Dr Kieu Thi Phuong Nhan

Dean of the Medicine Faculty, Buon Ma Thuot Medical University;

Head of the Internal Medicine Department, Buon Ma Thuot Medical University Hospital, Vietnam.

The American Thoracic Society (ATS) has recently updated its guidelines for community-acquired pneumonia (CAP). These updates were prompted by recent advances in evidence, clinical experiences and emerging technologies that have reshaped the approach to the diagnosis and management of CAP.¹

In this interview, Dr Kieu Thi Phuong Nhan from Buon Ma Thuot Medical University Hospital discussed how the new 2025 ATS guidelines for CAP have influenced the diagnosis and management of CAP in Vietnam.

Q1: The recently published 2025 ATS guidelines for CAP now recommend lung ultrasound (LUS) as an alternative to chest radiography for the diagnosis of CAP.¹ What are the opportunities and challenges of implementing the use of LUS in Vietnam?

There is a strong potential for implementing the use of LUS in Vietnam²:

1. Convenience
   LUS can be performed at the bedside, even in remote or rural areas where traditional chest X-ray machines may not be available or patients with limited mobility. This is a major advantage in Vietnam, where many communities lack access to well-equipped hospitals.
2. Safety
   Patients undergoing LUS do not get exposed to radiation, which is a major benefit for vulnerable groups like pregnant women, children, or those who require frequent check-ups.
3. Cost-effectiveness
   Ultrasound machines are generally less expensive than X-ray machines.
4. Diagnostic value
   LUS allows for the examination of the pleural space, which cannot be done by chest X-rays. Furthermore, for patients with a high suspicion of CAP but a negative X-ray result, LUS serves as a crucial alternative diagnostic tool. LUS provides immediate, real-time imaging, allowing doctors to make quick diagnostic and therapeutic decisions.
5. Ongoing monitoring
   LUS can be performed multiple times to assess the progression of the disease and the patient’s response to CAP treatment, making it more convenient than repeated X-rays.

While implementing LUS in Vietnam offers significant opportunities, it also presents notable challenges³:

1. Interpretation of LUS results
   The biggest challenge is that LUS is highly operator-dependent. Interpreting LUS images requires specific training and expertise, which is not yet standardised in many medical schools and hospitals in Vietnam. The nuances of lung artifacts, like A- and B-lines, and the differentiation between different pathologies, can be difficult for inexperienced clinicians.
2. Protocols for performing LUS
   There is a need for standardised protocols for performing LUS and documenting findings to ensure consistency and quality across different healthcare facilities. In Vietnam, with a high prevalence of tuberculosis, implementing LUS for CAP diagnosis is particularly challenging.

Q2: As CAP can be caused by a variety of aetiologies (e.g., bacterial, viral and fungal pathogens), how do you decide on a recommended course of action in your clinical practice? When do you consider antibiotics (e.g., quinolones), and what guides that decision?

In clinical practice, identifying the causative agent of pneumonia can sometimes be challenging, especially at the initial stage when microbiological test results cannot be performed or results are not yet available. We need to rely on a clinical examination and some paraclinical tests that can suggest the pathogen, such as blood count, C-reactive protein, procalcitonin, and imaging from a chest X-ray, pleural ultrasound, or occasionally computed tomography scan.^4,5

The empiric diagnosis of bacterial agents causing pneumonia is based on^6,7: (1) the severity of the pneumonia; and (2) the patient’s background, including their age, lifestyle habits and comorbidities (pulmonary and systemic). The selection of an antibiotic should be based on the causative pathogen and the antimicrobial spectrum of various antibiotics, which then guides the empiric antibiotic regimen. Since bacterial pathogens of CAP often coexist with viruses, and there are currently no rapid and accurate tests to determine if the cause is solely viral. It is crucial to start an empiric antibiotic regimen early whenever a bacterial or co-bacterial/viral cause is suspected.⁸

Common bacterial pathogens causing CAP include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and intracellular bacteria, with Streptococcus pneumoniae being the most common cause.⁹ Accordingly, the three most common antibiotic classes used to treat CAP are β-lactams, macrolides, and fluoroquinolones.⁷

Respiratory fluoroquinolones (e.g., levofloxacin and moxifloxacin) have a broad antimicrobial spectrum that covers both S. pneumoniae and atypical bacteria.¹⁰ However, this class of antibiotics should be reserved for the later line and not be a first-line choice for outpatients without comorbidities, those who do not have risk factors for drug-resistant S. pneumoniae infection, or those who have not recently used antibiotics, in order to reduce the risk of antibiotic resistance.¹

Q3: Given the new guideline recommendation to limit antibiotic treatment for clinically stable outpatients with CAP to 5 days or shorter, have you observed any differences in patient recovery or relapse risk between shorter versus longer antibiotic courses?

The recommendation to limit antibiotic treatment for clinically stable outpatients with CAP to 5 days or shorter is based on numerous randomised controlled trials and meta-analyses.¹ The overwhelming conclusion from this evidence is that shorter courses of antibiotics are non-inferior to longer courses for the majority of patients with uncomplicated CAP.¹ For stable outpatients with CAP, using antibiotics for 5 days or less has shown comparable effectiveness to longer courses.¹

In reality, many outpatients with CAP in Vietnam are prescribed a 7- to 10-day course of antibiotics. However, most patients stop taking the medication after 3 to 5 days when they feel better or have fully recovered. Shorter treatment durations do not appear to increase the likelihood of infection recurrence. While shorter treatment durations offer greater convenience for outpatients, improve adherence, and may provide effective treatment outcomes, it is important to note that prematurely discontinuing antibiotics before completing the prescribed course may contribute to antimicrobial resistance.^11,12

Q4: The updated guidelines recommend against prescribing corticosteroids for hospitalised patients with non-severe CAP.¹ Based on your clinical experience, are quinolones alone sufficient for this patient population? When do you consider prescribing corticosteroids, and what guides your decision?

In most cases, quinolones (or other appropriate antibiotic regimens) are sufficient for hospitalised patients with non-severe CAP. The core principle of treating non-severe CAP is to use effective antimicrobial therapy to eliminate the bacterial pathogen. Due to their broad-spectrum coverage, quinolones can be used as a monotherapy.⁸

Based on the evidence that guides the new recommendations, corticosteroids are not for routine use in non-severe CAP.¹ Instead, their use is limited to a specific subset of patients where the potential benefits outweigh significant risks.¹ The decision to prescribe corticosteroids is guided by the severity of the illness and the presence of a dysregulated, hyper-inflammatory response.¹

References

1. Jones BE, et al. Am J Respir Crit Care Med 2025 Jul. doi: 10.1164/rccm.202507-1692ST. [Epub ahead of print]
2. Marini TJ, et al. Radiol Cardiothorac Imaging 2021;3:e200564.
3. Rocca E, et al. Adv Respir Med 2023;91:203-223.
4. Ito A, Ishida T. Ann Transl Med 2020;8:609.
5. Nambu A, et al. World J Radiol 2014;6:779-793.
6. Lutfiyya MN, et al. Am Fam Physician 2006;73:442-50.
7. Armstrong C. Am Fam Physician 2020;102:121-124.
8. Metlay JP, et al. Am J Respir Crit Care Med 2019;200:e45-e67.
9. Regunath H, Oba Y. Community-Acquired Pneumonia. [Updated 2024 Jan 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430749/
10. García-Rodríguez JA, Muñoz Bellido JL. Int J Antimicrob Agents 2000;16:281-285.
11. Mayo Clinic. Antibiotics: Are you misusing them? Available at: https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/antibiotics/art-20045720. Accessed 23 September 2025.
12. John Hopkins Medicine. Antibiotics. Available at: https://www.hopkinsmedicine.org/health/wellness-and-prevention/antibiotics. Accessed 23 September 2025.