In this episode, I’ll discuss the recent conflict between ATS and IDSA over the Community Acquired Pneumonia guidelines.
New guidelines for treating patients with community-acquired pneumonia were published earlier in 2025 by the American Thoracic Society, but unlike previous versions, these were not endorsed by the Infectious Disease Society of America.
The reason for IDSA’s non-endorsement was described in their position statement published in Clinical Infectious Diseases titled: Why IDSA Did Not Endorse the ATS Community-Acquired Pneumonia Guidelines 2025 Update.
The reasoning is as follows: The Infectious Diseases Society of America (IDSA) agreed with 8 of the 10 recommendations in the guidelines but declined to endorse the full guidelines because they include two problematic recommendations: One was for the use of antibiotics in outpatients with comorbidities who test positive for respiratory viruses and the second was for inpatients with nonsevere CAP who test positive for respiratory viruses.
The guidelines note that bacterial coinfections are common and that delaying antibiotics may be harmful. But IDSA counters with the opinion that nondiscriminatory use of antibiotics for patients with CAP and positive viral assays confers more risks than benefits. They further argue that most patients do not have bacterial coinfections, and briefly withholding antibiotics for patients with nonsevere illness to clarify the diagnosis is safe. IDSA concludes that:
In this era of precision medicine, IDSA instead recommends individualized, dynamic decision-making that takes into account each patient´s evolving trajectory, severity of illness and balance of clinical features for and against coinfection.
Perhaps more concerning than the clinical disagreement is the context revealed in the accompanying editorial, We Dissent: Lessons From the 2025 CAP Guidelines.
The editorialists describe a troubling development process. They note that the meeting format (a hybrid of remote and in-person attendees) and an imbalance in society representation favoring ATS in the Guideline Methodology Training Program may have skewed the outcomes. Most disturbingly, they claim that dissenting viewpoints – specifically those defending antimicrobial stewardship – were repeatedly questioned on “ethical grounds.”
The authors describe a discouraging environment in which the negative framing of stewardship principles was used to undermine collaborative efforts, sometimes resulting in comments directed at specific individuals.
This is an unfortunate turn of events that the two societies could not agree on a standard set of guideline recommendations for CAP, and it is very puzzling how, in the era of antimicrobial stewardship, mildly ill patients with viral infections are being recommended antibiotics on what essentially amounts to a “just in case” basis that ignores the adverse consequences of unnecessary antibiotic use.
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I feel like the answer is to make more antibiotics. I’ve always agreed that you shouldn’t harm the person in front of you for the sake of the larger public, and antibiotic stewardship does just that. But the long term solution for the sake of the larger public is 100 new antibiotic pharmacophores. Then antibiotic stewardship can be mostly ignored.