[PDF] - Community-Acquired Pneumonia acquired pneumonia as: a. An ailment PDF Document

SLIDE 1

Community-Acquired Pneumonia

Rachel Chin, MD University of California, San Francisco San Francisco General Hospital 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 really bad.

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 really bad.

Roadmap

 Background  Etiology  Diagnosis  Treatment  Prevention

CAP: Background - Epidemiology

 5 million cases/year in the US  80% of CAP is treated outpatient  6th leading cause of death  Inpatient mortality 10-35%  Outpatient mortality <1%

CAP: Symptom Frequency

 Cough

90%

 Dyspnea

66%

 Sputum

66%

 Pleuritic chest pain

50%

But, only 4% of all visits for cough turn out to be pneumonia….

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

SLIDE 2

Clinical Presentation: Geriatrics

 Less “classic” presentations

10% have NONE of the classic signs or symptoms

 Up to 40% will not have fever  Up to 45% will have altered mental status

Mehr DR, et al. J Fam Prac 2001;50(11);1101 Riquelme R, et al. Am J Respir Crit Care Med 1997;156:1908

Roadmap

 Background  Etiology  Diagnosis  Treatment  Prevention

Host Defenses

 Mechanical factors

Nasal hair
Turbinates
Mucocilliary apparatus
Cough
Airway branching

 Antimicrobial factors

IgA (and IgG, IgM)
Complement
Alveolar lining fluid
Cytokines (TNF, IL-1, IL-

8, others)

Macrophages
PMNs
Lymphocytes

“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

 But – no history, exam, laboratory or

radiographic features predict organism

Typical vs. Atypical

 Typical

Visible on Gram stain,

grows in routine culture

Susceptible to beta

lactams

S. pneumoniae, H.

influenzae

 Atypical

Not visible on Gram stain,

special culture techniques

Not treated with beta

lactams

M. pneumoniae, C.

pneumoniae, Legionella

X X

Etiology

 Streptococcus pneumoniae 20-60%  Haemophilus influenzae 3-10%  Mycoplasma pneumoniae up to 10%  Chlamydophila pneumoniae up to 10%  Legionella up to 10%  Enteric Gram negative rods up to 10%  Staphylococcus aureus up to 10%  Viruses up to 10%  No etiologic agent 20-70%

SLIDE 3

Roadmap

 Background  Etiology  Diagnosis  Treatment  Prevention

Community Acquired Pneumonia (CAP): definition

 At least 2 new symptoms  New infiltrate on chest x-ray and/or

abnormal chest exam

 No hospitalization or other nursing facility

prior to symptom onset

Fever or hypothermia Cough Rigors and/or diaphoresis Chest pain Sputum production or color change Dyspnea

Diagnosis

 Chest radiograph – needed in all cases?

Avoid over-treatment with antibiotics
Differentiate from other conditions
Specific etiology, e.g. tuberculosis
Co-existing conditions, such as lung mass or pleural

effusion

Evaluate severity, e.g. multilobar

 Unfortunately, chest physical exam not sensitive or

specific and significant variation between

bservers

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

Sputum for CAP

 In general, sputum cultures are not indicated in

the management of outpatient CAP

 For inpatient CAP, sputum is indicated:

 High-quality specimen, right to the lab  ICU, Cavitary infiltrates, Underlying lung disease

Blood Cultures in CAP

 Limitations

Positive in < 10% of cases High percentage of contaminants Culture change antibiotics in < 5% of patients Costly

Metersky ML, et al. Am J Respir Crit Care Med 2004;169 (3):342-7

SLIDE 4

Blood Cultures in CAP

 In general, blood cultures are not indicated in the

management of outpatient CAP.

 For inpatient CAP, blood cultures are optional unless

clear risk factors for positive blood cultures:

 ICU, severe liver disease, cavitary infiltrates, pleural

effusion

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

Diagnostic testing for CAP

 Get the CXR (esp. outpatient)  Blood and sputum cultures generally

discouraged in outpatient CAP

 General trend away from blood and sputum in

non-ICU patients admitted with CAP

Other diagnostic tests in CAP

 Pneumococcal urinary antigen

 Rapid test, specificity > 90% (but specificity poor in

children, possibly due to carriage)

 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.

Microbiological Investigation - Inpatients

 Consider evaluation for Legionella

Urinary antigen test for L. pneumophila serogroup 1 (70%)
Culture with selective media

The future in CAP - biomarkers

 Procalcitonin: precursor of calcitonin

No hormonal activity
Inflammatory marker
Increased in sepsis, bacterial infection

Microbiological Investigation - Inpatients

 Other studies as clinically indicated, e.g. influenza  M. pneumoniae serologic studies can be considered but are

uncommon in routine practice (mostly IgM-specific assays)

 Serologic studies of Chlamydophila largely for epidemiology

For C. pneumoniae, IgM is available, titer > 1:16 considered

positive

 Bronchoscopy perhaps for fulminant course, unresponsive to

conventional therapy, or for specific pathogens (e.g. M. tuberculosis, Pneumocystis)

SLIDE 5

Case # 1

 28 year old HIV positive man complains of

productive cough for 1 week and fevers. CD4

800. He has no history of Opportunistic

Infection (OI’s) and takes no medicines. O2 saturation 93%. CXR pending.

Bacterial Pneumonia

 Clinical presentation

CD4 cell count: any
Symptoms: Fever, SOB, chest pain, productive

cough w/ purulent sputum

Duration: 3-5 days
Signs: Focal lung findings
Labs: WBC often (relatively) elevated

Case # 1

 28 year old HIV positive man complains of dry

cough for 2-4 weeks and fevers. He has no history of Opportunistic Infection (OI’s) and takes no medicines. CD4 150. Normal Vital

signs. O2 saturation 95%. CXR clear.

 Returns 10 days later with diffuse pneumonia

and goes to the ICU with the diagnosis of PCP.

 What could have changed this management?  What was the stage of the HIV infection?

What is the Stage of HIV infection?

 Defined by CD4 count:

Early: CD4 > 500/mm3
Intermediate: CD4 200-500/mm3
Late: CD4 < 200/mm3
?Very Late: CD4 < 50/mm3

 Pulmonary disease is one of the most common

HIV-related emergencies

 PCP is the leading AIDS-defining condition in

the United States

 Pneumocystis jiroveci (“yee row vet zee” -

formerly carinii) pneumonia

SLIDE 6

Pneumocystis jiroveci Pneumonia

 Clinical presentation

CD4 cell count ≤ 200 cells/mm3
Symptoms: fever, DOE, dry cough, fatigue
Duration: >2-4 weeks
Signs: Nonspecific
Labs: Serum LDH often elevated

Treatment

 Trimethoprim-sulfamethoxazole  Clindamycin + Primaquine  Trimethoprim + Dapsone  Atovaquone  Pentamidine  Treat for 21 days followed by prophylaxis

Steroids 40 mg PO BID if Pa02 < 70 mm Hg

Roadmap

 Background  Etiology  Diagnosis  Treatment  Prevention

A healthy 48 yo woman who was recently treated for cystitis (1 month ago) with cipro presents with fever, cough, sob. CXR reveals RLL infultrate and you dx CAP and decide to treat as an outpatient. Which of the following is the best treatment regimen?

a. Levofloxacin PO
b. Azithromycin PO
c. Ertapenem IV
d. Augmentin PO and Azithromycin PO
e. Doxycycline PO and penicillin PO

Etiology of CAP

Outpatients (mild) Non-ICU Inpatients ICU inpatient S pneumoniae S pneumoniae S pneumoniae M pneumoniae M pneumoniae Legionella spp H influenzae C pneumoniae H influenzae C pneumoniae H influenzae GNRs Resp viruses Legionella spp S Aureus Resp viruses File TM. Lancet 2003;362:1991.

Treatment Principle #1

Outpatients (mild) S pneumoniae M pneumoniae H influenzae C pneumoniae Resp viruses

Must cover all these organisms

SLIDE 7

Treatment Principle #2

Outpatients (mild) S pneumoniae M pneumoniae H influenzae C pneumoniae Resp viruses

“Wimpy” pneumococcus Drug-resistant S. pneumoniae (DRSP) Penicillin, erythromycin, macrolides, etc

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

Treatment of CAP

Outpatient, healthy, no DRSP risk factors Doxycycline or macrolide Macrolide = azithro, clarithro, erythro

Treatment of CAP

Outpatient, DRSP risk factors Oral fluoroquinolone OR Oral β-lactam + doxy or β-lactam + macrolide (DRSP = drug-resistant “angry” strep pneumo)

NOTE: macrolides are no longer indicated for outpatients with DRSP risk factors (US resistance > 40%)

Treatment of 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)

Augmentin (875mg PO bid)

A healthy 48 yo woman who was recently treated for cystitis (1 month ago) with cipro presents with fever, cough, sob. CXR reveals RLL infultrate and you dx CAP and decide to treat as an outpatient. Which of the following is the best treatment regimen?

a. Levofloxacin PO
b. Azithromycin PO
c. Ertapenem IV
d. Augmentin PO and Azithromycin PO
e. Doxycycline PO and penicillin PO

SLIDE 8

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

A healthy 48 yo woman who was recently treated for cystitis (1 month ago) with cipro presents with fever, cough, sob. CXR reveals RLL infultrate and you dx CAP and decide to treat as an outpatient. Which of the following is the best treatment regimen?

a. Levofloxacin PO
b. Azithromycin PO
c. Ertapenem IV
d. Augmentin PO and Azithromycin PO
e. Doxycycline PO and penicillin PO

Treatment of CAP

Outpatient, DRSP risk factors Oral fluoroquinolone OR Oral β-lactam + doxy or β-lactam + macrolide Outpatient, healthy, no DRSP risk factors Doxycycline or macrolide

Treatment of CAP

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

Joint Commission and CMS Performance Measures Joint Commission and CMS Performance Measures

http://www.jointcommission.org/assets/1/6/Pneumonia.pdf http://www.jointcommission.org/core_measure_sets.aspx

SLIDE 9

Duration of Therapy

 7 – 10 days has been standard for most

patients but may not be necessary

Shorter course with azithromycin or high dose

levofloxacin

Meta-analysis that patients with mild to

moderate disease can be treated with 7 days or less

Li et al. Am J Med. 2007;120(9):783-90

Duration of Therapy

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

- IDSA/ATS Guidelines

Duration of Therapy

 Minimum of 5 days

If afebrile for 48-72

 For most, 7 days total

Take –Home Points

 Etiology: No predictors for “typical” or “atypical”

– need to treat

 Etiology: Recognize CA-MRSA as a cause for

severe CAP

 Diagnosis: Do not routinely get blood or sputum

cultures in outpt CAP

Take –Home Points

 Treatment: doxycycline or macrolide for healthy

utpatient with no DRSP risk-factors

 Treatment: fluoroquinolone or β-lactam +

macrolide/doxy for outpt with DRSP risk factors

 Treatment: most 7 days  Prevention: pneumovax, flu vax, smoking,