The PES (Pseudomonas, Enterobacteriaceae ESBL, Methicillin-resistant Staphylococcus aureus) Concept in Community-acquired Pneumonia

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One of the main concerns about the management of community-acquired pneumonia (CAP) is to choose an adequate empirical antibiotic treatment. Patients with CAP usually respond to the standard antibiotics suggested by CAP guidelines; however, a small percentage of patients need a different and more aggressive treatment because of the presence of resistant pathogens. The critical point is to identify this small subgroup of CAP patients and to avoid the overtreatment of the remaining CAP patients. Therefore, it is important to create a tool to stratify patients at risk for resistant pathogens. The definition of health care–associated pneumonia has not proven to be effective. Moreover, recent studies proposed new scores on the basis of specific factors to screen the population at risk. However, they presented limitations: there was a lack of strong external validation, they included immunosuppressed patients, and they used different definitions of multidrug-resistant pathogens. In this review, we underline the limitations of the current approach to guide empirical antibiotic therapy in CAP. We propose to avoid the term multidrug resistant in favor of a novel definition called “PES concept,” which includes the 3 most frequent resistant pathogens in CAP that are not susceptible to the antibiotics suggested by the guidelines: Pseudomonas aeruginosa, Enterobacteriaceae ESBL positive, and methicillin-resistant Staphylococcus aureus. This new concept is treatment oriented and classifies pathogens according to their response to a specific class of antibiotics. Thus, we present a conceptual framework to guide the empirical antibiotic selection considering 3 groups of patients: immunosuppressed patients with CAP, patients with CAP without risk factors for PES, and patients with CAP with high risk for PES pathogens.

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