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Disclosures I have nothing to disclose Updates In CAP/HAP/VAP - PDF document

3/20/2019 Disclosures I have nothing to disclose Updates In CAP/HAP/VAP Rachel Bystritsky, MD University of California, San Francisco Outline Outline CAP: CAP Epidemiology - Epidemiology Microbiology - Microbiology


  1. 3/20/2019 Disclosures I have nothing to disclose Updates In CAP/HAP/VAP Rachel Bystritsky, MD University of California, San Francisco Outline Outline CAP: CAP    Epidemiology - Epidemiology  Microbiology - Microbiology  Diagnosis  Management - Diagnosis HAP/VAP  - Management  Diagnosis  Management HCAP  1

  2. 3/20/2019 Community Acquired Pneumonia Talk will focus on adults  Excluding severely immunocompromised pts  EPIDEMIOLOGY Impact of age on incidence of Epidemiology (CAP) patients hospitalized with CAP 2016 CDC data   48,632 deaths 1  15.1 deaths/100,000 population 1  PNA+Influenza 8 th leading cause of death in US 2  California: 5,981 deaths from Influenza+PNA 3 Most common cause of death from infectious  disease ED visits: 544,000 in 2015  National Vital Statistics Reports, Vol. 67, No. 5, July 26, 2018 1. CID 2017; 65: 1806-1812 2. National Vital Statistics Report, Vol. 67, No 6, July 26, 2018 CDC National Center for Health Statistics 3. National Hospital Ambulatory Medical Care Survey: 2015 4. 2

  3. 3/20/2019 Impact of comorbid conditions on incidence of patients hospitalized Microbiology with CAP No etiological agent is found in the majority of  cases even using advanced techniques S pneumoniae is the most commonly detected  bacterial pathogen Respiratory viruses increasingly recognized   Role remains unclear: single pathogen, co-pathogen or tigger for dysbiosis? CID 2017; 65: 1806-1812 Pathogen Detection among U.S. Adults with Effect of Conjugate Pneumococcal Community-Acquired Pneumonia Requiring Vaccine Hospitalization, 2010–2012 On rates of invasive pneumococcal disease in adults CDC: VPD Surveillance Manual Pneumococcal: Chapter 11.1 Jain S et al. N Engl J Med 2015;373:415-427. 3

  4. 3/20/2019 Antibiotic Resistance in Antibiotic Resistance in Pneumococcus Pneumococcus Trends in Pneumococcal Resistance Invasive Pneumococcal Isolates, 2015 1 Antibiotic Susceptible (%) Intermediate (%) Resistant (%) Penicillin 95.7 2.0 2.4 Cefotaxime 97.6 2.0 0.4 Erythromycin 69.6 0.2 30.1 Red = Erythromycin Green = Cefotaxime Tetracycline 88.9 0.2 10.9 Levofloxacin 99.9 0.0 0.1 Vancomycin 100.0 CDC: Active Bacterial Core surveillance 1. CDC. 2015. Active Bacterial Core Surveillance Report, EIPN, Streptococcus pneumoniae, 2015 Diagnosis: Imaging CXR should be obtained in pts with suspected PNA   History and exam have inadequate spec/sens for dx of PNA with high inter-observer variability 1,2  Identifies complications (i.e. empyema) CT: Has higher sensitivity and specificity than CXR 3   Higher exposure to radiation and cost  No evidence re: effect on outcomes  Should be reserved for high risk patients with DIAGNOSIS inconclusive CXR Ultrasound: may be a helpful adjunctive modality 4   Requires an experienced operator Arch Intern Med 1999; 159: 1082-1087. 1. JAMA 1997; 278: 1440-1445. 2. 3. Am J Respir Crit Care Med 2015; 192: 974-982. Chest 2017; 151: 374-382. 4. 4

  5. 3/20/2019 2007 IDSA/ATS Guidelines: Diagnosis: Microbiology Microbiological Studies Sputum culture:   Helpful if single pathogen is detected – can guide de- escalation or change in abx if poor response/adverse rx to empirical therapy  Many patients can not produce an adequate sample 1  Sensitivity is poor, worse if abx given prior 1  Should be obtained in hospitalized patients Blood cultures:   Positive 5-16% in hospitalized patients 1,2  Higher yield in higher severity illness 1. Eur J Clin Microbien Infect Dis 2006; 24:241-249. 2. Chest 1995; 108: 932. Diagnosis: Urine Antigen Diagnosis: Other Studies Testing IDSA/ATS Criteria have poor sens/spec for Influenza PCR when virus circulating   predicting which patients will have a positive test 1 Respiratory viral PCR   Strep Pneumo (SP): 61% sens, 39% spec  Can potentially help with de-escalation  Legionella (serotype 1) (LP): 63% sens, 35% spec  Caution in interpretation  may be co-pathogen or incidental finding Bronchoscopy   Consider for non-response to tx or concern for unusual pathogen No clinical features useful for predicting +SP test  Clinical features associated with + LP test:   Hyponatremia, fever, diarrhea, and recent travel 5

  6. 3/20/2019 Diagnosis: Procalcitonin (PCT) Diagnosis: Procalcitonin Precursor of calcitonin, rises in response to  Limitations: bacterial infection   No threshold value perfectly distinguishes viral vs Levels are higher in bacterial than viral infections bacterial infection  Can be used as an adjunct to help guide initiation  Often not elevated with intracellular pathogens (i.e.  of abx and duration of therapy: Legionella and Mycoplasma) 1  Pts with low PCT (< 0.25 used at UCSF) less likely to  Not validated in special populations (surgery, have bacterial infection (can consider not starting pregnancy, immunocompromised) therapy in low risk patients) Should not replace clinical judgment   Discontinuation of therapy once PCT less than 0.25 or decreased ≥ 80% from peak Large RCT in hospitalized patients showed no  impact on antibiotic use 1 1. Clin Infect Dis 2017; 65: 183-190 1. NEJM 2018; 379: 236-249 Management: Risk Stratification Once dx is made, next step is determining severity  of illness and appropriate site for treatment  Outpatient vs. inpatient Validated CAP severity scores:   PORT Score  CURB-65  SMART-COP CURB-65 is the simplest but may not be as  MANAGEMENT sensitive as PORT Score or SMART-COP 1 PORT Score best validated, identifies patients that  can be safely managed as outpatients 1. QJM 2014; 107: 595-596. 6

  7. 3/20/2019 PORT Score PORT Score Stratifies patients into 5 classes  Includes 20 variables:   Demographics  Comorbidities  Exam findings  Laboratory findings (including blood gas)  Imaging (presence/absence of pleural effusion) N Engl J Med 1997;336:243-250. N Engl J Med 1997;336:243-250. PORT Score: Limitations Question #1: A 25 year old woman presents with 2 days of cough, and fevers to 39. She is ill Oversimplifies interpretation of predictor variables: appearing with a T 38.1, BP 75/35, HR 153.   Pt in previous question would have a port score of 45 Should this patient be hospitalized? (Class II: outpatient treatment reasonable) Developed inn cohort that excluded  Yes immunocompromised, pregnant patients A) No Does not take into consideration important co- B)  factors (i.e. psychosocial factors, ability to take PO 7

  8. 3/20/2019 Question #2: CURB - 65 A 58 year old man presents to urgent care with 3 days of cough, fevers, mild R sided Simplest scoring system: chest pain. VS are normal, CXR shows RLL  infiltrate. He is otherwise healthy. What  Confusion antibiotic would you choose?  BUN  Respiratory rate Amoxicillin A)  Systolic BP Azithromycin  Age B) Levofloxacin Sensitivity for predicting ICU admission/critical care C)  Doxycycline intervention is poor 1 : D) Amoxicillin + azithromycin  Of Pts with scores of 0 or 1 (rec outpatient E) management) 15.6% were admitted to ICU and 6.4% received critical care intervention  Pt in question would have a score of 1: consider outpatient management 1. Ann Emerg Med 2018; pii: S0196-0644(18)30548-1. Treatment: 2007 IDSA/ATS Treatment: 2007 IDSA/ATS Guidelines Guidelines Outpatient (empirical): Inpatient (empirical): non-ICU    Previously healthy no risk factors for drug resistance  Respiratory fluoroquinolone  A macrolide (1 st choice)  β -lactam + macrolide  Doxycycline Inpatient (empirical): ICU   Comorbidities, prev abx within 3 mo, or high rate of  β -lactam + macrolide or fluoroquinolone drug resistant Strep pneumo  β -lactam = ceftriaxone, cefotaxime or amp-sulbactam  Respiratory fluoroquinolone  β -lactam + macrolide (1 st choice) or doxycycline Recommend avoiding macrolide monotherapy if  local rate of resistance >25% for S pneumo This guideline has been archived and is currently being updated: projected publication Fall 2019 8

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