engleski

Guidelines for the management of community-acquired pneumonia

Despite substantial progress in management options, community-acquired pneumonia (CAP) remains a significant cause of morbidity and mortality worldwide and continues to be surrounded by major controversies. Variations in admission and discharge decision making, diagnostic methods and especially in antibiotic therapy exist among countries, hospitals and individual physicians. In the past decade, numerous guidelines for management of CAP have been published in different countries. Many of these guidelines have similar features, but each is unique in its focus and recommendations. Although these documents can be confusing to the practicing physician, guidelines have been able to organize in a concise way a large amount of information, leading to national standards for the treatment of CAP. Review and comparison of the guidelines from around the world can help in solving some of controversies in the management of pneumonias. The most important guidelines (several American, Canadian, British, European) published within the past three years were reviewed and compared in regards to antimicrobial choices for empiric treatment of CAP. Because of a dynamic correlation between pathogens and antimicrobial drugs, the guidelines should constantly be updated and adapted to new circumstances. Nowdays all guidelines agree that the important part of an initial empiric regimen is coverage of atypical pathogens. For outpatients, North American guidelines, recommend macrolides, doxycycline, or new antipneumococcal fluoroquinolones as treatment options that provide coverage of S. pneumoniae and atypical pathogens. For inpatients preferred options are either an antipneumococcal fluoroquinolone or beta-lactam plus a macrolide. Controversy exists regarding the use of newer macrolides versus newer fluoroquinolones in initial empiric treatment. The literature reports on increasing level of pneumococcal resistance. However, this in vitro resistance level has not been accompanied by reduced rates of clinical efficacy. According to an empirical antibiotic treatment of CAP various practical approaches were developed, which suggested the etiology of pneumonia. In this way the management guidelines are based on disease severity, patient, s age, comorbidity and risk factors, epidemiological characteristics, and especially the treatment setting: outpatients, hospital ward or intensive care unit. Basic clinical classification of pneumonias into bacterial and atypical is also very important. In general, younger patients with no comorbidity are treated at the outpatients with oral administration of macrolides or doxycycline. Patients older than 65 years are most often hospitalized, as well as younger patients with comorbidity, and require parenteral administration of beta-lactam antibiotics. In all hospitalized patients, if the suspicion of legionnaires, disease or other atypical pathogens is present, macrolide antibiotic or quinolone should be added. New fluoroquinolones with good activity against S. pneumoniae can be alternative choice in the empirical treatment of the all above mentioned groups of patients. Modern guidelines for the treatment of CAP predict a switch from parenteral to oral type of drug administration (&#8220 ; switch therapy&#8221 ; ) as soon as the patients, condition stabilizes (most commonly after 72 hours since the initiation of treatment). In general, we recommend penicillins, respectively penicillins with beta-laktamase inhibitor, or a cephalosporins as initial empiric therapy for patients with bacterial CAP. If an atypical respiratory pathogen infection is suspected, a macrolide (azithromycin) or a doxycycline is recommended.

community acquired pneumonia

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