Guidelines for the management of community ... - Brit Thoracic

BTS guidelines
services, with appropriate modification to take into account
differences in licensing and availability of antimicrobial agents.
1.5 What patient populations are we including and excluding?
These guidelines address the management of unselected adults
with CAP who are managed by their general practitioner or
admitted to hospital as an emergency.
Although there are similarities in the principles of management
between pneumonic lower respiratory tract infection (ie,
CAP) and non-pneumonic lower respiratory tract infection,
there are differences in the aetiology, severity assessment,
management and outcome. Recommendations for the antibiotic
management of acute exacerbations of chronic obstructive
pulmonary disease (COPD) are included in the guideline on the
management of COPD published by the National Institute of
Health and Clinical Excellence (NICE). 7
We do not consider the management of pneumonia in:
c Patients where the pneumonia is an expected terminal event
or who are known to have lung cancer, pulmonary
tuberculosis or cystic fibrosis or primary immune deficiency
or secondary immune deficiency related to HIV infection, or
drug or systemic disease-induced immunosuppression. We
do include patients receiving oral corticosteroid therapy as
this is a not uncommon situation for patients admitted on
medical take.
c Patients who have been in hospital within the previous
10 days and may have hospital acquired pneumonia.
Patients admitted from healthcare facilities such as nursing
homes and residential homes will be commented on
separately.
c Children with CAP (please refer to the BTS guidelines for
the management of CAP in childhood 8 ).
1.6 What changes have happened in the area of CAP since the
2004 guidelines?
c Concerns regarding health care-associated infections
(HCAIs), particularly methicillin-resistant Staphylococcus
aureus (MRSA) and Clostridium difficile infection, have
grown in recent years. These HCAIs are associated with
volume of antibiotic use. Antibiotic stewardship should
now be an essential responsibility for all clinicians. Measures
to avoid and reduce inappropriate antibiotic use are therefore
at the forefront of management strategies for all
infective episodes. 9
c Fluoroquinolone antibiotics with enhanced activity against
Gram-positive organisms (the so-called ‘‘respiratory quinolones’’
such as levofloxacin and moxifloxacin) have been
widely available for some years now. Their activity against
most major respiratory pathogens led initially to widespread
use of these antibiotics for respiratory tract infections,
including CAP. However, more recently these antibiotics
have been associated with both methicillin-resistant S aureus
10 11
(MRSA) and C difficile infections. This has promoted
increasing pressure to limit the use of these antibiotics in
favour of other classes of antibiotics where appropriate. 9
c Antimicrobial resistance in Streptococcus pneumoniae was
noted to rise in the late 1990s. Fortunately, a reversal of this
trend has been observed in the last 5 years, with rates of
penicillin-resistant S pneumoniae in the UK remaining below
4% (see Section 8.4).
c Pneumonia admissions to hospital rose by 34% between
1997–8 and 2004–5. 12 This was matched by an increase in
admissions to intensive care units for CAP 13 (see Section
2.1).
Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
c
c
c
The processes for managing acutely ill medical patients
admitted to hospital have undergone important changes.
The specialty of acute medicine has developed substantially
and, in many hospitals, teams run by acute medicine
physicians are already taking responsibility for the early
stages of acutely ill medical patients. This shift, together
with the demands on junior doctors’ hours arising from the
European Working Time Directive, mean that patient care
increasingly involves different teams of doctors. Effective
handover between teams, careful patient review and
coherent clinical guidelines are key aspects of patient
management in this context. 14
Timeliness of treatment has enlarged as a priority in clinical
care processes. This is perhaps most evident in the ‘‘4-hour
admission to treatment’’ target applied to emergency
departments across the UK. 15 Increased attention to speed
to treatment as a measure of performance may have the
inadvertent effect of increasing the inappropriate or
excessive use of antibiotics in patients with suspected but
unconfirmed CAP, thus exacerbating any existing problems
with HCAIs (see Section 8.9).
Newer microbiological tests for the detection of infection by
respiratory pathogens such as urine antigen tests are
becoming increasing available routinely, while previously
established tests such as complement fixation tests are
gradually being phased out.
1.7 Guidelines Committee membership
The Guidelines Committee was established in January 2008
with representatives from a range of professional groups
including the Royal College of General Practitioners, Royal
College of Physicians, British Geriatric Society, British Infection
Society, British Society for Antimicrobial Chemotherapy,
General Practice Airways Group, Health Protection Agency
and the Society for Acute Medicine (see Section 11). Three
members in the current committee also served on the 2001 and
2004 Guidelines Committee.
The Guidelines Committee agreed the remit of the guidelines.
The Centre for Reviews and Dissemination and Centre for
Health Economics at the University of York was commissioned
by the BTS to undertake literature searches on behalf of the
Guidelines Committee.
1.8 How the evidence was assimilated into the guidelines
1.8.1 Literature searches
Systematic electronic database searches were conducted in order
to identify potentially relevant studies for inclusion in the CAP
guidelines. For each topic area the following databases were
searched: Ovid MEDLINE (including MEDLINE In Process),
Ovid EMBASE, Ovid CINAHL and the Cochrane Library
(including the Cochrane Database of Systematic Reviews, the
Database of Abstracts of Reviews of Effects, the Cochrane
Central Register of Controlled Trials, the Health Technology
Assessment database and the NHS Economic Evaluation
Database).
The searches were first run in December 2007 and were
updated in August 2008. Searches included a combination of
indexing terms and free text terms, and were limited to English
language publications only. Full search strategies for each
database are available in the web-based supplement.
1.8.2 Appraisal of the literature
One individual (HR) read the title and abstract of each article
retrieved by the literature searches and decided whether the
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