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| |  ATS: New Canadian Guidelines for the Management of Pneumonia By Guenther Krueger Special to DG News
SAN FRANCISCO, CA -- May 22, 2001 -- New developments in the diagnosis, pathogenesis, management and outcomes of patients with community-acquired pneumonia have led to the introduction of a number of new guidelines for treatment. Dr. Ron F. Grossman of the University of Toronto, outlined the new Canadian Guidelines which are similar to those about to be introduced by the American Thoracic Society in the United States. These new guidelines are based on site-of-care, either in the home or community, the hospital where there is further division between general ward and intensive care unit, or nursing home. However, the vast majority of patients are seen as outpatients. Studies looking at outcome have traditionally used mortality and certainly for patients hospitalized this is appropriate. But for the large numbers treated outside of hospital, Dr. Grossman suggested that measures such as morbidity, time to return to work, and economics, are more appropriate measures to use. Drug resistance is also an issue. He cited data from a number of studies to show that length of stay is increased and mortality is altered when this is the case. Dr. Grossman said, "It would be ideal if we could identify the pathogen from the get-go and have directed rather than empirical therapy." This would have the clear advantage of limiting polypharmacy, lowering costs, and decreasing the likelihood of adverse drugs reactions. It would also decrease antibiotic selection pressure and reduce the emergence of resistance. However, the reality is that laboratory information arrives too late to initiate treatment based on findings, and rapid testing may not be accurate enough. For these reasons, guidelines have been developed. For outpatients with no specific risk factors the first choice is a macrolide with doxycycline as an alternative. This is true also for those with obstructive airway disease where the risk is for Hemophilus influenza. Dr. Grossman said, " Those patients with gram negative infection, chronic oral corticosteroid therapy, broad spectrum antibiotics or structural lung disease, here for the first time we recommend a fluoroquinolone as an agent of first choice." In nursing homes, a fluoroquinolone is also recommended with the option of adding amoxicillin/clavulanate. However, outcome data is lacking for this group. Patients in hospital should receive fluoroquinolone as the agent of first choice with a second or third generation cephalosporin as a second option. For those in intensive care, it should be determined whether there is a risk for infectious pseudomonas. If that is the case, ciprofloxacin given parenterally plus another anti-pseudomonal beta-lactam is recommended. For others, a second or third generation cephalosporin plus a macrolide or a betalactase inhibitor or fluoroquinolone plus a cephalosporin is indicated.
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