New guidelines give specifics for pneumonia care

An update by the Infectious Diseases Society of America offers more detailed drug treatment recommendations for community-acquired pneumonia, while keeping an eye out for antibiotic resistance.

By Susan J. Landers, amednews staff. Dec. 22/29, 2003.

Washington -- As the nation braces for an especially virulent flu season, revised guidelines to aid physicians in the management of a well-known and dangerous flu complication -- community-acquired pneumonia -- were released by the Infectious Diseases Society of America.

The IDSA guidelines are updated every few years to, in part, try to stay ahead of the rapidly evolving resistance developed by many infectious agents to even the most advanced and effective antibiotics.

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In this go-round, the guidelines address new issues such as the emergence of the SARS virus and the advent of bioterrorism, in which physicians must be watchful for evidence of possible use of deadly weaponized agents that can cause respiratory distress.

Community-acquired pneumonia is a common and potentially lethal infection that causes the deaths of more than 45,000 Americans each year.

The IDSA notes that vaccinations against both the flu and pneumococcus infection are available as prevention mainstays, though not everyone who can benefit from them takes advantage of these measures.

The new guidelines will also serve as a template for a joint document now under development by IDSA and the American Thoracic Society, which has published its own set in past years, said lead IDSA guideline author Lionel A. Mandell, MD, chief of the infectious diseases division at McMaster University School of Medicine in Hamilton, Ontario.

Flu should be treated within 48 hours of the onset of symptoms.

The joint recommendations are expected to be released in about a year.

"We felt it was really important to have both societies together, but in the meantime we didn't want to go for four years without any update," Dr. Mandell said. The last IDSA offering was released in 2000.

One of the main changes in the updated IDSA approach is the specificity of the treatments, said Dr. Mandell. "The treatment table last time was pretty sparse," he said. "Now we went into more detail, and outpatients are broken down into a number of specific categories."

One category might include, for example, an otherwise well 35-year-old who jogs every day, and another category might include patients with such comorbidities as congestive heart failure, cancer or renal failure.

The guidelines try to throw a protective arm around fluoroquinolones.

"Fluoroquinolones are very good drugs, and they are very appealing because a lot of them are once-a-day treatments and they are very well tolerated," said Dr. Mandell. "But people end up using them for just about everything. The fear is that in five to 10 years, resistance to them will build and they will become useless."

The resistance movement

The entire medical community has mounted a broad effort to fight against this growing resistance to formerly effective antibiotics.

The AMA, for example, is supporting federal legislation that would halt the widespread use of antibiotics for animals because of its role in promoting antibiotic-resistant strains of bacteria.

The AMA praised the Preservation of Antibiotics for Medical Treatment Act of 2003 for its intent to limit the use of antimicrobial animal drugs.

Another bill, the School Nutrition Antibiotic Safety Act, also garnered the AMA's praise for prohibiting the school lunch and summer foods programs for children from purchasing products made from chickens that have been fed or administered fluoroquinolones. Fast food chains, such as McDonald's and Wendy's, have forced their suppliers to phase out fluoroquinolones, and the AMA would like the school lunch program to follow their example.

Thus, rather than relying heavily on fluoroquinolones, the new pneumonia guidelines encourage physicians to use macrolides, a popular and long-standing class of antibiotics for patients who were previously healthy and who have not been treated with antibiotics within the preceding three months.

The IDSA also recommends early treatment for the flu -- within 48 hours of the onset of symptoms.

The new recommendations call for initiating antibiotic therapy within four hours of hospital admission. The previous recommendation was for antibiotics to be started within eight hours of admission.

In addition, the guidelines include smoking cessation as a goal for smokers who are hospitalized with community-acquired pneumonia.

"These new updated guidelines will provide an important resource for practicing physicians and academicians alike," said Dr. Mandell.

ADDITIONAL INFORMATION:

Get the shot -- not the disease

Public health officials urge that high-risk groups be vaccinated against pneumococcal pneumonia, one type of bacterial pneumonia.

There are about 60,000 U.S. cases of invasive pneumococcal disease each year. One-third occur in people 65 and older.
Half of the 6,000 to 7,000 annual deaths from invasive pneumococcal disease occur among elderly people.
Influenza vaccination coverage for adults 65 and older is 68% for whites, 48% for African-Americans, and 54% for Hispanics.
Pneumococcal vaccination coverage is 60% for whites, 38% for African-Americans, and 36% for Hispanics.
46,000 to 48,000 American adults die each year from vaccine-preventable diseases at a cost to society of more than $10 billion.

Source: Centers for Disease Control and Prevention

Weblink

"Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults," Clinical Infectious Diseases, Dec. 1 (www.journals.uchicago.edu/CID/journal/issues/v37n11/32441/32441.html)

American Thoracic Society's "Guidelines for the management of adults with community-acquired pneumonia," American Journal of Respiratory and Critical Care Medicine, June 2001 (ajrccm.atsjournals.org/cgi/content/full/163/7/1730)