ATS Reading List

Pneumonia

Community Acquired Pneumonia

Prediction Rules

Fine MJ, Auble TE, Yealy DM et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336:243-50. This oft-cited prediction rule, the Pneumonia Severity Index (PSI), incorporates patient demographics, co-morbidities, vitals, labs, and chest film to identify patients likely to do well with outpatient treatment of CAP.
PMID: 8995086
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Lim WS, Lewis S, Macfarlane JT. Severity prediction rules in community acquired pneumonia: a validation study. Thorax 2000; 55:219-23. The CURB-65 (also validated as the CRB-65 when BUN is unavailable) is simpler to use than the PSI but is not as sensitive for predicting mortality.
PMID: 10679541
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Treatment

Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72. An influential consensus statement from two major societies.
PMID: 17278083
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Schuetz P, Christ-Crain M, Thomann R, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA 2009; 302:1059-66. 1359 patients with lower respiratory tract infections in 6 Swiss academic hospitals were randomized to a treatment algorithm based on procalcitonin (PCT) levels or to treatment based on current evidence based guidelines. PCT-guided therapy reduced total antibiotic exposure without any change in adverse outcomes. Controversy exists regarding the unusually high prevalence of "severe" pneumonia by PSI score, and that reduction in exposure was primarily due to reduced duration of antibiotics rather than avoidance.
PMID: 19738090
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Bartlett JG, Gorbach SL. The triple threat of aspiration pneumonia. Chest 1975 ;68:560-6. Classic review of the presentation, pathophysiology, and natural history of chemical pneumonitis, bacterial pneumonia, and airway obstruction resulting from aspiration of toxic fluids, bacteria, and inert matter respectively.
PMID: 1175415
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Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial. Lancet 2015; 385: 1511-8.This, the largest trial in this population to date, randomized 785 patients with community acquired pneumonia of varying severity (only 5% in the ICU) to prednisone 50 mg x 7 days vs placebo and found a 1.4 day reduction in "time to clinical stability" (24 consecutive hours of stable vitals) and a 1-day reduction in duration of hospital stay in the steroid group.  Death, ICU admission, duration of ICU admission, and duration of antibiotics did not differ.
PMID: 25608756
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Radiographic Resolution

Mittl RL, Schwab RJ, Duchin JS et al. Radiographic resolution of community-acquired pneumonia. Am J Respir Crit Care Med 1994;149:630-5. Prospective follow-up of both inpatients and outpatients with diagnosis of CAP is cited as a guide for when to look for endobronchial lesions in the setting of slowly clearing pneumonia. The study found age and multilobar disease were independent predictors of delayed resolution. Radiographic resolution seen in 51% at 2 weeks, 67% at 4 weeks, and 90% at 12 weeks.

PMID: 8118630

Ventilator Associated Pneumonia

Diagnosis

Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia.N Engl J Med. 2006; 355:2619-30.Randomized trial (N= 740) found the use of bronchoalveolar-lavage with quantitative culture vs. routine culture of endotracheal-aspiration resulted in similar clinical outcomes and antibiotic use when used for the diagnosis of ventilator-associated pneumonia. The exclusion of immunocompromised patients and those infected or colonized with MRSA or Pseudomonas, the format for empiric antibiotic use, and the criterion for a positive BAL culture are concerns raised about the applicability of the findings.
PMID: 17182987
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Treatment

Kalil A, Metersky M, Klompas M, et al. Executive Summary: 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. Clin Infect Dis. 2016; 63:575-82. This revision of the 2004 guidelines eliminates the designation of healthcare-associated pneumonia and is noteworthy for recommending a 7-day course of therapy for uncomplicated cases regardless of the presence of MRSA and pseudomonas. It also recommends each hospital generate its own antibiogram and addresses the use of biomarkers, such as procalcitonin, to guide therapy.
PMID: 27521441
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Chastre J, Wolff M, Fagon J et al. Comparison of 8 vs. 15 days of antibiotic therapy for ventilator-associated pneumonia in adults. JAMA 2003;290:2588-98. RCT comparing 8 vs. 15 days of antibiotic in 401 immunocompetent patients with VAP (diagnosed by bronchoscopic quantitative cultures) found no difference in pulmonary infection recurrence, 28-day mortality, ventilator free-days, organ failure-free days, and length of ICU stay between groups. The 8-day group had a higher recurrence of pulmonary infections due to non-lactose fermenting gram negative rods, including Pseudomonas aeruginosa (41% vs. 25%), although the 2016 IDSA/ATS guidelines recommend limiting treatment to 7 days.
PMID: 14625336
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Last Reviewed: June 2017