||July 2, 2007
An Exclusive Continuing Education Publication of Acadiana Consultant Pharmacy Service
Author, Publisher, Editor-in Chief, Typesetter & Printer, Charles S. Feucht,PD,FASCP PharmD candidate
Medication News & Update
Guidelines on management of community-acquired pneumonia:
The Infectious Diseases Society of America and the American Thoracic Society have developed new, unified guidelines on the management of community-acquired pneumonia.
Key point: The Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) have developed a unified guideline on the management of community-acquired pneumonia (CAP). Primary differences from previous guidelines include a focus on a new assessment tool to determine if patients should be admitted to the hospital and criteria for direct admission to the intensive care unit (ICU), updated recommendations for empiric therapy of CAP and duration of therapy, new approaches to management of community-acquired methicillin-resistant Staphylo-coccus aureus (CA-MRSA), and considerations for the treatment of pandemic influenza infections.
Finer points: The 2007 guidelines recommend continuing to use disease severity assessment tools such as the Pneumonia Severity Index (PSI), but also recommend the British Thoracic Society's Community Acquired Pneumonia Severity Score (CURB-65) as easier to implement at the bedside. CURB-65 includes 5 factors (confusion, uremia, respiratory rate, low blood pressure, and age of 65 years or older) for determining whether a patient is an ideal candi-date for outpatient treatment. According to the new guidelines, patients with a CURB-65
score of 2 or higher should be admitted to the hospital. Patients with lower scores may be treated as outpatients while those with higher scores may require admission to the ICU. Of course, patient-specific factors should be considered as well (e.g., ability to take oral medications).
Key alterations to empiric therapy in the 2007 guidelines include the addition of ertapenem as an appropriate alter-native in select hospitalized patients on the general wards. In addition, use of telithromycin as a potential treatment option for CAP has been deferred until more safety information is made available. The 2007 guidelines also state that empiric therapy should be initiated in the emergency department as soon as the diagnosis of CAP is likely; however, an appropriate time to first antibiotic dose is not specified. The duration of therapy for CAP was also revised to specify that all patients with CAP should be treated for a minimum of 5 days, should be afebrile for 48 to 72 hours, and should have no more than 1 CAP-associated sign of clinical instability before discontinuation of therapy.
Recommendations for otherwise healthy outpatients with CAP include the use of macrolide or doxycycline mono-therapy. Use of respiratory fluoroquinolones, including high-dose levofloxacin 750 mg daily, or combination therapy consisting of a beta-lactam plus a macrolide or doxycycline is reserved for higher risk outpatients and non-ICU–hospitalized patients, including those at higher risk of drug-resistant Streptococcus pneumoniae (DRSP) or patients with comorbidities such as cardiovascular disease, pulmonary disease, renal/hepatic dysfunction,
diabetes, alcohol-ism, cancer, asplenia, or immunosuppression or those who have been on antibiotics within the last 3 months. For out-patients, the preferred beta-lactam is high-dose amoxicillin (1gram three times daily) or amoxicillin-clavulanate (2 grams twice daily).
The 2007 guidelines also highlight the increased emergence of CA-MRSA as a CAP pathogen. If CA-MRSA is suspected, empiric therapy should include either vancomycin or linezolid. Finally, a focus on the management of pan-demic flu was included in the 2007 update. Patients with influenza symptoms and known exposure to poultry in areas with previous H5N1 infection should be tested, and those suspected of having the disease should be treated. Osel-tamivir (Tamiflu—Roche) and antibacterial agents targeting S. pneumoniae and S. aureus, the most common causes of secondary bacterial pneumonia in patients with influenza, should be administered.
What you need to know: CAP, together with influenza, is the seventh leading cause of death in the United States. Therefore, a clear understanding of current practice guidelines for the management of CAP is essential to reduce mortality. Previously, IDSA and ATS had separate practice guidelines for the management of CAP; however, the most recent update combines the recommendations of both organizations and aids in eliminating potential confusion among practitioners.
What your patients need to know: CAP is a serious condition that is associated with a high rate of death. Appro-priate empiric therapy should be initiated in a timely manner, and patients should stay on therapy for a minimum of 5 days.
· · Mandell LA et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Suppl 2):S27–72.
· · Mandell LA et al. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis. 2003;37:1405–33.
· · American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia. Am J Respir Crit Care Med. 2001;163:1730–54.
Related Resources on pharmacist.com
· · News article: New treatment guidelines issued for community-acquired pneumonia.
Contact the editor: L. Michael Posey, BPharm, APhA DrugInfoLine
Posted June 27, 2007, 5:30pm EST