MANAGING CAP: Are you up-to-date?
New recommendations aim for outpatient treatment whenever appropriate, and a better vaccination rate
By definition, CAP is acquired outside a hospital or long-term care facility. However, the new guidelines include ambulatory residents of nursing homes.
Adults with CAP are the focus of the guidelines, not immunocompromised patients, cancer patients receiving chemotherapy, patients on high-dose steroid therapy, or children under 18 years.
Epidemiology. There are about 5.6 million cases of CAP in the United States annually, and the cost is about $8.4 billion.1 Death rates increase with comorbidities and older age. There are no race or gender differences in morbidity.
Limitations of the guidelines. The decision whether to admit a patient with CAP is crucial, since the majority of the pneumonia care expenditures are the result of in-patient care.2 The guidelines do not state the outcomes that were considered or adverse events associated with therapy. It is weakened by lack of cost analysis and absence of clinical algorithms.
How the evidence was graded. Electronic databases were searched through June 2006. Experts considered reviews and meta-analyses and weighted the evidence according to a rating scheme. They graded each recommendation on the quality of the literature (levels I, II, or II) and by expert interpretation (strong, moderate, or weak). A strong recommendation required that more than 50% of the experts grade it as strong and the majority of the remainder grade it as moderate.
Most patients with CAP should receive a strongly rated intervention, and the rationale for variation should be apparent from the medical record. With a moderate or weak recommendation, the committee suggested, most physicians would follow the recommended management, but many would not.
