-65 criteria to identify patients with CAP who may be candidates for out- patient treatment. | | | | | Evidence Quality: Level 1 | | | | | Recommendation Strength: Strong | |
| | Imperative: | Objective criteria or scores should always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. {Rec_1:Imp_ 2 } | | | | | Directive: Supplement objective criteria or scores with physician determination of subjective factors, including ability to safely and reliably take oral medication and availability of outpatient support resources | | | | | Evidence Quality: level II evidence | | | | | Recommendation Strength: Strong recommendation | |
| | Conditional: | For patients with CURB-65 scores ≥2, more-intensive treatment that is, hospitalization or, where appropriate and available, intensive in-home health care services is usually warranted. {Rec_1:Cond_ 1 } | | | | | Decision Variable: patients with CURB-65 scores ≥2 | | | | | Action: more-intensive treatment that is, hospitalization | | | | | Action: where appropriate and available, intensive in-home health care services | | | | | Evidence Quality: level III evidence. | | | | | Recommendation Strength: Moderate recommendation | | | | | Logic:
If
patients with CURB-65 scores ≥2
Then
more-intensive treatment that is, hospitalization
OR
where appropriate and available, intensive in-home health care services | |
| | | | | | | RECOMMENDATION: ICU admission decision. | | Conditional: | Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respi- ratory failure requiring intubation and mechanical ven- tilation. {Rec_2:Cond_ 2 } | | | | | Decision Variable: septic shock requiring vasopressors | | | | | Decision Variable: acute respiratory failure requiring intubation and mechanical ventilation. | | | | | Action: Direct admission to an ICU is required | | | | | Evidence Quality: level II evidence. | | | | | Recommendation Strength: Strong recommendation; | |
| | Conditional: | Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed in table 4 {Rec_2:Cond_ 3 } | | | | | Decision Variable: patients with 3 of the minor criteria for severe CAP | | | | | | | Value: Resp rate .GE.30; PaO2/FiO2 .LE. 250; multilobar infiltrates; confusion/disorientation; uremia; leukopenia (WBC .LT.4000; thrombocytopenia <100,000; hypothermia .LT. 36; hypotension requiring aggressive fluid resuscitation | |
| | | | Action: Direct admission to an ICU or high-level monitoring unit | |
| | | | | | | RECOMMENDATION: Diagnostic Testing | | Imperative: | In addition to a constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting mi- crobiological data, is required for the diagnosis of pneumonia. {Rec_3:Imp_ 4 } | | | | | Directive: a constellation of suggestive clinical features is required for the diagnosis of pneumonia | | | | | Directive: a demonstrable infiltrate by chest radiograph or other imaging technique is required for the diagnosis of pneumonia | | | | | Evidence Quality: level III evidence. | | | | | Recommendation Strength: Moderate recommendation; | | | | | Logic: If Then a constellation of suggestive clinical features is required for the diagnosis of pneumonia. AND a demonstrable infiltrate by chest radiograph or other imaging technique is required for the diagnosis of pneumonia. | |
| | | | | | | RECOMMENDATION: Recommended diagnostic tests for etiology. | | Conditional: | Patients with CAP should be investigated for specific pathogens that would significantly alter standard (empirical) management decisions, when the presence of such pathogens is suspected on the basis of clinical and epidemiologic clues. {Rec_2:Cond_ 2 } | | | | | Decision Variable: when the presence of pathogens that would significantly alter standard empirical management decisions is suspected on the basis of clinical and epidemiologic clues | | | | | Action: Patients with CAP should be investigated for specific pathogens | | | | | Evidence Quality: level II evidence. | | | | | Recommendation Strength: Strong recommendation; | |
| | Imperative: | Routine diagnostic tests to identify an etiologic diagnosis are optional for outpatients with CAP {Rec_2:Imp_ 2 } | | | | | Directive: Routine diagnostic tests to identify an etiologic diagnosis are optional for outpatients with CAP. | | | | | Evidence Quality: level III evidence. | | | | | Recommendation Strength: Moderate recommendation; | |
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