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Community-Acquired Pneumonia

Community-Acquired Pneumonia. Shireesha Dhanireddy, MD Division of Allergy & Infectious Diseases University of Washington 12 September 2014. Objectives. Diagnosis and management of CAP Differentiate between healthcare-associated pneumonia (HCAP) and CAP

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Community-Acquired Pneumonia

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  1. Community-Acquired Pneumonia Shireesha Dhanireddy, MD Division of Allergy & Infectious Diseases University of Washington 12 September 2014

  2. Objectives • Diagnosis and management of CAP • Differentiate between healthcare-associated pneumonia (HCAP) and CAP • Identify risk factors for resistant organisms and less common causes of pneumonia

  3. CAP - Epidemiology • Very common • 5 million cases/year in North America • At least 1 million hospitalizations/year • 9th leading cause of infectious death in US • 30 day morality for hospitalized patients is up to 23% • $17 billion/year in healthcare costs in US

  4. www.cdc.gov/flu

  5. Which of these patients have community-acquired pneumonia (CAP)? • 34 yo hospital employee, previously healthy, admitted for acute pneumonia. • 56 yo man admitted with CHF, noted to have pneumonia the day after admission. • 76 yo bedridden man transferred from a nursing home for acute confusion, noted to have a new infiltrate on CXR. ✔ ✔

  6. Alphabet Soup of Terms • CAP: Community-acquired pneumonia • Outside of hospital or extended-care facility • HCAP: Healthcare-associated pneumonia • Long-term or extended care facility, hemodialysis, outpatient chemo, wound care, etc. • HAP: Hospital-acquired pneumonia • ≥ 48 h from admission • VAP: Ventilator-associated pneumonia • ≥ 48 h from endotracheal intubation

  7. Pneumonia - Definitions Kollef MH et al. CID 2008:46 (suppl 4)

  8. Case 1 70 yo man presents to ED with acute onset of cough productive of yellow sputum, R-sided pleuritic CP and dizziness. Hx diabetes and HTN. Meds include: HCTZ, lisinopril, glyburide and metformin. PEx: T 35° C, BP 110/70 HR 120 RR 36 GEN: Appears in acute respiratory distress. PULM: Dullness to percussion, increased fremitus, crackles at R base. NEURO: Oriented only to self. LABS: WBC 23 (40% bands), Hct 42%, Plts 150. BUN 46, Cr 1.4. ABG: 7.48 /30 /50 on RA. CXR shows RLL infiltrate. Which of following is the most appropriate management? Admit to general medical floor. Admit to intensive care unit. Observe in the ED for 12 hours. Treat as outpatient.

  9. Clinical Presentation Acute cough (>90%) Fevers/chills (80%) Sputum production (66%) Dyspnea (66%) Pleuritic chest pain (50%) Tachypnea (RR > 24) Egophony Bronchial breath sounds Percussion dullness Diminished breath sounds

  10. Clinical Presentation Acute cough (>90%) Fevers/chills (80%) Sputum production (66%) Dyspnea (66%) Pleuritic chest pain (50%) • Lung physical exam • Sensitivity 47-69% ; Specificity 58-75% Tachypnea (RR > 24) Egophony Bronchial breath sounds Percussion dullness Diminished breath sounds

  11. CXR

  12. To Admit or Not?Pneumonia Severity & Deciding Site of Care • Objective criteria to risk stratify & assist in decision re outpatient vs inpatient management • Pneumonia Severity Index (PSI) • CURB-65 • Caveats • Other reasons to admit apart from risk of death • Not validated for ward vsICU • Not validated in some populations (i.e. HIV+)

  13. 70 20 15 20 10 Total 135

  14. Criteria for Severe CAP(Admit to ICU) • Minor criteria • Respiratory rate ≥30 breaths/min • PaO2/FiO2 ratio ≥250 • Multilobar infiltrates • Confusion/disorientation • Uremia (BUN ≥20 mg/dL) • Leukopenia (WBC <4000 cells/mm3) • Thrombocytopenia (platelets <100,000 cells/mm3) • Hypothermia (core T <36C) • Hypotension requiring aggressive fluid resuscitation • Major criteria • Invasive mechanical ventilation • Septic shock with the need for vasopressors 2007 IDSA/ATS Guidelines for CAP in Adults.

  15. Microbiology • TYPICAL • Streptococcus pneumoniae • Haemophilus influenzae • Moraxella catarrhalis • Klebsiella pneumoniae • ATYPICAL • Mycoplasma pneumoniae • Chlamydophila pneumoniae • Legionella pneumophila

  16. Microbiology of CAP among hospitalized patients

  17. Age-specific Rates of Hospital Admission by Pathogen Marsten. Community-based pneumonia incidence study group. Arch Intern Med 1997;157:1709-18

  18. Comorbidities & Associated Pathogens • Strep pneumoniae • Oral anaerobes • Klebsiella pneumoniae • Acinetobacter spp • M. tuberculosis • Haemophilusinfluenzae • Pseudomonas aeruginosa • Legionellaspp • S. pneumoniae • Moraxella catarrhalis • Chlamydophilapneumoniae

  19. Gram-negative enteric pathogens • Oral anaerobes • CA-MRSA • Oral anaerobes, microaerophilic streptococci, Actinomyces, Nocardia spp • Endemic fungi • M. tuberculosis, atypical mycobacteria • P. aeruginosa • Burkholderia cepacia • S. aureus • Pneumocystis jirovecii • Cryptococcus • Histoplasma • Tuberculosis • Aspergillus • P. aeruginosa

  20. MRSAModern-day CAP pathogen • 51 Staphylococcus aureus CAP cases in 19 states reported 2006-2007 • 79% MRSA • Median age 16 yrs (range <1 to 81) • 47% antecedent viral illness • 11 of 33 (33%) tested had lab-confirmed influenza • 51% died a median of 4 days from symptom onset Lesson: Must consider MRSA, MSSA coverage in severe CAP, esp during flu season! Kallen, Ann Emerg Med. 2009 Mar;53(3):358-65.

  21. MRSACAPClinical Features • Cavitary infiltrate or necrosis • Rapidly increasing pleural effusion • Gross hemoptysis (not just blood-streaked) • Concurrent influenza • Neutropenia • Erythematous rash • Skin pustules • Young, previously healthy patient • Severe pneumonia during summer months Wunderink, N Engl J Med. 2014;370:543-51.

  22. Is sputum culture helpful? • Sputum Gram stain and culture • Low sensitivity (25-40%) • Considered optional for outpatients • Blood culture • Positive < 10% • May help guide antibiotic therapy textbookofbacteriology.net

  23. Diagnosis: Cultures • Pre-abxBlood Cultures • Yield 5-15% • Stronger indication for severe CAP • Host factors: cirrhosis, asplenia, complement deficiencies, leukopenia • Pre-abxexpectorated sputumGs & Cx • Yield can be variable • Depends on multiple factors: specimen collection, transport, speed of processing, use of cytologic criteria • Adequate sample w/ predominant morphotype seen in only 14% of 1669 hospitalized CAP pts (Garcia-Vasquez, Arch Intern Med 2004) • Pre-abxendotracheal aspirateGs & Cx • Pleural effusions >5 cm on lateral upright CXR

  24. Diagnosis: Other testing • Urinary antigen tests • S. pneumoniae • L. pneumophilaserogroup 1 • 60-80% sensitive, >90% specific in adults • Pros: rapid (15 min), simple, more sensitive than Cx, can detect Pneumococcus after abx started • Cons: no susceptibility data, not helpful in patients with recent CAP (prior 3 months)

  25. Diagnosis: Other testing • Acute-phase serologies • C. pneumoniae, Mycoplasma, Legionella spp • Not practical given slow turnaround & single acute-phase result unreliable • Influenza testing • Hospitalized patients:Severe respiratory illness (T> 37.8°C with SOB, hypoxia, or radiographic evidence of pneumonia) without other explanation and suggestive of infectious etiology should get screened during season • NP swab or nasal wash/aspirate • Rapid flu test (15 min) - Distinguishes A vs B • Sensitivity 50-70%; specificity >90% • Respiratory virus DFA & culture - reflex subtyping for A • Respiratory viral PCR panel - reflex subtyping for A • Epidemic Influenza PCR panel – screens for A & B with reflex subtyping for A

  26. Case 29 yo previously healthy but morbidly obese woman admitted in March with 5 days of progressive SOB, intubated in field after being found home unresponsive, hypoxic with Sat 80%. Initial BP 100/80, HR 120. PaO2 60 on 80% FiO2. CXR reveals diffuse patchy infiltrates with some lower lobar consolidation R>L. Sputum could not be obtained but endotracheal aspirate shows 3+ polys and 3+GPC in clusters. Which of the following abx would you start empirically? • Ceftriaxone + azithromycin • Zanamavir + vancomycin + azithromycin • Oseltamavir + vancomycin + azithromycin • Oseltamavir + vancomycin + piperacillin-tazobactam • Oseltamavir + daptomycin + azithromycin

  27. Outpatient Empiric CAP Abx • Healthy; no abx x past 3 months • Macrolide: azithromycin • 2nd choice: doxycycline • Comorbidities; abx x past 3 mon • Respiratory fluoroquinolone: Moxifloxacin, levofloxacin 750 mg, gemifloxacin • Beta-lactam (preferred: amoxicillin 1 g3 or amox/clav 2 g2; alternative: ceftriaxone, cefuroxime 500 mg2), + macrolide • Regions with >25% high-level macrolide-resistant S. pneumo (MIC ≥16), consider alternative agents 2007 IDSA/ATS Guidelines for CAP in Adults.

  28. Inpatient Empiric CAP Abx1 • Inpatients in ward • Respiratory fluoroquinolone • ß-lactam (cefotaxime/ceftriaxone or ampicillin/sulbactam) + macrolide • Inpatients in ICU • ß-lactam + macrolide • Respiratory fluoroquinolone for PCN-allergic pts • Pseudomonas (if concerns exists) • Anti-pneumococcal & anti-pseudomonal ß-lactam + azithromycin + cipro/levofloxacin (750 mg) • Can substitute quinolone with aminoglycoside • PCN-allergic: can substitute aztreonam • CA-MRSA: Add vanco or linezolid* (or ceftaroline2) • CA-MSSA: Nafcillin or cefazolin or ceftriaxone 1 2007 IDSA/ATS Guidelines for CAP in Adults. 2 File, et. al. CID 2010. 51(12): 1395-1405.

  29. Risk Factors for Multidrug Resistance (MDR) • Antibiotics in the past 90 days • High frequency of antibiotic resistance in community • Immunosuppressive disease or medications • HCAP Risk Factors: • Hospitalization for at least 2 days in the past 90 days • Residence in a SNF • Home infusion therapy • Dialysis within 30 days • Family member with MDR infection Kollef MH et al. CID 2008:46 (suppl 4)

  30. Kollef MH et al. CID 2008:46 (suppl 4)

  31. Influenza pneumoniaTreatment • First-line Tx is neuroaminidase inhibitors for both influenza A and B: • Oseltamavir 75-150* mg PO BID x 5+ days • Zanamavir10 mg INH BID x 5+ days • NOTE: influenza A resistant to adamantanes (amantadine, rimantadine) * There is limited data in support of double dosing. But we do it anyway.

  32. Antiviral Therapy for Influenza Should be started ASAP in: • Anyone hospitalized with suspected or confirmed influenza • Anyone with severe, complicated or progressive respiratory illness • Anyone at higher risk of complications from influenza CDC Guidelines for Influenza 2012-2013

  33. Individuals at Higher Risk for Influenza Complications • Extremes of age: children <2, adults ≥65 years • Comorbid conditions: • Chronic pulmonary • Cardiovascular (except HTN alone) • Renal, hepatic, hematologic, metabolic (DM) • Neurologic, neuromuscular (cerebral palsy, epilepsy, CVA, SCI) • Immunosuppression (caused by meds, HIV infection) • Pregnant or post-partum (<2 wks) women • Persons <19 years on long-term aspirin • American Indians & Alaskan Natives • Morbidly obese (BMI ≥40) • Residents in NH or chronic-care facilities CDC Guidelines for Influenza 2012-2013

  34. Influenza pneumoniaWhat about the 48-hr rule? • Antiviral treatment within 48 hrs • Reduce likelihood of lower tract complications & antibacterial use in outpatients • Hospitalized patients likely benefit even if started up to 3-5 days from illness onset 1,2,3 • Additional exceptions to <48 h rule: • Immunocompromisedpatients • Severe, complicated or progressive illness 1 Siston, et. al. JAMA 2009. 2 Yu, Clin Infect Dis 2011. 3 Louie, Clin Infect Dis 2012.

  35. Follow-up ResponseExpected improvement? • Clinical improvement w/ effective abx: 48-72 hrs • Fever can last 2-5 days with Pneumococcus, longer with other etiologies, esp Staph aureus • CXR clearing • If healthy & <50 yo, 60% have clear CXR x 4 wks • If older, COPD, bacteremic, alcoholic, etc. only 25% with clear CXR x 4 wks • Switch from IV to PO • Hemodynamically stable, improving clinically • Able to ingest meds with working GI tract

  36. Question… What is far & away the most common reason for non-response to antibiotics in CAP? • Cavitation • Pleural effusion • Multilobar involvement • Discordant antibiotic/etiology • Host factors

  37. May. Kennewick, WA. • A 58 y/o man with advanced liver disease, construction worker in outdoor excavation • C/O acute fever, cough, pleuritic chest pain, WBC 23,000. • CXR and chest CT show RML nodule and effusion. No response to Unasyn + Levo. • Concern for pneumococcal pneumonia. Thoracentesis and BAL are performed….

  38. Coccidioides immitis- Endemic to the desert southwest- Dissemination more common in non-Caucasians, pregnant, immunocompromised- Acute & chronic pulmonary syndromes (“valley fever”—fever, cough, arthralgias, Erythema nodosum)- Diagnosis based on serology, culture, or histopathology NW Infections: Coccidioides

  39. Exposures & Associated Pathogens • Legionella spp • Coccidioides spp • Hantavirus pulmonary syndrome (Sin Nombre virus) • Burkolderia pseudomallei • Avian influenza A (H7N9) • MERS-CoV • Influenza • S. pneumoniae • Staph aureus (MSSA, MRSA) • H. influenzae • Bordetella pertussis

  40. Zoonotic Exposures & Associated Pathogens

  41. Take Home Points • Ask patients about co-morbidities and travel/other potential exposures when they present with a respiratory illness • Evaluate patients for MDR risk factors when managing patients in the community with respiratory illness

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