Guidance for Managing Community-Acquired Pneumonia in Immunocompromised Patients Is Published

A multidisciplinary panel of 45 physicians has developed a consensus statement that provides guidance on the initial management strategies that should be considered among immunocompromised patients with suspected community-acquired pneumonia (CAP).

According to the statement’s authors, while current guidelines for CAP management have aided in standardizing initial empiric therapy, the guidelines have not included guidance for the treatment of immunocompromised patients.

“Immunocompromised patients have been excluded from guidelines because of their need for complex, often individualized, treatment, the expanded spectrum of potential pathogens, and their exclusion from the large prospective studies of antibiotic efficacy used to support guideline recommendations,” the authors wrote.

The panel members—who all had experience in managing CAP in patients who are immunocompromised—reviewed all available English literature on the topic. After doing this and reaching consensus, the panel developed 21 general suggestions on empiric therapy, microbiological work-up, likely pathogens, site of care, and population definitions.

Among the suggestions for the management of CAP in patients who are immunocompromised were the following: 

• The decision to perform a bronchoscopy or bronchoalveolar lavage should be individualized.
• Initial empiric therapy targeting only the core respiratory pathogens can be administered without any additional risk factors for drug-resistant bacteria.
• When risk factors for drug-resistant organisms or opportunistic pathogens are present and when the delay in empiric antimicrobial therapy will increase the patient’s risk for mortality, consider extending empiric therapy beyond core respiratory pathogens.
• Use the presence of severe pneumonia as an indication to initiate empiric therapy for resistant gram-positive and gram-negative organisms, followed by rapid de-escalation if no multidrug-resistant pathogen is identified.
• To cover the possibility of CAP due to methicillin-resistant Staphylococcus aureus (MRSA), consider administering initial empiric therapy among patients with a history of colonization or MRSA infection in the previous 12 months.
• Do not begin empiric therapy to cover the possibility of CAP due to parasites.

“Despite our suggestions of empirical therapy for specific pathogens in specific situations, we stress the importance of making a concerted effort to establish a rapid and accurate etiologic diagnosis and to de-escalate complex therapies once a presumptive pathogen is properly ruled out,” the authors concluded. “It is also important to consider local susceptibility patterns when selecting empiric therapy.” 

—Colleen Murphy

Reference:

Ramirez JA, Musher DM, Evans SE, et al. Management of community-acquired pneumonia in immunocompromised adults: a consensus statement regarding initial strategies. Chest. Published online June 16, 2020. doi:10.1016/j.chest.2020.05.598