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
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
3/20/2019 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
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
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
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
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
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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