Key differences from the 2019 American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) guidelines for the treatment of adults with community-acquired pneumonia (CAP)

Patient group

ATS/IDSA outpatient CAP empiric antibiotic recommendations

UpToDate CAP outpatient empiric antibiotic recommendations

Adult outpatients aged <65 years, without comorbidities or smoking, and who have not used antibiotics within the prior three months

The ATS/IDSA recommends amoxicillin monotherapy. For those who cannot use penicillins, monotherapy with either a macrolide or doxycycline is recommended, provided local resistance rates among S. pneumoniae isolates are <25%.*

UpToDate suggests amoxicillin plus a macrolide or doxycycline as preferred therapy because there is a potential morbidity benefit and the downside of a short course of therapy for most patients is low.

Adult outpatients who meet any of the following criteria:

Age ≥65 years old
Active smoking
Presence of comorbidities (ie, chronic pulmonary, liver, heart, or kidney disease; cancer, diabetes mellitus, heart failure, or alcohol use disorder)
Antibiotic use within the prior three months

ATS/IDSA recommends either:

Combination therapy with a beta-lactam plus macrolide or doxycycline
or
Monotherapy with a respiratory fluoroquinolone

There is no stated preference between these regimens.

UpToDate suggests combination therapy with amoxicillin-clavulanate plus a macrolide or doxycycline. Amoxicillin-clavulanate has reliable activity against S. pneumoniae and an overall favorable adverse effect profile.

Our approach is generally similar to the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines with few exceptions noted in this table. Refer to UpToDate text for complete regimens, dosing, and rationale for antibiotic selection.

CAP: community-acquired pneumonia; ATS/IDSA: American Thoracic Society/Infectious Diseases Society of America; S. pneumoniae: Streptococcus pneumoniae.

* For macrolides, resistance rates among S. pneumoniae are often >30% in the United States and typically >25% for most parts of the world, apart from some regions in Northern Europe. For doxycycline, resistance rates are less well established but are approximately 10 to 20% in the United States and likely rising.

Reference:

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200:e45.

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Key differences from the 2019 American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) guidelines for the treatment of adults with community-acquired pneumonia (CAP)