#127 – What’s Pneu in Community-Acquired Pneumonia Part 2

Understanding the New ATS CAP Guidelines and IDSA's Stance Hello faithful listeners. Welcome to Breakpoints, the Society of Infectious Diseases Pharmacist podcast. I'm Ryan Minster, Professor of Pharmacy Practice at Saint Louis College of Pharmacy at UHSP, and I am back with you this month to talk CAP again. Now, when last I left you, we had a wonderful discussion with Doctors Hartledge and Wyndham talking about the CAP evidence that had been published since the 2019 IDSAATS CAP guidelines. Then as you all know, and we mentioned at the beginning of last episode, 2 days after we had recorded the brand new ATS guidelines were published. There are two particularly notable aspects to these new guidelines. Number one is that they are not a comprehensive update to the 2019 guidelines. Just for example, empiric antimicrobial selection was not addressed in this update. But this document focused on 4 specific clinical questions. And the second interesting point is that the Infectious Diseases Society of America elected not to endorse this guideline update. I'm going to take a moment to set the stage before we let our experts weigh in and give you their perspectives. The American Thoracic Society and the Infectious Diseases Society of America have been collaborating on guidelines for the management of community acquired pneumonia since 2007. Now, given the length of time between the 2007 and 2019 guidelines in the dynamic evidence base for CAP, a joint committee which included nine members from ATS and 9 from IDSA, as well as an IDSA and ATS Co chair, set the goal of generating more rapid incremental guideline recommendations. The first of the incremental updates was published in 2021 and addressed nucleic acid testing for non influenza, non SARS, COV 2 viruses. This current update to the diagnosis and management of community acquired pneumonia was as we said earlier, not meant to be an all-encompassing update to the 2019 guidelines, but focused on 4 clinical questions. Two of these were new questions and two of these were established questions posed in the 2019 document. Our first two questions are new questions. We're #1 should lung ultrasound be considered a reasonable alternative to chest X-ray to diagnose CAP? And the second question, should adults with CAP who test positive for a respiratory virus be treated with empiric antimicrobial therapy? And our two established questions were, should adults with CAP who reach clinical stability be treated with less than 5 days of antibiotics? And our final question, should adults who are hospitalized with CAP be treated with systemic corticosteroids? The guideline update underwent peer review by 16 content experts, 4 from ATS and 11 from IDSA, and following multiple cycles of revision and review was approved by a multiple disciplinary board of directors from ATS but was not approved by IDSA. Dr. Hartlage Reviews New CAP Guidelines and Identifies Gaps That definitely leaves us with a few things to talk about this month, and in order to help us do that, we have three wonderful guests to give their perspectives and help us navigate these new guidelines and how to think about using them in conjunction with the 2019 CAP guidelines. First, we're going to have a short visit with one of our guests from the previous episode, Doctor Whitney Hartledge, to see how this guideline update matched her thoughts that we recorded back in August. Then we're going to be joined by Doctor Sharon Weissman, a representative leader with an IDSA and Sahil Angelo, a representative from the critical care community who is also cross trained in ID. Let's start by hearing from Doctor Hartledge. So we are thrilled to be joined again by Doctor Whitney Hartledge. And as a reminder to all the listeners, Dr. Hartledge is an antimicrobial stewardship, an infectious diseases pharmacist at Harborview Medical Center in Seattle, WA. Thanks for joining us again, Whitney. Speaker 2 Thanks for having me back, Ryan. Speaker 1 Well, let's jump right into this, taking into consideration a lot of what we discussed a couple of months ago. Do these updated guidelines addressed some, all, or none of the issues that you would hope they would? Speaker 2 Yeah. So as a whole, the guidelines covered some of the questions that I was hoping that they would. So as Ryan, you mentioned earlier, this update wasn't meant to be a large and comprehensive review. So I wasn't anticipating that they would cover every single question that I had. And again, they did focus on those 4 main areas in the diagnosis and management of immunocompetent adults with KAP highlighting those four areas of ultrasound for diagnosis, antibiotic use in patients who test positive for respiratory virus, duration of therapy, and then the role of corticosteroids. I will start off by saying that I do appreciate the idea in this new approach for the guideline development where choosing a few high priority questions are done and then performing more frequent evaluations to really help get this updated guidance out more quickly. And I do think that's where we're heading more so in the future. But with that being said, I do think that there are still some big questions that are unanswered after the development and then publication of these guidelines. So for example, there's still currently quite a bit of debate out there still surrounding antimicrobial therapy, which was a huge gap in this guideline that Ryan also mentioned. And specifically thinking about which indications may warrant more broader empiric coverage for our patients. And then, of course, which is a big question for me too, is whether a typical coverage is truly necessary. And then another huge gap that I think was not addressed to is the role of molecular diagnostic testing. And of course, we all know like how much more available these tests are for a lot of our centers and clinicians out there. So I think we probably do need more direction. I would say we do need more direction on how to best utilize these test results. Another area that I would also love to see some discussion on in the future too, is like how can we implement electronical medical record tools or other decision support to really help some of our frontline clinicians when choosing appropriate therapy and then testing in real time? And then also, of course, being a steward. I think it's incredibly important in these guidelines to have sections and really highlight how we can best balance some of these decisions with good, you know, diagnostic and then antimicrobial stewardship principles in mind. So with that being said, I give the authors all the credit for all the incredible work that they put into getting this guidance updated. And I do think that the suggestions that they mentioned will have huge implications. But I do think we're due for some more evaluation and guidance around diagnostics and then antimicrobial management and some of the more future versions. Speaker 1 I agree completely. And you brought something up that I think is very interesting as we look at it right now for antimicrobial therapy, it seems like we have a pretty decent body of evidence for certain patients that we could modify that therapy, potentially taking macrolides off the table or not needing them perhaps as often as we use them right now. I was sort of struck by the committee prioritizing question #2 the respiratory viral panel and the antimicrobial therapy question. And even in their discussion of the evidence, admitting that there wasn't a lot of evidence out there to answer this question, but they decided to tackle it anyway. It was an important enough question for them to tackle. What do you think about that being just the balance of the evidence that we might have for the antimicrobial therapy and what they had and what was used with regard to question #2 and antimicrobial therapy in the positive respiratory viral panel? Why IDSA Didn't Endorse and Hartlage's Practice Integration Yeah, Ryan, that's that's such a great point. And I think another question and concern that I was also interested that they felt was a high priority. I think on one hand we are seeing this increase in these viral diagnostic testing. And then of course, I think we're having a better understanding in the role of viral pneumonia in the whole clinical syndrome of pneumonia in general. But I will say that I was kind of surprised to see that they made that clear recommendation in the space, especially as you mentioned that there was no high quality data or even randomized controlled studies to support this. So I absolutely agree that I think this is an interesting area to focus. And then, of course, I would just encourage everyone to go through and read some of these details in the rationale and the studies they included to support this recommendation 'cause it's, it's super fascinating, I think to just have that understanding as a whole. But I think it's especially important too, whenever we're thinking about how to incorporate this recommendation into practice. The authors did a really great job of including a table with factors that may strengthen or weaken this recommendation. And I think these are especially important when we think about how we can individualize care for our patients and then use clinical judgment as a whole, I would say I agree with you overall. Speaker 1 Well, let's talk a little bit more about one of the major talking points with regard to this guideline update. I just want to know what are your thoughts on the lack of IDSA endorsement for this update? Speaker 2 Yeah. I mean, I think honestly, I have a ton of respect for IDSA. And then especially this is even more enhanced in the fact that they did decide to pull out. I do think it takes a ton of boldness to really take a step back from such a major guideline such as this if you don't, you know, fully agree or endorse all the recommendations. So I think that was a huge step and I think very bold of them. And then also, I think it sends a very clear message for, you know, all the audiences out there and then its members and then other societies too. But then I think this approach and then collaboration with ATSI think it also highlights all the nuances and management and then just the different minds and approaches that different groups take when caring for these patients. Speaker 1 Unfortunately, it's not an easy answer, right? These things are nuanced and evolve a lot of data and absolutely credit to everybody, even ideas, say, for working with them throughout the guidelines and ATS for for sticking to something that they strongly felt needed to be in the guidelines too. Excellent. Well, I wanted to close this portion of our discussion by asking you a question that I'm also going to pose to Doctors Wiseman and Angelo later in the podcast. And that is, how do you plan on integrating these guidelines with the 2019 ATSIDSA guidelines into your practice? Speaker 2 Yeah, that's a fantastic question. So just thinking about those 4 topics that were covered, I would say the sections that focused on surrounding and really thinking about how to use ultrasound to guide diagnosis as well as corticosteroid use aren't really areas that I think will impact my day-to-day practice as both an ID and stewardship pharmacist. But I will say the recommendations around duration of therapy as well as antibiotic use in this setting of viral CAP absolutely will. So now again coming back to what Ryan mentioned earlier, So these new ATS guidelines now suggest treatment courses as short as three days for immunocompetent adults with community acquired pneumonia. So this applies to both outpatients as well as in patients with non severe disease who reach clinical stability, which I think is great. It's encouraging to see that we're starting to push the needle more for that. Shorter is better. And then the authors for this recommendation do note that this is a conditional recommendation based on low quality of evidence, but they do go on to site. This recommendation was supported by 4 randomized control trials. So with that being said and thinking about this in my practice, I do wish that they were maybe a bit more definitive in that recommendation rather than saying, you know, less than five days, but a minimum of three. It would have been nice I think personally to see a clear endorsement for that three day duration. And then thinking about my institution as a whole, I think that this three day treatment duration will be a major shift as I imagine it may be for many of you all as well. So thinking about the evidence at this point, to me I think it's pretty clear that three days is adequate for outpatients and those randomized control trials do support that. I think for non severe inpatients, I do see our standard duration shifting from that five days down to three days as well. And then of course extending for those patients who haven't reached that clinical stability criteria by day three. And then also I'll just add from like a practicality standpoint too, I think this will make a huge difference, especially for our inpatients who are ready for discharge around say day three or four. So instead of having to send them home with, you know, one day or two days worth of antibiotics, I think our teams will be able to feel confident that since they're stable enough for discharge and are clinically appropriate at that point, then hopefully they will feel confident that we can stop therapy before or even at discharge. So I think that's that's a huge part with the antibiotic duration piece. And then we've already kind of talked about antibiotic use and viral cap. But I'll just add, I think this may be a little bit harder for me in general to adopt the suggestion into my practice as a whole. And as I mentioned previously, I was honestly a bit surprised about this recommendation given the lack of that high quality data. And then I I won't spend too much time talking about this 'cause I know that you guys are planning to have a very thoughtful and robust discussion later. But I will note that the authors themselves did even acknowledge that this recommendation, End Quote was there were no published studies that were identified and these recommendations are based on non comparative evidence and expert opinion, which led to that very low quality of evidence recommendation. So that being said, I do appreciate that in their discussion they did highlight that it is important to individualize our care and clinical judgement when thinking about how to apply this recommendation. So as a whole, I think big takeaways for me and how I'm going to incorporate this into my practice is that we now have stronger evidence to support shorter is better when it comes to duration of therapy, which I love. And then we also have multiple randomized control trials now to support and have also demonstrated this. And then also thinking about empiric antibiotic use and viral CAP, we really should use severity of illness and then other clinical suspicions for bacterial coal infection to really guide this for our patients, as the authors outlined very well too. So just thinking about with more sensitive viral diagnostics being available and then of course, our increased understanding and the prevalence of viral cap, I think we may end up seeing an increase in antibiotic use if we're not thoughtful about how to really interpret these recommendations and these guidelines. And then lastly, I'll just end by saying that I think we've all seen that it can be extremely tough to undo practice habits that were based and built on limited to no evidence. So I think being intentional about how we apply these recommendations is going to be extremely, extremely key thinking about these in the future. Speaker 1 Great points. The devil's in the details here, right? Just make sure that we encompassingly as providers, read all of the recommendations and not just look at the ticked executive summary there because they do a good job of explaining some of the background for why. So don't just take it at face value, but read all the little nitty gritty details. Well, I know that was a quick review, but I want to thank you so much for coming back and joining us again and sharing your thoughts on the guideline update. Speaker 2 Of course, thanks for having me run. Dr. Weissman Explains IDSA's Non-Endorsement of Guidelines In this section of the podcast, we are joined by two wonderful guests. Our first guest is Doctor Sharon Wiseman. Dr. Wiseman is a professor of medicine and Chair of the Department of Medicine at the University of South Carolina. She has over 30 years experience as an infectious diseases physician and she currently serves as the chair of the Infectious Diseases Society of America's Standards, Practice and Guidelines Subcommittee. Thank you for joining us, Sharon. Next, we are joined by Doctor Sahil Angelo. Doctor Angelo is an infectious diseases and critical Care fellow at the University of Pittsburgh Medical Center. He's a member of the UPMC Antimicrobial Stewardship Committee and was Chief Fellow of the ID Program last year. He is also a committee member of the new IDSAIDCCM committee. His research interests are at the intersection of antimicrobial resistance, sepsis, and health equality. Great to have you here, Sahil. Speaker 3 Pleasure to be here. I'm an avid Breakpoints fan, so it's really exciting for me. Speaker 1 Great, excellent. We always love to have fans on the podcast too. Now for our first question, I really wanted to start off with Sharon because as we stated in the introduction, Sharon is in a unique position and she's the current Chair of IDSA Standards Practice and Guidelines Subcommittee. Sharon, could you tell us what you know about why these guidelines were not endorsed by IDSA? Speaker 4 They were not endorsed really because of the two recommendations regarding the use of antibiotics and individuals who tested positive for respiratory virus who were community acquired with comorbid illnesses or in the hospital setting. And IDSA felt that these recommendations really opened up for a lot of overuse of antibiotic, particularly in the commuting setting where many people are diagnosed with pneumonia, often using vague criteria and have positive respiratory viral panel. Speaker 1 I certainly think that's understandable from an IDSA perspective. When you're a big advocate for antimicrobial stewardship, it is a little bit difficult to see the recommendation like that when you consider what some of the downstream effects could be. I want to hear from Sahil here. Now, understanding that we know you weren't a part of the guideline committee, but you are someone with both ID and critical care training, what was your response to reading the updated guidelines and then learning that IDSA had not endorsed them? Speaker 3 I really wasn't sure what to make of the ideas say not endorsing it, but I'm not surprised to hear Doctor Weissman's explanation that I really had to hinge around those two recommendation points. It's as an early trainee, I initially thought guidelines were gospels, so I would have read something like this and just taken them blindly. But obviously as I've progressed, I know there's a lot more nuance. And so I do appreciate her point and think it's valid that we need to be really careful about what we say and how we say it. Speaker 1 Thank you. That's a great perspective as well. I think something that to me at least, was unique in looking at these guidelines is the authors take a pretty significant portion of the early section to state some of what you were just talking about, Sahil, that guidelines are not meant to be gospel or fit every single patient. There a starting point. And I think that probably this is something we may see with future guidelines as well, and it might have been in some other ones. I just particularly noticed it in this case that they really devoted some time to thinking about that. Experts Debate Empiric Antibiotics for Viral CAP Patients Well, no secret, you both have hit on it. Question 2 is probably the most controversial point of these guidelines and I'm curious what you think about what the committee recommended. I wanted to start with Sahil on this point just to see what your thoughts are on the recommendation that outpatients with comorbidities and hospitalized patients with non severe CAP should be treated with empiric antimicrobial therapy even if they have a respiratory viral panel for a virus positive. Speaker 3 Thanks, Ryan. It's a great question. The committee was very transparent that there was absolutely no data to back up the recommendation. When they did their systematic and meta analysis, they couldn't find any studies looking specifically at this issue and so reading in between the lines, it seems like they took a more conservative approach. But when I think about community acquired pneumonia, 10 to 30% of patients who are diagnosed with a CAP don't actually meet criteria, 40% have a pathogen with strep pneumo be most common. And depending on which studies you read, anywhere between 40 to 50% have no pathogen. And so I think it's really hard to know if we have a source which is a virus, whether we can really just endorse empirically treating. And I'll give an example of the danger. My father was diagnosed with COVID last year and his PCP decided to just put him on doxy for seven days empirically to prevent or to Co treat bacterial infection which he didn't have. And even when I talked to him and his PCP he said well this is what I'm just going to do. So I think this is the problem. We have guidelines also recommending something like this. Without more nuance, I think it could be difficult and hard for community doctors who really look to these guidelines for support. I will say that I think the advent of rapid viral panels has really been helpful from an epidemiological standpoint. I've had a lot of really sick patients with human metapneumovirus or rhinovirus and I think we just don't necessarily understand how pathogenic some of these viruses can be. And I some patients could really respond poorly. I think some of the studies I was reading showed that you can have upwards of 30% mortality, particularly in immunocompromised patients. So I do think that helpful to have these tests, but it comes down to how much are you willing to be wrong. And when you look at the supplements, they specify the comorbidities and you can see there's a gradient of support where 50% of the community said COPD, end stage liver disease, ESRD were all significant comorbidities. But some of these other risk factors like controlled HIV or rheumatologic diseases, there's a lot more variation between how committee members felt whether or not these populations should qualify for antibiotics. But it's a mixed bag. And I, I think that from a stewardship perspective, it really concerns me. I find myself often de escalating antibiotics or even stopping workup if I have a positive virus. Now if they're in the ICU on pressors or in septic shock or have severe cap, my threshold of being wrong is so much lower or willing to be wrong is so much lower that I'm just going to treat them empirically anyways. And then the last thing I'll say is with lung ultrasound, I find that if there is consolidated pattern that is more predictive for bacterial pneumonia. And so in that population, maybe there's a way we can think about if they have a positive RVP, a consolidation pattern on lung ultrasound, maybe they're the right population to treat. Speaker 1 That's a really good point and some good perspectives there. You're bringing in the first new clinical question using lung ultrasound as an alternative to chest X-rays, a diagnosis for CAP. Sharon, I think you let us in a little bit, but what are your thoughts on this point on Question 2? Speaker 4 I'm going to go back to something that Sahil said at the beginning, which is as a young provider, our new provider, he used to just look at guidelines and just read him his gospel and just follow. And that was one of the big concerns about the recommendation regarding the use of antibiotics and individuals in the community who have comorbid illnesses that most people will not go and read the fine print. They will just see the final recommendation is use antibiotics. If you do read through it, the fine print says it's a conditional recommendation and understanding how grade guidelines are developed, a conditional means that doesn't necessarily mean that the antibiotics need to be used. And there's a fine print about the table which goes into all the various reasons why you may lean towards or against using antibiotics. But the problem is, is that most people don't go to the fine print. They want the answer. And so therefore would lead to a lot of excess antibiotics use in the community and therefore undue harm. There was also in sort of some of the discussions behind the scene that perhaps there's no harm to starting antibiotics. You can stop them later, but I think from the ideas safe perspective, we felt differently that the harm for even a few doses of a quinolone, which is sort of the first line recommendations can be quite significant. And that there's actually in a otherwise healthy, stable person who's has no signs of sepsis that there there's really no harm in waiting to try to sort out. Do they really need antibiotics? Speaker 3 I also think practically if a patient is stable enough to be outpatient, you probably have time to wait to see if they do have a bacterial Co infection to declare itself. And any patient gets admitted for a cap usually gets a dose of antibiotics empirically in the Ed. So I'm not entirely sure. Like if that's enough of 1 dose of subtract so and azithromycin reduces the bio burden enough for your immune system to clear out the rest and so it's just hard to tell. Speaker 5 Those are great points as. Speaker 1 Well, I think too about what Sharon was saying and I think Sahil too where sometimes, well, you can stop the antibiotics later, you can start them now and stop them later. I think we all know that that becomes very difficult to do in the outpatient setting. We kind of colloquially call it where I practice antibiotic inertia, right. It's going, you're going to keep getting them and is anybody really going to follow up and tell them to stop? But then there is also that other side that Sharon brought up that some of the damage, whether you're talking about the potential for precipitating future resistance or changing the gut microbiome, some of that damage can already be done in those instances. There was something else that Sharon, you were bringing up about the fine print in these guidelines. Another aspect that I really appreciate it was it broke down the committee votes for each one of these questions and they had some subclinical questions too. And what that does for me at least, is it gives me a little bit of insight that there was some division amongst the committee members with this point, especially in this point we're talking about in Question 2, I believe it was in the 70%. It was certainly the lowest agreement, still above a majority, but it was the lowest agreement of any of the clinical questions that they tackled. Speaker 5 This sort of brings me into my. Speaker 1 Next question for both of you and you've done such a good job already of touching on a little bit of this, but it has to do with the utility of these non influenza, non SARS, COVID 2 respiratory viral panels, especially for people who would perhaps stick more to the letter of the law with the guideline, even though we know that they shouldn't do that necessarily. Assessing Viral Panel Utility and Shorter Antibiotic Durations Do you still think these tests have utility in clinical practice? And we can start with Sharon on this one, but that's obviously a. Speaker 4 Complex question because you really want to think about two things. One is the public health and understanding the epidemiology in your community. So they're often, these tests are often used to help us understand when flu is suddenly in our community or you mentioned non flu, non COVID, but also now it's RSV or metapneumovirus when these are in your community. So you can help intervene or advise people about avoidance of exposure. But you know, if you were to stick to the letter of the law, maybe you don't need them because you're just going to treat them anyway with antibiotic. But obviously from my standpoint, that would really help me not use antibiotics And someone who I felt borderline because I would want to look through that fine print and say, well, now I know that I have a reason for their symptoms and I can send them home comfortably telling them just to get some rest and come back if they get sicker. Speaker 5 What do you think about that point? Speaker 1 Sahil, do you think there's still utility for these respiratory viral panels? Yeah. Speaker 3 I think I'm in the camp where I order them probably more often than I should, but I work in the ICU mostly. And I find that having an answer, even if I can't treat it, is at least helpful for me to know that I don't need to keep slamming them antibiotics. Or it might explain the new fever that they're having because their family member was sick and came in and visited them in ICU. So I think it's helpful from that standpoint. And then the guidelines don't touch on immunocompromised patients, which I think is a big asterisk because in our transplant patients, it's really things like adenovirus, particularly in the winter, it can cause really severe disease. And it's helpful to know that a patient might have that. And then I think in the last episode that you had, there was a great discussion about how there's so many different RVPS or viral tests with different pathogens on, on and off. Ours has mycoplasma included in it. And so if I think they have a low suspicion for Legionella and their mycoplasma is negative, then I don't need to give them azithromycin or doxycycline. And you know, there's always chlamydia. But I think this could be helpful for de escalation techniques as well as stopping a work of if. I feel pretty comfortable that this is explaining a fever and their increase in oxygen requirements that are not so severe that I can't be wrong. Speaker 5 I want to ask a quick follow up. Speaker 1 Question to what you both have said, which I think are great points. Do you think the utility of these respiratory viral panels becomes even greater if we have another rapid nucleic acid test that has more bacterial targets? The thing I'm thinking of is if we were I practice, we have a respiratory viral panel and then we have to send off a separate pneumonia PCR panel. If you saw a pneumonia PCR panel with bacterial targets that were negative for the targets that are tested and then you had a respiratory viral panel that was positive for something non influenza, non SARS COVID, would that be even a little bit more impactful to you in terms of deescalating antibiotics? Sahil, do you think so? Speaker 5 Yeah, I guess in a. Speaker 3 Way it's a souped up MRSA nares. That being said, just like with MRSA, if a patient is super sick and I can't be wrong, I'm not going to necessarily always rely on the on the final panel, but I think it could be helpful. My fear is that people will see a positive strep pneumo, for example, and then empirically treat it when and they're not understanding that this is just picking up fragments of DNA and so that they might just be colonized and not actually causing an infection. Sharon, what do? Speaker 5 You think about that. Speaker 1 Point does that help you at all if you were to have more targets bolstering the respiratory viral panel? You know, I worry. Speaker 4 About the converse, So we know a lot of people are colonized with bacteria and they're easy to pick up with these PCR panels that are causing infection. And I worry that we're going to see the converse where we're going to see, Oh well, if there's one of these bacterial tests that are positive, so they're therefore they're Co infected, therefore we need to use antibiotics. So I I would actually prefer to keep it a pure viral panel at this point. More tests, more problems. Speaker 1 We look for things, we find things we don't know what to do and we see that urine. Speaker 4 Cultures are the classic example, absolutely. Speaker 1 All right. I'm going to move us out of controversy. We've talked a lot about question 2. I really do also want to touch on Question 3. This was one of the questions that was addressed in the 2019 version of the guidelines having to do with antimicrobial duration. The guideline committee recommended less than five days, but at least three days of antibiotics in adult outpatients and inpatients with non severe CAP who reached clinical stability. Sharon, is this something you would implement in your clinical practice or is this something that you've already been doing? It's definitely something. Speaker 4 I've already been doing and so here you mentioned something early on you said, well, maybe that one dose that they got in the emergency room with ceftriaxin was enough. And you do wonder, you know, a lot of we used to joke about, you know, how do we pick the number of days of antibiotics? We count our fingers. You do wonder, do you really need even 3 days? I've definitely except for the rare settings, you know, where it's like Pseudomonas or a more difficult to treat bacteria gone to the five days at the Max. And that's great for the hospitalized patient who you want to get discharged home to. Absolutely. Speaker 1 Sahil, how about you? Is less more for you? Yeah. Speaker 5 Almost always I. Speaker 3 Totally agree with Sharon. It's something I've already been doing and I really have to be convinced by the patient's clinical status to push me to do 5 days or they have to have a pathogen like Pseudomonas that's difficult to treat. Good. Speaker 5 Agreement there. I. Speaker 1 Think we're all in agreement shorter is better most of the time. Missing Empiric Therapy Guidance and Guideline Integration Strategies Now, I do want to talk for a moment about what isn't in this update. And one of those major points are changes to empiric antimicrobial therapy or recommendations for empiric antimicrobial therapy. In our CAP episode from August, our panelists had a pretty robust discussion about empiric therapy and that we may have the evidence now to narrow therapy in some patients and forgo prescribing macrolide antibiotics. Sahil, would you have liked empiric therapy addressed in this particular update? Speaker 5 I think it would have been. Speaker 3 Helpful because there is so much that's changed in the community acquired pneumonia literature over the past five or six years that. Speaker 5 Being said, I think. Speaker 3 Amoxicillin, doxycycline as a first line still makes sense and there I can understand that there's more work to do if there's not much more movement on the regimen. But perhaps maybe they could have had a more focused discussion on a typical pneumonia and whether or not to use doxy or azithromycin. I will say it also provides an opportunity to stress penicillin delabeling and allergies. If you were say, you know, we have reviewed the data, we still recommend amoxicillin. Oh, by the way, we should also Delabel our patients use the Pennfast tool or other things like that, because I think pneumonia and UTI are the two infectious diseases where a lot of the community will interface. And so the more we can kind of hammer this home from multiple angles, the better. Speaker 5 Sharon, do you think? Speaker 1 We have the evidence now to support narrower therapy in certain groups. And would you like to have seen that addressed in this guideline update? So I'm going to take this. Speaker 4 From the point of view of how guidelines get developed and the timeline behind that and making sure that you know the data and also the work in time that goes into answering one single question. So yes, it would be nice to, but at the time that these were beginning to be developed, we probably didn't have information. So hence it didn't come through. Maybe in the next iteration of the community acquired pneumonia guidelines is that would be a good thing to address. Speaker 1 It does seem like that's a massive question to tackle and I can certainly appreciate it. I think if you're making sweeping recommendations like that, you probably do want a really solid body of evidence that's fairly well built out before you tackle it. I'll just put a little plug. Speaker 4 Into how IDSA sort of change their guidelines. It's going to be more, it's more pico question focus where we do one question at a time. So we don't necessarily redo a whole guideline, but here's new evidence in this particular area. And part of that is to be able to be more flexible as you know, maybe the guidelines essentially great. But there's one thing, we have new information that we really need to bring forth to the community, I think. Speaker 5 That's a really. Speaker 1 Important point and I believe most practitioners really appreciate that because if you look at some of the past intervals between guidelines, understandably they're really difficult to do, but there's some pretty big gaps in there. Even if you just look at cap from 2007 to 2019 and then you would get into this interval where there's a lot of things you have to review when you're doing a pretty all-encompassing review. I think that's great that we're doing it a little bit faster. Speaker 5 Now this next. Speaker 1 Question I asked to our earlier guest as well. Given the controversy and overall quality of the evidence, how do you plan on integrating these new guidelines or this update into or with the 2019 ATSIDSA guidelines into your practice? So Sharon, how do you plan on integrating the 2025 ATS guidelines into practice? So I'm going to focus on the. Speaker 4 Controversial questions, which is I'm going to read the fine print and really go back to that. You really have to make that individualized clinical decision based on factors that relate to that patient and some settings even somewhat of a shared decision making. If there's someone on the borderline, how will, how willing are they to come back? How willing are they, how willing reliable are they to tell you if they're not doing as well, how reachable are they, etcetera. So, so yeah, I'd say I'm going to probably do the same thing I always did, which is focusing on really the patient specific fact. What about? Speaker 5 You Sahil. Speaker 1 I. Speaker 3 Echo what Sharon said, but some of the other recommendations I just want to touch on. I'm a big believer of lung ultrasound. It's quick, it's easy. I think in many ways it's the future. You can take it to low resource settings still you have the right training. But for me it's been really helpful just distinguishing COPD, heart failure, pneumonia in 2 minutes or less. And then like we talked about, I already do three days if possible. I just want to touch on the steroids piece because if you'd asked me a month ago, I would have been pro steroids based on the Cape Cod trial and some of the guidelines that have come out. But Remap CAP just published their community choir pneumonia domain with steroids and it showed that there was no benefit and maybe even a signal for harm. And so I am left confused and not really knowing what to do with steroids, which I think seems to be a trend for the past 30 years with medicine, which I'm only entering now. So I don't really know how to implement that piece of it. Truthfully. I probably will still pull the trigger on steroids but now I'm confused I think. Speaker 1 For me and what you both have said, this serves as a really valuable lesson in that you do have to read the fine print. The guidelines are not going to be applicable to every single person and it's up to the individual practitioner. Just take this as a starting point for some people and then see whether or not things apply. And I think that's a really useful perspective to take, one we should probably all have, and I feel like most people do. But that's one of the big points I took away in reading these guidelines. ATS/IDSA Collaboration, Panelist Wishes, and Episode Conclusion Now my last. Speaker 5 Question for both of. Speaker 1 You. I want you to get out your crystal balls here. Do you think the two societies will get together on future versions of these guidelines or should they? Sharon, I wanted to start with you here. I have. I have an inside. Speaker 4 Crystal ball, 'cause, you know, they've been a lot of discussions about this and almost immediately after IDSA chose not to endorse these guidelines, you know they're working on also the hospital acquired guideline and. Speaker 5 American Thoracic Society reached out to. Speaker 4 Us and said can you look at these questions well we want to make sure we frame these questions right so that we can be collaborative as we move forward was essentially the question they asked for us. And one of the things we recognized why those questions around the use of antibiotics in community choir pneumonia who test positive for viral antigens were so controversy is the way they were asked if they were asked a different way taking into account public health implications harm from antibiotics, they probably would have come to a completely different answer and we would have endorsed them. So in developing those guidelines and trying to stick with the grade criteria of how guidelines are developed and how you the answers are worded, we were stuck with the question that was posed and the question that had been researched. So options when you could have gone back and rewritten the question and then have to restart, which would have delayed this months and months and months. Or try to emphasize the fine print in the the table that describes when or when you might consider using antibiotics. I guess from the American Thoracic Society. They really felt like they had to stick with the language of the grade that answered the question that was asked and maybe it was the wrong question. That's my opinion. Or they had to start over and that's where we got stuck at the end. The long answer, the short answer to that is yes, I think that we will and try to continue to collaborate and maybe work together at an earlier phase to make sure that we're posing the questions appropriately so we can get to better consensus and we should. That is wonderful. Speaker 1 Inside Insight, and I think we're glad to hear it. I do want to pose the same question to Sahil, though. Do you think the band will get back together? And should they get back together? I guess what I'll say. Speaker 3 It's above my pay grade, pun intended. But I want to refrain the question a little bit because I think the COVID pandemic and now with this assault on vaccines, there's a huge assault on science. And I think the more united we could be as physicians and a scientific community, the better. I think as academics, we appreciate the nuances, the disagreements. Like, I'm very proud that IDSCAIDIDSA, excuse me, wanted to take a stand against empiric antibiotics. And I appreciate the nuances there. But I think that leaves opening for somebody who doesn't understand these dynamics to start trying to needle and create more divisions. And I think the more united we could be as a community across communities, the better it is for science and ultimately our patients. That's a wonderful. Speaker 5 Point really. Speaker 1 Really good, especially where we are right now. A united front is certainly better for the patients, which is why everybody's here. Well, excellent. Speaker 5 Thank you both. Speaker 1 So much for sharing your insights and helping us navigate this really new era of CAP guidelines and thinking about what we should do or giving us some good food for thought. But now we get to move on to everyone's favorite portion of the pod, our I Feel Nerdy segment. This is meant to be a safe space and closing segment for our panelists to nerd out over their favorite ID topics, quirks, and fun facts. For today's segment, I want to know if you could add one thing to the next version of the CAP guidelines, what would that be? Let's hear from Sharon first. Let. Speaker 5 Me. Think about this I think. Speaker 4 Knowing where the controversy is, I would want to really address the questions around antimicrobial stewardship use of. Speaker 5 Antibiotics for the. Speaker 4 The community based person I guess I would repose the question as there are more is there more harm versus risk? Trying to think of a PICO question should we start antibiotics add that public health and stewardship perspective on to those community acquired pneumonia guidelines similar to. Speaker 5 What's been focused a little? Speaker 4 Bit on the UTI guidelines as we report. Speaker 5 Sahil, how about you do? Speaker 1 You mind if I be greedy and? Speaker 3 Say two things. It's your show. I'm just a. Speaker 5 Traffic cop here. Speaker 1 I would love more guidance. Speaker 3 On immunocompromised populations, I think there's a whole spectrum of what we consider to be immunocompromised. And I feel like I spend so much of my day on the consult service trying to figure out, well, how immunocompromised as a patient and what do I do about it. And there's more and more medications that are coming out to treat different diseases. And so I think it'd be really helpful even if it's expert opinion with no data to have some guidance on how to think about this. And then my second. Speaker 5 Thing I. Speaker 3 Can't be on breakpoints without giving a shout out to my dear friend Aaron Ryan Shields and the UPMC stewardship team who basically trained me and instilled a love for antimicrobial resistance and stewardship. So I suspect whenever the next set of guidelines come out in five to 10 years, there'll be a lot more predictive models for AMR risk and figuring out which patient should we give ceftriaxone versus empiric miropenem or just doxycycline, if the guidelines could include sections on how to interpret those and which tools they recommend or don't. Speaker 1 Recommend. Speaker 3 I think that would be helpful. I want to bring Whitney back in here. Speaker 1 And allow her to weigh in on our I feel nerdy question. So Whitney, if you could add one thing to the next version of the cap guidelines, what would that be? Honestly, I would love to see. Speaker 2 More input from hospitalists and then also more antimicrobial stewards in the next CAP guidelines. I think these teams do manage and really impact the majority of patients with pneumonia as a whole in our day-to-day work. So I think adding their perspective and then also seeing increased representation from these groups I think could be extremely valuable. So I think if I could add one thing, it would be more inclusion of these two groups. Sounds like we're all. Speaker 5 In the boat of some. Speaker 1 Kind of antimicrobial stewardship portion to the guidelines, how it either affects the individual patients, antimicrobial selection or society as a whole. Great. Those are wonderful responses and with that, thank. Speaker 5 You for listening to. Speaker 1 Breakpoints, the SIDP podcast, a huge thank you to all of our guests for sharing their time and insights with us. For Doctors Whitney Hartledge, Sharon Wiseman and Sahil Angelo, I'm Ryan Minster, and we'll catch you next time on Breakpoints, the viewpoints and opinions. Speaker 5 Expressed here are our. Speaker 1 Own and do not necessarily reflect that of the institutions that employ us. Breakpoints was created by Julianne Gusto, Aaron Mccurry and Jason Pogue. This episode was produced by Megan Clat and Laci Wharton. It was edited by Amanda Galliano, peer reviewed by Noah Slotky and Laci Wharton, and transcribed by Beth Addington. The executive producer of Breakpoints is Lisa Dumco, and our theme song was recorded by SIDP member Steve Smoke. You can subscribe to Breakpoints on Apple Podcasts, Spotify, or wherever you get your podcasts. If you'd like to support us further, please consider writing a review on your favorite podcast platform and sharing this episode with a friend. Thank you, dear listener, for your ongoing support of our podcast and helping SIDP achieve our vision of safe and effective antimicrobials for now and the future.