A panel of 45 multidisciplinary physicians has achieved consensus responses to 21 questions used to address initial management strategies of immunocompromised patients with community-acquired pneumonia. An overview of these general suggestions has been published in Chest.
In the United States, it is estimated that 3% of the adult population is immunosuppressed, with immunocompromised conditions present in an estimated 20% to 30% of hospitalized patients with community-acquired pneumonia. There is an increasing number of immunocompromised patients who are at risk for community-acquired pneumonia due to factors including the longer survival of patients with cancers, the better recognition of immunocompromising conditions, and the approval of newer immunomodulatory agents. However, the current guidelines exclude immunocompromised patients. Therefore, a document was developed with general suggestions for the initial management of immunocompromised patients with community-acquired pneumonia.
In total, a panel of 45 multidisciplinary physicians with experience in the management of community-acquired pneumonia in immunocompromised patients answered 21 questions that were focused on initial management strategies for immunocompromised patients with community-acquired pneumonia. To come to consensus on each question, the Delphi survey methodology was used in conjunction with a 5-point Likert scale to evaluate agreement or disagreement with each proposed answer. When more than 75% of participants agreed or strongly agreed with a particular suggestion, it was considered to be consensus.
Researchers achieved consensus in defining the population, site of care, likely pathogens, microbiological work-up, general principles of empiric therapy, and empiric therapy for specific pathogens.
Briefly, researchers defined immunocompromised patients as those at elevated risk for pneumonia not only from so-called common organisms, but also from “uncommon avirulent or opportunistic organisms.” Immunocompromised patients can be admitted to the hospital based on clinical judgement; severity scores such as the Pneumonia Severity Index have not been well-validated in these patient populations. Additionally, both immunocompromised and non-immunocompromised patients are susceptible to the same core respiratory pathogens. Beyond these core pathogens, when considering disease etiology, physicians should focus on respiratory pathogens for which antimicrobial therapies are available.
When treating patients, the researchers suggested that physicians conduct a “comprehensive microbiological work-up,” with the ultimate treatment goal of pathogen-directed therapy followed by therapy de-escalation. The decision to perform either bronchoscopy or bronchoalveolar lavage should be individualized to each patient being treated, and bronchoalveolar lavage in particular should be guided by the presence of risk factors for specific pathogens.
The researchers also determined that patients who are immunocompromised, but who have no additional risk factors for drug-resistant bacteria, may receive initial empiric therapy targeted only toward the core respiratory pathogens. Severe pneumonia may indicate the start of empiric therapy for gram-positive or gram-negative organisms followed by rapid treatment de-escalation.
For community-acquired pneumonia resulting from specific pathogens, such as MRSA, Pseudomonas aeruginosa, gram-negative or multidrug resistant gram-negative bacilli, Pneumocystis jirovecii pneumonia, Aspergillus, Mucorales, Nocardia, the Varicella-zoster virus, and cytomegalovirus, the researchers suggest that empiric therapy “be extended to cover the possibility” that these pathogens are present. For community-acquired pneumonia resulting from Mycobacterium tuberculosis or parasites, empiric therapy targeting these pathogens generally would not be recommended.
“[T]his document…offers general suggestions for the initial management of the immunocompromised patient who arrives at the hospital with pneumonia,” the authors concluded. “When possible, the care of these patients should be carried out by a multidisciplinary group of specialists.”
Ramirez JA, Musher DM, Evans SE, et al. Management of community-acquired pneumonia in immunocompromised adults: a consensus statement regarding initial strategies [published online June 16, 2020]. Chest. doi:10.106/j.chest.2020.05.598