This protocol covers adults (age 18 years or older) admitted to hospital with severe community-acquired pneumonia who have no risk factors for MRSA or Pseudomonas aeruginosa — a patient group for whom a distinct antibiotic strategy applies.
Severe CAP is defined by at least one major criterion or three or more minor criteria. Management takes place in the inpatient setting. The absence of MRSA and Pseudomonas aeruginosa risk factors is central to antibiotic selection in this population.
Combination antibiotic therapy anchored by a β-lactam is recommended, paired with one of two guideline-supported complementary antibiotic classes — both combinations carry strong recommendations. Once stability criteria are reached, transition from intravenous to oral therapy is appropriate. The complete regimen, agent selection, and timing criteria are in the full protocol.
The treatment target is clinical stability: resolution of vital sign abnormalities (heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature), the ability to eat, and normal mentation. Most patients achieve stability within the first 48 to 72 hours, guiding the minimum duration of therapy.
In inpatient adults with severe CAP without risk factors for MRSA or P. aeruginosa, we recommend (note, specific agents and doses are the same as 9.1):
Validated definition includes either one major criterion or three or more minor criteria.
a β-lactam plus a macrolide (strong recommendation, moderate quality of evidence); or a β-lactam plus a respiratory fluoroquinolone (strong recommendation, low quality of evidence).
We recommend that the duration of antibiotic therapy should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities [heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature], ability to eat, and normal mentation), and antibiotic therapy should be continued until the patient achieves stability and for no less than a total of 5 days (strong recommendation, moderate quality of evidence).
As most patients will achieve clinical stability within the first 48 to 72 hours, a total duration of therapy of 5 days will be appropriate for most patients.
DOI: 10.1164/rccm.201908-1581ST
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