Severe community-acquired pneumonia (CAP) remains a life-threatening disease, causing 78 % of infection-related deaths and is the most common cause of sepsis. Empirical antibiotic therapy is started before the results of bacteriological diagnosis are available. The diversity of pathogens often makes it difficult to choose a drug for etiotropic empirical therapy. Isolates of bacteria responsible for CAP sometimes show high resistance to several antibiotics, including cephalosporins and carbapenems. We analyzed scientific publications from the PubMed database for the last 5 years on the problem of empirical antimicrobial therapy of CAP. Currently, empirical therapy for pneumonia is determined by the site of infection (hospital or other settings), but may be conditioned by the presence of risk factors for multidrug-resistant pathogens, regardless of the site of infection. A rational approach to making decisions about prescribing broad-spectrum antibiotics is to use risk prediction models at the patient level. Recommendations for empirical therapy of CAP have been developed, taking into account individual risk factors for multidrug-resistant infection, and their use, according to the results of 30-day mortality, has proven to be more effective than the use of classification by site of pneumonia.Among the current directions of empirical antimicrobial therapy of CAP are use of drugs with a narrow spectrum of action based on the use of an algorithm for determining the risk of multidrug-resistant infection, as well as a procalcitonin test; use of an algorithm for choosing an alternative antimicrobial agent in case of a history of penicillin allergy; reduction of the total duration of antimicrobial therapy; widespread introduction of antimicrobial stewardship programs in the activities of not only hospitals but also primary care facilities.

Modern Directions of Optimization of Empirical Antimicrobial Therapy of Community-Acquired Pneumonia (Review)

Abstract The coronavirus disease 2019 (COVID-19) pandemic upended our approach to imaging community-acquired pneumonia, and this will alter our diagnostic algorithms for years to come. In light of these changes, it is worthwhile to consider several postpandemic scenarios of community-acquired pneumonia: (1) patient with pneumonia and recent positive COVID-19 testing; (2) patient with air space opacities and history of prior COVID-19 pneumonia (weeks earlier); (3) multifocal pneumonia with negative or unknown COVID-19 status; and (4) lobar or sublobar pneumonia with negative or unknown COVID-19 status. In the setting of positive COVID-19 testing and typical radiologic findings, the diagnosis of COVID-19 pneumonia is generally secure. The diagnosis prompts vigilance for thromboembolic disease acutely and, in severely ill patients, for invasive fungal disease. Persistent or recurrent air space opacities following COVID-19 infection may more often represent organizing pneumonia than secondary infection. When COVID-19 status is unknown or negative, widespread airway-centric disease suggests infection with mycoplasma, Haemophilus influenzae, or several respiratory viruses. Necrotizing pneumonia favors infection with pneumococcus, Staphylococcus , Klebsiella , and anaerobes. Lobar or sublobar pneumonia will continue to suggest the diagnosis of pneumococcus or consideration of other pathogens in the setting of local outbreaks. A positive COVID-19 test accompanied by these imaging patterns may suggest coinfection with one of the above pathogens, or when the prevalence of COVID-19 is very low, a false positive COVID-19 test. Clinicians may still proceed with testing for COVID-19 when radiologic patterns are atypical for COVID-19, dependent on the patient's exposure history and the local epidemiology of the virus.

Community-Acquired Pneumonia: Postpandemic, Not Post-COVID-19

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Community-Acquired Pneumonia: Postpandemic, Not Post-COVID-19