More than 4 million episodes of communityacquired

Overview of Recent Guidelines for the Management of Community-Acquired Pneumonia David C. Rhew, MD More than 4 million episodes of communityacquired pneumonia (CAP) occur each year in the United States, causing significant morbidity and mortality. Managing CAP can be challenging, and variability in practice patterns has been demonstrated [1 4]. Guidelines for managing CAP have been developed by medical societies and other organizations to help guide clinicians. However, there are differences between guidelines, even among those that use an evidence-based approach [5 8]. The objective of this paper is to review the management recommendations for patients with CAP from recently published guidelines, with a focus on addressing the following key management questions: Should a chest radiograph be performed for all patients with CAP? What other diagnostic tests should be ordered? Which patients can be managed in the outpatient setting? Which empiric antibiotics should be administered? How long should patients with CAP be treated? Search Strategy A search of the MEDLINE, EMBASE, Best Evidence, and Cochrane Systematic Review databases from January 1966 through March 2002 was performed to identify CAP guidelines by a major organization (or a body representing a major organization) as well as to identify supporting studies for the guidelines. The search terms used are listed in the Appendix. Guidelines were excluded if they were not in the English language or were older than 5 years (ie, prior to 1998). If the same organization published more than one set of guidelines, the most recently published set was included. Guidelines and Recommendations We initially identified 10 CAP guidelines [5 14]. Guidelines from the South African Pulmonology Society [9] were excluded because they were published prior to 1998. Older guidelines from the American Thoracic Society [10], British Thoracic Society [11], and Infectious Diseases Society of America [12] were excluded because more recent guidelines had been published. The 6 remaining guidelines were from the following: American Thoracic Society (ATS, 2001) [5] British Thoracic Society (BTS, 2001) [6] Infectious Diseases Society of America (IDSA, 2000) [7] Canadian Infectious Diseases Society/Canadian Thoracic Society (CIDS/CTS, 2000) [8] U.S. Centers for Disease Control and Prevention s Drug-Resistant Streptococcus Pneumoniae Therapeutic Working Group (CDC, 2000) [13] European Respiratory Society (ERS, 1998) [14] Diagnostic Tests Chest radiograph. The ATS, IDSA, and the CIDS/CTS recommend that chest radiographs be ordered for all patients with suspected CAP (Table 1). The BTS states that the chest radiograph is not necessary for the majority of patients managed in the outpatient setting but should be ordered for all inpatients with CAP. The ERS recommends that chest radiographs be ordered for patients who have failed first-time empiric therapy or who have focal chest signs. According to the ERS, chest radiographs should be considered when risk factors for occurrence or severity of CAP are present; these are listed in the footnote to Table 1. Sputum Gram stain and culture. The guidelines generally support sputum studies for patients hospitalized with CAP. The BTS states that routine microbiologic examination in outpatients is not routinely recommended, but sputum Gram stain and culture should be performed in outpatients who do From Zynx Health, Inc., and Cedars-Sinai Health System Department of Health Services Research, Beverly Hills, CA. www.turner-white.com Vol. 9, No. 7 July 2002 JCOM 381

COMMUNITY-ACQUIRED PNEUMONIA Table 1. Guidelines for Diagnosis of Immunocompetent Adults with Community Acquired Pneumonia (CAP) BTS [6] ATS [5] Chest radiograph Not necessary for the majority of outpatients but recommended for all inpatients Yes, if feasible Sputum Gram stain and culture (outpatient) Sputum Gram stain and culture (inpatient) Not recommended routinely but should be considered for patients not responding to empiric antibiotic therapy For patients with severe CAP or those failing to improve. Also for patients with nonsevere CAP who have not received prior antibiotics. Optional If suspect drug-resistant pathogen or organism not covered by empiric therapy. If sputum culture is ordered then it should be obtained before antibiotics and correlated with Gram stain. Blood cultures Recommended for all hospitalized patients (minimum 20 ml) 2 sets for hospitalized patients Serology (C. pneumoniae, M. pneumoniae) Legionella urinary antigen test Paired serologic tests are recommended for all patients with severe CAP, those who are unresponsive to β-lactam antibiotics, those with epidemiologic risk factors or for whom a microbiologic diagnosis is important for public health reasons Recommended for all patients with severe CAP, those with risk factors for legionellosis, and during outbreaks of legionella Not helpful in initial management of CAP but may be helpful for epidemiologic surveillance Recommended for severe CAP (requiring ICU) hpf = high-power field; ICU = intensive care unit; lpf = low-power field; PMN = polymorphonuclear cells; SEC = squamous epithelial cells. *Risk factors include age > 65 years, residence in a nursing home, alcoholism, presence of comorbid condition (chronic obstructive pulmonary disease, cardiovascular disease, neurological disease, diabetes mellitus, chronic liver failure or renal failure, recent viral infection), hospital admission within the previous year, recent treatment with antibiotics, and aspiration. not respond to empiric therapy. For patients hospitalized with nonsevere CAP, sputum cultures may be ordered as long as the patient is able to expectorate a purulent sample and has not been started on antibiotics. Sputum cultures also should be performed in all patients with severe CAP as well as those failing to respond to therapy. The ATS, IDSA, and CIDS/CTS indicate that sputum Gram stain and culture are optional in outpatients but should be performed in inpatients, with certain caveats (Table 1). For patients in the intensive care unit (ICU), the CIDS/CTS recommends a more aggressive effort to obtain lower respiratory tract secretions [8]. The ERS states that microbiologic evaluation of sputum is usually not necessary but is indicated when patients have failed first-time empiric therapy or have risk factors for specific organisms. The ERS does not specify whether this recommendation applies to inpatients or outpatients. Blood cultures. Many organizations, including ATS, IDSA, CIDS/CTS, and ERS, recommend that 2 sets of blood cultures be drawn for all patients with CAP who are hospitalized. The BTS recommends blood cultures for all hospitalized patients. The rationale for recommending blood cultures includes the following: bacteremia may be a prognostic factor for poorer outcomes and recognizing this may be important (BTS, ATS, CIDS/CTS); resistant organisms may be identified (ATS); an etiologic diagnosis may be established, which can improve care for the patient and the community (IDSA); and drawing blood cultures may be costeffective for patients with risk factors (IDSA, ERS). Serologies. The ATS, IDSA, and CIDS/CTS do not recommend routine serologies to diagnose atypical pathogens. A primary reason for this is the slow turnaround time, with results from serologies often not obtained until after the patient has been discharged [15]. However, these same organizations comment that serology may be helpful for epidemiologic surveillance. On the other hand, the BTS recommends paired serologic tests for all patients who have severe CAP, are unresponsive to β-lactam antibiotics, have epidemiologic risk factors, or in whom a microbiologic diagnosis is important for public health reasons. The ERS recommends serologies to detect atypical agents in hospitalized patients with CAP. Legionella urinary antigen. The legionella urinary antigen test identifies Legionella pneumophila serogroup 1, which is the most common serogroup causing illness. The sensitivity of the test ranges from 70% to 100%, specificity is 100%, and turnaround time is short [16 18]. The BTS, ATS, IDSA, and CIDS/CTS recommend legionella urinary antigen testing for patients with severe CAP (eg, requiring ICU care). The BTS 382 JCOM July 2002 Vol. 9, No. 7 www.turner-white.com

IDSA [7] CDC [13] CIDS/CTS [8] ERS [14] Yes Optional If it is a deep-cough specimen obtained prior to antibiotics, adequate cytologic specimen (except for legionella and mycobacterium) and interpreted by a trained personnel or staff 2 sets for hospitalized patients Not helpful in initial management of CAP but may be helpful for epidemiologic surveillance Recommended for severe CAP (requiring ICU) Yes, if feasible Not routinely, but may be selectively appropriate If prior to antibiotics, adequate sample (< 25 SECs/lpf), assessed within 1 2 hours of collection, and interpreted by a trained staff 2 sets for hospitalized patients Not helpful in initial management of CAP but may be helpful for epidemiologic surveillance Recommended for severe enigmatic CAP (requiring ICU) Yes, with failure of first-time empiric therapy or when focal chest signs are present. Consider, when risk factors* are present. Recommended when risk factors* are present or with failure of first-time empiric therapy In routine cases, sputum examination (sputum obtained after mouth washing; Gram stain > 25 PMNs and < 10 SECs/hpf; sputum culture with single agent or when agent > 10 7 cells/ml) is optional. However, sputum sampling is recommended for all patients fulfilling criteria for immediate severity. 2 sets for hospitalized patients (but only costeffective for those with risk factors*) Recommended for hospitalized patients Recommended for hospitalized patients Table 2. Guidelines for Triage of Immunocompetent Adults with Community-Acquired Pneumonia BTS [6] ATS [5] IDSA [7] CDC [13] CIDS/CTS [8] ERS [14] Modified BTS Pneumonia Severity Pneumonia Severity Pneumonia Severity rule [40] Index [19] Index [19] Index [19] BTS rule [21] Addresses criteria for ICU admission (severe respiratory failure, severe hemodynamic instability, metabolic or hematologic criteria) but not criteria for hospitalization ICU = intensive care unit. and IDSA also comment that legionella testing should be performed for patients with CAP who have risk factors for legionellosis and during outbreaks of legionella infection. The BTS identifies recent travel (within 10 days of onset), occupational exposure (eg, to domestic plumbing systems), and immunosuppression as risk factors for legionella infection. The IDSA identifies the following as risk factors for legionella infection: seriously ill without an alternative diagnosis (especially if aged > 40 years, immunocompromised, or nonresponsive to β-lactams) and having clinical features suggestive of legionellosis. The ERS recommends legionella urinary antigen testing for CAP patients who are hospitalized. Triage Decision Several organizations have endorsed the use of decision tools to assist clinical judgment in the admission decision (Table 2). The IDSA and CID/CTS have endorsed the use of the Pneumonia Severity Index (PSI) [19]. Using a point system, the PSI stratifies patients into 5 risk classes based on factors such as age, comorbid conditions, physical examination findings, and laboratory results. Patients in class I and class II have a 30-day mortality rate of less than 1% and are considered appropriate candidates for outpatient management. Patients in class III have an associated 30-day mortality rate of up to 2.8% and may receive outpatient management with close follow-up [20] or be briefly admitted. Patients in class IV ( mortality rate, 8.2% to 9.3%) and class V (mortality rate, 27.0% to 31.1%) may be treated in-hospital [19]. Another rule, the BTS rule, states that in patients with at least 2 of the following core risk factors on admission, the odds of death are 21 times greater than in those without these risk factors: respiratory rate 30 bpm or higher, diastolic www.turner-white.com Vol. 9, No. 7 July 2002 JCOM 383

COMMUNITY-ACQUIRED PNEUMONIA Table 3. Guidelines for Outpatient Treatment of Immunocompetent Adults with Community-Acquired Pneumonia BTS [6] ATS [5] IDSA [7] CDC [13] Amoxicillin Alternatives: Erythromycin or clarithromycin No cardiopulmonary disease and/or modifying factors: Azithromycin or clarithromycin or doxycycline With cardiopulmonary disease and/or modifying factors: β-lactam (oral cefopodoxime, cefuroxime, high-dose amoxicillin, amoxicillin-clavulanate, or parenteral ceftriaxone followed by oral cefpodoxime) + (macrolide or doxycycline); or antipneumococcal fluoroquinolone alone Doxycycline or macrolide or antipneumococcal fluoroquinolone Macrolide or doxycycline or (cefuroxime or amoxicillin or amoxicillinclavulanate) Alternative: Antipneumococcal fluoroquinolone COLD = chronic obstructive lung disease. Table 4. Guidelines for Inpatient Treatment of Immunocompetent Adults with Community-Acquired Pneumonia BTS [6] ATS [5] Empiric therapy (ward) Admitted for nonclinical reasons or previously untreated: Amoxicillin po Alternative: erythromycin po or clarithromycin po Somewhat sicker: Oral Amoxicillin po + erythromycin po; or clarithromycin po alone Alternative: antipneumococcal fluoroquinolone If intravenous needed Ampicillin IV; or benzylpenicillin IV + (erythromycin IV or clarithromycin IV) Alternative: IV antipneumococcal fluoroquinolone No cardiopulmonary disease and/or modifying factors: IV azithromycin alone (or if macrolide intolerant: doxycycline + β-lactam) or antipneumococcal fluoroquinolone alone With cardiopulmonary disease and/or modifying factors: IV β-lactam (cefotaxime or ceftriaxone or ampicillin-sulbactam or high-dose ampicillin) + (IV or oral macrolide or doxycycline); or IV antipneumococcal fluoroquinolone alone Empiric therapy (ICU) (Co-amoxiclav or cefuroxime or cefotaxime or ceftriaxone [all IV]) + (erythromycin IV or clarithromycin IV) ± rifampicin po or IV Alternative: IV or po antipneumococcal fluoroquinolone ± benzylpenicillin IV No risk for P. aeruginosa: (IV cefotaxime or ceftriaxone) + (IV azithromycin or IV fluoroquinolone) Risk for P. aeruginosa: IV antipseudomonal β-lactam + IV ciprofloxacin; or IV antipseudomonal β-lactam + IV ciprofloxacin + (IV azithromycin or IV nonpseudomonal fluoroquinolone) ICU = intensive care unit; IV = intravenous; po = by mouth. *Antipseudomonal agent (IDSA): piperacillin, piperacillin-tazobactam, carbapenem, or cefepime. Antipseudomonal β-lactam (ATS): cefepime, imipenem, meropenem, or piperacillin-tazobactam. 384 JCOM July 2002 Vol. 9, No. 7 www.turner-white.com

CIDS/CTS [8] ERS [14] No modifying factors: Macrolide 2nd choice: doxycycline COLD, no recent antibiotics or steroids (3 mo): Azithromycin or clarithromycin 2nd choice: doxycycline COLD with recent antibiotics or steroids: Respiratory fluoroquinolone 2nd choice: amoxicillin-clavulanate + macrolide; or 2nd-generation cephalosporin + macrolide Suspected aspiration: Amoxicillin-clavulanate ± macrolide 2nd choice: antipneumococcal fluoroquinolone + (clindamycin or metronidazole) Nursing home: Antipneumococcal fluoroquinolone alone; or amoxicillin-clavulanate + macrolide 2nd choice: 2nd-generation cephalosporin + macrolide Aminopenicillin (amoxicillin, ampicillin) Alternatives: Tetracycline or oral cephalosporin or antipneumococcal fluroquinolone or oral streptogramin or macrolide Chronic lung disease, recent treatment or failure of aminopenicillin: Aminopenicillin-β-lactamase inhibitor IDSA [7] CDC [13] CIDS/CTS [8] ERS [14] (Cefotaxime or ceftriaxone) + macrolide; or β-lactamβ-lactamase inhibitor + (fluoroquinolone or macrolide) Structural lung disease: Antipseudomal agent* + high-dose ciprofloxacin Suspected aspiration: Fluoroquinolone ± (clindamycinor metronidazole or a β-lactamβ-lactamase inhibitor) (Parenteral cefuroxime or cefotaxime or ceftriaxone or ampicillin-sulbactam) + macrolide Alternative: Antipneumococcal fluroquinolone Antipneumococcal fluoroquinolone Alternative: 2nd-, 3rd-, or 4th-generation cephalosporin + macrolide (IV 2nd- generation cephalosporin or IV 3rdgeneration cephalosporin or oral or IV β-lactam-β-lactamase inhibitor or IV benzyl penicillin or IV amoxicillin or IV ampicillin) ± macrolide Suspected aspiration: IV amoxicillin-clavulanate (Cefotaxime or ceftriaxone or β- lactam-β-lactamase inhibitor) + (fluoroquinolone or macrolide) Structural lung disease: Same as for ward Suspected aspiration: Same as for ward (IV ceftriaxone or cefotaxime) + IV macrolide; or (IV ceftriaxone or cefotaxime) + antipneumococcal fluoroquinolone Alternative (with caution): Antipneumococcal fluroquinolone alone No suspicion of P. aeruginosa: IV antipneumococcal fluoroquinolone + (cefotaxime or ceftriaxone or β-lactamβ-lactamase inhibitor) 2nd choice: IV macrolide + (cefotaxime or ceftriaxone or β-lactam- β-lactamase inhibitor) Suspicion of P. aeruginosa: Ciprofloxacin + (antipseudomoral β-lactam or aminoglycoside) 2nd choice: antipseudomonal β-lactam + aminoglycoside + macrolide (IV 2nd- or 3rd-generation cephalosporin) + (ofloxacin or ciprofloxacinor macrolide ± rifampicin) www.turner-white.com Vol. 9, No. 7 July 2002 JCOM 385

COMMUNITY-ACQUIRED PNEUMONIA Table 5. Guidelines for Duration of Antibiotic Treatment for Patients with Community-Acquired Pneumonia BTS [6] ATS [5] IDSA [7] 7 days for outpatient, inpatient (not severe), or pneumococcal (uncomplicated) 10 days for inpatient (severe) 14 days for atypical pathogen except Legionella 14 21 days for Legionella, staphylococcal, or gram-negative enteric bacilli infections Patients with S. pneumoniae and other bacterial infections (including patients with bacteremia who have a good clinical response): generally, 7 10 days M. pneumoniae, C. pneumoniae, Legionella: 10 14 days Treated with corticosteroids: 14 days Patients with S. pneumoniae: until patient has been afebrile for 72 hr S. aureus, P. aeruginosa, Klebsiella, and anaerobes: 14 days M. pneumoniae, C. pneumoniae, Legionella (in immunocompetent host): 14 days Azithromycin may be used for shorter courses blood pressure 60 mm Hg or lower, and blood urea greater than 7 mmol/l [21]. The BTS rule [22] has been modified with the addition of a fourth core risk factor: presence of confusion on admission, defined as a score of 8 or lower on a 10-point scale. Patients with 2 or more core risk factors from the modified BTS rule receive a recommendation for hospital admission. Patients with 1 core risk factor and an arterial oxygen saturation less than 92% are also eligible for hospital admission. Patients with no core risk factors who have at least one other pre-existing factor (age 50 years, presence of any coexisting chronic illness) and an arterial oxygen saturation less than 92% may be considered for hospital admission. The ATS describes the PSI and the original and modified BTS rules as tools to assist in the admission decision. The ERS does not define criteria for admission to the hospital but does describe criteria for admission to the ICU. Antimicrobial Therapy Outpatient treatment. Atypical pathogens (eg, Legionella, Mycoplasma, Chlamydia) are often identified as sole or possibly co-pathogens in CAP [23 29]. While a secondary analysis of a prospective study has demonstrated that coverage for atypicals may not be required in patients with less severe CAP [15], the ATS, IDSA, and CIDS/CTS recommend that therapy for CAP outpatients include coverage for atypical organisms (Table 3). The BTS recommends that outpatients with CAP be treated with oral amoxicillin. The CDC states that outpatients may be treated with an oral β-lactam with good antipneumococcal activity (eg, cefuroxime, amoxicillin, or amoxicillin-clavulanate). Antibiotic recommendations from the ERS do not reflect a requirement to include coverage for atypical pathogens in the outpatient setting; according to the ERS, the primary choice of antibiotic is an aminopenicillin alone. Inpatient treatment. Similar to their outpatient treatment recommendations, the ATS, IDSA, and CIDS/CTS also recommend empiric coverage for atypicals in hospitalized patients (Table 4). The BTS recommends oral amoxicillin for inpatients with nonsevere CAP but coverage for atypicals in other inpatients. The CDC recommendations for empiric treatment of hospitalized patients with CAP all include coverage for atypical agents. The ERS does not require coverage for atypical pathogens in the inpatient setting, recommending a β-lactam agent plus or minus a macrolide for hospitalized ward patients. The BTS recommends oral therapy for hospitalized patients with nonsevere CAP. Randomized controlled trials have shown that patients hospitalized with CAP may be safely and effectively treated with oral antibiotic therapy [30 32]. Duration of treatment. The optimal duration of antibiotic therapy for CAP remains unestablished. In several randomized controlled trials, duration of therapy ranged between 5 and 14 days [33 38]. Guideline recommendations differ (Table 5). The ATS and ERS state that 7 to 10 days may be appropriate for most patients with S. pneumoniae or other typical bacterial pneumonias. The BTS states that for patients with uncomplicated S. pneumoniae infection and for nonseverely ill patients treated in either the outpatient or inpatient setting, 7 days of therapy is generally sufficient, while patients who are severely ill warrant 10 days of therapy. The IDSA recommends that patients with S. pneumoniae infection should be afebrile for 72 hours prior to discontinuing treatment. Furthermore, the IDSA states that recovery of pathogens that can cause a necrotizing pneumonia (eg, S. aureus, P. aeruginosa, anaerobes) should result in an extension of treatment to at least 14 days. The BTS recommends 14 to 21 days for S. aureus and for gram-negative enteric pneumonias. The ERS states that S. aureus and severe CAP warrant 21 days of treatment. The ATS and ERS recommend that M. pneumoniae and C. pneumoniae infections be treated for 10 to 14 days, the BTS recommends 14 days, and the IDSA recommends at least 14 days. For Legionella infections, the BTS and ATS recommend 10 to 14 days of treatment, the IDSA at least 14 days, and the ERS 21 days of treatment. 386 JCOM July 2002 Vol. 9, No. 7 www.turner-white.com

Appendix. Terms Used in Search Strategy CDC [13] CIDS/CTS [8] ERS [14] Classical bacterial or uncomplicated CAP: 7 10 days M. pneumoniae and C. pneumoniae: 10 14 days Legionella, S. aureus, severe CAP: 21 days Summary The guidelines discussed vary, suggesting that differences in interpretation of the evidence as well as regional differences in antimicrobial resistance, prescribing patterns, and economic pressures may have played a role in guideline development. In general, the North American guidelines (ATS, IDSA, CIDS/CTS, CDC) differ from European guidelines (BTS, ERS) in the areas of chest radiograph, serologies, and empiric antibiotic choice. North American organizations tend to agree that chest radiographs should be performed for all patients with suspected CAP, routine ordering of serologies should be avoided, and empiric antibiotics should cover atypical pathogens. European guidelines recommend that chest radiographs be ordered only for inpatients (BTS) or for those with risk factors (ERS), that serologies be ordered for those with severe CAP (BTS) or routinely for hospitalized patients (ERS), and that penicillin or amoxicillin be the initial empiric antibiotic for outpatient treatment. A possible reason why European guidelines continue to recommend penicillin is that the rate of penicillin-resistant S. pneumoniae is lower in Europe (10.4%) than in North America (14.0%), while the rate of macrolide-resistant S. pneumoniae is higher (20.4% vs. 17.7%) [39]. Another possible reason is that authors of North American guidelines may feel that coverage for atypicals is important in both the inpatient and outpatient settings, while European guideline authors may feel that coverage for atypicals is important only for the sickest hospitalized patients. Based on this review, the answers to the 5 questions posed at the beginning of the article are as follows. Recommendations from the 4 evidence-based guidelines (ATS, BTS, IDSA, CIDS/CTS) are given special emphasis. 1. Should a chest radiograph be performed? Answer: Yes. Three of the 4 evidence-based guidelines (ATS, IDSA, CIDS/CTS) recommend that the chest radiograph be ordered (whenever possible) for all patients with suspected pneumonia. The following MeSH headings were searched using the operator OR: Pneumonia Respiratory tract infections Community-acquired infections The following terms/title words were added to the above search using the operator AND: Antibiotics Antigens, bacterial Blood specimen collection Pneumonia Respiratory tract infections Guidelines Hospitalization Legionnaire s disease Legionella Legionella pneumophila Meta-analysis Practice guidelines Patient admission Patient discharge Radiography, thoracic Serology Sputum Community-acquired* Pathway* Guideline* Outcome* Discharge* *Title word. 2. What other diagnostic tests should be ordered? Answer: Recommendations by 3 of the 4 evidencebased guidelines (ATS, IDSA, CIDS/CTS) indicate that the sputum Gram stain and culture are optional for outpatients but should be performed for inpatients; 2 sets of blood cultures should be drawn for all hospitalized patients with CAP; serologies should not be routinely ordered to diagnose atypical pathogens; and patients with severe CAP (ie, requiring ICU care) should receive legionella urinary antigen testing. 3. Should the patient be managed in the outpatient or inpatient setting? Answer: This decision should be based on several patient-specific factors. Prediction rules such as the PSI [19] and modified BTS rule [22] may assist in the decision-making process, and prediction rules have been endorsed by all 4 evidence-based guidelines. www.turner-white.com Vol. 9, No. 7 July 2002 JCOM 387

COMMUNITY-ACQUIRED PNEUMONIA 4. Which empiric antibiotics should be administered? Answer: Specific recommendations for choice of empiric antibiotics differ amongst the major organizations. Recommendations by 3 of the 4 evidencebased guidelines (ATS, IDSA, CIDS/CTS) support the use of a regimen that possesses activity against atypical pathogens for both the outpatient and inpatient settings. All 6 guidelines support covering for atypicals (in particular, Legionella) in severely ill hospitalized patients. 5. How long should antibiotic treatment last? Answer: Recommendations from major organizations differ with regard to optimal duration of antibiotic therapy. Some organizations recommend that S. pneumoniae and other non-atypical non-necrotizing bacterial pneumonias be treated with an antibiotic course of 10 days or less (BTS, ATS, ERS) or until afebrile for at least 72 hours for S. pneumoniae (IDSA). Treatment for atypical pathogens may warrant longer courses of therapy, ranging from 10 to 21 days. Corresponding author: David C. Rhew, MD, Zynx Health, Inc., 9100 Wilshire Blvd., East Tower, Ste. 655, Beverly Hills, CA 90212. References 1. Heckerling PS, Tape TG, Wigton RS. Relation of physicians predicted probabilities of pneumonia to their utilities for ordering chest x-rays to detect pneumonia. Med Decis Making 1992;12:32 8. 2. Feagan BG, Marrie TJ, Lau CY, et al. Treatment and outcomes of community-acquired pneumonia at Canadian hospitals. CMAJ 2000;162:1415 20. 3. Fine MJ, Stone RA, Singer DE, et al. Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study. Arch Intern Med 1999;159:970 80. 4. Gilbert K, Gleason PP, Singer DE, et al. Variations in antimicrobial use and cost in more than 2,000 patients with community-acquired pneumonia. Am J Med 1998;104:17 27. 5. American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001;163:1730 54. 6. British Thoracic Society Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults. Thorax 2001;56 Suppl 4:IV1 64. 7. Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis 2000;31:347 82. 8. Mandell LA, Marrie TJ, Grossman RF, et al. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. The Canadian Community-Acquired Pneumonia Working Group. Clin Infect Dis 2000;31:383 421. 9. Management of community-acquired pneumonia in adults. South African Pulmonology Society and the Antibiotic Study Group of South Africa. S African Med J 1996;86:1152 63. 10. Niederman MS, Bass JB Jr, Campbell GD, et al. Guidelines for the initial management of adults with communityacquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. American Thoracic Society. Medical Section of the American Lung Association. Am Rev Respir Dis 1993;148:1418 26. 11. Guidelines for the management of community-acquired pneumonia in adults admitted to hospital. The British Thoracic Society. Br J Hosp Med 1993;49:346 50. 12. Bartlett JG, Breiman RF, Mandell LA, File TM Jr. Community-acquired pneumonia in adults: guidelines for management. The Infectious Diseases Society of America. Clin Infect Dis 1998;26:811 38. 13. Heffelfinger JD, Dowell SF, Jorgensen JH, et al. Management of community-acquired pneumonia in the era of pneumococcal resistance: a report from the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group. Arch Intern Med 2000;160:1399 408. 14. ERS Task Force Report. Guidelines for management of adult community-acquired lower respiratory tract infections. European Respiratory Society. Eur Respir J 1998;11:986 91. 15. Mundy LM, Oldach D, Auwaerter PG, et al. Implications for macrolide treatment in community-acquired pneumonia. Hopkins CAP Team. Chest 1998;113:1201 6. 16. Kashuba AD, Ballow CH. Legionella urinary antigen testing: potential impact on diagnosis and antibiotic therapy. Diagn Micro Infect Dis 1996;24:129 39. 17. Waterer GW, Baselski VS, Wunderink RG. Legionella and community-acquired pneumonia: a review of current diagnostic tests from a clinician s viewpoint. Am J Med 2001;110:41 8. 18. Stout JE, Yu VL. Legionellosis. N Engl J Med 1997;337:682 7. 19. Fine MJ, Auble TE, Yealy DM, et al. 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