Guidelines for diagnosis and management of community-and hospital-acquired pneumonia in adults: Joint ICS/NCCP(I) recommendations

SYNOPSIS OF RECOMMENDATIONS Diagnosis and management of community-acquired pneumonia (CAP) What is the role of chest radiograph in the diagnosis of CAP? Wherever feasible, a chest radiograph should be obtained in all patients suspected of having CAP (1A). In the absence of availability of chest radiograph, patients may be treated on the basis of clinical suspicion (3A). Chest radiograph should be repeated if the patient is not improving and also for all those patients who have persistence or worsening of symptoms/physical signs or those in whom an underlying malignancy needs to be excluded. It is not routinely necessary to repeat a chest radiograph in patients who have improved clinically (2A). What is the role of computed tomography (CT) in the diagnosis of CAP? T of the thorax should not be performed routinely in patients with CAP (2A). CT of the chest should be performed in those with non-resolving pneumonia and for the assessment of complications of CAP (2A). Which microbiological investigations need to be performed in CAP? Blood cultures Blood cultures should be obtained in all hospitalized patients with CAP (2A). Blood cultures are not required in routine outpatient management of CAP (2A). Sputum Gram stain and cultures An initial sputum Gram stain and culture (or an invasive respiratory sample as appropriate) should be obtained in all hospitalized patients with CAP (2A). Sputum quality should be ensured for interpreting Gram stain results (2A). Sputum for acid-fast bacilli (AFB) should be obtained as per RNTCP guidelines for non-responders (UPP). Pneumococcal antigen detection Pneumococcal antigen detection test is not required routinely for the management of CAP (2A). Pneumococcal PCR Pneumococcal PCR is not recommended as a routine diagnostic test in patients with CAP (1A) Legionella antigen detection Legionella urinary antigen test is desirable in patients with severe CAP (1B). Other atypical pathogens Investigations for atypical pathogens like Mycoplasma, Chlamydia, and viruses need not be routinely done (2A). What general investigations are required in patients with CAP? For patients managed in an outpatient setting, no investigations are routinely required apart from a chest radiograph (3A). Pulse oximetry is desirable in outpatients (2B). Pulse oximetric saturation, if available, should be obtained as early as possible in admitted patients (2A). Arterial blood gas analysis should be performed in those with an oxygen saturation ≤90% and in those with chronic lung disease (3A). Blood glucose, urea, and electrolytes should be obtained in all hospitalized patients with CAP (3A). Full blood count and liver function tests are also helpful in the management of patients with CAP (3B). What is the role of biomarkers in the diagnosis of CAP? Procalcitonin and CRP measurement need not be performed as routine investigations for the diagnosis of CAP (2A). Should patients with CAP be risk stratified? What should be the optimum method of risk stratification? Patients with community-acquired pneumonia should be risk stratified (1A). Risk stratification should be performed in two steps [Figure 1] based upon the need for hospital admission followed by assessment of the site of admission (non-ICU vs. ICU). Accordingly, patients can be managed as either outpatient or inpatient (ward or ICU) (1A). Initial assessment should be done with CRB-65. If the score is >1, patients should be considered for admission (1A). Clinical judgment should be applied as a decision modifier in all cases (3A). Pulse oximetry can be used to admit hypoxemic patients (2A). Hypoxemia is defined as pulse oximetric saturation ≤92% and ≤90% for age ≤50 and >50 years, respectively (3A). Patients selected for admission can be triaged to the ward (non-ICU)/ICU based upon the major/minor criteria outlined in Table 6 (2A). If any major criterion or ≥3 minor criteria are fulfilled, patients should generally be admitted to the ICU (1A). Figure 1: Algorithmic approach to diagnosis and management of CAP (ARDS, acute respiratory distress syndrome; CXR, chest radiograph; ICU, intensive care unit; LFTs, liver function tests; SaO2, arterial saturation)What practices are recommended regarding use of antibiotics in CAP? Antibiotics should be as early as is in severe CAP (2A). What should be the in the outpatient should be of the (1A). should be stratified as those with or (3A). antibiotics are or for outpatient (1A). For outpatients with is recommended (1A). is to (3B). should not be used for (1A). Antibiotics should be in to of (1A). What should be the in the hospitalized recommended is a of a a and (1A). In the of to respiratory may be used if is not a diagnostic admission (1A). Patients should also sputum for acid-fast bacilli if are used in of of or should be based upon the clinical of the patient and the judgment regarding and of the antibiotics (3A). to from is clinical in to severe CAP (2A). What should be the in ICU recommended is a or a for patients risk for (2A). If is an an or should be (2A). may be considered with of (3A). may be used if is not a diagnostic admission (1A). Patients should also sputum for acid-fast bacilli if are should be to (2A). should be done for chest as required (1A). If a patient not to should be for the of of of atypical (3A). to from is clinical in to severe CAP (2A). should patients be Patients can be considered for if are and are for a of (2A). should be treated for and for (1A). Antibiotics may be in patients with and CAP by Legionella and bacilli (2A). Antibiotics may also be the for those with or with lung and if the initial not the (3A). What is the role of biomarkers in the of CAP? should not be routinely used to as not to clinical (1A). What are for the management of CAP? are not recommended for use in CAP (2A). should be used for or in to CAP to the management for (1A). is no role of chest and in the routine management of CAP (1A). and CAP to and should be managed to the management for (1A). may be used in patients with CAP and acute respiratory (2A). What is the role of and for the of CAP? use of for of CAP is not recommended (1A). Pneumococcal may be considered for of CAP in who are risk for invasive disease (2A). should be considered in for of CAP (3A). should be for all (1A). Diagnosis and management of pneumonia pneumonia What is the of pneumonia risk stratification regarding of should be an of for (UPP). What is the of are the pathogens in the and should be routinely considered as the of What is the approach to diagnosis of can be clinically defined [Figure criteria (2A). In patients with a suspicion of for the of should be done (2A). In patients with suspected or respiratory and blood should be for cultures to of antibiotics (1A). patients suspected of having should be with sputum (3A). CT should not be routinely obtained for (3A). cultures can performed in of cultures (1A). management should not be in clinically patients for the of diagnostic (UPP). Figure Algorithmic approach to diagnosis and management of of culture cultures of respiratory are and for the of as to cultures (UPP). invasive to respiratory and or cultures like or and are for the diagnosis of (2A). culture on sample obtained a is a (2A). In a patient suspected of having the method for respiratory sample or or upon and is the and (UPP). What is the role of biomarkers in the diagnosis of biomarkers should not be used to (1A). available, may in and may in for (2B). either used clinical and can be to and and (UPP). on the to be in a of suspected should have for in based on microbiological and (1A). should be In not have the in guidelines is recommended (3A). should What is the role of routine culture culture is not An approach should be followed (2A). a of for the of and is no to is to the recommended initial as a to the of pathogens in and with an to the of of the initial (UPP). the culture are available, the should be to the (1A). What is the recommended for antibiotics in suspected In patients with suspected antibiotics should be as early as possible the for culture (1A). of to be is based on of and initial should be to the culture are (1A). is not recommended as an initial for (3A). with and is not recommended (2A). What is the for for of antibiotics is recommended (1A). as the on microbiological should be of antibiotics [Figure patients with suspected in whom an for is is recommended antibiotics should be (1A). If cultures are of and is clinical with cultures antibiotics should be for followed by assessment of on the If is antibiotics can be if is should be for If cultures antibiotics are and is clinical is recommended a of the management the of antibiotics be should be repeated of also needs to for of or of and should not be used as a routine in all patients if cultures are and is clinical worsening (3A). What is the of In patients with to and a of is recommended (1A). of on may the patients in whom be early (2A). In patients with who are clinically a of antibiotics is recommended (1A). of antibiotics in patients to is recommended as is with clinical (2A). What is the role of antibiotics in the of antibiotics and may be a to antibiotics in the of pathogens is a (2A). antibiotics should not be used as and should be used with antibiotics (2A). Should Patients with should not be treated with antibiotics (2A). What are the of for of In patients with suspected the use of (1A) or (2A). use of in should be of use in is an to (1A) if the patient is and is to For of the and (2A). with and or for cases or suspected cases with may be should be in patients to (2B). to For of initial with a and either a or an (1A). should be to What are the practices to be followed in the should be used in patients with or should be used in patients with is to and should be used and in those any to with a or a should be routinely used in all ICU patients with no to of is recommended in patients with a or a Blood should be a of in those with and is in patients with count or if is is if is a in the tests and is or if a is is an clinical is by a as as a general In of of on the to are guidelines to are no the in of and the clinical is of in the It considered to guidelines for the use of of pneumonia guidelines as a by the of of and with from two Chest and of Chest for of the two and from and those from the of and followed by a of performed by the the of in major guidelines from the of and also Diagnosis of community-acquired pneumonia of Diagnosis of and pneumonia and of and with a and a on the basis of on with to the as as the to all the the for of and in and in the of all the in the based on a approach on the used for the quality of as or of as or upon the of in the guidelines should be as recommended and the as a the of and in the of also 1: of of and of based on the quality of the by the as as by What is the of CAP? CAP can be defined on clinical and In the absence of chest radiograph, CAP is defined of an acute respiratory with or of chest for and and severe and chest signs on with no for the from a chest radiograph is available, CAP is defined and signs as with for is no to or may be in the of a or of a or or with no and What is the of CAP in the to the in the hospitalized with pneumonia and from the disease in from are in Table of on of CAP from the is the of CAP in are no from on the of on the of by respiratory are of to respiratory in the to for for and of the to in is by respiratory of CAP from is to in the In of patients admitted with patients In on patients with CAP of and of patients to or respiratory and in from for respiratory in is the of CAP microbiological diagnosis be in of cases of CAP is the the in is are for CAP in as as of the is for culture in In from patients hospitalized for CAP an in as to in the of the of CAP from is the of CAP in are on the of In a of blood cultures performed in the followed by and An also to be the also in of the Legionella is an is not considered in the In a of patients with CAP for and to be the in of are no have viruses as the of CAP apart from the in is the in hospitalized patients with for of also In the microbiological in the not from those of the disease is a in patients with It the underlying cases in and the in of is to patients the of and bacilli may be in not to the of the risk for CAP with a is in patients with of CAP are in CAP also severe in is not In to the no to of in the or are not in to the with also to be in patients with pneumonia to those with either pneumonia or CAP of also is with a is to worsening of and disease and not to an is a in Risk for pneumonia chronic respiratory and chronic have all to be of CAP to In the of a chronic or the of Diagnosis What are the clinical of CAP and is in of CAP sputum and chest may of and of is an not in of of the clinical signs either or in is and are to for the diagnosis of and pulse oximetric saturation have to be of no is and to CAP from respiratory and with a are by patients with clinical may be with atypical pathogens like and of the of of is the role of chest radiograph in the diagnosis of CAP? chest radiograph is the for the diagnosis of In a of patients with respiratory judgment of pneumonia a of of of and a of to the chest In patients with a chest are for the diagnosis of CAP in the of signs and diagnosis of CAP can be suspected if of the is on the chest an in lung with of an of by a lung as a if an is obtained as a of the and for with or of is to in the of and chest radiograph is also helpful in CAP from of acute respiratory like or of chest radiograph may clinical and to of patients may not may be in the Patients with have or the clinical of clinical or In the of clinical to a chest of by 6 in of or like and Wherever feasible, a chest radiograph should be obtained in all patients suspected of having CAP (1A). In the absence of availability of chest radiograph, patients may be treated on the basis of clinical suspicion (3A). Chest radiograph should be repeated if the patient is not improving and also for all those patients who have persistence or worsening of symptoms/physical signs or those in whom an underlying malignancy needs to be excluded. It is not routinely necessary to repeat a chest radiograph in patients who have improved clinically (2A). What is the role of computed tomography (CT) in the diagnosis of CAP? CT of CAP and of the In a of patients with the followed by and and also with pneumonia of and in the lung the for pneumonia and CT pneumonia from pneumonia with a and of and are not for CT chest be in the diagnosis of complications of pneumonia like lung and In to of pneumonia be on CT with a or chest have clinical and based on to chest are the clinical of a CT chest in patients with suspected CAP and a chest radiograph CT is an diagnostic with and the risk of CT of the thorax should not be performed routinely in patients with CAP (2A). CT of the chest should be performed in those with non-resolving pneumonia and for the assessment of complications of CAP (2A). Which microbiological investigations need to be performed in CAP? Blood cultures Blood cultures have a in the of blood cultures and in In a of in of patients and of all patients blood In a blood cultures in of to in and in of a in of the of blood the of CAP is in a of patients with Blood cultures should be obtained in all hospitalized patients with CAP (2A). Blood cultures are not required in routine outpatient management of CAP (2A). Sputum Gram stain and cultures of sputum cultures from to In a of the and of sputum Gram stain and in the diagnosis of to sputum a Gram stain of sputum is as results and can the to from sputum should be of in should be If are the sample should be for If the of is the of with to of a of the should be for to the on pneumonia for of invasive for the of respiratory An initial sputum Gram stain and culture (or an invasive respiratory sample as appropriate) should be obtained in all hospitalized patients with CAP (2A). Sputum quality should be ensured for interpreting Gram stain results (2A). Sputum for acid-fast bacilli (AFB) should be obtained as per RNTCP guidelines for non-responders (UPP). Pneumococcal antigen detection Pneumococcal antigen can be in the from to to stain of sputum or cultures of sputum and all are to the test a any in the the and availability of the may not have a Pneumococcal antigen detection test is not required routinely for the management of CAP (2A). Pneumococcal PCR Pneumococcal PCR a In a the and for PCR as and or patients with by as in blood and Pneumococcal PCR is not recommended as a routine diagnostic test in patients with CAP (1A). Legionella antigen detection and of for Legionella urinary antigen detection is and In the in the patients from results of the Legionella urinary antigen Legionella is an of CAP in the is a test not the of Legionella test is and the of Legionella urinary antigen test is desirable in patients with severe CAP (1B). Other atypical pathogens Mycoplasma, Chlamydia, and respiratory viruses are of culture for are not also the are of on the of of the sample and the availability of an of are may be in PCR based tests done in respiratory are a of to is to in the and the of for the diagnosis of acute by is test is considered the for the of a of and test to and of and and of diagnostic like PCR are not and not If and are Legionella are with to and a for atypical for and in patients with to CAP not be are no tests for and and tests are for respiratory have any on the management of the patient from PCR is a and method for the detection of is not routinely required in the of an Investigations for atypical pathogens like Mycoplasma, Chlamydia, and viruses need not be routinely done (2A). What general investigations are required in patients with CAP? from a chest radiograph, are investigations required for outpatient of pulse oximetry the detection of arterial Arterial saturation ≤90% for in and clinical In admitted is a to glucose, urea, and blood and liver function also a of score for in assessment of is with an in to and a in assessment of is with an risk of in patients admitted to the intensive care For patients managed in an outpatient setting, no investigations are routinely required apart from a chest radiograph (3A). Pulse oximetry is desirable in outpatients (2B). Pulse oximetric saturation, if available, should be obtained as early as possible in admitted patients (2A). Arterial blood gas analysis should be performed in those with an oxygen saturation ≤90% and in those with chronic lung disease (3A). Blood glucose, urea, and electrolytes should be obtained in all hospitalized patients with CAP (3A). Full blood count and liver function tests are also helpful in the management of patients with CAP (3B). of biomarkers In the diagnosis of CAP is with based on clinical and chest radiograph CAP can be with or is to CAP of from of like and may be of in in and in can be considered as an to clinical be used as a for of can be helpful in the or absence of is not a of early 6 a may be and should be obtained to use in the of a suspected have also a role for CRP as a diagnostic for CRP can pneumonia from of and CRP have used to and in hospitalized patients with acute respiratory the a diagnostic with CRP is to management as or to and CRP measurement need not be performed as routine investigations for the diagnosis of CAP (2A). Risk Should patients with CAP be risk stratified? risk assessment of patients with CAP is for a of is a of if the initial assessment is not the can all patients of CAP should be admitted and the of admission and risk of routine is a need for risk stratification to the site of care and of What are the of risk stratification? are for the risk in a patient with pneumonia and of used criteria for risk stratification in is a the of based on risk of It to the risk of to CAP risk with the in from in to with of the the used to the the and the of the and the in the decision based on the are of in and outpatient on and of and score from the of on CAP in the and the on a score Blood blood or blood age patients to be stratified to risk of from to based on clinical from a clinical assessment results respiratory blood and also and to with the risk of and need for and stratified is clinically the criteria or the early score to a in use or clinical of of the score to of to be in the age those can be with clinical judgment pulse In a of performed in the of pneumonia and the in hospital to the of all of risk in an to risk in the age patients with a be managed as and are not as as the are recommended by for the initial assessment and risk stratification of score from the CAP of of CAP and in is a of blood chest respiratory and arterial score of ≥3 of patients who invasive respiratory and criteria criteria are helpful in the of care (ward vs. ICU) the admission decision are two major and minor and the of any of the major criteria or of the minor criteria for an ICU admission An early to the ICU of a CAP patient is with of and have the use of criteria for ICU are regarding the use of minor criteria in Other criteria the and are not as as the and need What should be the optimum method of risk stratification? have from of patients and and to in from CAP the of of in ICU to be the in patients with no in test and all for in with a of with to are in use of oxygen saturation or of oxygen in blood to be an of and in Patients with community-acquired pneumonia should be risk stratified (1A). Risk stratification should be performed in two steps [Figure 1] based upon the need for hospital admission followed by assessment of the site of admission (non-ICU vs. ICU). Accordingly, patients can be managed as either outpatient or inpatient (ward or ICU) (1A). Initial assessment should be done with CRB-65. If the score is >1, patients should be considered for admission (1A). Clinical judgment should be applied as a decision modifier in all cases (3A). Pulse oximetry can be used to admit hypoxemic patients (2A). Hypoxemia is defined as pulse oximetric saturation ≤92% for age ≤50 and ≤90% in patients >50 (3A). Patients selected for admission can be triaged to the ward (non-ICU)/ICU based upon the major/minor criteria outlined in Table If any major criterion or ≥3 minor criteria are fulfilled, patients should generally be admitted to the ICU (1A). Which are the antibiotics for in initial is based on a of the of and of and of the and is as is the in a of to have results of antibiotics not the of any results not in antibiotics and used antibiotics are either or of on of antibiotics for of a need to atypical Mycoplasma, Chlamydia, and also to the of the need for of in CAP in the outpatient as no of with antibiotics in the outpatient should be to patients with severe of the to atypical pathogens and in patients with severe pneumonia to for severe pneumonia treated on outpatient for are in Table should be used with in the as use with for in is the role of in of CAP in have recommended in guidelines for the of is of all have in of is to use is with of and risk of to the use of for the of CAP in should be of on the use of in should be the to antibiotics should be as as possible the diagnosis of CAP is In severe antibiotics should be as as In a diagnosis should be Antibiotics should be as early as is in severe CAP (2A). should be of the (1A). should be stratified as those with or (3A). antibiotics are and or for outpatient (1A). For outpatients with is recommended (1A). is to (3B). should not be used for (1A). Antibiotics should be in to of (1A). Table of used in recommended is of a a and (1A). In the of to respiratory may be used if is not a diagnostic admission (1A). Patients should also sputum for acid-fast bacilli if are used in of of or should be based upon the clinical of the patient and the judgment regarding and of the antibiotics (3A). ICU recommended is a or a for patients risk for (2A). If is an an or should be used (2A). may be considered with of (3A). may be used if is not a diagnostic admission (1A). Patients should also sputum for acid-fast bacilli if are should be to the (2A). should be done for chest as required (1A). If a patient not to should be for the of of of atypical (3A). What is the optimum of are treated with In ward may be with a the is Patients may be to as as clinically and are to to is as as in to severe CAP and results in in the of patients are not required to be as as with no in or or risk of or be in as or community-acquired and atypical on are and have to be in the clinical should patients be may be the patient is and are no acute have is as as with in the risk of of and no in to from is clinical in to severe CAP (2A). Patients can be considered for if are and are for a of (2A). should be treated for and for (1A). Antibiotics may be in patients with and CAP by Legionella and bacilli (2A). Antibiotics may also be the in those with or with lung and if the initial not the (3A). of role of biomarkers as a to the of in with a of on the for the of are admission to a in the of antibiotics a in the in two are not on the use of should not be routinely used to as not to clinical (1A). What is the role of the use of in severe Other have the use of In a of for not in hospitalized In a of in the use of the of hospital to in patients with to CAP vs. is of in is no in and the risk of and may be to use of should be to patients with and patients with early acute respiratory distress What is the role of is no to the of as chest and in the routine management of to be and the to the ICU and the risk of in the ICU if applied early in the of Should to CAP be treated Patients with and to CAP should be managed to should be used in patients with are not recommended for use in CAP (2A). should be used for or in to CAP to the management for (1A). is no role of chest and in the routine management of CAP (1A). and CAP to and should be managed to the management for (1A). may be used in patients with CAP and acute respiratory (2A). What is the role of for of CAP? guidelines with and for the guidelines by the of in not the use of on a routine Pneumococcal to and recommended in patients no to the of in invasive disease in considered in patients from chronic patients with or Pneumococcal to