Pneumonia, a preventable yet deadly disease, claimed over two million lives in 2021, according to the Global Burden of Disease report. This alarming statistic underscores the critical need for evidence-based guidance on its diagnosis and management. The American Thoracic Society has recently published a new clinical practice guideline (CPG) that expands upon its 2019 recommendations, offering fresh insights into the treatment of pneumonia in adults.
One of the key highlights of the new guideline is the treatment duration with antibiotics. Julio Ramirez, MD, co-lead of the guideline panel and emeritus professor of medicine in the Division of Infectious Diseases at the University of Louisville, emphasizes the importance of tailoring the duration of therapy to the individual. If the patient does not have severe pneumonia and the symptoms improve within three days of treatment, the patient can be treated with a minimum of three days of therapy. This personalized approach is a significant departure from previous guidelines, reflecting the latest understanding of pneumonia's progression and response to treatment.
The latest guideline, published early online in the American Journal of Respiratory and Critical Care Medicine, provides updates to two questions from the 2019 guideline and addresses two new questions: the use of ultrasound for the diagnosis of pneumonia and the need for antibiotic therapy in patients with a positive test for a viral pathogen. It also includes a very important table that provides a framework for individualization of the recommendations, since most of them are conditional (without high-quality evidence).
Using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework, the panel made the following recommendations:
Should lung ultrasound be considered a reasonable alternative to chest x-ray for diagnosis in adults with suspected community-acquired pneumonia (CAP)? (New)
For adults with suspected CAP, we suggest lung ultrasound is an acceptable alternative to chest x-ray in medical centers where appropriate clinical expertise exists (conditional recommendation, low-quality evidence).Should adults with community-acquired pneumonia who test positive for a respiratory virus be treated with antibacterial therapy? (New)
For adult outpatients without co-morbidities who have clinical and imaging evidence of CAP and who test positive for a respiratory virus, we suggest not prescribing empiric antibiotics (conditional recommendation, very low-quality evidence).Should adults with community-acquired pneumonia who reach clinical stability be treated with less than 5 days of antibiotics? (Update from 2019)
For adult outpatients with CAP who reach clinical stability, we suggest less than five days of antibiotics (minimum of 3 days duration), rather than five or more days of antibiotics (conditional recommendation, low-quality evidence).Should adults who are hospitalized with community-acquired pneumonia be treated with corticosteroids? (Update from 2019)
For adult inpatients with non-severe CAP, we recommend NOT administering systemic corticosteroids (strong recommendation, low-quality evidence).
For adult inpatients with severe CAP, we suggest systemic corticosteroids (conditional recommendation, low-quality evidence).
For patients like Lauren Surett of North Carolina, the value of evolving clinical guidelines is clear. Her experience with pneumonia has reshaped how she thinks about respiratory illness, public health, and the need for clear, up-to-date clinical guidance that reflects how viruses and bacteria evolve – and how those changes affect real people's lives.
For a quick reference, watch this video for a summary of the guidelines. The ATS has published more than 30 clinical practice guidelines since 2016 on various conditions, ranging from allergy and asthma to TB and other pulmonary infections. The Society also develops guideline implementation tools and derivatives.
