New Pneumonia Guidelines Recommend Shorter Antibiotic Course

Revised clinical practice guidelines announced this month by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) recommend treating hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) with shorter antibiotic courses than physicians typically prescribe.

The recommendation of seven or fewer days of antibiotics for most HAP and VAP infections, which account for 20 to 25 percent of hospital-acquired infections, is based on evidence from topic-specific systematic literature reviews and reflects a change from previous guidelines originally published in 2005. Shorter antibiotic courses balance the need to ensure safe and effective treatment while limiting the development of more antibiotic-resistant pathogens.

The new guidelines, developed by a multidisciplinary panel of experts from around the globe, also recommend that hospitals adopt “antibiogram” protocols for conducting regular analysis of bacteria strains causing local pneumonia infections and determining which antibiotics are optimum for effectively treating them. The guidelines specify that whenever possible, the antibiogram should be specific to the particular hospital’s intensive care unit patients, and should be updated regularly at the most appropriate intervals as determined by the institution.

“Once clinicians are updated regularly on what bugs are causing VAP and HAP in their hospitals as well as their sensitivities to specific antibiotics, they can choose the most effective treatment,” said Dr. Andre C. Kalil, MD, MPH, lead author of the guidelines, professor of medicine in the Division of Infectious Diseases and director of the Transplant Infectious Diseases Program at the University of Nebraska Medical Center, in an IDSA press release. “This helps individualize care, ensuring patients will be treated with the correct antibiotic as soon as possible.”

The guidelines document published in Clinical Infectious Diseases is titled “Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society,” and stresses that adherence to the guidelines is intended to be voluntary, must be nuanced to account for individual variations among patients, and are not intended to override physician’s judgment regarding particular patients or special clinical considerations, with ultimate treatment decisions regarding their application to be made by the doctor depending on the patient’s individual circumstances.

The 2005 guidelines recommended different lengths of antimicrobial therapy based on which bacterium was causing the infection. The 2016 guidelines recommend seven days or fewer for all bacteria, including those causing VAP or HAP infections. For those infections, the guidelines now recommend a seven-day course of antimicrobials rather than a longer duration such as 15 days.

“Newer evidence suggests that the shorter course of treatment does not reduce the benefits of therapy; in addition, this can reduce antibiotic-related side effects, the risk of Clostridium difficile, a serious diarrheal infection, antibiotic resistance and costs,” Kalil said. “In some cases, such as when a patient doesn’t improve or worsens, longer treatment may be necessary.”

The IDSA notes that mechanical ventilators help patients breathe during surgery with general anesthesia and by those who suffer from impaired lung function. However, one of every 10 patients on ventilators will develop VAP, which has a roughly 13 percent fatality rate, and also increases the length of time the patient must remain on a ventilator by 7.6 to 11.5 days on average, and lengthens hospital stays from 11.5 to 13.1 days on average.

Typically, HAP infections will be less severe than VAP infections, but half of HAP patients will develop serious complications that can potentially include respiratory failure, fluid buildup in the lungs, septic shock, and kidney failure.

The guidelines panel featured experts from around the world, including infectious disease, pulmonary and critical care specialists, surgeons, pharmacologists, microbiologists, professional librarians and methodologists.