Reply to Huttner et al.: 2019 Community-acquired Pneumonia Treatment Guidelines: There Is a Need for a Change toward More Parsimonious Antibiotic Use

From the Authors:

We appreciate this additional letter submitted in response to the recently published guidelines for the treatment of community-acquired pneumonia (CAP) in adults (1).

Huttner and colleagues emphasize the importance of antimicrobial stewardship principles in shaping antibiotic treatment guidelines. We strongly agree. The adult CAP guideline emphasizes that when multiple options are presented the final antibiotic choice should be influenced by local and individual patient factors. We also emphasized the importance of deescalating antibiotics when appropriate and limiting the duration of antibiotic therapy. However, our highest priority was to assure that adequate empiric treatment is provided, especially for patients with more severe CAP. We did recommend amoxicillin as monotherapy for uncomplicated outpatients, but the recommendation for expanded antibiotic therapy for outpatients with comorbidities reflected the need to cover for a broader range of potential pathogens. These outpatients represent a group that has not been clearly shown to be safely treated with β-lactam monotherapy. Ceftaroline was included as an option for treatment of inpatients with CAP given the available high-grade evidence (cited by Huttner and colleagues) that it is at least equivalent if not superior to ceftriaxone without evidence of an increased adverse event profile.

Finally, although we acknowledge that antimicrobial stewardship is relevant for all antibiotic prescribing decisions, it is important to highlight that, in a recent analysis of all outpatient antibiotic prescribing in the United States, pneumonia was only the 14th most common diagnosis, accounting for a small percentage of all antibiotics prescribed (2). For antimicrobial stewardship to actually impact the individual and population risks of inappropriate antibiotic prescribing, including the risks attributed to respiratory fluoroquinolones, more gains will be achieved by focusing on treatment strategies for upper respiratory infections, urinary tract infections, and gastrointestinal infections.