Presentation on theme: "IDSA/ATS Guidelines on Community-Acquired Pneumonia in Adults"— Presentation transcript:
1 IDSA/ATS Guidelines on Community-Acquired Pneumonia in Adults Patty W. Wright, MDMarch 2011with special thanks toTom Talbot, MD, MPH
2 CAP: ObjectiveTo discuss the recommendations outlined by the Infectious Diseases Society of America and American Thoracic Society’s guidelines on the management of community acquired pneumonia, with a particular focus on changes from prior versions of these guidelines.
3 CAP: Definition and Epidemiology Lower respiratory tract infection in people with limited or no contact with medical institutions or settingsUp to 5.6 million cases/yr in U.S.Up to $ 9.7 billion spent annuallyUp to 60,000 deaths each year in U.S.
4 CAP: Risk Factors Altered Mental Status Smoking Alcohol consumption MalnutritionImmunosuppressionUnderlying lung diseaseAge ≥65 years
5 CAP: Clinical Presentation Symptoms:Cough (typically productive)Fever with chills and sweatsShortness of breathChest painSigns:Fever, tachycardia, tachypneaCrackles/rhonchi on lung examLeukocytosis
6 CAP: Diagnosis – Imaging Infiltrate on Cxray (or other imaging) required for the diagnosis of pneumoniaIf clinically suspect CAP, but negative Cxray consider:Chest CTEmpiric treatment and repeat Cxray in hrs
8 CAP: Microbiology Streptococcus pneumoniae Haemophilus influenzae “Atypicals”Mycoplasma pneumoniaeChlamydia pneumoniaeLegionella spPseudomonas sp.Viral – Influenza, RSV, Parainfluenza, HMPVSpneumo – 2/3 of all bacteremic pneumoniaeOften cause is not identified -- ~6% outpatients and ~25% inpatients
9 CAP: Diagnosis – Sputum Gram Stain/Culture Optional for routine outpt evaluationCulture-positive rates range from 2-50%If require admission, obtain sputum Gram stain & culture and blood culturesIdeally obtain sputum before abx, but do not delay abx waiting for a sputum sampleCx allows to streamline abx choice, report notifiable diseasesBlood cultures – if obtained within 24hrs of admit, assoc with improved survival
10 CAP: Diagnosis – Special Tests Urinary Legionella AntigenSerotype 1 onlyAccounts for 88% of USA isolatesSensitivity: 70%; specificity: >90%Urinary Pneumococcal AntigenSensitivity: 60-90%, specificity: 100%Recent study found 10% of specimens from pts with non-pneumococcal pneumonia were positive
11 CAP: Poor Prognostic Factors Age > 65 yearsNursing home resident (HCAP)Presence of chronic lung diseaseHigh APACHE scoreNeed for mechanical ventilation
12 CAP: Treatment Guidelines Where to treat:Many can be treated as an outpatientMust consider illness severity, comorbidities, home support, adherence to therapy
13 CAP: Treatment Guidelines Pneumonia Severity Index (PSI)Prediction rule to stratify risk of death from CAPAssists in determining location of Rx for CAPShould not supercede clinical judgmentPneumonia Patient Outcomes Research Team
14 Fine, M. J. et al. N Engl J Med 1997;336:243-250 CAP: PSIFine, M. J. et al. N Engl J Med 1997;336:
15 CAP: PSI Then, add up their risk points: Risk Score II < 70 III 71-90IV91-130V> 130
16 Fine, M. J. et al. N Engl J Med 1997;336:243-250 CAP: PSIPSI IndexMortality RateI%II%III0-2.8%IV%V27-31%Consider Outpt TxNeeds Inpt TxFine, M. J. et al. N Engl J Med 1997;336:
17 CAP: CURB-65 CURB-65 criteria Confusion Uremia (BUN >20) Respiratory rate (RR >30)Blood pressure (SBP <90 or DBP < 60)Age 65 years or greater
19 CAP: TreatmentAbx initiated in the emergency dept, ideally within 4 hrsQuick administration has been associated with reduced mortalityUse of empiric guidelines have reduced costs, mortality, LOSBased upon severity of illness and host immune statusTarget regimen based upon culture results
20 CAP: IDSA-ATS Treatment Guidelines Stratify empiric outpatient treatment based onDrug-resistant Strep pneumo risk> 25% resistance rate (e.g. Nashville, TN)Presence of co-morbiditiesAlcoholism/Aspiration riskBronchiectasis/COPDIVDAPost-influenzaPrior abx use in the preceding 3 months
21 CAP: IDSA-ATS Treatment Guidelines Empiric Treatment – Outpatient:No confounding factors:macrolide (azithromycin 500mg x 1 day then 250mg Qday or clarithromycin 500mg po Q12hrs or clarithro-ER 1000mg Qday)ordoxycycline 100mg Q12hrs
25 CAP: Risk Factors for Pseudomonas Structural lung diseases, such as bronchiectasisRepeated exacerbations of severe COPD leading to frequent steroid and/or antibiotic useHealth-Care Associated Pneumonia (HCAP)
26 HCAP: DefinitionHospitalized in acute care hospital two or more days within 90 days prior to infectionReside in long-term care facilityReceived IV abx, chemotx, or wound care in last 30 daysDialysis
27 CAP: Pseudomonas Coverage Beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) + ciprofloxacin or levofloxacin orBeta-lactam + aminoglycoside + azithromycin orBeta-lactam + aminoglycoside + respiratory quinolonePCN-allergic = substitute aztreonam for the beta-lactam
28 CAP: MRSA Consider empiric coverage of MRSA if: HCAP Necrotizing pneumoniaPost-influenza pneumoniaHistory of MRSA or recurrent skin abscessesTreat with vancomycin or linezolid
29 CAP: MRSA – Vancomycin vs. Linezolid Retrospective analysis of data from two separate, prospective trials (n = 1,019)Patients with nosocomial pneumoniaAztreonam + vancomycin or linezolidNo difference in survival except in MRSA pneumonia subgroup (63.5% vs. 80%, p=0.03)Linezolid is an alternative to vancomycin in new IDSA/ATS guidelinesWunderink, et al. Chest 2003
30 CAP: Oral Abx Therapy Switch to po abx when… Hemodynamically stable Clinically improvingAble to tolerate poHave normal GI tract fxn
31 CAP: Length of Therapy Rx for a minimum of 5 days Before discontinuation of therapy:Pt should be afebrile for 48–72 hrsPt should have no more than one CAP-associated sign of clinical instabilityLonger duration usually indicated with Legionella, Chlamydia, MRSA
32 CAP: Criteria for Clinical Stability Temperature <37.8°CHeart rate <100 beats/minRespiratory rate <24 breaths/minSystolic blood pressure >90 mm HgArterial oxygen saturation > 90% or pO2 > 60 mm Hg on room airAbility to maintain oral intakeNormal mental status
33 “Pneumonia Prevention Vest, Crochet Version” CAP: Prevention“Pneumonia Prevention Vest, Crochet Version”Vaccinations(I hope you were awakeearlier this morning!)
34 CAP: Example PatientJane is a 66 yo female with diabetes who presents to the ED with fever, cough, sputum production, and pleuritic chest pain. She denies associated N/V/D. Vital signs: T100.7, RR 24, BP 110/70, P 100. Exam: A&O x 4, left basilar rhonchi. Cxray: left lower lobe infiltrate. Labs: WBC 14k, gluc 215, BUN 27, cr 1.2.Should Jane be admitted?
35 CAP: Example Patient CURB-65 criteria ConfusionUremia (BUN >20)Respiratory rate (RR >30)Blood pressure (SBP <90 or DBP < 60)Age 65 years or greaterJane’s score = 2…Recommend admission
36 CAP: Example PatientWhat additional work-up would you recommend?
37 CAP: Example Patient Blood cultures Sputum Gram stain and culture Consider urinary pneumococcal antigen
38 CAP: Example Patient Jane has no drug allergies. What antibiotic treatment would you recommend?
39 CAP: Example Patient Respiratory quinolone alone or Beta-lactam + macrolide or doxycyclineIf Jane tells you that she took ciprofloxacin for a UTI last month, how would that change your rx choice?
40 CAP: Example PatientJane rapidly improves with antibiotics and hydration. After two days of hospitalization, she is afebrile with normal vital signs. She continues to tolerate oral medications without problem.When can you discharge Jane?How many more days of antibiotic therapy does she require?
41 CAP: Example PatientJane can be discharged today on po abx to complete a total of 5 days of abx therapy.
42 CAP: Example Patient Unfortunately, we are not done with Jane… Approximately a month after discharge, Jane falls and breaks her leg. She requires casting, which limits her mobility. She begins to note increasing shortness of breath, low grade fever, and a return of her cough, prompting her to present to her primary care provider for further evaluation.
43 CAP: Example PatientJane is sent for CT angiogram of the chest which is negative for pulmonary embolus, but does show a new infiltrate in her right lower lobe with some areas of cavitation.Should Jane be re-admitted to the hospital?What antibiotics should she receive?
44 CAP: Example PatientJane now has HCAP and is at risk for resistant pathogens, such as Pseudomonas and MRSA.She should be admitted for iv abx.Rx with beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) + ciprofloxacin or levofloxacin + vancomycin or linezolid.
45 CAP: Conclusions Not all patients with CAP require hospitalization Outpatients should be stratified by drug-resistant pneumococcus risk, comorbities, and prior abx use in the past 3 monthsInpatients should be stratified by severity of illness and Pseudomonas/MRSA riskPatients should be treated with a minimum of 5 days of abx