Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults

IDSA/ATS Guidelines for CAP in Adults • CID 2007:44 (Suppl 2) • S31 33.A longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis.(Weak recommendation; level III evidence.)Other Treatment Considerations 34.Patients with CAP who have persistent septic shock despite adequate fluid resuscitation should be considered for treatment with drotrecogin alfa activated within 24 h of admission.(Weak recommendation; level II evidence.)35.Hypotensive, fluid-resuscitated patients with severe CAP should be screened for occult adrenal insufficiency.(Moderate recommendation; level II evidence.)36.Patients with hypoxemia or respiratory distress should receive a cautious trial of noninvasive ventilation unless they require immediate intubation because of severe hypoxemia (PaO 2 /FiO 2 ratio, !150) and bilateral alveolar infiltrates.(Moderate recommendation; level I evidence.)37. Low-tidal-volume ventilation (6 cm 3 /kg of ideal body weight) should be used for patients undergoing ventilation who have diffuse bilateral pneumonia or acute respiratory distress syndrome.(Strong recommendation; level I evidence.)Management of Nonresponding Pneumonia Definitions and classification.38.The use of a systematic classification of possible causes of failure to respond, based on time of onset and type of failure (table 11), is recommended.(Moderate recommendation; level II evidence.)As many as 15% of patients with CAP may not respond appropriately to initial antibiotic therapy.A systematic approach to these patients (table 11) will help to determine the cause.Because determination of the cause of failure is more accurate if the original microbiological etiology is known, risk factors for nonresponse or deterioration (table 12) figure prominently in the list of situations in which more aggressive and/ or extensive initial diagnostic testing is warranted (table 5).Prevention (see table 13) 39.All persons у50 years of age, others at risk for influenza complications, household contacts of high-risk persons, and health care workers should receive inactivated influenza vaccine as recommended by the Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention.(Strong recommendation; level I evidence.)40.The intranasally administered live attenuated vaccine is an alternative vaccine formulation for some persons 5-49 years of age without chronic underlying diseases, including immunodeficiency, asthma, or chronic medical conditions.(Strong recommendation; level I evidence.)41.Health care workers in inpatient and outpatient settings and long-term care facilities should receive annual influenza immunization.(Strong recommendation; level I evidence.)42.Pneumococcal polysaccharide vaccine is recommended for persons у65 years of age and for those with selected high-risk concurrent diseases, according to current Advisory Committee on Immunization Practices guidelines.(Strong recommendation; level II evidence.)43.Vaccination status should be assessed at the time of hospital admission for all patients, especially those with medical illnesses.(Moderate recommendation; level III evidence.)44.Vaccination may be performed either at hospital discharge or during outpatient treatment.(Moderate recommendation; level III evidence.)45.Influenza vaccine should be offered to persons at hospital discharge or during outpatient treatment during the fall and winter.(Strong recommendation; level III evidence.)46.Smoking cessation should be a goal for persons hospitalized with CAP who smoke.(Moderate recommendation; level III evidence.)47.Smokers who will not quit should also be vaccinated for both pneumococcus and influenza.(Weak recommendation; level III evidence.)48.Cases of pneumonia that are of public health concern should be reported immediately to the state or local health department.(Strong recommendation; level III evidence.)49.Respiratory hygiene measures, including the use of hand hygiene and masks or tissues for patients with cough, should be used in outpatient settings and EDs as a means to reduce the spread of respiratory infections.(Strong recommendation; level III evidence.)