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The new BTS guidelines on the management of community acquired pneumonia (CAP) in adults1 are welcome if they lead to improved diagnosis of pneumonia, better assessment of severity of illness, and thus more appropriate treatment according to clinical needs. It is widely accepted, however, that inappropriate implementation of the previous guideline contributed to large increases in unnecessary use of broad spectrum antibiotics with resultant increases in antibiotic resistance and Clostridium difficile infection. The authors acknowledge this, but the new guidelines seem likely to continue this unfortunate trend.
Firstly, there is no mention of the use of oral penicillin for treatment of mild cases of CAP. This is a first line choice in Scandinavian countries which have a commendably restrained history of antibiotic use (and consequently low rates of resistance).2 The new BTS guideline recommendation for widespread use of the broader spectrum amoxicillin cannot help current antibiotic resistance problems. The pharmacodynamic arguments favouring amoxicillin may be important in those areas having problems with penicillin intermediate and resistant pneumococci, but in many areas of the UK—including much of Scotland—these strains are rare.3 Did the authors consider oral penicillin as an option for mild cases?
Secondly, for treatment of severe pneumonia there is no mention of parenteral penicillin. The recommendation of co-amoxiclav or cefuroxime for this condition, while covering uncommon Gram negative pathogens and methicillin sensitive Staphylococcus aureus (MSSA), may lead to inadequate treatment of CAP due to penicillin resistant pneumococci. Surely benzyl penicillin is an option in young previously healthy people with severe CAP (the majority of whom will have pneumococcal infection).4 Then, if there is a reasonable risk of infection with a pneumococcus with reduced susceptibility to penicillin, the dose of benzyl penicillin can be raised accordingly.
Thirdly, the recommendations for macrolide use in the first version of the guideline have probably been the main reason for the doubling of macrolide consumption in our local hospital since the previous guidelines were introduced (unpublished observation). If this observation is indicative of a more widespread trend, it may well be contributing to the current national problem with MRSA and other macrolide resistant organisms. To what benefit I wonder? Certainly, a laboratory diagnosis of atypical pneumonia is rare in our population. Isn't this another case for stratifying patients according to risk rather than treating all severely ill hospitalised patients with a macrolide?
I appreciate the huge body of evidence considered by the authors and the disappointing number of studies which were helpful in guiding best recommendations for treatment. Nevertheless, at a time when there is widespread concern about inappropriate antibiotic use, much of it with broad spectrum agents, it is crucial that new guidelines urge restrained prescribing unless the risks (inadequate spectrum) clearly outweigh the benefits (reduced ecological damage). At the same time, severe cases require the best treatment and this should not be compromised out of a desire to do the impossible and cover all conceivable (but unlikely) pathogens all of the time.