In this episode, I’ll discuss the recent consensus statement published in CHEST on the Treatment of Community-Acquired Pneumonia in immunocompromised patients.
Authors in the journal CHEST published a consensus statement on the Treatment of Community-Acquired Pneumonia in immunocompromised patients. This patient population was left out of the updated IDSA CAP guidelines likely because of their exclusion from the major prospective studies used to support evidence-based guideline recommendations.
The consensus statement contains answers to over 20 questions about the care of immunocompromised patients with CAP.
Question 8: What empiric therapy should be started in hospitalized patients with CAP who are immunocompromised?
We suggest that immunocompromised patients without any additional risk factors for drug-resistant bacteria can receive initial empirical therapy targeting only the core respiratory pathogens.
This recommendation is made because many immunocompromised patients do not have additional risk factors for drug-resistant pathogens. The authors consider the core respiratory pathogens for CAP to be:
Gram positives: Streptococcus and MSSA
Gram negatives: H. influenza, M. catarrhalis, Klebsiella, and E coli
Atypicals: Legionella, Chlamydophila, Mycoplasma, and Coxiella
These are essentially the same pathogens empiric therapy in the IDSA CAP guidelines are directed to.
Question 9: In which patients with CAP who are immunocompromised should empiric therapy be extended beyond the core respiratory pathogens?
We suggest to extend empirical therapy beyond core respiratory pathogens when (1) risk factors for drug-resistant organisms or opportunistic pathogens are present and (2) the delay in waiting for identification of the pathogen for choosing empirical antimicrobial therapy will place the patient at increased risk of mortality.
The authors predict that the need for empiric therapy for other pathogens will continue to evolve as more point-of-care tests are developed for rapid diagnosis, especially for opportunistic pathogens.
Question 10: What role does the severity of pneumonia play in the selection of initial empiric therapy?
We suggest that the presence of severe pneumonia can be used as an indication to start empirical therapy for resistant gram-positive and gram-negative organisms, followed by rapid deescalation if no multidrug-resistant pathogen is identified.
The main point the authors make within the details of this response is that normal pathogens, like strep pneumo or legionella can cause a severe pneumonia, so that alone is not a predictor of infection with resistant organisms. At issue though is that with severe pneumonia, the risk of missing a resistant pathogen with the initial empiric coverage is of greater consequence. Therefore the preference is for broad coverage with prompt de-escalation.
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