COVID-19 Pandemic Requires Reinterpretation of Community-Acquired Pneumonia Guidelines

By Will Boggs MD

May 12, 2020

NEW YORK (Reuters Health) - The recently released guidelines for treating adults with community-acquired pneumonia (CAP) need to be reinterpreted in the context of the COVID-19 pandemic, the guideline co-chairs say.

"It is important to remember that even during the peak of the COVID-19 pandemic, there are other microbiological causes of community-acquired pneumonia and the available coverage guidelines for CAP can be applied in this setting," Dr. Joshua P. Metlay from Massachusetts General Hospital and Harvard Medical School, Boston, told Reuters Health by email.

Writing in Annals of Internal Medicine, Dr. Metlay and Dr. Grant W. Waterer from Royal Perth Hospital and University of Western Australia offer their interpretation of the American Thoracic Society and Infectious Diseases Society of America Guideline for Treatment of Adults with Community-Acquired Pneumonia as it applies to the management of patients with COVID-19.

They offer five principles. First, they recommend empirical coverage for bacterial pathogens in patients with CAP without confirmed COVID-19, but not necessarily in all patients with confirmed COVID-19-related pneumonia.

"The issue of whether to treat all or some patients with proven COVID-19 and pneumonia with antibacterial therapy for community-acquired pneumonia is controversial and will require more study, especially in terms of optimally defining the population that needs antibiotic treatment," Dr. Metlay said.

Second, the relevant bacterial pathogens in patients with COVID-19 and pneumonia are likely to be the same as in previous patients with CAP, so the empirical antibiotic recommendations should be the same.

The guideline recommends a beta-lactam or a respiratory fluoroquinolone as monotherapy for low-risk inpatients and a beta-lactam plus macrolide or beta-lactam plus fluoroquinolone for high-risk/ICU patients with bacterial CAP.

Third, testing for bacterial pathogens with sputum and blood cultures should be considered when there is concern for multidrug-resistant pathogens, including Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus.

Fourth, an elevated procalcitonin level is a useful biomarker for bacterial pneumonia, so a low procalcitonin level early in the course of confirmed COVID-19 illness can support the decision to withhold antibiotics or to discontinue them early, especially among patients with less severe disease.

Finally, while immunologic processes likely play a key role in the lung damage that leads to respiratory failure and adverse outcomes in patients with COVID-19, corticosteroids and other immunomodulating therapies are not currently recommended as adjunct treatments for patients with COVID-19-related pneumonia.

The authors note that additional research is needed to address the many unanswered questions regarding the management of patients with COVID-19-related pneumonia, including risk factors for bacterial co-infection, the prevalence of multidrug-resistant and other pathogens, the role of biomarkers like procalcitonin, and the safety and efficacy of immunomodulating therapies.

"The push to develop effective antiviral therapy will be a key advance in the treatment of CAP, especially as viral causes of CAP have become increasingly more common even before the COVID-19 pandemic," Dr. Metlay added.

SOURCE: https://bit.ly/2YVe0RB Annals of Internal Medicine, online May 7, 2020.

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