CONFERENCE UPDATE: ERS 2023
A comprehensive approach to the management of sCAP: The 2023 ERS/ESICM/ESCMID/ALAT guidelines
Community-acquired pneumonia (CAP) is a common respiratory infectious disease and approximately 40% of patients affected will require hospitalization.1 Among these patients, 5% will be admitted to the intensive care unit (ICU) and are referred to as having severe CAP (sCAP).1 While previous guidelines on general CAP management have included a subsection on managing sCAP, these recommendations only cover some aspects while failing to include or sufficiently develop other aspects of sCAP management.1
These new international guidelines have been collectively developed by the European Respiratory Society (ERS), the European Society of Intensive Care Medicine (ESICM), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), and the Asociación Latinoamericana del Tórax (Latin American Thoracic Association; ALAT).1 The main objective of these guidelines is to provide guidance on the most effective treatments and management strategies specifically for adult patients with sCAP.1
Professor Ignacio Martin-Loeches from the Multidisciplinary Intensive Care Research Organization (MICRO) of Trinity College, Republic of Ireland presented the guidelines at the ERS International Congress 2023.1 These guidelines focus on 8 clinical questions which cover the areas of diagnosis, biomarkers, stratification for severity, antibiotic treatment, and co-adjuvant treatments.1 These recommendations will help standardize the treatment and management of critically ill patients with sCAP, benefitting patients with the highest disease severity and mortality risk.1 Moreover, a multidisciplinary approach involving specialists from different healthcare systems and medical domains was used to develop these guidelines, which further highlight current knowledge gaps and recommendations for future research.1
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Questions |
Recommendations |
Level of Evidence |
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1. In patients with sCAP, should rapid microbiological techniques be added to current testing of blood and respiratory tract samples? |
If the technology is available, we suggest sending a lower respiratory tract sample (either sputum or endotracheal aspirates) for multiplex PCR testing (virus and/or bacterial detection) whenever non-standard sCAP antibiotics are prescribed or considered |
Conditional recommendation, very low quality of evidence |
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2. In hypoxemic patients with sCAP, can either NIV or HFNO be used initially rather than supplemental standard oxygen administration to avoid intubation and reduce mortality? |
In patients with sCAP and acute hypoxemic respiratory failure not needing immediate intubation, we suggest using HFNO instead of standard oxygen |
Conditional recommendation, very low quality of evidence |
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NIV might be an option in certain patients with persistent hypoxemic respiratory failure not needing immediate intubation, irrespective of HFNO |
Conditional recommendation, low quality of evidence
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3. When using initial empirical therapy for sCAP, should a macrolide or fluoroquinolone be used as part of combination therapy, to reduce mortality and adverse clinical outcomes? |
We suggest the addition of macrolides, not fluoroquinolones, to beta-lactams as empirical antibiotic therapy in hospitalized patients with sCAP |
Conditional recommendation, very low quality of evidence. |
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4. In patients with sCAP, can serum PCT be used to reduce the duration of antibiotic therapy and improve other outcomes in comparison to standard of care not guided by serial biomarker measurements? |
We suggest the use of PCT to reduce the duration of antibiotic treatment in patients with sCAP |
Conditional recommendation, low quality of evidence |
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5. Should oseltamivir be added to standard therapy in patients with sCAP and confirmed influenza? |
We suggest the use of oseltamivir for patients with sCAP due to influenza confirmed by PCR |
Conditional recommendation, very low quality of evidence |
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When PCR is not available to confirm influenza, we suggest the use of empirical oseltamivir during the influenza season |
Conditional recommendation, very low quality of evidence |
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6. Does the addition of steroids to antibiotic therapy in specific sCAP populations lead to better outcomes in comparison to when steroid therapy is not used? |
In patients with sCAP, we suggest the use of corticosteroids if shock is present |
Conditional recommendation, low quality of evidence |
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7. Does the use of a prediction score for drug-resistant pathogens lead to more appropriate therapy and improved outcomes (mortality, treatment failure, duration of antibiotic therapy, prolonged ICU stay)? |
We suggest integrating specific risk factors (eventually computed into clinical scores) based on local epidemiology and previous colonization to guide decisions regarding drug-resistant pathogens (excluding those immunocompromised) and empirical antibiotic prescription in sCAP patients |
Conditional recommendation, moderate quality of evidence |
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8. Do patients with sCAP and aspiration risk factors have better outcomes (mortality, length of stay, treatment failure) if treated with a risk-based therapy regimen instead of standard sCAP antibiotics? |
In patients with sCAP and aspiration risk factors, we suggest standard CAP therapy regimen and not specific therapy targeting anaerobic bacteria
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Ungraded, good practice statement |
Table 1: Summary of research questions and recommendations
HFNO: High-flow nasal oxygen; ICU: Intensive care unit; NIV: Non-invasive ventilation; PCT: Procalcitonin; PCR: Polymerase chain reaction; sCAP: Severe community-acquired pneumonia
