Community-Acquired Pneumonia Richard G. Wunderink, M.D., and Grant W. Waterer, M.B., B.S., Ph.D. N Engl J Med 2014;370: R3 김선혜 /Prof. 박명재 1

CASE F/67, mild Alzheimer’s disease transferred from a nursing home to the ER department. no recent use of antibiotic agents ROS: productive cough, fever, and increased confusion (2-day) V/S 145/85mmHg-120/min-30/min-38.4°C, SaO2 (RA) 91% P/E : crackles in BLLZ Lab : WBC 4,000/mm², Na 130, BUN 25mg/dl CXR : increased infiltration on BLLZ  How and where should this patient be treated? 2

PNEMONIA Pneumonia is sometimes referred to as the forgotten killer. : M/C infectious cause of death in the world (3rd M/C cause overall), w/ almost 3.5 million deaths yearly. Community-acquired pneumonia (CAP) : severe enough to require hospitalization, also need economic costs. – focus of Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (TJC) quality-improvement efforts, public reporting of outcomes, and possible pay-for-performance initiatives. This article focuses on management strategies for CAP, with particular emphasis on interventions to reduce mortality & costs. 3

DIAGNOSIS Typical presentations : a triad of evidence of infection (fever or chills & leukocytosis), signs or symptoms localized to the respiratory system (cough, sputum, shortness of breath, chest pain, or abnormal pulmonary examination), and a new or changed infiltrate as observed on radiography The diagnosis of CAP can be very difficult  patients with lung cancer, pulmonary fibrosis or other chronic infiltrative lung disease, or congestive heart failure  Atypical presentations (e.g. confusion in elderly patients) 4

INITIAL MANAGEMENT 1> the choice of antibiotic therapy 2> the extent of testing to determine the cause 3> the appropriate location of treatment (home, GW, or ICU) 5

INITIAL MANAGEMENT 1> the choice of antibiotic therapy 2> the extent of testing to determine the cause 3> the appropriate location of treatment (home, GW, or ICU) 6 1> Choice of Antibiotic Therapy The key to appropriate therapy is adequate coverage of Streptococcus pneumoniae and the atypical bacterial pathogens (mycoplasma, chlamydophila, and legionella). For outpatients, the coverage of atypical bacterial pathogens is most important  Macrolides, doxycycline, & fluoroquinolones For patients admitted to a regular hospital unit, first-line therapy  respiratory fluoroquinolone (moxifloxacin at a dose of 400 mg/day or levofloxacin at a dose of 750 mg/day) or 2 nd - or 3rd- generation cephalosporin and a macrolide.

INITIAL MANAGEMENT 1> the choice of antibiotic therapy 2> the extent of testing to determine the cause 3> the appropriate location of treatment (home, GW, or ICU) 7 CMS-TJC : administration of the 1st antibiotic dose within 6 hours after presentation. interval > 4 hours btw the initial presentation and the 1st antibiotic dose  increased in-hospital mortality. The current IDSA–ATS guidelines do not recommend a specific time to the administration of the 1st antibiotic dose but instead encourage treatment as soon as the diagnosis is made. The current recommendation for CAP : 5 to 7 days.

TREATMENT OF PATIENTS AT RISK FOR RESISTANT ORGANISMS 8 Empirical broad-spectrum therapy with dual coverage for Pseudomonas aeruginosa & routine MRSA coverage has been recommended for patients with risk factors for health care– associated pneumonia  antibiotic overtreatment of many patients.  initial broad spectrum therapy remain controversial

TREATMENT OF PATIENTS AT RISK FOR RESISTANT ORGANISMS 9 CAP with structural lung disease (bronchiectasis or severe COPD)  P. aeruginosa infection ↑ MRSA is commonly identified in pt with risk factors for health care–associated pneumonia has increasingly been recognized

10 DIAGNOSTIC TESTING

SITE OF CARE 1> the choice of antibiotic therapy 2> the extent of testing to determine the cause 3> the appropriate location of treatment (home, GW, or ICU) 11 Scoring systems that predict short-term mortality, such as the Pneumonia Severity Index (PSI) and the CURB-65 scores to make admission decisions more objective. Patients transferred to the ICU within 48 hrs after initial admission to a general ward have higher mortality than those with an obvious need for ICU care at the time of admission.  IDSA–ATS minor criteria (Criteria for consideration of ICU adm.) CURB-65 score (≥3 indicating the need for hospitalization) 1. BUN ≥20 mg/dl 2. RR ≥30/min 3. SBP <90mmHg or DBP≤60 mmHg 4. Age ≥65 years 5. Confusion

12  IDSA–ATS minor criteria (≥3 or more) : increased attention in the ER department  decrease in mortality (from 23 to 6%)  fewer floor-to-ICU transfers (from 32 to 15%)

AREAS OF UNCERTAINTY 1> the choice of antibiotic therapy 2> the extent of testing to determine the cause 3> the appropriate location of treatment (home, GW, or ICU) 13 Patients with health care–associated pneumonia have shown markedly lower rates of antibiotic-resistant pathogens and high rates of culture-negative cases.  increased risks of adverse outcomes  increased mortality Pneumonia-specific criteria Traditional antibiotic regimens when cultures are negative

CASE F/67, mild Alzheimer’s disease transferred from a nursing home to the ER department. no recent use of antibiotic agents ROS: productive cough, fever, and increased confusion (2-day) V/S 145/85mmHg-120/min-30/min-38.4°C, SaO2 (RA) 91% P/E : crackles in BLLZ Lab : WBC 4,000/mm², Na 130, BUN 25mg/dl CXR : increased infiltration on BLLZ  Antibiotics : cephalosporin + azithromycin or fluoroquinolone  Diagnositic test (blood & sputum culture, influenza, urine pneumococcal & legionella Ag)  Admission, consider ICU care 14

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