Guidelines for the initial Management of Adults with Community-acquired Pneumoma : Diagnosis , Assessment of Severity ; and initial Antimicrobial fieraky

Community-acquired pneumonia (CAP) remains a common and serious illness despite the availability of potent new antimicrobials and effective vaccines. In the United States, pneumonia is the sixth leading cause of death, and the number one cause of death from infectious d-&eases (1,2). Because pneumonia is not a reportable illness, information about its incidence is based on crude estimates, but it appears that as many as 4 million cases of community-acquired pneumonia occur annually, and as much as one fifth of these require hospitalization (1). In the outpatient setting, the mortality rate of pneumonia remains low, in the range of 1 to 5%, but among patients with community-acquired pneumonia who require hospitalization, the mortality rate approaches 25%, particularly if the patient requires admission to the intensive’care unit (3-Q). In recent years, both the epidemiology and treatment of pneumonia have undergone changes. Pneumonia is increasingly common among older patients and those with comorbidii (coexisting illness). Such illnesses include chronic obstructive lung disease, diabetes melliis. renal insufficiency, congestive heart failure, chronic liir d&ease, and other similar medical condiins These patients may beoome infected with a variety of newly identified, or previously unrecognized, pathogens (5). At the same time, a number of new antimicrobial agents have become available, some with utilii for community-acquired pneumonia. Parallel to the improvement in our antibiotic armamentarium, bacterial resistance mechanisms have evolved. In the lQQQs, the prospect of pneumowccal resistance to penicillin therapy has become a realii. This document is a summary of a conference that was convened to develop an approach to the initial management of community-acquired pneumonia, taking into account the evolving epidemiology of this infection and current therapeutic approaches. The discussion is limited to the apparently immune competent patient with communityacquired pneumonia because thii represents the population encountered most commonly. me approach to the immunocompromisad patient is different because of the large number of potential etidogic agents for pneumonia in these patients. Thus, the discussion does not deal directly with the problems of pneumonia in the HIV-infected patient or in those patients immunocompromised because of myelosuppressive chemotherapy, organ transplantation, or?radiinaF immunosuppressive illnesses such as Hodgkin’s disease.