Speaker: Claire Andrejak
The management of community-acquired pneumonia (CAP) has been updated in the 2024 recommendations from the Société de Pneumologie de Langue Française (SPLF) and the Société de Pathologie Infectieuse de Langue Française (SPILF). In contrast to the previous guidelines from 2010, the new recommendations highlight the importance of imaging. Imaging is recommended if feasible, ideally conducted within three days of initiating antibiotics or, if necessary, after a second dose. Systematic use of C-reactive protein (CRP) and procalcitonin (PCT) biomarkers is not advocated, regardless of whether the patient is ambulatory or hospitalized. Antigen testing is recommended only in cases of severe illness or if there is significant suspicion of Legionella. Respiratory samples are to be limited; however, complete blood count remains recommended.
For patients hospitalized during an epidemic period, triplex or quadriplex polymerase chain reaction (PCR) testing targeting influenza, respiratory syncytial virus (RSV), and COVID-19 is recommended, with additional testing for atypical pathogens if initial tests are negative. In severe cases, lower panel tests that include bacteria such as pneumococcus and Haemophilus influenzae, along with resistance profiles, may be utilized. Treatment guidelines have been simplified, favoring beta-lactams. Amoxicillin is the first-line treatment for ambulatory patients, with alternatives including pyostacine for those with allergies and amoxicillin-clavulanic acid for patients with comorbidities or suspected viral superinfection. For hospitalized patients, the standard treatment remains beta-lactams, with the addition of macrolides for severe cases. Fluoroquinolones are now recommended only as a last resort in cases where beta-lactams are contraindicated or unavailable. In the updated 2024 guidelines for CAP management, several key changes and considerations are highlighted. A particular focus has been placed on addressing specific bacterial concerns, such as Staphylococcus aureus with Panton- Valentine. For patients with prior pseudomonas infections, recent antibiotic use, or conditions like cystic fibrosis or bronchiectasis, targeted therapy for Pseudomonas aeruginosa should be carefully selected. In such cases, aztreonam should be avoided due to their inadequate coverage of typical pneumonia pathogens like Streptococcus pneumoniae. Instead, cefepime or piperacillin-tazobactam are preferred.
The recommendations emphasize a reduction in the duration of antibiotic treatment based on clinical stability. If patients meet stabilization criteria within three days, antibiotic therapy can be discontinued at that point. If stabilization occurs between three and five days, therapy should be stopped after five days. In cases where stabilization is not achieved by seven days, treatment should continue for a maximum of seven days, unless complications such as emphysema or pleural effusion are present. This approach is supported by data from multiple studies and meta-analyses indicating that shorter antibiotic courses do not adversely affect patient outcomes, with no significant differences in recovery at day 10 or day 28 between 3 day and 8 days regimens. Furthermore, the role of corticosteroids has been revised. While they are not recommended for ambulatory or non-severely hospitalized patients, they may be considered for severe cases or those in intensive care. In such situations, hydrocortisone hemisuccinate should be administered at a dose of 200 mg per day (50 mg four times daily) and adjusted based on patient response, with a maximum duration recommended. This approach aligns with practices for septic shock management.
The update on corticosteroid use in CAP management reflects new evidence and evolving understanding of their impact. Since the 2010 guidelines, numerous studies have investigated corticosteroids, but results have been inconsistent, with some studies showing benefits while others highlight complications such as hyperglycemia and increased risk of rehospitalization and reinfections. The variability in these studies—regarding timing of corticosteroid initiation, dosing, and treatment duration—contributed to the lack of consensus. A pivotal change has come from the CAPCODE study, a French study evaluating hydrocortisone in severe CAP cases. This study, which excluded patients with influenza and those with diabetes, demonstrated significant benefits: reduced risk of intubation, shorter duration of hospitalization and intensive care unit stay, and decreased need for vasopressors. This evidence supports the use of hydrocortisone hemisuccinate (50 mg four times daily) for 8 to 14 days in severe CAP cases without influenza, as it significantly improves patient outcomes.
In summary, for diagnostic purposes, it is recommended to obtain chest X-rays or echocardiography within 3 days, if feasible. Fluoroquinolones should not be used as the first-line treatment. Instead, amoxicillin or amoxicillin-clavulanate should be administered to non-ICU patients. Stabilization criteria should be reassessed after 3 days. Hydrocortisone is indicated only for severe patients in the ICU, provided they do not have influenza, aspiration pneumonia, or myelosuppression.
European Respiratory Society Congress 2024, 7–11 September, Vienna, Austria.