Community-acquired pneumonia: similarities and differences between European and American guidelines – A narrative review –

Abstract

Community-acquired pneumonia (CAP) is severe disease. Early prescription of an adequate treatment has a positive impact in the CAP outcome. Despite the evidence of existing relevant differences between CAP across geographical areas, general guidelines can be designed to be applied everywhere. Eight years have passed between the publication of the European (EG) and American (AG) CAP guidelines, thus the aim of this narrative review is to compare both guidelines and summarize their recommendations. The main similarity between both guidelines is the antibiotics recommendation with the exception that AG mention new antimicrobials that were not available at the time of EG publication. Both guidelines recommend against routinely adding steroids as an adjuvant treatment. Finally, both guidelines acknowledge that the decision to hospitalize a patient is clinical and should be complemented with an objective tool for risk assessment. EG recommend the CRB-65 while AG recommend the Pneumonia Severity Index (PSI). EG and AG share a similar core of recommendations and only differ in minor issues such as new antibiotics. Likewise, both guidelines recommend against the routine prescription of steroids as an adjuvant therapy.

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“…The choice of antibiotic would be tailored by the patient’s age, comorbidities, allergies, likely causative organism and antibiotic resistance patterns ( Postma et al, 2015 ). Most guidelines recommend β-lactam antibiotics or macrolides for non-severe CAP, and β-lactam-macrolide or respiratory fluoroquinolones for severe CAP ( World Health Organization, 2014 ; Lee et al, 2018 ; Metlay et al, 2019 ; NICE guideline, 2019 ; Barberán et al, 2021 ). However, the use of antibiotics may lead to adverse events and potential risks ( NICE guideline, 2019 ; Huttner et al, 2020 ).…”

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“…Antibiotics can also be classified based on the cellular target they bind to and the cellular process they inhibit. Alternatively, antibiotics can be classified based on their type of synthesis (natural, synthetic, or semisynthetic), their structural class, and whether they have been approved for use in clinics (which varies depending on the regulatory agency) (Barberán et al, 2021). .…”

“…Antibiotics can also be classified based on the cellular target they bind to and the cellular process they inhibit. Alternatively, antibiotics can be classified based on their type of synthesis (natural, synthetic, or semisynthetic), their structural class, and whether they have been approved for use in clinics (which varies depending on the regulatory agency) (Barberán et al, 2021 ). Table A1 shows the most important antibiotics in clinical use approved by major regulatory agencies, such as the US Food and Drug Administration (FDA), the European Medicines Agency (EMA), and other important national agencies, according to information collected from different databases (Drugs@FDA database, https://www.accessdata.fda.gov/scripts/cder/daf/ ; EUCAST, https://www.eucast.org/publications-and-documents/consultations ; PRAC, 2021 ; STABILIS, https://www.stabilis.org/ ; CIMA, https://cima.aemps.es/cima/publico/home.html ; AMMI Canada, https://choosingwiselycanada.org/infectious-disease ).…”

D-PRISM, a global study of diagnostic approaches in severe pneumonia.

“…Pneumonia is responsible for a substantial healthcare burden, with estimated costs reaching 10 billion US dollars annually and accounting for more than 2.5 million deaths a year worldwide [1]. Several international guidelines have been published on diagnosing and managing CAP, HAP, and VAP [6][7][8][9][10][11][12][13]; however, the clinical application of these guidelines remains inconsistent [14][15][16].…”

“…Despite the prevalence and clinical signi cance of pneumonia in the ICU, guidelines on the clinical de nition, diagnostic investigation, and management show divergence across the globe [6][7][8][9][10][11][12][13][14]. There is also a shortage of evidence regarding comparative clinical practice across the domains of diagnosis and management.…”