The Old Mans Friend Andrew Elkins Consultant Chest medicine PRH

Community acquired Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Legionella pneumophilia Mycoplasma pneumoniae Chlamydia spp. Staphylococcus aureus

Hospital acquired Staphylococcus aureus Klebsiella pneumoniae Pseudomonas aeruginosa Escherichia Coli Acinetobacter spp. Serratia spp

Strep pneumoniae

H Influenzae Blood liking ! 75% nasal mucosa Capsulated

Mycoplasma pneumoniae Epidemic Extrapulmonary manifestations eg assoc cerebeller syndrome /Guillian Barre Rashes- Nodosum, multiforme

Legionella pneumoniae Renal failure and death

Pseudomonas aeruginosa

Risk factors for Pseudomonas aeruginosa At least 2 from Recent hospitalisation Frequent (>4/year) or recent antibiotivs ( within 3/12) Severe disease FEV1 < 30% Previous isolation

Klebsiella spp Cavitation/abcesses Alcoholics

CURB-65 - Severity Score for Community Acquired Pneumonia CNew onset confusion (AMT < 8/10) UUrea > 7mmol/L RRespiratory rate > 30 BSystolic blood pressure < 90 or diastolic < 60 65Age over 65 years

Hospital management of community acquired pneumonia (CAP) in the first 4 h Lim W S et al. Thorax 2009;64:iii1-iii55 ©2009 by BMJ Publishing Group Ltd and British Thoracic Society

For all patients, the CURB65 score should be interpreted in conjunction with clinical judgement. ? AF ? Comorbidity ? Multilobar involvement Exrtapulmonary manifestations Eg Cardiac, Liver, Renal involvement

Low severity Home (eg, CURB65 = 0–1 or CRB-65 score = 0, <3% mortality) None routinely. PCR, urine antigen or serological investigations* may be considered during outbreaks (eg, Legionnaires’ disease) or epidemic mycoplasma years, or when there is a particular clinical or epidemiological reason.

Home Amoxicillin 500 mg tds Doxycycline 200 mg loading dose then 100 mg orally or clarithromycin 500 mg bd orally

Low Severity Hospital (eg, CURB65 = 0–1, <3% mortality) but admission indicated for reasons other than pneumonia severity (eg, social reasons) None routinely PCR, urine antigen or serological investigations* may be considered during outbreaks (eg, Legionnaires’ disease) or epidemic mycoplasma years, or when there is a particular clinical or epidemiological reason.

Hospital Amoxicillin 500 mg tds orally If oral administration not possible: amoxicillin 500 mg tds IVDoxycycline 200 mg loading dose then 100 mg od orally or clarithromycin 500 mg bd orally

Moderate severity (eg, CURB65 = 2, 9% mortality) Blood cultures (minimum 20 ml) Sputum for routine culture andsensitivity tests for those who have not received prior antibiotics(±Gram stain*) Pneumococcal urine antigen test Pleural fluid, if present, culture and pneumococcal antigen detection PCR or serological investigations* maybe considered during mycoplasma years and/or periods of increased respiratoryvirus activity. Legionella is suspected (a) urine for legionellaantigen (b) sputum or other respiratory samplefor legionella culture and direct immunofluorescence (if available). If urine antigen positive, ensure respiratory samples for legionella cul

Moderate severity Hospital Amoxicillin 500 mg –1.0 g tds orally plus clarithromycin 500 mg bd orally If oral administration not possible: amoxicillin 500 mg tds IV or benzylpenicillin 1.2 g qds IV plus clarithromycin 500 mg bd IV Doxycycine 200 mg loading dose then 100 mg orally or levofloxacin 500 mg od orally or moxifloxacin 400 mg od orally

High severity (eg, CURB65 = 3–5, 15–40% mortality) As for moderate severity Definitely investigate for Legionella pneumonia (a) Urine for legionella antigen (b) Sputum or other respiratory sample‡for legionella culture and direct immunofluorescence (if available) Investigations for atypical and viralpathogens, sputum or otherrespiratory sample for PCR or direct immunofluorescence (or other antigendetection test) for Mycoplasma pneumoniae Chlamydia spp, influenza Aand B, parainfluenza 1–3, adenovirus, respiratory syncytial virus,Pneumocystis jirovecii and consider initial and follow-upviral and “atypical pathogen” serology§

High severity Hospital ! Antibiotics given as soon as possible Co-amoxiclav 1.2 g tds IV plus clarithromycin 500 mg bd IV (If legionella strongly suspected, consider adding levofloxacin†) Benzylpenicillin 1.2 g qds IV plus either levofloxacin 500 mg bd IV or ciprofloxacin 400 mg bd IV or Cefuroxime 1.5 g tds IV or cefotaxime 1 g tds IV or ceftriaxone 2 g od IV, plus clarithromycin 500 mg bd IV(If legionella strongly suspected, consider adding levofloxacin)

Blood cultures High specificity Positive in 4-18% untreated CAP Obtain on admission 34% positive if taken within 4 days of symptom evolution, 12% if later S Pneumoniae 60% H Influenzae 2-13%

Hospital acquired pneumonia

Switch IV - oral Resolution of fever for > 24 hours Pulse rate < 100 beats / min Resolution of tachypnoea Clinically hydrated and taking oral fluids Resolution of hypotension Absence of hypoxia Improving white cell count Non-bacteraemic infection No microbiological evidence of legionella, staphylococcal or gram –ve enteric bacilli infection No concerns over GI absorption

Duration Community managed or those with uncomplicated low / moderate severity –7 days is recommended High severity, no positive microbiology –7–10 days is recommended If Staphylococcus aureus or gram –ve enteric bacilli suspected / confirmed, duration may need to be extended to days Stop / review dates should be specified both on the drug-chart and in the medical notes

Treatment failure If amoxicillin monotherapy, add or substitute macrolide If moderate severity pneumonia on amoxicillin + macrolide, change to doxycycline or fluoroquinolone (e.g. moxifloxacin oral or levofloxacin IV) Adding levofloxacin IV is an option to those with high severity pneumonia failing to respond to co-amoxiclav IV + clarithromycin IV

Macrolides and Statins Risk of myopathy & acute rhabdomyolysis Macrolides inhibit the cytochrome P450 isoenzyme CYP3A4 by which simvastatin is metabolised –And to some extent atorvastatin –Pravastatin, rosuvastatin & fluvastatin are not affected  levels of simvastatin Not all patients affected Withhold simvastatin for the duration of the course of clarithromycin Be alert for unexplained muscle pain, tenderness or weakness or dark coloured urine

Macrolides and warfarin Marked increase in INR has been seen in some patients Unpredictable, can occur rapidly Macrolides stimulate liver enzymes to produce metabolites which bind to cytochrome P450 to form inactive complexes –Metabolism of warfarin reduced –  INR No need to avoid concurrent use Monitor INR closely –especially those who metabolise warfarin slowly –e.g. elderly / those on low doses

Prolonged QT interval Both macrolides & quinolones have been shown to prolong QT interval Risk of torsades de pointes if used in conjunction with another drug that prolongs the QT interval e.g. amiodarone Concurrent use should be avoided Ciprofloxacin appears to have less of an effect on QT interval than levofloxacin or moxifloxacin

Additional treatment Humidification Hydration Low molecular weight Heparin Non invasive ventilation- not liekly to be beneficial Steroids no place unless assoc septic shock

Learning points To admit or not to admit To admit to ward or consider intensive care Choice of antibiotic- worth some thought Simple micro helpful but other tests only if prolonged or severe

9 attendees 6 Score 5 ( Excellent) 3 score 4 ( Good)