Segment Description: Thomas Lodise, PharmD, PhD, professor, Albany College of Pharmacy, shares his initial reactions to the updated CAP guidelines.
Interview transcript: (modified slightly for readability)
I have had a chance to review the [community-acquired pneumonia] guidelines. They only became available this week, so I haven't been able to do a very deep dive. My overall impression is, this is largely consistent with the previous guidelines. They still stratify patients, either outpatient or inpatient. In the outpatient setting, they provide treatment recommendations in the presence of or absence of comorbid conditions like heart failure, renal disease, and things of that nature. And then for the inpatient setting, they stratify patients by hospital ward versus the ICU [intensive care unit], and the ICU is your typical ICU patient patients, septic sepsis or septic shock.
Across those different stratifications, there are a few differences. First, as I mentioned before, macrolides should not be used in monotherapy with regions greater than 25% macrolide resistance in Streptococcus pneumoniae, which is the No. 1 cause of CABP. Unfortunately, we don’t have a lot of good surveillance data, with Streptococcus pneumoniae in different regions. And when we do look at it, most regions have 40%.
So really the guidelines indicate that macrolides should not be used alone, which is a new recommendation and contrasted to [the 2007 guidelines]. For patients with comorbidities, they recommend using β-lactams or fluoroquinolones. However, they make mention of some of the concerns with the fluoroquinolones within the guidelines. There's been a number of boxed warnings over the past few years. In years past we had issues with QTC prolongation, tendinitis and tendon rupture. More recently, the most recent update is the increased risk of aortic aneurysm, particularly among patients with cardiac risk factors.
I think from that standpoint, we have a few different iterations. But largely the treatment choices are the same. Inpatient, it's still a beta-lactam with the macrolides or respiratory fluoroquinolones for your hospital ward patients. And for our critically ill patients in the ICU, it’s a β-lactam with a macrolide or a β-lactam with a fluoroquinolone. They do discuss that there appears to be some advantage in our ICU patients using a β-lactam with a macrolide over with a fluoroquinolone. However, they said either one is an acceptable recommendation.
Another big difference with the guidelines is the whole idea of HCAP. So actually HCAP is health care-associated pneumonia. This was from the previous ATS IDSA [American Thoracic Society and Infectious Diseases Society of America] pneumonia guidelines. So they make mention of this and said that this designation should be avoided. And rather what they added is the treatment of community-acquired pneumonia and patients at risk for MRSA or Pseudomonas aeruginosa. So, what they did in this circumstance with someone who's at risk, prior Pseudomonas or MRSA infection, or was colonized with MRSA or Pseudomonas, those individuals should be empirically treated if they're in septic shock, or if they have a positive culture at presentation among our hospital ward patients. So this is a recommendation primarily for your inpatients. Because if patients do have risk factors for MRSA or Pseudomonas, those are the ones that tend to be admitted who have high acute disease severity.
Interestingly, for our hospital ward patients, they indicated to only add MRSA or Pseudomonas coverage if the pathogen is identified. For MRSA, it could be PCR for Pseudomonas on a clinical culture or the patient has history of MRSA or Pseudomonas infection. In that circumstance, if MRSA is previously recovered, to use vancomycin or linezolid, if Pseudomonas was previously identified, then consider an anti-Pseudomonal β-lactam.
And then again, those in septic shock, [the committee] recommend to use those drugs empirically and de-escalate if they’re not recovered. So I think these are some of the biggest differences, you know, still largely the same, but they did provide greater clarity on that HCAP designation which we all struggle with. They do mention about patients at risk for MRSA, within a hospital, the risk of MRSA should be predicated on some validated institution-specific clinical prediction rules, they acknowledge those are not readily available. So this is something that will need further clarification as we move forward in practice.
I think the biggest thing is that if they had MRSA in the past, you should probably cover MRSA. Pseudomonas in the past, cover Pseudomonas. If you have it on culture, personally, I think I would probably cover them empirically and in a high-risk patient, perhaps coming from a nursing home, or as a health care frequent flyer with a lot of prior antibiotic exposures. However, this recommendation that’s made is in conflict for patients who are sick with pneumonia admitted but not treated within the ICU. So these are the patients without severe pneumonia.