ASHP 2019 News Network: Reviewing the Updated CAP Guidelines


Segment Description: Lisa Dumkow, PharmD, BCPS, BCIDP, clinical pharmacist, antimicrobial stewardship, Mercy Health Saint Mary's, discusses the updates to the CAP guidelines.

Interview transcript: (modified slightly for readability)

So the new IDSA [Infectious Diseases Society of America]/ATS [American Thoracic Society] guidelines came out in early October. I've definitely reviewed them. It's been a hot topic in infectious disease and stewardship. I think as stewards and as pharmacists, we were really excited for those guidelines.

So the previous guidelines were from 12 years ago. Probably the biggest change that I think is beneficial is the removal of that HCAP definition. So the health-care associated pneumonia, they recommended retiring that definition. So that opens up a lot of patients who are receiving extremely broad spectrum antibiotics, so those targeting anti-MRSA [methicillin-resistant Staphylococcus aureus] and the anti-Pseudomonas, and actually just bringing them back to Strep pneumo [Streptococcus pneumoniae] coverage, so it gives them an option for more narrow coverage up front. So that's a big change and a big deal that a lot more patients will not need to receive such broad antibiotics, which hopefully will reduce their risk of adverse effects such as Clostridioides difficile, so we'll hopefully just reduce their overall burden of antibiotics that they need to receive.

Then the other big thing there too is their update to the outpatient recommendations for community-acquired pneumonia. So that Z-Pak, like give me a Z-Pak, has been really ingrained in our society for the past 10 or more years. And so these guidelines recommend against azithromycin monotherapy for outpatient antibiotics, which is something we've been doing locally at our site for over 5 years now, just knowing that our local Strep pneumo susceptibilities, were only about 60% or less over the last 5 years, and it's not really safe for our patients locally to be doing that. So these guidelines recognize that actually nationwide, it's not safe to be doing that, and now recommend dual coverage with a beta-lactam plus a macrolide, or plus a tetracycline for outpatient therapy. So that is a really great thing that they did with those guidelines.

So I do think there were several questions that still remain with these guidelines, first and foremost, lefamulin and came out right around the same time that the guidelines did and so it was mentioned in the guidelines but they still do recommend fluoroquinolones, a second line to our beta line beta lactam therapy. Again, we're trying to really be fluoroquinolones spearing for several reasons. First and foremost, just being adverse effects. So there's quite a few black box warnings on fluoroquinolones. It's not the safest option for the majority of our patients. So having a another option that isn't a fluoroquinolone is exciting.

Something that we hope future guidelines would maybe push a little higher to say "don't use a fluoroquinolone, use this first" and maybe a fluoroquinolone could be third line option. The other thing is that they still recommend beta-lactam plus macrolide therapy as first line. There's been several studies actually showing that beta-lactam monotherapy, might be just as efficacious as that combination, and they really didn't go into that data within those guidelines. So again, just another way that we could maybe be better stewards and not give such broad coverage to our patients if they don't need it.

But most of the things that they put in there we feel are great. So that short durations of therapy, that removal the HCAP, but yeah, there's a few things they could do to even improve more from a stewardship standpoint.

So they recommend against corticosteroids now in the guidelines, and that was something that was maybe controversial in the past as well. I think that could even still be controversial, because the guidelines also recommend against procalcitonin. We see new procalcitonin studies coming out for lower respiratory tract infections, including pneumonia, even every week still. So I think those 2 points, it was nice that they address them but I think those are still going to be controversial even in coming updates of the guidelines. The big issue with the guidelines is that it's taken 12 years to get a new version of the guidelines so who knows when the next guideline version that we're going to get is. It's an exciting time to be treating cap right now. And yeah, who knows when the next version will come out?

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