Infectious Diseases Society of America (IDSA) position statement: why IDSA did not endorse the community-acquired pneumonia guidelines 2025 update

To the Editor: The Infectious Disease Society of America (IDSA) has been a proud collaborator with the American Thoracic Society (ATS) in developing guidelines for the diagnosis and management of community-acquired pneumonia (CAP) since 2007. IDSA appreciates the contributions and expertise of the CAP guideline panel members in the 2025 update. However, after much deliberation, IDSA elected against endorsing this guideline revision.1 IDSA agreed with 8 of the 10 recommendations, but was unable to accept 2 recommendations advocating antibiotics for CAP patients testing positive for respiratory viruses. As representatives of IDSA’s Standards & Practice Guidelines Subcommittee, Antimicrobial Stewardship Centers of Excellence Subcommittee, and IDSA membership, we are writing on behalf of IDSA to summarize the rationale for this decision. The updated CAP guidelines make 4 conditional recommendations regarding the use of antibiotics in patients with a clinical and radiological diagnosis of CAP who test positive for a respiratory virus. The guidelines suggest empiric antibiotics should not be used in adult outpatients without comorbidities, and suggest empiric antibiotics should be used in hospitalized adults with severe CAP. IDSA supports both of these recommendations. However, the guidelines also suggest empiric antibiotics for adult outpatients with comorbidities and adult inpatients with non-severe CAP, due to concern for bacterial-viral co-infection.1 IDSA does not support these approaches because they will lead to large numbers of patients with viral infections being treated with antibacterials that are unlikely to help them, and could increase both individual and population-level risks for harm. IDSA does not agree that it would be appropriate for the majority of adult outpatients with comorbidities and adult inpatients with non-severe CAP to receive antibiotics in case of bacterial-viral co-infection because the best available evidence suggests co-infections occur in only a minority of patients and antibacterials are less time sensitive in patients with non-severe CAP. The guideline authors acknowledge that there are no randomized trials or high-quality observational data to guide the decision on whether to give antibiotics to patients with CAP and positive viral assays. In particular, they note there is no evidence that withholding antibiotics in patients with viral pneumonia is safe. However, there is also no evidence that giving antibiotics is helpful.2,3 Indeed, while the potential benefits of antibiotic therapy for viral pneumonia have not been established, the risks of antibiotic-related complications, including Clostridioides difficile colitis, microbiome disruption, and selection for antimicrobial resistance, are well known. In addition, the plurality of medication-related adverse events leading to emergency ­department visits is attributable to antibiotics.4 As such, assuming that treating with antibiotics is “safer” than withholding antibiotics is not supported. The guideline authors base their recommendations in favor of antibiotics for outpatients with comorbidities and inpatients with non-severe CAP on the concern that bacterial co-infection is common, morbid, and associated with worse outcomes if antibiotic treatment is delayed. The panel cited studies estimating that between 3% and 39% of hospitalized patients who test positive for viruses have bacterial co-infection.1 The wide variability in coinfection estimates underscores the imprecision and uncertainty underlying the estimates. Moreover, growth of bacteria in respiratory cultures does not necessarily indicate infection: bacterial colonization of the respiratory tract is common, particularly in patients with chronic lung diseases.4,5 Similarly, concerns that any delay in starting antibiotics in the subset of patients that are coinfected will lead to worse outcomes is not supported. The association between time-to-antibiotics and mortality is strongly moderated by severity of illness. Delays are associated with increased mortality in patients with septic shock and rarely in patients without sepsis.6,7 Although classified as “conditional,” these recommendations imply that antibiotics are suitable for most patients. The guidelines adherence to the GRADE framework and PICO methodology did not sufficiently account for the risks of broader public health impact of antibiotic use.2,3 Antibiotic overuse during the COVID-19 pandemic significantly increased multi-drug-resistant organisms and hospital-acquired infections.8-10 Importantly, the scope of antibiotic overuse for viral pneumonia is potentially enormous given the frequency of pneumonia, the high fraction of pneumonias attributable to viruses, and the high rate of pneumonia over-diagnosis.11,12 There is also concern that national healthcare organizations may develop quality metrics based on the updated CAP guidelines, which may further promote antibiotic overuse. We acknowledge that empiric antibiotics are warranted for some outpatients with comorbidities and some inpatients with non-severe CAP with positive respiratory viral assays and suggest prescribing empiric antibiotics when individual patient factors indicate concern for bacterial-viral co-infection. Table 1 of the guidelines includes a thoughtful summary of factors that strengthen versus weaken the guidelines’ recommendations in favor of antibiotics, including which virus was identified, duration of symptoms, severity of illness, biphasic illness, inflammatory markers, radiographic findings, rapid diagnostic test results, and illness trajectory. None of these factors alone is diagnostic, but we believe clinicians should have the ­latitude to weigh and balance these considerations to determine whether empiric antibiotics are warranted or not. IDSA is proud to collaborate with ATS on guidelines for CAP and other pulmonary infections and deeply regrets that our organizations were not able to reach consensus on the 2025 guideline update. IDSA is committed to collaborating with ATS on future iterations of these guidelines, while continuing to improve the methodological and dialogical tools used to develop recommendations that appropriately balance patient-centered care and public health. We continue to believe that clinicians, patients, and policy makers are best served when professional societies are able to project a common message that represents the consensus of both societies. Supplementary material is available at American Journal of Respiratory and Critical Care Medicine online. Please see the ICMJE disclosure forms, which have been provided as supplementary material.