CAP, HCAP, HAP, VAP community-acquired pneumonia as: a. An ailment - PDF document

1. In 1898, William Osler described CAP, HCAP, HAP, VAP community-acquired pneumonia as: a. An ailment that often leads to suffocation and death. b. A friend of the aged. Brad Sharpe, M.D. Professor of Clinical Medicine c. A common and mortal disease which can be Department of Medicine diagnosed by simple observation and UCSF percussion of the chest. sharpeb@medicine.ucsf.edu d. Bad. Really bad. I have no relevant financial relationships to disclose. CAP: A Practical Approach 1. In 1898, William Osler described "Pneumonia may well be called the friend of the community-acquired pneumonia as: aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those ‘cold gradations of decay’ so distressing of himself and to his friends.“ a. An ailment that often leads to suffocation -- William Osler, M.D., 1898 and death. b. A friend of the aged. c. A common and mortal disease which can be diagnosed by simple observation and percussion of the chest. d. Bad. Really bad. CAP: A Practical Approach CAP: A Practical Approach 1

CAP, HCAP, HAP, VAP “Brad, pneumonia sucks.” -- Mary R. Sharpe November 2011 CAP: A Practical Approach CAP: A Practical Approach Roadmap Roadmap • Background • Community-acquired pneumonia (CAP) • Healthcare-associated pneumonia (HCAP) • Hospital-acquired pneumonia (HAP) • Ventilator-associated pneumonia (VAP) CAP: A Practical Approach 2

Specific Goals: Caveats • Describe the most common causes of • Will not talk about other types of pneumonia (in pneumonia in different settings HIV, aspiration, etc.) • Initiate appropriate antibiotics in the treatment of CAP, HCAP, HAP, and VAP • Will not discuss admission decision (complex) • State the optimal duration of therapy in pneumonia in different settings • Syllabus or specific questions: (sharpeb@medicine.ucsf.edu) CAP: Current & Future Community-Acquired Pneumonia Roadmap Definition of Pneumonia(s) • Background • Community-acquired (CAP): pneumonia acquired outside of hospitals or healthcare • Community-acquired pneumonia (CAP) setting • Healthcare-associated pneumonia (HCAP) • Hospital-acquired pneumonia (HAP) • Healthcare-associated (HCAP): pneumonia • Ventilator-associated pneumonia (VAP) in a patient with significant healthcare exposure 3

Definition of Pneumonia(s) Why does it matter? • Hospital-acquired (HAP): pneumonia • Risk factors for changing microbiology acquired > 48-72 hours after admission • Ventilator-associated (VAP): pneumonia acquired > 48-72 hours after intubation Roadmap • Background • Community-acquired pneumonia (CAP) Clinical, microbiology, treatment • • Healthcare-associated pneumonia (HCAP) • Hospital-acquired pneumonia (HAP) • Ventilator-associated pneumonia (VAP) CAP: A Practical Approach 4

CAP: Background Clinical Presentation: Geriatrics • Less “classic” presentations Cough 90%* • 10% have NONE of the classic signs or symptoms Dyspnea 66% • Up to 35% will not have fever Sputum 66% • Up to 50% will have altered mental status Pleuritic chest pain 50% • Up to 50% will have “asthenia” * Yet, only 4% of all visits for cough are pneumonia Mehr DR, et al. J Fam Prac 2001;50(11):1101. Riquelme R, et al. Am J Respir Crit Care Med 1997;156:1908. Halm EA, Teirstein AS. N Engl J Med Sund-Levander M, et al. Scand J Inf Dis . 2002;347(25):2039. 2003;35:306. Simoneti AF, et al . Ther Adv ID . 2014;2:3. CAP: A Practical Approach Community-Acquired Pneumonia Microbiology of CAP Microbiology • Many studies examining microbiology No Cause Bacteria Viruses Other Musher DM, et al. CID. 2017. Musher DM, et al. CID. 2017. CAP, HCAP, HAP, VAP CAP, HCAP, HAP, VAP 5

Diagnosis of CAP Etiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient • S pneumoniae • S pneumoniae • S pneumoniae • Resp. viruses • Legionella • Resp. viruses • M pneumoniae • H influenzae • M pneumoniae • Others • GNRs • H influenzae • S aureus • Legionella spp • Resp. viruses (?) File TM. Lancet 2003;362:1991. IDSA/ATS Guidelines. CID . 2016;63. CAP: Current & Future CAP: A Practical Approach Metlay JP, et al. JAMA 1997;278(17):1440. Diagnosis of CAP Chest Radiograph – Gold Standard • All expert guidelines state should have 1) Select clinical features positive CXR to make diagnosis (e.g. cough, fever, sputum, pleuritic chest pain) ● History & exam not good enough (50% sensitive) • In outpt setting, should see an infiltrate. AND ● Order CXR if you are concerned about CAP ● If CXR negative, may not treat for CAP 2) Infiltrate by CXR or other imaging • In the inpatient setting, can see pneumonia with a negative CXR (~30%) IDSA/ATS Guidelines. CID . 2016;63. Metlay J. Ann Intern Med . 2003. CAP: A Practical Approach Community-Acquired Pneumonia 6

Chest Radiograph – Gold Standard? • Should (generally) order CXR in all patients with suspected pneumonia. • In the hospital, a positive CXR is not necessary to treat as CAP (but consider other diagnoses) . Community-Acquired Pneumonia CAP: A Practical Approach A 72 year-old man with a PMH of gout and HTN presented to Etiology of CAP your clinic with cough and shortness of breath. Based on the history, exam, and CXR (RML infiltrate), he is diagnosed with community-acquired pneumonia. He is well enough to be treated as an outpatient. He has no allergies. Outpatients (mild) Non-ICU inpatients ICU inpatient Which of the following is the best treatment regimen? • S pneumoniae • S pneumoniae • S pneumoniae • Resp. viruses • Legionella • Resp. viruses • M pneumoniae • H influenzae • M pneumoniae A. Levofloxacin PO • Others • GNRs • H influenzae • S aureus • Legionella spp B. Azithromycin PO • Resp. viruses (?) C. Ertapenem D. Amoxicillin/clavulanate PO and azithromycin PO E. Piperacillin/tazobactam & Vanco & Flagyl File TM. Lancet 2003;362:1991. CAP: Current & Future CAP: A Practical Approach Metlay JP, et al. JAMA 1997;278(17):1440. 7

A 72 year-old man with a PMH of gout and HTN presented to Treatment CAP your clinic with cough and shortness of breath. Based on the history, exam, and CXR (RML infiltrate), he is diagnosed with community-acquired pneumonia. He is well enough to be treated as an outpatient. He has no allergies. Outpatient, Oral fluoroquinolone OR Which of the following is the best treatment regimen? Risk factors for resistant Oral b -lactam + doxy OR Strep. pneumoniae b -lactam + macrolide A. Levofloxacin PO b -lactam: High-dose amoxicillin (1gm PO tid) B. Azithromycin PO Amoxicillin/clavulanate (875mg PO bid) C. Ertapenem D. Amoxicillin/clavulanate PO & azithromycin PO NOTE: macrolides are not indicated for outpatients with E. Piperacillin/tazobactam & Vanco & Flagyl DRSP risk factors (US resistance > 40%) CAP: A Practical Approach CAP: A Practical Approach Risk Factors for DRSP Treatment CAP • Age > 65 years old • Chronic disease ▪ Heart, lung, renal, liver • Diabetes mellitus • Alcoholism • Malignancy (active) • Immunosuppression • Antibiotics in the last 3 months CAP: A Practical Approach CAP: A Practical Approach 8

A 37 year-old man with no PMH presented to your clinic with A 37 year-old man with no PMH presented to your clinic with fever, cough, and shortness of breath. Based on the history, fever, cough, and shortness of breath. Based on the history, exam, and CXR (RML infiltrate), he is diagnosed with exam, and CXR (RML infiltrate), he is diagnosed with community-acquired pneumonia. He is well enough to be community-acquired pneumonia. He is well enough to be treated as an outpatient. He has no allergies. treated as an outpatient. He has no allergies. Which of the following is the best treatment regimen? Which of the following is the best treatment regimen? A. Levofloxacin PO A. Levofloxacin PO B. Azithromycin PO B. Azithromycin PO C. Doxycycline PO C. Doxycycline PO D. Amoxicillin/clavulanate PO and azithromycin PO D. Amoxicillin/clavulanate PO and azithromycin PO E. Piperacillin/tazobactam & Vanco & Flagyl E. Piperacillin/tazobactam & Vanco & Flagyl CAP: A Practical Approach CAP: A Practical Approach Treatment CAP Risk Factors for DRSP • Age > 65 years old Outpatient, healthy, no Doxycycline or macrolide • Chronic disease risk factors for resistance ▪ Heart, lung, renal, liver • Diabetes mellitus • Alcoholism • Malignancy (active) • Immunosuppression • Antibiotics in the last 3 months CAP: A Practical Approach CAP: A Practical Approach 9

Treatment CAP Treatment of CAP Outpatient, healthy, NO Doxycycline or macrolide risk factors for resistance Outpatient, Oral fluoroquinolone OR risk factors for resistant Oral b -lactam + doxy or Strep. pneumoniae b -lactam + macrolide CAP: A Practical Approach CAP: A Practical Approach Take Home Points Take Home Points 1) 1) Outpatient CAP: Brad Pitt vs. Donald Rumsfeld 2) 2) 3) 3) 4) 4) 5) 5) CAP, HCAP, HAP, VAP CAP, HCAP, HAP, VAP 10