Community-Acquired Pneumonia Current & Future State Brad - - PDF document

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Community-Acquired Pneumonia

Current & Future State

Brad Sharpe, M.D. Professor of Clinical Medicine Department of Medicine UCSF sharpeb@medicine.ucsf.edu

CAP: A Practical Approach

• 1. 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 bad.

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CAP: A Practical Approach

• 1. 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 bad.

CAP: A Practical Approach

"Pneumonia may well be called the friend of the

• aged. Taken off by it in an acute, short, not
• ften painful illness, the old man escapes those

‘cold gradations of decay’ so distressing of himself and to his friends.“

• - William Osler, M.D., 1898

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CAP: A Practical Approach

“Brad, pneumonia sucks.”

• - Mary R. Sharpe

November 2011

CAP: A Practical Approach

Update in CAP

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CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

CAP: A Practical Approach

Sources

• Guidelines for Community-Acquired

Pneumonia

♦ IDSA/ATS Consensus Guidelines 2007

(IDSA = Infectious Disease Society of America) (ATS = American Thoracic Society)

♦ BTS: British Thoracic Society

• Updated Literature Review

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Community-Acquired Pneumonia

Caveats

• Will not talk about healthcare-associated

pneumonia (HCAP)

• Will not discuss admission decision (complex)
• Syllabus (sharpeb@medicine.ucsf.edu)

CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

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CAP: A Practical Approach

CAP: Background

• 5 million cases/year in the U.S.
• 80% of CAP is treated outpatient
• Sixth leading cause of death
• Inpatient mortality 10-35%
• Outpatient mortality < 1%

CAP: A Practical Approach

CAP: Background

• Some evidence that quality of care for

African-Americans with CAP is worse

• Higher mortality among Caucasians

Mortensen EM, et al. BMC Health Serv Res. 2004;4:20. Mayr FB, et al. Crit Care Med. 2010;38:759.

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CAP: A Practical Approach

CAP: Background

Cough 90%* Dyspnea 66% Sputum 66% Pleuritic chest pain 50%

* Yet, only 4% of all visits for cough are pneumonia

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

Community-Acquired Pneumonia

Clinical Presentation: Geriatrics

• Less “classic” presentations
• 10% have NONE of the classic signs or symptoms
• Up to 35% will not have fever
• Up to 50% will have altered mental status
• Up to 50% will have “asthenia”

Mehr DR, et al. J Fam Prac 2001;50(11):1101. Riquelme R, et al. Am J Respir Crit Care Med 1997;156:1908. Sund-Levander M, et al. Scand J Inf Dis. 2003;35:306. Simoneti AF, et al. Ther Adv ID. 2014;2:3.

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CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

CAP: A Practical Approach

“Typical” vs. “Atypical”

• Typical organisms

♦ S. pneumoniae, H. influenzae, M. catarrhalis, etc.

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CAP: A Practical Approach

“Typical” vs. “Atypical”

• Atypical organisms

♦ M. pneumoniae, C. pneumoniae, Legionella spp, etc.

CAP: A Practical Approach

“Typical” vs. “Atypical”

• Classic teaching is not supported by the

literature

• Some general trends
• S. pneumoniae in older pts, co-morbidities
• Viruses more common in older patients
• Mycoplasma in patients < 50 years old

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CAP: A Practical Approach

“Typical” vs. “Atypical”

• Classic teaching is not supported by the

literature

• Some general trends
• But - no history, exam, laboratory, or

radiographic features predict organism

• “Walking pneumonia”
• “Classic lobar pneumonia”

CAP: A Practical Approach

Etiology of CAP

Outpatients (mild)

• S pneumoniae (30-50%)
• Resp. viruses (10-30%)
• M pneumoniae
• H influenzae
• C pneumoniae

Non-ICU inpatients

• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp
• Resp. viruses

ICU inpatient

• S pneumoniae
• Legionella spp
• H influenzae
• GNRs
• S aureus

File TM. Lancet 2003;362:1991.

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CAP: A Practical Approach

Etiology of CAP

Outpatients (mild)

• S pneumoniae (30-50%)
• Resp. viruses (10-30%)
• M pneumoniae
• H influenzae
• C pneumoniae

Non-ICU inpatients

• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp
• Resp. viruses

ICU inpatient

• S pneumoniae
• Legionella spp
• H influenzae
• GNRs
• S aureus

File TM. Lancet 2003;362:1991.

CAP: A Practical Approach

Etiology of CAP

Outpatients (mild)

• S pneumoniae (30-50%)
• Resp. viruses (10-30%)
• M pneumoniae
• H influenzae
• C pneumoniae

Non-ICU inpatients

• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp
• Resp. viruses

ICU inpatient

• S pneumoniae
• Legionella spp
• H influenzae
• GNRs
• S aureus

File TM. Lancet 2003;362:1991.

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CAP: A Practical Approach

Etiology of CAP

Outpatients (mild)

• S pneumoniae (30-50%)
• Resp. viruses (10-30%)
• M pneumoniae
• H influenzae
• C pneumoniae

Non-ICU inpatients

• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp
• Resp. viruses

ICU inpatient

• S pneumoniae
• Legionella spp
• H influenzae
• GNRs
• S aureus

File TM. Lancet 2003;362:1991.

CAP: A Practical Approach

Etiology of CAP

Outpatients (mild)

• S pneumoniae (30-50%)
• Resp. viruses (10-30%)
• M pneumoniae
• H influenzae
• C pneumoniae

Non-ICU inpatients

• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp
• Resp. viruses

ICU inpatient

• S pneumoniae
• Legionella spp
• H influenzae
• GNRs
• S aureus

File TM. Lancet 2003;362:1991.

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CAP: A Practical Approach

CA-MRSA

• Community-acquired MRSA (CA-MRSA)
• Rare: ~ 5% of all CAP
• Key clinical scenarios:
• Post-influenza
• Young, necrotizing, rapidly progressive

CAP: A Practical Approach

CA-MRSA

Clinical Features % of Patients

• Shock

50-100%

• Multi-lobar

50-100%

• Necrotizing

33-100%

• Leukopenia

25-100%

• Ventilated

50-100%

• Mortality

~ 40%

• Lancet. 2009.

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CAP: A Practical Approach

Etiology of CAP

Outpatients (mild)

• S pneumoniae (30-50%)
• Resp. viruses (10-30%)
• M pneumoniae
• H influenzae
• C pneumoniae

Non-ICU inpatients

• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp
• Resp. viruses

ICU inpatient

• S pneumoniae
• Legionella spp
• H influenzae
• GNRs
• S aureus

File TM. Lancet 2003;362:1991.

CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

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CAP: A Practical Approach

• 2. A 65-year old man presents to urgent care complaining
• f subjective fever, chills, and productive cough x 3 days. He

reports mild shortness of breath. His temperature is 38.6o C, RR 20, O2 saturation 95% on RA. He has crackles at the right base on lung exam. You should:

• a. Treat for community-acquired pneumonia.
• b. Send him for a PA and lateral CXR.

c. Send him for blood and sputum cultures.

• d. Prescribe sudafed and robitussin and send him

home.

• e. Perform trans-tracheal aspiration

f. B and C

CAP: A Practical Approach

• 2. A 65-year old man presents to urgent care complaining
• f subjective fever, chills, and productive cough x 3 days. He

reports mild shortness of breath. His temperature is 38.6o C, RR 26, O2 saturation 95% on RA. He has crackles at the right base on lung exam. You should:

• a. Treat for community-acquired pneumonia.
• b. Send him for a PA and lateral CXR.

c. Send him for blood and sputum cultures.

• d. Prescribe sudafed and robitussin and send him

home.

• e. Perform trans-tracheal aspiration

f. B and C

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CAP: A Practical Approach

Diagnosis of CAP

1) Select clinical features

(e.g. cough, fever, sputum, pleuritic chest pain)

AND 2) Infiltrate by CXR or other imaging

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

Community-Acquired Pneumonia

Chest Radiograph – Gold Standard

• All expert guidelines state should have

positive CXR to make diagnosis

• History & exam not good enough (50% sensitive)
• In outpt setting, should see an infiltrate.
• Order CXR if you are concerned about CAP
• If CXR negative, likely should not treat for CAP
• In the inpatient setting, can see

pneumonia with a negative CXR (~30%)

Metlay J. Ann Intern Med. 2003.

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Community-Acquired Pneumonia

Chest Radiograph – Gold Standard?

• Should (generally) order CXR in all

patients with suspected pneumonia.

• In the hospital, a positive CXR is not

necessary to treat as CAP (but consider other

diagnoses).

CAP: A Practical Approach

• 2. A 65-year old man presents to urgent care complaining
• f subjective fever, chills, and productive cough x 3 days. He

reports mild shortness of breath. His temperature is 38.6o C, RR 26, O2 saturation 95% on RA. He has crackles at the right base on lung exam. You should:

• a. Treat for community-acquired pneumonia.
• b. Send him for a PA and lateral CXR.

c. Send him for blood and sputum cultures.

• d. Prescribe sudafed and robitussin and send him

home.

• e. Perform trans-tracheal aspiration

f. B and C

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CAP: A Practical Approach

• 2. A 65-year old man presents to urgent care complaining
• f subjective fever, chills, and productive cough x 3 days. He

reports mild shortness of breath. His temperature is 38.6o C, RR 26, O2 saturation 95% on RA. He has crackles at the right base on lung exam. You should:

• a. Treat for community-acquired pneumonia.
• b. Send him for a PA and lateral CXR.

c. Send him for blood and sputum cultures.

• d. Prescribe sudafed and robitussin and send him

home.

• e. Perform trans-tracheal aspiration

f. B and C

CAP: A Practical Approach

Blood Cultures

• Provides a specific diagnosis
• The data:
• Cultures within 24 hours are associated

with lower 30d mortality

• No evidence of benefit in outpatient setting

Meehan TP, et al. JAMA 1997;278.

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CAP: A Practical Approach

Blood Cultures in CAP

• Limitations
• Positive in < 10% of cases
• Medicare database of 13,000 patients
• Determined predictors of blood-culture

positivity

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

CAP: A Practical Approach

Blood Cultures in CAP

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

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CAP: A Practical Approach

Blood Cultures in CAP

• Limitations
• Positive in < 10% of cases
• High percentage of contaminants (6%)
• Rarely impacts antibiotics
• Costly

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

CAP: A Practical Approach

Blood Cultures in CAP

• In general, do not get blood cultures for
• utpatient CAP
• For inpatient CAP, blood cultures are
• ptional
• Consider if risk factors:

▪ ICU, severe liver disease, cavitary

infiltrates, pleural effusion

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

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CAP: A Practical Approach

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

CAP: A Practical Approach

Sputum Cultures in CAP

• In general, sputum cultures are not

indicated in outpatient CAP

• For inpatient CAP, sputum is indicated:
• High-quality specimen, right to the lab
• ICU, cavitary infiltrates, underlying lung

disease

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

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CAP: A Practical Approach

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

CAP: A Practical Approach

The future in CAP - biomarkers

• Procalcitonin: precursor of calcitonin
• No hormonal activity
• Inflammatory marker
• Increased in bacterial infection

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CAP: A Practical Approach

Diagnosing Pneumonia

Procalcitonin: Bacterial vs. Non-bacterial

Intl J. Lung Dz. 2006

CAP: A Practical Approach

Meta-analysis/systematic review

• Four studies, ~3500 patients with

respiratory tract infections

• Specific algorithm
• Less antibiotic exposure**
• A 22% decrease in prescriptions
• Average 2.3 days less abx overall
• No difference in mortality/clinical outcomes

Soni NJ, et al. JHM. 2013;8:530.

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CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

CAP: A Practical Approach

25

CAP: A Practical Approach

Etiology of CAP

Outpatients (mild)

• S pneumoniae
• M pneumoniae
• H influenzae
• C pneumoniae
• Resp. viruses

Non-ICU inpatients

• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp
• Resp. viruses

ICU inpatient

• S pneumoniae
• Legionella spp
• H influenzae
• GNRs
• S aureus

File TM. Lancet 2003;362:1991.

CAP: A Practical Approach

Treatment Principle #1

Outpatients (mild)

• S pneumoniae
• M pneumoniae
• H influenzae
• C pneumoniae
• Resp. viruses

Must cover all these organisms

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CAP: A Practical Approach

Treatment Principle #2

Outpatients (mild)

• S pneumoniae
• M pneumoniae
• H influenzae
• C pneumoniae
• Resp. viruses

“Wimpy” pneumococcus Drug-resistant “angry”

• S. pneumoniae (DRSP)

Penicillin, erythromycin, macrolides, etc.

CAP: A Practical Approach

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

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CAP: A Practical Approach

Treatment Principle #2

Outpatients (mild)

• S pneumoniae
• M pneumoniae
• H influenzae
• C pneumoniae
• Resp. viruses

“Wimpy” pneumococcus Drug-resistant S. pneumoniae (DRSP)

CAP: A Practical Approach

Treatment CAP

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CAP: A Practical Approach

Treatment of CAP

CAP: A Practical Approach

Treatment CAP

Outpatient, healthy, no DRSP risk factors Doxycycline or macrolide

Macrolide = azithro, clarithro, erythro

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CAP: A Practical Approach

Treatment CAP

CAP: A Practical Approach

Risk Factors for DRSP

• Age > 65 years old
• Chronic disease

Heart, lung, renal, liver

• Diabetes mellitus
• Alcoholism
• Malignancy
• Immunosuppression
• Antibiotics in the last 3 months

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CAP: A Practical Approach

Treatment CAP

Outpatient, DRSP risk factors

Oral fluoroquinolone OR Oral β-lactam + doxy or β-lactam + macrolide NOTE: macrolides are no longer indicated for outpatients with DRSP risk factors (US resistance > 40%)

(DRSP = drug-resistant “angry” strep pneumo)

CAP: A Practical Approach

Treatment 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)

Amoxicillin/clavulanate (875mg PO bid)

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CAP: A Practical Approach

• 3. A 72 year-old man with a PMH of gout and DJD presents

to your clinic with cough and shortness of breath. Based on the history, exam, and CXR (RML infiltrate), he is diagnosed with community-acquired pneumonia. He is well enough to be treated as an outpatient. He has no allergies. Which of the following is the best treatment regimen?

• A. Levofloxacin PO
• B. Azithromycin PO
• C. Ertapenem
• D. Ampicillin/clavulanate PO and azithromycin PO
• E. Zosyn & Vanco & Flagyl

CAP: A Practical Approach

Risk Factors for DRSP

• Age > 65 years old
• Chronic disease

Heart, lung, renal, liver

• Diabetes mellitus
• Alcoholism
• Malignancy
• Immunosuppression
• Antibiotics in the last 3 months

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CAP: A Practical Approach

Treatment 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)

Amoxicillin/clavulanate (875mg PO bid)

CAP: A Practical Approach

• 3. A 72 year-old man with a PMH of gout and DJD presents

to your clinic with cough and shortness of breath. Based on the history, exam, and CXR (RML infiltrate), he is diagnosed with community-acquired pneumonia. He is well enough to be treated as an outpatient. He has no allergies. Which of the following is the best treatment regimen?

• A. Levofloxacin PO
• B. Azithromycin PO
• C. Ertapenem
• D. Ampicillin/clavulanate PO and azithromycin PO
• E. Zosyn & Vanco & Flagyl

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CAP: A Practical Approach

• 4. A healthy 41 year-old woman who was recently treated

(1 month ago) for cystitis with cipro presents to your clinic with fever, cough, sob. Her CXR reveals RLL infiltrate and you diagnose community-acquired pneumonia and decide to treat as an outpatient. Which of the following is the best treatment regimen?

• A. Levofloxacin PO
• B. Azithromycin PO
• C. Ertapenem
• D. Ampicillin/clavulanate PO and azithromycin PO
• E. Doxycycline PO and penicillin PO

CAP: A Practical Approach

Risk Factors for DRSP

• Age > 65 years old
• Chronic disease

Heart, lung, renal, liver

• Diabetes mellitus
• Alcoholism
• Malignancy
• Immunosuppression
• Antibiotics in the last 3 months

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CAP: A Practical Approach

Treatment of CAP

• 3. A healthy 48 year-old woman who was recently

treated (1 month ago) for cystitis with cipro presents to your clinic with fever, cough, sob. Her CXR reveals RLL infiltrate and you diagnose community-acquired pneumonia and decide to treat as an outpatient. Which of the following is the best treatment regimen?

• A. Levofloxacin PO
• B. Azithromycin PO
• C. Ertapenem
• D. Ampicillin/clavulanate PO and Azithromycin PO
• E. Doxycycline PO and penicillin PO

CAP: A Practical Approach

Treatment CAP

Outpatient, healthy, no DRSP risk factors Doxycycline or macrolide Outpatient, DRSP risk factors

Oral fluoroquinolone OR Oral β-lactam + doxy or β-lactam + macrolide

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CAP: A Practical Approach

Treatment – Inpatient

CAP: A Practical Approach

Treatment – Inpatient, Non-ICU

Non-ICU inpatients

• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp
• Resp. viruses

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CAP: A Practical Approach

Treatment – Inpatient, ICU

ICU inpatient

• S pneumoniae

(resistant)

• Legionella spp
• H influenzae
• GNRs
• S aureus

CAP: A Practical Approach

“Guideline Concordant Abx”

Benefits

• Frei CR, et al. Am J Med. 2006;119:865
• Retrospective study of 631 pts with CAP
• Early switch to orals, shorter LOS, lower mortality
• Mortensen EM, et al. Am J Med. 2006;119:859.
• Retrospective study of 787 pts with CAP
• Decreased mortality at 48 hours
• Mortensen EM, et al. Am J Med. 2004;117:726-31
• Improved 30-day mortality

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CAP: A Practical Approach

“Guideline Concordant Abx”

Benefits

• Arnold FW, et al. Arch Intern Med. 2009;169:1515.
• Retrospective study of 1725 pts with CAP;
• Shorter LOS, mortality 10% lower (NNT = 10)
• Mccabe C, et al. Arch Intern Med. 2009;169:1525.
• Retrospective study of > 50,000 with CAP
• Decreased mortality by 30%
• Asadi L, et al. Respir Med. 2012;106:451.
• Retrospective study of 2973 outpatients with CAP
• Decreased mortality by 77%

CAP: A Practical Approach

Treatment Inpatient CAP

Inpatient, non- ICU Fluoroquinolone OR β-lactam + macrolide OR β-lactam + doxycycline**

** At UCSF, we use ceftriaxone & doxycycline

38

CAP: A Practical Approach

Treatment Inpatient CAP

Inpatient, non- ICU Fluoroquinolone OR β-lactam + macrolide OR β-lactam + doxycycline** Inpatient, ICU

IV β-lactam + macrolide + vancomycin OR IV β-lactam + fluoroquinolone + vancomycin

CAP: A Practical Approach

Treatment CAP: New Data

39

CAP: A Practical Approach

Treatment CAP: New Data

• Two European RCTs comparing β-lactam

to β-lactam + macrolide or fluoroquinolone

• One study showed no difference
• One study showed better outcomes with

atypical coverage for:

1) Sicker patients

2) Atypical pathogens

CAP: A Practical Approach

Treatment CAP: New Data

• May not be generalizable:
• European patient population
• Used amoxicillin or 2nd-generation ceph.
• More than 30% got antibiotics before

admission

• Not enough to change practice

40

CAP: A Practical Approach

Treatment – Inpatient, Non-ICU

Non-ICU inpatients

• S pneumoniae
• M pneumoniae
• C pneumoniae
• H influenzae
• Legionella spp
• Resp. viruses

CAP: A Practical Approach

Treatment Inpatient CAP

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

41

CAP: A Practical Approach

Doxycycline

• Similar spectrum to macrolides
• Much cheaper!
• Good side effect profile (GI upset)
• Less Clostridium difficile infection
• Rates 27% lower in hospitalized patients

with CAP vs. other regimens

Doernberg SB, et al. Clin Infect Dis. 2012 Sep;55:615.

CAP: A Practical Approach

Treatment – Inpatient, ICU

ICU inpatient

• S pneumoniae

(resistant)

• Legionella spp
• H influenzae
• GNRs
• MRSA

42

CAP: A Practical Approach

Treatment Inpatient CAP

Inpatient, non- ICU Fluoroquinolone OR β-lactam + macrolide OR β-lactam + doxycycline** Inpatient, ICU

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

CAP: A Practical Approach

Duration of therapy

43

CAP: A Practical Approach

• 5. A 67 year-old man with CHF and diabetes is admitted to

the hospital with CAP (non-ICU). He is treated with ceftriaxone and doxycycline and does well. The cultures are all negative. On hospital day 3 he is ready for discharge. What is the optimal duration of total therapy for his CAP?

• A. 14 days
• B. 10 days
• C. 7 days
• D. 3 days
• E. Who cares. He probably won’t take it anyway.

I hate my job.

CAP: A Practical Approach

• 5. A 67 year-old man with CHF and diabetes is admitted to

the hospital with CAP (non-ICU). He is treated with ceftriaxone and doxycycline and does well. The cultures are all negative. On hospital day 3 he is ready for discharge. What is the optimal duration of total therapy for his CAP?

• A. 14 days
• B. 10 days
• C. 7 days
• D. 3 days
• E. Who cares. He probably won’t take it anyway.

I hate my job.

44

CAP: A Practical Approach

Duration of therapy

CAP: A Practical Approach

Duration of therapy?

• Meta-analysis of 15 RCTs, 2796 patients

with mild to moderate CAP

• Compared short-course (< 7 days) with

longer courses.

• Looked at clinical failure, bacterial

eradication, and mortality.

Li JZ, et al. Am J Med. 2007;120:783.

45

CAP: A Practical Approach

Duration of therapy?

• No difference in clinical failure
• No difference in bacterial eradication
• No difference in mortality
• In subgroup analysis, trend toward

favorable efficacy with short-course.

Li JZ, et al. Am J Med. 2007;120:783.

CAP: A Practical Approach

Duration of therapy

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

• - IDSA/ATS Guidelines

46

CAP: A Practical Approach

Duration of therapy

• Minimum of 5 days

▪ If afebrile for 48-72

• For most, 7 days total

CAP: A Practical Approach

• 4. A 67 year-old man with CHF and diabetes is admitted to

the hospital with CAP (non-ICU). He is treated with ceftriaxone and doxycycline and does well. The cultures are all negative. On hospital day 3 he is ready for discharge. What is the optimal duration of total therapy for his CAP?

• A. 14 days
• B. 10 days
• C. 7 days
• D. 3 days
• E. Who cares. He probably won’t take it anyway.

I hate my job.

47

CAP: A Practical Approach

Following at home?

• Have pts take temp q8 hours & report if >

101o F or if > 99o F after 48 hours

• Encourage pts to drink 1-2 quarts of liquid

daily

• If they respond appropriately, have them

follow-up within 10-14 days

Niederman M. Ann Intern Med. 2009

CAP: A Practical Approach

Follow-up CXR?

• Standard practice?
• Prior ATS guidelines said yes, recent

guidelines do not address

• CXR resolution:

▪ At 28 days, ~ 50% had not resolved

• Can consider in “high-risk” patients

▪ Significant smoking history, etc. ▪ Probably should wait > 3 months

Bruns AH. CID. 2007;45:983.

48

CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

CAP: A Practical Approach

Vaccinations

• Will get a full vaccination update

tomorrow morning

49

CAP: A Practical Approach

Smoking Cessation Counseling

• Should provide it to all of our patients

that smoke

• Some evidence that tobacco is a risk

factor for pneumonia

CAP: A Practical Approach

Prevention

Smoking and Invasive Pneumococcus

Cigs / d

OR Current Smokers

1 - 14

2.3 15 - 24 3.7 ≥ 25 5.5 All 4.1 (2.4-7.3)

Hrs / d

OR Passive Smokers ≤ 4

2.4 > 4 3.9 All 2.5 (1.2-5.1)

Nuorti, NEJM, 2000

50

CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention – Avoid the purple pill!

CAP: A Practical Approach

Proton Pump Inhibitors

• Gulmez, et al. Arch Intern Med. 2007.
• - Current use of PPI: CAP OR = 1.5
• - Recent start: CAP OR = 5.0
• Sarkar, et al. Ann Intern Med. 2008.
• - Recent PPI start: CAP OR = 3.8
• Herzig, et al. JAMA. 2009.
• - 52% of hosp pts got PPI, HAP OR = 1.3
• Eurich, et al. Am J Med. 2010.
• - Rates recurrent CAP after CAP admit
• - Starting PPI: OR 2.1% (7% abs risk)

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CAP: A Practical Approach

Roadmap

• Background
• Etiology
• Diagnosis
• Treatment
• Prevention

CAP: A Practical Approach

Take-Home Points

• Etiology: No predictors for “typical” or

“atypical” – need to treat both

• Etiology: Recognize CA-MRSA as a cause for

severe CAP

• Diagnosis: Do not routinely get blood or

sputum cultures in outpt CAP

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CAP: A Practical Approach

Take-home Points

• Treatment: doxycycline or macrolide for

healthy outpatient with no DRSP risk-factors

• Treatment: fluoroquinolone or β-lactam +

macrolide/doxy for outpt with DRSP risk factors

• Treatment: most 7 days
• Prevention: stop smoking, avoid PPIs

Community-Acquired Pneumonia

Current & Future State

Brad Sharpe, M.D. Professor of Clinical Medicine Department of Medicine UCSF sharpeb@medicine.ucsf.edu

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CAP: A Practical Approach CAP: A Practical Approach

CURB-65 Score

• Validated severity-of-illness scoring system

▪ Retrospective then prospective

• Advocated by the British Thoracic Society
• Based on five easily measurable clinical

factors

Lim WS. Thorax 2003; 58:377–82

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CAP: A Practical Approach

CURB-65 Score C – Confusion (disoriented) U – BUN > 20mg/dL R – RR > 30/min B – SBP < 90mmHg or DBP < 60mmHg 65 – Age > 65

Lim WS. Thorax 2003; 58:377–82

CAP: A Practical Approach

CURB65 Score

Lim WS. Thorax 2003; 58:377–82

CURB65 Score Mortality

0.7% 1 2.5% 2 11.0% 3 15.5% 4 40.6% 5 57.0%

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CAP: A Practical Approach

CURB65 Score

Lim WS. Thorax 2003; 58:377–82

CURB65 Mortality Treatment

0.7% Outpatient 1 2.3% Outpatient 2 11.0% Inpatient 3 15.5% Inpatient 4 40.6% ICU 5 57.0% ICU

CAP: A Practical Approach

Admission Decision

• Consider using a prognostic score in CAP

♦ Especially useful in “borderline” cases

• CURB65 easy to use