By Stan Deresinski, MD, FIDSA
Synopsis: An update of elements of community-acquired pneumonia guidelines has been published. Of note is that these were not endorsed by the Infectious Diseases Society of America because of disagreement over recommendations for empiric antibiotic administration to some patient subsets with positive tests for respiratory viral infection.
Source: Jones BE, Ramirez JA, Oren E, et al. Diagnosis and Management of Community-acquired Pneumonia. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2025; Jul 18. doi: 10.1164/rccm.202507-1692ST. [Online ahead of print].
The American Thoracic Society has addressed new published information regarding some issues relative to the diagnosis and management of community-acquired pneumonia (CAP) in non-immunocompromised adults.
Diagnosis
- Of the 15 panel members, 13 agreed with a conditional suggestion that was based on low-quality evidence that lung ultrasound is an acceptable alternative to chest radiography in the diagnosis of CAP.
Empiric Antibiotic Treatment
The panel addressed the need for empiric antibacterial therapy in subsets of patients with CAP who have a positive test indicating the presence of a respiratory virus.
- For CAP outpatients without comorbidities, they made a conditional suggestion based on very low-quality evidence to withhold empiric antibiotics.
- For outpatients with comorbidities, they recommended the empiric administration of antibiotics because of concern for co-infection. This is a conditional suggestion based on very low-quality evidence.
- For inpatients with non-severe CAP, 12/15 panel members made a conditional suggestion, based on very low-quality evidence, to administer empiric antibacterials.
- For inpatients with severe CAP, 15/15 panel members made a conditional suggestion, based on very low-quality evidence, to administer empiric antibacterials.
Duration of Treatment
- For outpatients who achieve clinical stability, the panel conditionally suggests less than five days (minimum of three days) of antibiotic administration, depending on daily clinical assessment. The evidence was assessed as being of low quality.
- For inpatients, five days or more of antibiotic therapy was strongly suggested on the basis of low-quality evidence.
Adjunctive Systemic Corticosteroids
- The panel strongly recommended, albeit based on low-quality evidence, against the systemic administration of corticosteroids to inpatients with non-severe CAP.
- The panel suggested systemic corticosteroid administration to inpatients with severe CAP. This suggestion was conditional and based on low-quality evidence.
Commentary
Despite the participation of members of the Infectious Diseases Society of America (IDSA), the IDSA failed to endorse this guideline update. According to a posting by the chair of the IDSA Standards & Practice Guidelines Subcommittee, this was the result of disagreement concerning the suggestions that empiric antibiotics be administered to outpatients with comorbidities and non-severe CAP with a positive viral test as well as to inpatients with non-severe CAP and a positive viral test.1 This was the result of a lack of supportive evidence together with the potential for widespread overuse of antibiotics with associated risks of adverse clinical effects, disruption of the microbiome, and selection of antibiotic resistance. IDSA has submitted a letter to the editor of the journal further explaining their rationale.
Overall, it is disturbing that all but one of the statements regarding interventions were suggestions, not recommendations — with the exception of the recommendation against the use of systemic corticosteroids in inpatients with non-severe CAP. This was considered strong, as was the recommendation for more than five days of antibiotic therapy for inpatients with severe CAP; all the rest were conditional.
Overall, only two suggestions/recommendations were considered strong and seven were conditional. Conditional was defined as indicating that “a sizable minority of patients may not want the suggested course of action, and clinicians must help the patient arrive at a management decision consistent with their values and preferences.” All were based on low-quality or very low-quality evidence.
All this is consistent with the current situation with guidelines in much of the field of infectious diseases, especially regarding therapeutic interventions — the necessary evidence most often is inadequate or absent. Fifteen years ago, as chair of the IDSA guidelines committee, I was tasked with writing a response to two publications that pointed out the pitiful evidence base upon which many of our guidelines had been based, an observation with which I agreed. But, as a clinician, I recognized the need to do the best for our patients with the available information, hence the title of my commentary: “Guiding clinical care through evidence-free zones.” 2 The guideline reviewed here probably is the best we have — with the exceptions to which IDSA is objecting. The problem is not with the guideline development process but with the lack of reliable actionable evidence.
Stan Deresinski, MD, FACP, FIDSA, is Clinical Professor of Medicine, Stanford University.
References
- Weissman S. Re: 2025 ATS CAP Guidelines — not approved by IDSA? IDSA IDea Exchange. July 21, 2025.
- Deresinski S. Guiding clinical care through evidence-free zones. Clin Infect Dis. 2010;51(10):1157-1159.
An update of elements of community-acquired pneumonia guidelines has been published. Of note is that these were not endorsed by the Infectious Diseases Society of America because of disagreement over recommendations for empiric antibiotic administration to some patient subsets with positive tests for respiratory viral infection.
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