community-acquired pneumonia

1. Community-Acquired Pneumonia Joanna M. Delaney, D.O. Georgetown University / Providence Hospital June 8, 2007

3. Epidemiology Unclear! Few population-based statistics on the condition alone CDC combines PNA with influenza for morbidity & mortality data PNA & influenza = 7th leading causes of death in the US (2001) Age-adjusted death rate = 21.8 per 100,000 Mortality rate: 1-5% out-Pt, 12% In-Pt, 40% ICU Death rates increase with comorbidity and age Affects race and sex equally

4. Community Acquired Pneumonia Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care facility for = 2 weeks 5.6 million cases annually in the U.S. Estimated total annual cost of health care = $8.4 billion Most common pathogen = S. pneumo (60-70% of CAP cases)

5. “Nosocomial” Pneumonia Hospital-acquired pneumonia (HAP) Occurs 48 hours or more after admission, which was not incubating at the time of admission Ventilator-associated pneumonia (VAP) Arises more than 48-72 hours after endotracheal intubation n this study, the definition of HCA infection was a history of hospitalization, surgery, dialysis, or residence in a long-term care facility within a year of contracting the infection, or the presence of a permanent indwelling catheter or percutaneous medical device (eg, gastrostomy, tracheostomy, or Foley catheter). Despite this information, we have few studies that have used the same methodology to compare the bacteriology and outcomes of those persons with pneumonia arising in the community (ie, community-acquired pneumonia [CAP]) with those having health-care–associated pneumonia (HCAP), those nonintubated patients with hospital-acquired pneumonia (HAP), and those with ventilator-associated pneumonia (VAP) VAP: patients who require intubation after developing szevere HAP shuld be managed similar to patients with VAPn this study, the definition of HCA infection was a history of hospitalization, surgery, dialysis, or residence in a long-term care facility within a year of contracting the infection, or the presence of a permanent indwelling catheter or percutaneous medical device (eg, gastrostomy, tracheostomy, or Foley catheter). Despite this information, we have few studies that have used the same methodology to compare the bacteriology and outcomes of those persons with pneumonia arising in the community (ie, community-acquired pneumonia [CAP]) with those having health-care–associated pneumonia (HCAP), those nonintubated patients with hospital-acquired pneumonia (HAP), and those with ventilator-associated pneumonia (VAP) VAP: patients who require intubation after developing szevere HAP shuld be managed similar to patients with VAP

6. “Nosocomial” Pneumonia Healthcare-associated pneumonia (HCAP) Patients who were hospitalized in an acute care hospital for two or more days within 90 days of the infection; resided in a nursing home or LTC facility; received recent IV abx, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic Guidelines for the Management of Adults with HAP, VAP, and HCAP. American Thoracic Society, 2005

7. Pathogenesis Inhalation, aspiration and hematogenous spread are the 3 main mechanisms by which bacteria reaches the lungs Primary inhalation: when organisms bypass normal respiratory defense mechanisms or when the Pt inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment

8. Pathogenesis Aspiration: occurs when the Pt aspirates colonized upper respiratory tract secretions Stomach: reservoir of GNR that can ascend, colonizing the respiratory tract. Hematogenous: originate from a distant source and reach the lungs via the blood stream. Microaspiration: S. pneumo Inhalation: TB, viruses, Legionella Aspiration: anaerobes Bloodborne: Staph endocarditis, septic emboli Direct extension: Amebiasis, traumaMicroaspiration: S. pneumo Inhalation: TB, viruses, Legionella Aspiration: anaerobes Bloodborne: Staph endocarditis, septic emboli Direct extension: Amebiasis, trauma

9. Pathogens CAP usually caused by a single organism Even with extensive diagnostic testing, most investigators cannot identify a specific etiology for CAP in = 50% of patients. In those identified, S. pneumo is causative pathogen 60-70% of the time

10. Streptococcus pneumonia Most common cause of CAP Gram positive diplococci “Typical” symptoms (e.g. malaise, shaking chills, fever, rusty sputum, pleuritic hest pain, cough) Lobar infiltrate on CXR Suppressed host 25% bacteremic Predisposing factors: anorexia, ETOH, HIV, sickle cell disease, splenectomy, hematologic diseasesPredisposing factors: anorexia, ETOH, HIV, sickle cell disease, splenectomy, hematologic diseases

11. Atypical Pneumonia #2 cause (especially in younger population) Commonly associated with milder Sx’s: subacute onset, non-productive cough, no focal infiltrate on CXR Mycoplasma: younger Pts, extra-pulm Sx’s (anemia, rashes), headache, sore throat Chlamydia: year round, URI Sx, sore throat Legionella: higher mortality rate, water-borne outbreaks, hyponatremia, diarrhea

12. Viral Pneumonia More common cause in children RSV, influenza, parainfluenza Influenza most important viral cause in adults, especially during winter months Post-influenza pneumonia (secondary bacterial infection) S. pneumo, Staph aureus

13. Other bacteria Anaerobes Aspiration-prone Pt, putrid sputum, dental disease Gram negative Klebsiella - alcoholics Branhamella catarrhalis - sinus disease, otitis, COPD H. influenza Staphylococcus aureus IVDU, skin disease, foreign bodies (catheters, prosthetic joints) prior viral pneumonia

15. Guidelines American Thoracic Society Guidelines for the Management of Adults with CA (2001) Infectious Diseases Society of America Update of Practice Guidelines for the Management of CAP in Immunocompetent adults (2003) ATS and IDSA joint effort IDSA/ATS Consensus Guidelines on the Management of CAP in Adults (March 2007) Two of the most widely referenced organizations for the management of CAP are those of the Infectious Diseases Society of America and the American Thoracic Society. In response to confusion regarding differences between their respective guidelines, the IDSA and the ATS convened a joint committee to develop a unified CAP guideline document.Two of the most widely referenced organizations for the management of CAP are those of the Infectious Diseases Society of America and the American Thoracic Society. In response to confusion regarding differences between their respective guidelines, the IDSA and the ATS convened a joint committee to develop a unified CAP guideline document.

16. Guidelines 2001 ATS & 2003 IDSA Guideline Update Expert panels Evidence-based recommendations Recommend patient stratification to identify likely pathogens and suggested empiric abx Site of care Presence of cardiopulmonary disease Presence of “modifying factors” ID, critical care, pulmonary, internal medicineID, critical care, pulmonary, internal medicine

17. Clinical Diagnosis Suggestive signs and symptoms CXR or other imaging technique Microbiologic testing

18. Signs and Symptoms Fever or hypothermia Cough with or without sputum, hemoptysis Pleuritic chest pain Myalgia, malaise, fatigue GI symptoms Dyspnea Rales, rhonchi, wheezing Egophony, bronchial breath sounds Dullness to percussion Atypical Sx’s in older patients

19. Clinical Diagnosis: CXR Demonstrable infiltrate by CXR or other imaging technique Establish Dx and presence of complications (pleural effusion, multilobar disease) May not be possible in some outpatient settings CXR: classically thought of as the gold standard

20. Infiltrate Patterns

21. Clinical Diagnosis: Recommended testing Outpatient: CXR, sputum Cx and Gram stain not required Inpatient: CXR, Pox or ABG, chemistry, CBC, two sets of blood Cx’s If suspect drug-resistant pathogen or organism not covered by usual empiric abx, obtain sputum Cx and Gram stain. Severe CAP: Legionella urinary antigen, consider bronchoscopy to identify pathogen In general, sputum gram stain cannot be used to focus initial empiric antibioic therapy, but could be used to broaden initial antibiotic therapy. IDSA consensus group believes that a properly collected and examined Gram’s stain of expectorated sputum is helpful for focusing initial empiric therapy in CAP. A lower respiratory tract sample that is not heavily contaminated by oral secretions will typically have fewer than 10 squamous epithelial cells and > 25 neutrophils per LPF. Limitations: not all Pts can provide an adequate sample, interpretation-observer dependent, etc.In general, sputum gram stain cannot be used to focus initial empiric antibioic therapy, but could be used to broaden initial antibiotic therapy. IDSA consensus group believes that a properly collected and examined Gram’s stain of expectorated sputum is helpful for focusing initial empiric therapy in CAP. A lower respiratory tract sample that is not heavily contaminated by oral secretions will typically have fewer than 10 squamous epithelial cells and > 25 neutrophils per LPF. Limitations: not all Pts can provide an adequate sample, interpretation-observer dependent, etc.

22. Clinical Diagnosis Assess overall clinical picture PORT Pneumonia Severity Index (PSI) Aids in assessment of mortality risk and disposition Age, gender, NH, co-morbidities, physical exam lab/radiographic findings

23. IDSA: Outpt Management in Previously Healthy Pt Organisms: S. pneumo, Mycoplasma, viral, Chlamydia pneumo, H. flu Recommended abx: Advanced generation macrolide (azithro or clarithro) or doxycycline If abx within past 3 months: Respiratory quinolone (moxi-, levo-, gemi-), OR Advanced macrolide + amoxicillin, OR Advanced macrolide + amoxicillin-clavulanate

24. IDSA: Outpt Management in Pt with comorbidities Comorbidities: cardiopulmonary dz or immunocompromised state Organisms: S. pneumo, viral, H. flu, aerobic GN rods, S. aureus Recommended Abx: Respiratory quinolone, OR advanced macrolide Recent Abx: Respiratory quinolone OR Advanced macrolide + beta-lactam

25. IDSA: Inpt Management-Medical Ward Organisms: all of the above plus polymicrobial infections (+/- anaerobes), Legionella Recommended Parenteral Abx: Respiratory fluoroquinolone, OR Advanced macrolide plus a beta-lactam Recent Abx: As above. Regimen selected will depend on nature of recent antibiotic therapy.

26. IDSA: Inpt Management-Severe/ICU One of two major criteria: Mechanical ventilation Septic shock, OR Two of three minor criteria: SBP=90mmHg, Multilobar disease PaO2/FIO2 ratio < 250 Organisms: S. pneumo, Legionella, GN, Mycoplasma, viral, ?Pseudomonas PIF ratio: index of severity of hypoxemia. Used as part of the definition of ALI (acute lung injury) and ARDS. ALI, PIF=200-300 ARDS, PIF <200PIF ratio: index of severity of hypoxemia. Used as part of the definition of ALI (acute lung injury) and ARDS. ALI, PIF=200-300 ARDS, PIF <200

27. IDSA: Inpt Management: Severe/ICU No risk for Pseudomonas IV beta-lactam plus either IV macrolide, OR IV fluoroquinolone Risk for Pseudomonas Double therapy: selected IV antipseudomonal beta-lactam (cefepine, imipenem, meropenem, piperacillin/tazobactam), plus IV antipseudomonal quinolone -OR- Triple therapy: selected IV antipseudomonal beta-lactam plus IV aminoglycoside plus either IV macrolide, OR IV antipseudomonal quinolone

28. Switch to Oral Therapy Four criteria: Improvement in cough and dyspnea Afebrile on two occasions 8 h apart WBC decreasing Functioning GI tract with adequate oral intake If overall clinical picture is otherwise favorable, can can switch to oral therapy while still febrile.

29. Management of Poor Responders Consider non-infectious illnesses Consider less common pathogens Consider serologic testing Broaden antibiotic therapy Consider bronchoscopy Serologic testing: Legionella, Mycoplasma, viral agents, endemic fungiSerologic testing: Legionella, Mycoplasma, viral agents, endemic fungi

30. Prevention Smoking cessation Vaccination per ACIP recommendations Influenza Inactivated vaccine for people >50 yo, those at risk for influenza compolications, household contacts of high-risk persons and healthcare workers Intranasal live, attenuated vaccine: 5-49yo without chronic underlying dz Pneumococcal Immunocompetent = 65 yo, chronic illness and immunocompromised = 64 yo Vaccination may be done either at hospital discharge or during outpatient treatment ACIP: Advisory Committee on Immunization PracticesVaccination may be done either at hospital discharge or during outpatient treatment ACIP: Advisory Committee on Immunization Practices

31. Pneumonia in Children: Dx Symptoms Infants: non-specific manifestations Fever, poor feeding, irritability, vomiting, diarrhea, URI Sx, cough, respiratory distress Older children: more specific Fever, cough, chest pain, tachypnea, tachycardia, grunting, nasal flaring, retracting. Cyanosis usually very late. Signs/Physical exam RR > 60 for all ages Hypoxia Rales, wheezes, crackles, coarse breath sounds

32. Pneumonia in Children: Pathogens 0-4 wks: GBS, GN enterics, Listeria 4-12 wks: C. trachomatis, GBS, GN enterics, Listeria, viral (RSV/parainfluenza), B. pertussis 3 mos-4 yrs: Viral, S. pneumo, H. influenza, M. catarrhalis, Grp A Strep, Mycoplasma > 5yrs: Mycoplasma (5-15yrs), C. pneumo, S. pneumo, viral

33. Pneumonia in the Elderly Prevention important Presentation can be subtle Antibiotic choice in CAP is same as other adults Healthcare associated pneumonia Consider S. aureus (skin wounds) and GN bacteria (aspiration) Pneumonia in Older Residents of Long-term Care Facilities. AFP 2004; 70: 1495-1500.

34. Pneumonia in Immunocompromised Pts Smokers, alcoholics, bedridden, immuno-compromised, elderly Common still common S. pneumo Mycoplasma Pneumocystis Carinii Pneumonia P. jirovecii Fever, dyspnea, non-prod cough (triad 50%), insidious onset in AIDS, acute in other immunocompromised Pts CXR: bilateral interstitial infiltrates Steroids for hypoxia TMP-SMZ still first line Jirovecii is pronounced "yee row vet zee eye"). Trimethoprim-sulfamethoxazole is the drug of choice for PCP, and may be given orally or via the intravenous route depending on the severity of the illness. In individuals with low levels of oxygenation and moderate to severe PCP, corticosteroids are frequently used as well. Other antimicrobials used for the treatment of PCP include: pentamidine, trimethoprim/dapsone, clindamycin,/primaquine, and atovaquone. Jirovecii is pronounced "yee row vet zee eye"). Trimethoprim-sulfamethoxazole is the drug of choice for PCP, and may be given orally or via the intravenous route depending on the severity of the illness. In individuals with low levels of oxygenation and moderate to severe PCP, corticosteroids are frequently used as well. Other antimicrobials used for the treatment of PCP include: pentamidine, trimethoprim/dapsone, clindamycin,/primaquine, and atovaquone.

36. IDSA/ATS 2007 Guideline Hospital Admission Decision CURB-65 criteria (confusion, uremia, RR, low BP, age 65 yrs or greater) or PSI can be used to ID candidates for outpt management Diagnostic Testing Acknowledges the low yield and infrequent positive impact on clinical care Outpt testing for etiologic Dx remain optional Inpt testing for etiologic Dx recommended for specific indications Antimicrobial therapy: essentially unchanged Recommendations for Dx testing remain controversial. Overall low yield and infrequent positive impact on clinical care argue against the routine use of common tests,such as blood and sputum cultures. These cultures may have a major impact on the care of an individual patient and are important for epidemiologic reasons, including the antibiotic susceptibility patterns used to develop treatment guidelines. A list of clinical indications for more extensive diagnostic testing was developed on the basis of 2 criteria: 1-when the result is likely to change individual antibiotic management 2-when the test is likely to have the highest yield.Recommendations for Dx testing remain controversial. Overall low yield and infrequent positive impact on clinical care argue against the routine use of common tests,such as blood and sputum cultures. These cultures may have a major impact on the care of an individual patient and are important for epidemiologic reasons, including the antibiotic susceptibility patterns used to develop treatment guidelines. A list of clinical indications for more extensive diagnostic testing was developed on the basis of 2 criteria: 1-when the result is likely to change individual antibiotic management 2-when the test is likely to have the highest yield.

37. Summary Use overall clinical presentation to guide therapy The admission decision is an “art of medicine” decision Use risk factors and guidelines to assist with clinical judgement PSI is an adjunctive tool to support but not replace this process.PSI is an adjunctive tool to support but not replace this process.

38. References American Thoracic Society. Guidelines for the Management of Adults with Community-acquired Pneumonia. Am J Respir Crit Care Med 2001 Vol. 163:1730-1754. Mandell LA, Bartlett JG, Dowell SF, File TM Jr, Musher DM, Whitney C. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis 2003 Dec 1;37(11):1405-33. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27-72. Arch Ped Adol Med 1995; 149: 283-7.