2 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

2.1 Urine antigen testing

In moderate‑ to high‑severity community‑acquired pneumonia does using legionella and pneumococcal urinary antigen testing in addition to other routine tests improve outcomes?

Why this is important

Current practice and evidence suggest that giving a combination of antibiotics to patients with moderate‑ to high‑severity community‑acquired pneumonia reduces mortality. However, no randomised controlled trial has looked at using urinary antigen testing to target treatment. If effective, such targeted treatment could improve antibiotic stewardship, increase compliance and potentially reduce costs.

2.2 C-reactive protein guided antibiotic duration

In patients hospitalised with moderate‑ to high‑severity community‑acquired pneumonia, does using C‑reactive protein monitoring in addition to clinical observation to guide antibiotic duration safely reduce the total duration of antibiotic therapy compared with a fixed empirical antibiotic course?

Why this is important

The recommended duration of antibiotic therapy for adults hospitalised with moderate‑ to high‑severity community‑acquired pneumonia is based on evidence of very low quality; no relevant clinical trials were identified by NICE. The burden of community‑acquired pneumonia is large, and its treatment accounts for a high proportion of antibiotic use in hospitals. Overuse of antibiotics is associated with antimicrobial resistance, which is a national and global priority.

2.3 Continuous positive pressure ventilation

What is the clinical effectiveness of continuous positive pressure ventilation compared with usual care in patients with community‑acquired pneumonia and type I respiratory failure without a history of chronic obstructive pulmonary disease?

Why this is important

Type I respiratory failure is a common feature of pneumonia. Mild type I respiratory failure is easily corrected with low levels of supplemental oxygen, whereas severe life‑threatening hypoxemia needs immediate intubation and invasive ventilation. Research into whether continuous positive pressure ventilation improves gas exchange and subsequent outcomes, such as mortality, could help improve care for patients with respiratory failure between these extremes.

2.4 Hospital-acquired pneumonia

Can rapid microbiological diagnosis of hospital‑acquired pneumonia reduce the use of extended-spectrum antibiotic therapy, without adversely affecting outcomes?

Why this is important

Data are limited on the microbiology of hospital‑acquired pneumonia to guide antibiotic therapy. Hospital‑acquired infections can be caused by highly resistant pathogens that need treatment with extended‑spectrum antibiotics (for example, extended‑spectrum penicillins, third‑generation cephalosporins, aminoglycosides, carbapenems, linezolid, vancomycin, or teicoplanin), as recommended by British Society of Antimicrobial Chemotherapy guidance. Because routine microbial tests lack sensitivity and take 24–48 hours to identify a causative pathogen, patient characteristics are used to guide antibiotic choice. However, this may lead to unnecessary use of extended‑spectrum antibiotics in patients infected with non‑resistant organisms, and inappropriate use of first‑line antibiotics (such as beta‑lactam stable penicillins, macrolides or doxycycline) in patients infected with resistant organisms.

Rapid diagnostic tests to identify causative bacterial pathogens and determine whether they are resistant to antibiotics may have a role in guiding antibiotic choice for postoperative hospital‑acquired pneumonia.

To limit population variability and include high‑risk patients spending time in intensive care, studies should include postoperative patients from different surgical specialties.

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