Guidelines for severe community-acquired pneumonia in the western world

Background: Recently, several guidelines (ATS 1993/LDSA 1998; ERS 1998; SWA B 1998) have been issued for the initial therapy of patients with community -acquired pneumonia. In patients who fulfil the criteria for severe communi ty-acquired pneumonia (SCAP), it was advised to start with a macrolide (act ive against Legionella spp. and Mycoplasma pneumoniae) in combination with an agent active against both pneumococci and Pseudomonas aeruginosa by the ATS/IDSA guidelines, while the ERS suggested starting with a second or thir d generation cephalosporin, in combination with either a macrolide or secon d generation quinolon plus or minus rifampicin. In the SWAB guidelines, no recommendations for SCAP were made. Methods: Sixty-two cases admitted to the intensive care units of a tertiary -care university hospital with SCAP between 1992 and 1996 were studied retr ospectively The causative pathogens, clinical and laboratory characteristic s of severity, antibiotic therapy and mortality were analysed. Immunocompro mised patients, patients using immunosuppressive agents and patients with a malignancy were excluded. Results: Indices of severe illness were widely seen and 37% developed shock while 45% required vasoactive drugs. Bilobular or multilobular abnormaliti es were seen in 34% of the patients. Forty-five patients (73%) required art ificial respiration and 54 (87%) had an underlying disease. The overall mor tality was 42%. in 41 patients (66%), a pathogen was isolated. The most fre quent causes of SCAP in this study were Streptococcus pneumoniae (22 cases or 35%), Haemophilus influenzae (seven cases or 11%). Pseudomonas aeruginos a (four cases or 7%), and other Enterobacteriaceae (twice in combination wi th pneumococci and once with H. influenzae). Legionella pneumophila was ide ntified in three cases. In patients with severe chronic obstructive pulmona ry disease (COPD), pneumococci were the most important pathogens six cases or 27%), followed by P. aeruginosa (14%) and H. influenzae (14%). Conclusions: The guidelines for the management of SCAP issued by the ATS an d IDSA in 1993 are only partially adequate in the Dutch setting. Coverage o f P. aeruginosa would seem useful, given the fact that isolation of this pa thogen has been shown to be a predictor of mortality, but only in patients with severe COPD or structural disease of the lung, and especially in patie nts in whom the Gram stain reveals Gram-negative rods, as is also suggested in the revised IDSA guidelines (1998). Risk factors for P. aeruginosa coul d be added to the ERS guidelines. Including SCAP as a separate entity in th e SWAB guidelines may be useful. (See Editorial p. 103) (C) 1999 Elsevier S cience B.V. All rights reserved.