SUPPLEMENT ARTICLE Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults Lionel A. Mandell,1,a Richard G. Wunderink,2,a Antonio Anzueto,3,4 John G. Bartlett,7 G. Douglas Campbell,8 Nathan C. Dean,9,10 Scott F. Dowell,11 Thomas M. File, Jr.12,13 Daniel M. Musher,5,6 Michael S. Niederman,14,15 Antonio Torres,16 and Cynthia G. Whitney11 1McMaster University Medical School, Hamilton, Ontario, Canada; 2Northwestern University Feinberg School of Medicine, Chicago, Illinois; 3University of Texas Health Science Center and 4South Texas Veterans Health Care System, San Antonio, and 5Michael E. DeBakey Veterans Affairs Medical Center and 6Baylor College of Medicine, Houston, Texas; 7Johns Hopkins University School of Medicine, Baltimore, Maryland; 8Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; 9Division of Pulmonary and Critical Care Medicine, LDS Hospital, and 10University of Utah, Salt Lake City, Utah; 11Centers for Disease Control and Prevention, Atlanta, Georgia; 12Northeastern Ohio Universities College of Medicine, Rootstown, and 13Summa Health System, Akron, Ohio; 14State University of New York at Stony Brook, Stony Brook, and 15Department of Medicine, Winthrop University Hospital, Mineola, New York; and 16Cap de Servei de Pneumologia i Alle`rgia Respirato`ria, Institut Clı´nic del To`rax, Hospital Clı´nic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biome`diques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain. EXECUTIVE SUMMARY priate starting point for consultation by specialists. Substantial overlap exists among the patients whom Improving the care of adult patients with community- these guidelines address and those discussed in the re- acquired pneumonia (CAP) has been the focus of many cently published guidelines for health care–associated different organizations, and several have developed pneumonia (HCAP). Pneumonia in nonambulatory guidelines for management of CAP. Two of the most residents of nursing homes and other long-term care widely referenced are those of the Infectious Diseases facilities epidemiologically mirrors hospital-acquired Society of America (IDSA) and the American Thoracic pneumonia and should be treated according to the Society (ATS). In response to confusion regarding dif- HCAP guidelines. However, certain other patients ferences between their respective guidelines, the IDSA whose conditions are included in the designation of and the ATS convened a joint committee to develop a HCAP are better served by management in accordance unified CAP guideline document. with CAP guidelines with concern for specific The guidelines are intended primarily for use by pathogens. emergency medicine physicians, hospitalists, and pri- mary care practitioners; however, the extensive litera- Implementation of Guideline Recommendations ture evaluation suggests that they are also an appro- 1. Locally adapted guidelines should be imple- Reprints or correspondence: Dr. Lionel A. Mandell, Div. of Infectious Diseases, mented to improve process of care variables and McMaster University/Henderson Hospital, 5th Fl., Wing 40, Rm. 503, 711 relevant clinical outcomes. (Strong recommen- Concession St., Hamilton, Ontario L8V 1C3, Canada ([email protected]). This official statement of the Infectious Diseases Society of America (IDSA) dation; level I evidence.) and the American Thoracic Society (ATS) was approved by the IDSA Board of Directors on 5 November 2006 and the ATS Board of Directors on 29 September 2006. It is important to realize that guidelines cannot always account for individual a Committee cochairs. variation among patients. They are not intended to supplant physician judgment Clinical Infectious Diseases 2007;44:S27–72 with respect to particular patients or special clinical situations. The IDSA considers ᮊ 2007 by the Infectious Diseases Society of America. All rights reserved. adherence to these guidelines to be voluntary, with the ultimate determination 1058-4838/2007/4405S2-0001$15.00 regarding their application to be made by the physician in the light of each patient’s DOI: 10.1086/511159 individual circumstances. IDSA/ATS Guidelines for CAP in Adults • CID 2007:44 (Suppl 2) • S27 Enthusiasm for developing these guidelines derives, in large take oral medication and the availability of outpatient support part, from evidence that previous CAP guidelines have led to resources. improvement in clinically relevant outcomes. Consistently ben- ICU admission decision. eficial effects in clinically relevant parameters (listed in table 3) 7. Direct admission to an ICU is required for patients with followed the introduction of a comprehensive protocol (in- septic shock requiring vasopressors or with acute respi- cluding a combination of components from table 2) that in- ratory failure requiring intubation and mechanical ven- creased compliance with published guidelines. The first rec- tilation. (Strong recommendation; level II evidence.) ommendation, therefore, is that CAP management guidelines 8. Direct admission to an ICU or high-level monitoring unit be locally adapted and implemented. is recommended for patients with 3 of the minor criteria Documented benefits. for severe CAP listed in table 4. (Moderate recommen- 2. CAP guidelines should address a comprehensive set of dation; level II evidence.) elements in the process of care rather than a single element In some studies, a significant percentage of patients with in isolation. (Strong recommendation; level III evidence.) CAP are transferred to the ICU in the first 24–48 h after hos- 3. Development of local CAP guidelines should be directed pitalization. Mortality and morbidity among these patients ap- toward improvement in specific and clinically relevant pears to be greater than those among patients admitted directly outcomes. (Moderate recommendation; level III to the ICU. Conversely, ICU resources are often overstretched evidence.) in many institutions, and the admission of patients with CAP who would not directly benefit from ICU care is also problem- atic. Unfortunately, none of the published criteria for severe Site-of-Care Decisions CAP adequately distinguishes these patients from those for Almost all of the major decisions regarding management of whom ICU admission is necessary. In the present set of guide- CAP, including diagnostic and treatment issues, revolve lines, a new set of criteria has been developed on the basis of around the initial assessment of severity. Site-of-care decisions data on individual risks, although the previous ATS criteria (e.g., hospital vs. outpatient, intensive care unit [ICU] vs. format is retained. In addition to the 2 major criteria (need general ward) are important areas for improvement in CAP for mechanical ventilation and septic shock), an expanded set management. of minor criteria (respiratory rate, 130 breaths/min; arterial Hospital admission decision. oxygen pressure/fraction of inspired oxygen (PaO2/FiO2) ratio, 4. Severity-of-illness scores, such as the CURB-65 criteria !250; multilobar infiltrates; confusion; blood urea nitrogen (confusion, uremia, respiratory rate, low blood pressure, level, 120 mg/dL; leukopenia resulting from infection; throm- age 65 years or greater), or prognostic models, such as bocytopenia; hypothermia; or hypotension requiring aggressive the Pneumonia Severity Index (PSI), can be used to iden- fluid resuscitation) is proposed (table 4). The presence of at tify patients with CAP who may be candidates for out- least 3 of these criteria suggests the need for ICU care but will patient treatment. (Strong recommendation; level I require prospective validation. evidence.) 5. Objective criteria or scores should always be supple- Diagnostic Testing mented with physician determination of subjective fac- tors, including the ability to safely and reliably take oral 9. In addition to a constellation of suggestive clinical fea- medication and the availability of outpatient support re- tures, a demonstrable infiltrate by chest radiograph or sources. (Strong recommendation; level II evidence.) other imaging technique, with or without supporting mi- у 6. For patients with CURB-65 scores 2, more-intensive crobiological data, is required for the diagnosis of pneu- treatment—that is, hospitalization or, where appropriate monia. (Moderate recommendation; level III evidence.) and available, intensive in-home health care services—is Recommended diagnostic tests for etiology. usually warranted. (Moderate recommendation; level III 10. Patients with CAP should be investigated for specific evidence.) pathogens that would significantly alter standard (em- Physicians often admit patients to the hospital who could pirical) management decisions, when the presence of be well managed as outpatients and who would generally prefer such pathogens is suspected on the basis of clinical and to be treated as outpatients. Objective scores, such as the CURB- epidemiologic clues. (Strong recommendation; level II 65 score or the PSI, can assist in identifying patients who may evidence.) be appropriate for outpatient care, but the use of such scores Recommendations for diagnostic testing remain controver- must be tempered by the physician’s determination of addi- sial. The overall low yield and infrequent positive impact on tional critical factors, including the ability to safely and reliably clinical care argue against the routine use of common