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Revised Guidelines for Hospital Acquired Pneumonia Stress Higher Doses and Shorter Duration of Antibiotic Treatment: Presented at CHEST

By Amanda Strong

MONTREAL, CANADA -- November 4, 2005 -- When faced with a suspected case of pneumonia, hospital physicians should collect a lower respiratory tract culture, initiate antibiotic therapy immediately at high doses, and stop treatment earlier, researchers recommended in a presentation here at the American College of Chest Physicians Annual Meeting (CHEST).

In addition, treatment should be tailored to culture results, according to newly released evidence-based guidelines for the management of hospital-acquired pneumonia presented on November 3^rd.

Presenter Richard G. Wunderink, MD, professor of medicine, division of pulmonary and critical care medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States, said the new guidelines also include healthcare-associated pneumonia (HCAP), which was previously included in guidelines for community-acquired disease.

"Nursing home or extended care facility residents are a group of patients that we ought to be thinking about and treating more like patients with hospital-acquired pneumonia than community-acquired pneumonia," Dr. Wunderink said during his presentation on the treatment portion of the guidelines.

The guidelines also include other conceptual changes, such as a de-emphasis on the way a diagnosis is made, and a stronger emphasis on tying diagnosis to disease management.

Guideline committee cochair Michael Neiderman, MD, FCCP, chairman, department of medicine, Winthrop University Hospital, Mineola, New York, United States, commented, "People are now trying to think of tying the diagnostic strategy to the management directly and not this sort of artificial thing, where we'll do the [bronchoalveolar lavages], take cultures and then wait for the results that we'll use to manage patients. Everyone agrees that the goal is to get them on the right therapy quickly and then find a way to de-escalate things."

The guidelines now advocate that, while waiting for lung culture results, appropriate broad-spectrum antibiotics should be started, from a drug class that the patient has not received previously. "One of the most common errors is trying to guess at the bug without a gram stain or cultures. The guidelines emphasise that you need to get a culture," Dr. Wunderink said in an interview.

De-escalation should be done once the culture identifies the pathogen. At this time antibiotic strategies should narrowed to target the particular pathogen. Antibiotics should also be used at appropriate doses. For many physicians, this means using higher initial doses of antibiotics.

Treatment should also be stopped once a culture is found to be negative. It's a recommendation that many physicians find difficult: "It is common practice to continue antibiotics even when the patient appears to be getting better. You don't need to stop all the antibiotics, but you do need to stop the ones that are covering bugs like pseudomonas and MRSA because those grow very readily [in culture]" said Dr. Wunderink. "

The guidelines also recommend a shorter duration of antibiotic treatment. In patients who respond well, a 7- to 8-day course of treatment should be sufficient. Beyond that, if the patient remains febrile, antibiotic therapy should be switched rather than prolonged. "I'm not sure that there is any justification for increasing the duration of therapy," Dr. Wunderink said during his presentation.

Dr. Neiderman made a similar point about failing therapy during his own presentation. "If your patient is not getting better by day 3, it's time to figure out why. Don't wait longer." Based on published evidence, he said, 3 days is more than enough time to determine if a patient is getting better, and that a patient who is responding to treatment should be back to baseline by about day 7.

Dr. Wunderink wrapped up the session by pointing out that there are really no new antibiotic classes in the horizon. "We have to be better stewards of the [antibiotics] that we have here and use them in the right way, and use them in innovative ways, because that's all we're going to have for a while."

Citation: Treatment Guidelines: Guidelines for the Management of Adults with Hospital-Acquired, Ventilator Associated, and Healthcare-associated Pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416.


[Presentation Title: Nosocomial Pneumonia: What's New?]

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