Community-Acquired Pneumonia Current & Future State Brad - - PDF document

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Community-Acquired Pneumonia

Current & Future State

Brad Sharpe, M.D. Professor of Clinical Medicine Department of Medicine UCSF sharpeb@medicine.ucsf.edu I have no relevant financial relationships to disclose.

CAP: A Practical Approach

• 1. In 1898, William Osler described

community-acquired pneumonia as:

• a. An ailment that often leads to suffocation

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.

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CAP: A Practical Approach

• 1. In 1898, William Osler described

community-acquired pneumonia as:

• a. An ailment that often leads to suffocation

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

"Pneumonia may well be called the friend of the

• aged. Taken off by it in an acute, short, not
• ften painful illness, the old man escapes those

‘cold gradations of decay’ so distressing of himself and to his friends.“

• - William Osler, M.D., 1898

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CAP: A Practical Approach

“Brad, pneumonia sucks.”

• - Mary R. Sharpe

November 2011

CAP: A Practical Approach

Update in CAP

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CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

Specific Goals:

• Describe the most common causes of

community-acquired pneumonia in the

• utpatient setting
• Order appropriate diagnostic tests for CAP
• Initiate appropriate antibiotics in the treatment
• f community-acquired pneumonia (CAP)
• State the optimal duration of therapy in CAP
• State the benefits and need for preventative

measures for CAP

CAP: Current & Future

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Community-Acquired Pneumonia

Caveats

• Will not talk about healthcare-associated

pneumonia (HCAP)

• Will not discuss admission decision (complex)
• Syllabus or specific questions:

(sharpeb@medicine.ucsf.edu)

CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

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CAP: A Practical Approach

CAP: Background

• 5 million cases/year in the U.S.
• 80% of CAP is treated outpatient
• Sixth leading cause of death
• Inpatient mortality 10-35%
• Outpatient mortality < 1%

CAP: A Practical Approach

CAP: Background

• Some evidence that quality of care for

African-Americans with CAP is worse

• Higher mortality among Caucasians

Mortensen EM, et al. BMC Health Serv Res. 2004;4:20. Mayr FB, et al. Crit Care Med. 2010;38:759.

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CAP: A Practical Approach

CAP: Background

Cough 90%* Dyspnea 66% Sputum 66% Pleuritic chest pain 50%

* Yet, only 4% of all visits for cough are pneumonia

Halm EA, Teirstein AS. N Engl J Med 2002;347(25):2039.

Community-Acquired Pneumonia

Clinical Presentation: Geriatrics

• Less “classic” presentations
• 10% have NONE of the classic signs or symptoms
• Up to 35% will not have fever
• Up to 50% will have altered mental status
• Up to 50% will have “asthenia”

Mehr DR, et al. J Fam Prac 2001;50(11):1101. Riquelme R, et al. Am J Respir Crit Care Med 1997;156:1908. Sund-Levander M, et al. Scand J Inf Dis. 2003;35:306. Simoneti AF , et al. Ther Adv ID. 2014;2:3.

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CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

CAP: A Practical Approach

“Typical” vs. “Atypical”

• Typical organisms

♦ S. pneumoniae, H. influenzae, M. catarrhalis, etc.

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CAP: A Practical Approach

“Typical” vs. “Atypical”

• Atypical organisms

♦ M. pneumoniae, C. pneumoniae, Legionella spp, etc.

CAP: A Practical Approach

“Typical” vs. “Atypical”

• Classic teaching is not supported by the

literature

• Some general trends
• S. pneumoniae in older pts, co-morbidities
• Mycoplasma in patients < 50 years old
• Bilateral hazy opacities more likely to be

atypical (but not always)

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CAP: A Practical Approach

“Typical” vs. “Atypical”

• Classic teaching is not supported by the

literature

• Some general trends
• But - no history, exam, laboratory, or

radiographic features predict organism

• “Walking pneumonia”
• “Classic lobar pneumonia”

CAP: A Practical Approach

Etiology of CAP

Outpatients (mild) Non-ICU inpatients ICU inpatient

File TM. Lancet 2003;362:1991.

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Community-Acquired Pneumonia

Microbiology of CAP

Jain S, et al. NEJM. 2015.

Community-Acquired Pneumonia

Microbiology of CAP

• Prospective study of 2320 patients with

CAP admitted to 5 hospitals

• All extensive diagnostic evaluation
• Blood cultures, sputum cultures
• Urine antigen for S. pneumoniae & Legionella
• Nasopharyngeal PCR for viruses,

Chlamydophila, Mycoplasma

• Some serologic testing

Jain S, et al. NEJM. 2015.

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Community-Acquired Pneumonia

Microbiology of CAP

Jain S, et al. NEJM. 2015.

Community-Acquired Pneumonia

Microbiology of CAP

Jain S, et al. NEJM. 2015.

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Community-Acquired Pneumonia

Microbiology of CAP

1) Rhinovirus 2) Influenza 3) Streptococcus pneumoniae

Jain S, et al. NEJM. 2015.

Community-Acquired Pneumonia

Microbiology of CAP

• No pathogen detected in > 60% of

patients

• Real-world ~ 80-90%
• Many possible explanations
• Mainly viruses?
• Inadequate diagnostic testing

Jain S, et al. NEJM. 2015.

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CAP: A Practical Approach

Etiology of CAP

Outpatients (mild) Non-ICU inpatients ICU inpatient

File TM. Lancet 2003;362:1991.

CAP: Current & Future

Etiology of CAP

Outpatients (mild)

• Resp. viruses
• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae

Non-ICU inpatients

• Resp. viruses
• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp

ICU inpatient

• S pneumoniae
• Legionella
• H influenzae
• GNRs
• S aureus
• Resp. viruses (?)

File TM. Lancet 2003;362:1991. Metlay JP , et al. JAMA 1997;278(17):1440.

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Community-Acquired Pneumonia

Take Home Points

1) 2) 3) 4) 5)

Community-Acquired Pneumonia

Take Home Points

1) Cover typical and atypical bacteria 2) 3) 4) 5)

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CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

CAP: A Practical Approach

• 2. A 65-year old man presents to urgent care complaining
• f subjective fever, chills, and productive cough x 3 days. He

reports mild shortness of breath. His temperature is 38.6o C, RR 20, O2 saturation 95% on RA. He has crackles at the right base on lung exam. You should: a. Treat for community-acquired pneumonia. b. Send him for a PA and lateral CXR. c. Send him for blood and sputum cultures. d. Prescribe sudafed and robitussin and send him home. e. Perform trans-tracheal aspiration f. B and C

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CAP: A Practical Approach

• 2. A 65-year old man presents to urgent care complaining
• f subjective fever, chills, and productive cough x 3 days. He

reports mild shortness of breath. His temperature is 38.6o C, RR 26, O2 saturation 95% on RA. He has crackles at the right base on lung exam. You should: a. Treat for community-acquired pneumonia. b. Send him for a PA and lateral CXR. c. Send him for blood and sputum cultures. d. Prescribe sudafed and robitussin and send him home. e. Perform trans-tracheal aspiration f. B and C

CAP: A Practical Approach

Diagnosis of CAP

1) Select clinical features

(e.g. cough, fever, sputum, pleuritic chest pain)

AND 2) Infiltrate by CXR or other imaging

IDSA/A TS Guidelines. CID. 2007;44:S27-72.

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Community-Acquired Pneumonia

Chest Radiograph – Gold Standard

• All expert guidelines state should have

positive CXR to make diagnosis

• History & exam not good enough (50% sensitive)
• In outpt setting, should see an infiltrate.
• Order CXR if you are concerned about CAP
• If CXR negative, likely should not treat for CAP
• In the inpatient setting, can see

pneumonia with a negative CXR (~30%)

Metlay J. Ann Intern Med. 2003.

Community-Acquired Pneumonia

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).

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CAP: A Practical Approach

• 2. A 65-year old man presents to urgent care complaining
• f subjective fever, chills, and productive cough x 3 days. He

reports mild shortness of breath. His temperature is 38.6o C, RR 26, O2 saturation 95% on RA. He has crackles at the right base on lung exam. You should: a. Treat for community-acquired pneumonia.

• b. Send him for a PA and lateral CXR.

c. Send him for blood and sputum cultures. d. Prescribe sudafed and robitussin and send him home. e. Perform trans-tracheal aspiration f. B and C

CAP: A Practical Approach

• 2. A 65-year old man presents to urgent care complaining
• f subjective fever, chills, and productive cough x 3 days. He

reports mild shortness of breath. His temperature is 38.6o C, RR 26, O2 saturation 95% on RA. He has crackles at the right base on lung exam. You should: a. Treat for community-acquired pneumonia. b. Send him for a PA and lateral CXR. c. Send him for blood and sputum cultures. d. Prescribe sudafed and robitussin and send him home. e. Perform trans-tracheal aspiration f. B and C

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Community-Acquired Pneumonia

Blood Cultures

• Specific organism vs. contaminants, cost
• Reality:
• No evidence of a benefit
• Rarely positive = ~ 7%
• Contaminant rate = ~ 7%
• More likely to be positive if sicker
• ICU, septic shock, etc.

CAP: A Practical Approach

Blood Cultures in CAP

• In general, do not get blood cultures for
• utpatient CAP
• For inpatient CAP, blood cultures are
• ptional
• Consider if risk factors:
• ICU, severe sepsis, cavitary infiltrates, pleural

effusion

IDSA/A TS Guidelines. CID. 2007;44:S27-72.

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CAP: A Practical Approach

Sputum for CAP

• Complicated and controversial
• Simple, inexpensive, specific for

pneumococcus

• Problems include:
• Up to 30% could not produce adequate

sputum

• Good quality available in only 14%
• Most don’t narrow antibiotics

CAP: A Practical Approach

Sputum Cultures in CAP

• In general, sputum cultures are not

indicated in outpatient CAP

• For inpatient CAP, sputum is indicated:
• High-quality specimen, right to the lab
• ICU, cavitary infiltrates, underlying lung

disease

IDSA/A TS Guidelines. CID. 2007;44:S27-72.

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CAP: A Practical Approach

The future in CAP - biomarkers

• Procalcitonin: precursor of calcitonin
• No hormonal activity
• Inflammatory marker
• Increased in bacterial infection

CAP: A Practical Approach

Diagnosing Pneumonia

Procalcitonin: Bacterial vs. Non-bacterial

Intl J. Lung Dz. 2006

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CAP: A Practical Approach

Meta-analysis/systematic review

• Four studies, ~3500 patients with

respiratory tract infections

• Specific algorithm
• Less antibiotic exposure
• A 22% decrease in prescriptions
• Average 2.3 days less abx overall
• No difference in mortality/clinical outcomes

Soni NJ, et al. JHM. 2013;8:530.

Community-Acquired Pneumonia

Take Home Points

1) Cover typical and atypical bacteria 2) 3) 4) 5)

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Community-Acquired Pneumonia

Take Home Points

1) Cover typical and atypical bacteria 2) Get the CXR, skip the cultures 3) 4) 5)

CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

25

CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

26

CAP: Current & Future

Etiology of CAP

Outpatients (mild)

• Resp. viruses
• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae

Non-ICU inpatients

• Resp. viruses
• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp

ICU inpatient

• S pneumoniae
• Legionella
• H influenzae
• GNRs
• S aureus
• Resp. viruses (?)

File TM. Lancet 2003;362:1991. Metlay JP , et al. JAMA 1997;278(17):1440.

CAP: A Practical Approach

Treatment Principle #1

Outpatients (mild)

• Resp. viruses
• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae

Must cover all these organisms

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CAP: A Practical Approach

Treatment Principle #2

Outpatients (mild)

• Resp. viruses
• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae

“Wimpy” pneumococcus Drug-resistant “angry”

• S. pneumoniae (DRSP)

Penicillin, erythromycin, macrolides, etc.

CAP: A Practical Approach

Risk Factors for DRSP

• Age > 65 years old
• Chronic disease

▪ Heart, lung, renal, liver

• Diabetes mellitus
• Alcoholism
• Malignancy (active)
• Immunosuppression
• Antibiotics in the last 3 months

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CAP: A Practical Approach

Treatment Principle #2

Outpatients (mild)

• Resp. viruses
• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae

“Wimpy” pneumococcus Drug-resistant “angry”

• S. pneumoniae (DRSP)

Penicillin, erythromycin, macrolides, etc.

CAP: A Practical Approach

Treatment CAP

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CAP: A Practical Approach

Treatment of CAP

CAP: A Practical Approach

Treatment CAP

Outpatient, healthy, no DRSP risk factors Doxycycline or macrolide

Macrolide = azithro, clarithro, erythro

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CAP: A Practical Approach

Treatment CAP

CAP: A Practical Approach

Risk Factors for DRSP

• Age > 65 years old
• Chronic disease

Heart, lung, renal, liver

• Diabetes mellitus
• Alcoholism
• Malignancy
• Immunosuppression
• Antibiotics in the last 3 months

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CAP: A Practical Approach

Treatment CAP

Outpatient, DRSP risk factors

Oral fluoroquinolone OR Oral β-lactam + doxy OR β-lactam + macrolide NOTE: macrolides are not indicated for outpatients with DRSP risk factors (US resistance > 40%)

(DRSP = drug-resistant “angry” strep pneumo)

CAP: A Practical Approach

Treatment CAP

Outpatient, DRSP risk factors

Oral fluoroquinolone OR Oral β-lactam + doxy OR β-lactam + macrolide

• Oral fluoroquinolone: moxi, gemi, levofloxacin
• β-lactam: High-dose amoxicillin (1mg PO tid)

Amoxicillin/clavulanate (875mg PO bid)

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Community-Acquired Pneumonia

Take Home Points

1) Cover typical and atypical bacteria 2) Get the CXR, skip the cultures 3) 4) 5)

Community-Acquired Pneumonia

Take Home Points

1) Cover typical and atypical bacteria 2) Get the CXR, skip the cultures 3) Outpatient: Brad Pitt vs. Donald Rumsfeld 4) 5)

33

CAP: A Practical Approach

• 3. A 72 year-old man with a PMH of gout and DJD presents

to 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. Which of the following is the best treatment regimen?

• A. Levofloxacin PO
• B. Azithromycin PO
• C. Ertapenem
• D. Ampicillin/clavulanate PO and azithromycin PO
• E. Zosyn & Vanco & Flagyl

CAP: A Practical Approach

Risk Factors for DRSP

• Age > 65 years old
• Chronic disease

Heart, lung, renal, liver

• Diabetes mellitus
• Alcoholism
• Malignancy
• Immunosuppression
• Antibiotics in the last 3 months

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CAP: A Practical Approach

Treatment CAP

Outpatient, DRSP risk factors

Oral fluoroquinolone OR Oral β-lactam + doxy OR β-lactam + macrolide

• Oral fluoroquinolone: moxi, gemi, levofloxacin
• β-lactam: High-dose amoxicillin (1mg PO tid)

Amoxicillin/clavulanate (875mg PO bid)

CAP: A Practical Approach

• 3. A 72 year-old man with a PMH of gout and DJD presents

to 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. Which of the following is the best treatment regimen?

• A. Levofloxacin PO
• B. Azithromycin PO
• C. Ertapenem
• D. Ampicillin/clavulanate PO and azithromycin PO
• E. Zosyn & Vanco & Flagyl

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CAP: A Practical Approach

• 4. A healthy 41 year-old woman who was recently treated

(1 month ago) for cystitis with cipro presents to your clinic with fever, cough, sob. Her CXR reveals RLL infiltrate and you diagnose community-acquired pneumonia and decide to treat as an outpatient. Which of the following is the best treatment regimen?

• A. Levofloxacin PO
• B. Azithromycin PO
• C. Ertapenem
• D. Ampicillin/clavulanate PO and azithromycin PO
• E. Doxycycline PO and penicillin PO

CAP: A Practical Approach

Risk Factors for DRSP

• Age > 65 years old
• Chronic disease

Heart, lung, renal, liver

• Diabetes mellitus
• Alcoholism
• Malignancy
• Immunosuppression
• Antibiotics in the last 3 months

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CAP: A Practical Approach

• 4. A healthy 41 year-old woman who was recently treated

(1 month ago) for cystitis with cipro presents to your clinic with fever, cough, sob. Her CXR reveals RLL infiltrate and you diagnose community-acquired pneumonia and decide to treat as an outpatient. Which of the following is the best treatment regimen?

• A. Levofloxacin PO
• B. Azithromycin PO
• C. Ertapenem
• D. Ampicillin/clavulanate PO and

azithromycin PO

• E. Doxycycline PO and penicillin PO

CAP: A Practical Approach

Treatment CAP

Outpatient, healthy, no DRSP risk factors Doxycycline or macrolide Outpatient, DRSP risk factors

Oral fluoroquinolone OR Oral β-lactam + doxy or β-lactam + macrolide

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CAP: A Practical Approach

Treatment Inpatient CAP

Inpatient, non- ICU Fluoroquinolone OR β-lactam + macrolide OR β-lactam + doxycycline**

** At UCSF , we use ceftriaxone & doxycycline

CAP: A Practical Approach

Treatment Inpatient CAP

Inpatient, non- ICU Fluoroquinolone OR β-lactam + macrolide OR β-lactam + doxycycline** Inpatient, ICU

IV β-lactam + macrolide + vancomycin OR IV β-lactam + fluoroquinolone + vancomycin ** At UCSF , we use ceftriaxone & doxycycline

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CAP: A Practical Approach

Treatment CAP: New Data

CAP: A Practical Approach

Treatment CAP: New Data

• Two European RCTs comparing β-lactam

alone to either β-lactam + macrolide OR to a fluoroquinolone

• One study showed no difference
• One study showed better outcomes with

atypical coverage for:

1) Sicker patients 2) Atypical pathogens

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CAP: A Practical Approach

Treatment CAP: New Data

• May not be generalizable:
• European patient population
• Used amoxicillin or 2nd-generation ceph.
• More than 30% got antibiotics before

admission

• Not enough to change practice

CAP: A Practical Approach

Duration of therapy

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CAP: A Practical Approach

• 4. A 67 year-old man with CHF and diabetes is admitted to

the hospital with CAP (non-ICU). He is treated with ceftriaxone and doxycycline and does well. The cultures are all negative. On hospital day 3 he is ready for discharge. What is the optimal duration of total therapy for his CAP?

• A. 14 days
• B. 10 days
• C. 7 days
• D. 3 days
• E. Who cares. He probably won’t take it anyway.

I hate my job.

CAP: A Practical Approach

Duration of therapy?

• Meta-analysis of 15 RCTs, 2796 patients

with mild to moderate CAP

• Compared short-course (< 7 days) with

longer courses.

• Looked at clinical failure, bacterial

eradication, and mortality.

Li JZ, et al. Am J Med. 2007;120:783.

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CAP: A Practical Approach

Duration of therapy?

• No difference in clinical failure
• No difference in bacterial eradication
• No difference in mortality
• In subgroup analysis, trend toward

favorable efficacy with short-course.

Li JZ, et al. Am J Med. 2007;120:783.

CAP: A Practical Approach

Duration of therapy

“Patients with CAP should be treated for a minimum of 5 days (level I evidence)”

• - IDSA/ATS Guidelines

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CAP: A Practical Approach

Duration of therapy

• Minimum of 5 days

▪ If afebrile for 48-72

• For most, 7 days total

CAP: A Practical Approach

• 4. A 67 year-old man with CHF and diabetes is admitted to

the hospital with CAP (non-ICU). He is treated with ceftriaxone and doxycycline and does well. The cultures are all negative. On hospital day 3 he is ready for discharge. What is the optimal duration of total therapy for his CAP?

• A. 14 days
• B. 10 days
• C. 7 days
• D. 3 days
• E. Who cares. He probably won’t take it anyway.

I hate my job.

43

Community-Acquired Pneumonia

Take Home Points

1) Cover typical and atypical bacteria 2) Get the CXR, skip the cultures 3) Outpatient: Brad Pitt vs. Donald Rumsfeld 4) 5)

Community-Acquired Pneumonia

Take Home Points

1) Cover typical and atypical bacteria 2) Get the CXR, skip the cultures 3) Outpatient: Brad Pitt vs. Donald Rumsfeld 4) Treat for 7 days (or 5) 5)

44

Steroids in Pneumonia?

CAP: Current & Future CAP: A Practical Approach

Follow-up CXR?

• Standard practice?
• Prior ATS guidelines said yes, recent

guidelines do not address

• CXR resolution:

▪ At 28 days, ~ 50% had not resolved

• Can consider in “high-risk” patients

▪ Significant smoking history, etc. ▪ Probably should wait > 3 months

Bruns AH. CID. 2007;45:983.

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CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

CAP: A Practical Approach

Vaccinations

• In general, follow the national guidelines
• Pneumococcal and influenza vaccine

46

CAP: Current & Future

Pneumovax

• Updated meta-analysis of 18 RCTs (~64,000 pts)

and 7 non-RCTs (~62,000 pts)

• Only high-quality studies

Relative Risk All-cause pneumonia

0.70 (0.45-1.12)

All-cause mortality

0.90 (0.74-1.09)

** No difference for elderly or chronic illness

Moberly S, et al. Cochrane. 2013; 1:CD000422

Pneumovax - Efficacy

• Four different trials looking at benefits of

pneumovax in patients hospitalized with CAP

• Compared vaccinated vs. non-vaccinated
• Looked at impact on ICU admission,

inpatient mortality, inpatient complications, and LOS

CAP: Current & Future

47

Pneumovax - Efficacy

CAP: Current & Future

Variable Outcome

ICU admission Decreased Inpt complications Decreased LOS Decreased Inpt mortality Decreased

Pneumovax - Efficacy

• Pneumococcal vaccine likely prevents

invasive pneumococcal disease.

• Probably reduces death, ICU admission,

complications, and LOS in patients hospitalized with CAP (“makes pneumonia less bad”)

CAP: Current & Future

48

Influenza Vaccine - Efficacy

• Adults aged < 65 years
• Prevents influenza illness in ~ 70-90%
• Adults aged > 65 years
• Prevents influenza illness in ~ 30-70%

CAP: Current & Future

ACIP Recs. MMWR 2003;52:1.

Influenza Vaccine - Efficacy

CAP: Current & Future

Nichol KL, et al. N Engl J Med 2007;357:1373. (Oct 4, 2007)

Hospitalization Risk Reduction Hospitalization for pna/flu 27%* All cause death 48%*

* All p values < 0.001

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CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention – Avoid the purple pill!

CAP: A Practical Approach

Proton Pump Inhibitors

• Gulmez, et al. Arch Intern Med. 2007.
• - Current use of PPI: CAP OR = 1.5
• - Recent start: CAP OR = 5.0
• Sarkar, et al. Ann Intern Med. 2008.
• - Recent PPI start: CAP OR = 3.8
• Herzig, et al. JAMA. 2009.
• - 52% of hosp pts got PPI, HAP OR = 1.3
• Eurich, et al. Am J Med. 2010.
• - Rates recurrent CAP after CAP admit
• - Starting PPI: OR 2.1% (7% abs risk)

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Anti-psychotics

• Knol W, et al. JAGS. 2009.
• - Recent anti-psychotic start (1 wk); OR 4.3**
• Trifiro, et al. Ann Intern Med. 2010.
• - Population based study, 2000 patients.

Current Use Risk of pneumonia Typical anti-psychotic OR = 2.6 (1.4-4.6) Atypical OR = 1.8 (1.2-5.3)

CAP: Current & Future Community-Acquired Pneumonia

Take Home Points

1) Cover typical and atypical bacteria 2) Get the CXR, skip the cultures 3) Outpatient: Brad Pitt vs. Donald Rumsfeld 4) Treat for 7 days (or 5) 5)

51

Community-Acquired Pneumonia

Take Home Points

1) Cover typical and atypical bacteria 2) Get the CXR, skip the cultures 3) Outpatient: Brad Pitt vs. Donald Rumsfeld 4) Treat for 7 days (or 5) 5) Vaccines = good

CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

52

Community-Acquired Pneumonia

Take Home Points

1) Cover typical and atypical bacteria 2) Get the CXR, skip the cultures 3) Outpatient: Brad Pitt vs. Donald Rumsfeld 4) Treat for 7 days (or 5) 5) Vaccines = good

Community-Acquired Pneumonia

Current & Future State

Brad Sharpe, M.D. Professor of Clinical Medicine Department of Medicine UCSF sharpeb@medicine.ucsf.edu

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CAP: A Practical Approach CAP: A Practical Approach

Urine Pneumococcal Antigen

• Rapid test, specificity > 90%
• If positive, tx for pneumococcal disease
• May not reduce antibiotic spectrum
• - > 70% with no change

Sorde R, et al. Arch Intern Med. 2011;171:166.

54

CAP: A Practical Approach CAP: A Practical Approach

Doxycycline

• Similar spectrum to macrolides
• Much cheaper!
• Good side effect profile (GI upset)
• Less Clostridium difficile infection
• Rates 27% lower in hospitalized patients

with CAP vs. other regimens

Doernberg SB, et al. Clin Infect Dis. 2012 Sep;55:615.

55

CAP: A Practical Approach CAP: A Practical Approach

CURB-65 Score

• Validated severity-of-illness scoring system

▪ Retrospective then prospective

• Advocated by the British Thoracic Society
• Based on five easily measurable clinical

factors

Lim WS. Thorax 2003; 58:377–82

56

CAP: A Practical Approach

CURB-65 Score C – Confusion (disoriented) U – BUN > 20mg/dL R – RR > 30/min B – SBP < 90mmHg or DBP < 60mmHg 65 – Age > 65

Lim WS. Thorax 2003; 58:377–82

CAP: A Practical Approach

CURB65 Score

Lim WS. Thorax 2003; 58:377–82

CURB65 Score Mortality

0.7% 1 2.5% 2 11.0% 3 15.5% 4 40.6% 5 57.0%

57

CAP: A Practical Approach

CURB65 Score

Lim WS. Thorax 2003; 58:377–82

CURB65 Mortality Treatment

0.7% Outpatient 1 2.3% Outpatient 2 11.0% Inpatient 3 15.5% Inpatient 4 40.6% ICU 5 57.0% ICU

CAP: A Practical Approach

Admission Decision

• Consider using a prognostic score in CAP

♦ Especially useful in “borderline” cases

• CURB65 easy to use