Special Article Infection & https://doi.org/10.3947/ic.2018.50.2.160 Chemotherapy Infect Chemother 2018;50(2):160-198 ISSN 2093-2340 (Print) · ISSN 2092-6448 (Online) Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia Mi Suk Lee1*, Jee Youn Oh2*, Cheol-In Kang3, Eu Suk Kim4, Sunghoon Park5, Chin Kook Rhee6, Ji Ye Jung7, Kyung-Wook Jo8, Eun Young Heo9, Dong-Ah Park10, Gee Young Suh11, and Sungmin Kiem12 1Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul; 2Division of Respiratory, Allergy and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul; 3Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medi- cine, Seoul; 4Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam; 5Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang; 6Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul; 7Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul; 8Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul; 9Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul; 10Division of Healthcare Technology Assessment Research, Nation- al Evidence-Based Healthcare Collaborating Agency, Seoul; 11Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; 12Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea Community-acquired pneumonia is common and important infectious disease in adults. This work represents an update to 2009 treatment guideline for community-acquired pneumonia in Korea. The present clinical practice guideline provides revised recom- mendations on the appropriate diagnosis, treatment, and prevention of community-acquired pneumonia in adults aged 19 years or older, taking into account the current situation regarding community-acquired pneumonia in Korea. This guideline may help reduce the difference in the level of treatment between medical institutions and medical staff, and enable efficient treatment. It may also reduce antibiotic resistance by preventing antibiotic misuse against acute lower respiratory tract infection in Korea. Key Words: Pneumonia; Community-acquired infections; Adults; Therapeutics; Guideline Received: February 5, 2018 Published online: June 26, 2018 Corresponding Author Sungmin Kiem, MD, PhD Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, 875, Haeun-daero, Haeundae-gu, Busan 48108, Korea Tel: +82-51-797-0320, Fax: +82-51-797-3229, E-mail: [email protected] Gee Young Suh, MD, PhD Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82-2-3410-3429, Fax: +82-2-3410-6956, E-mail: [email protected] * Mi Suk Lee and Jee Youn Oh contributed equally to the work. Sungmin Kiem and Gee Young Suh corresponded equally to the work. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and repro- duction in any medium, provided the original work is properly cited. Copyrights © 2018 by The Korean Society of Infectious Diseases | Korean Society for Chemotherapy www.icjournal.org www.icjournal.org https://doi.org/10.3947/ic.2018.50.2.160 • Infect Chemother 2018;50(2):160-198 161 Introduction the Korea Academy of Tuberculosis and Respiratory Diseases, the Korean Association of Family Medicine, the Korean Medi- 1. Background of guidelines cal Practitioners Association, and the National Evidence- Clinical practice guidelines based on evidence-based medi- based Healthcare Collaborating Agency participated in the cine promote evidence-based, objective, and efficient medical development of this guideline. practices. Numerous evidence-based clinical practice guide- lines have also been developed, including the treatment 2) Guideline target and scope guideline for community-acquired pneumonia developed in This guideline sets forth fundamental principles of antibiotic 2009. Additional data about the distribution of the causative use against community-acquired pneumonia in adults aged bacteria of community-acquired pneumonia and antibiotic 19 years or older, taking into account the current situation re- resistance have been obtained since then, and various guide- garding community-acquired pneumonia in Korea as of lines about the diagnosis, treatment, and prevention of pneu- March 2017. monia have also been developed abroad. It has therefore be- come necessary to revise the current guideline on community 3) Method of literature search -acquired pneumonia in Korea. Studies published in English in the last 10 years were Antibiotic resistance has recently been raised as a serious searched. OVID-MEDLINE and OVID-EMBASE were used to public health issue worldwide. This is because whereas resis- search for foreign studies, and KMBase and KoreaMed were tant bacteria that cannot be removed with existing antibiotics used to search domestic studies. Clinical practice guidelines are increasing in number, less and less novel antibiotics are were searched on NGC, G-I-N, and KoMGI. The search date is being developed. The issue of antibiotic resistance is much February 10th, 2017. more serious in Korea than in other countries, with major causative bacteria having the highest antibiotic resistance in 4) Recommendation and evidence levels the former worldwide. Antibiotic resistance is proportional to The level of recommendation was divided into “Strong, the level of antibiotic misuse. The level of antibiotic use in Ko- Weak”, and the level of evidence was divided into “High, Mod- rea is higher than the average level of antibiotic use world- erate, Low, Very low”. The level of recommendation and the wide. The rate of prescribing antibiotics for infections that do level of evidence were determined using an unofficially not require antibiotic treatment is also higher in Korea than in agreed method. A consensus was deemed reached if over 70% other countries. of the participating committee members agreed. The present clinical practice guideline provides revised rec- ommendations on the appropriate diagnosis, treatment, and (1) Level of recommendation prevention of community-acquired pneumonia. This guide- £ Strong: Benefits evidently outweigh costs or loss, or costs line may help reduce the difference in the level of treatment and loss evidently outweigh benefits. between medical institutions and medical staff, and enable ef- ¤ Weak: Level of evidence is low, or there is no clear differ- ficient treatment. It may also reduce antibiotic resistance by ence between benefits and loss. preventing antibiotic misuse against acute lower respiratory tract infection in Korea. (2) Level of evidence £ High: The possibility that the level of certainty about the 2. Development process of diagnosis and treatment estimated value of an effect will change in future studies guidelines is very low. ¤ Moderate: Future studies will have an important influ- 1) Guideline development committee ence on the level of certainty about the estimated value of An antibiotic treatment guideline development committee an effect, and the value may change. for lower respiratory tract infection in adults was formed in ¥ Low: Future studies are highly likely to affect the level of November 2016. The committee included as many associated certainty about the estimated value of an effect, and the medical institutions as possible. value is highly likely to change. Committee members recommended by the Korean Society ¦ Very low: An effect cannot be estimated with certainty. for Chemotherapy, the Korean Society of Infectious Diseases, 162 Lee MS, et al. Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia www.icjournal.org 5) Guideline developmental process adapted were scheduled for revisions in the near future, they This clinical practice guideline was developed using the ad- were not presented during the developmental period, and aptation method. First, 22 key questions (KQ) to be included could not be used in the development of this guideline. This in the guideline were selected. The key questions followed the guideline will undergo minor revisions as soon as the revised population intervention, comparison, and outcome (PICO) versions of these guidelines are published. This guideline will principle. During the literature search process, experts used also be revised every 4-5 years to reflect recent study results systematic search equations to search