Diagnosis, Empiric Management and Prevention of CAP

Pneumonia Acute infection of the pulmonary parenchyma accompanied by symptoms of acute illness accompanied by abnormal chest findings. Third leading cause of morbidity (2001) and mortality (1998) in Filipinos based on the Philippine Health Statistics (DOH). CPG is a joint statement from PSMID, PCCP and PAFP.

2004 CAP Guidelines in Immunocompetent Adults CAP definition: Lower respiratory tract infection Acute onset of within 24 hrs to 2 wks Patient with : cough Tachypnea (RR>20), tachycardia (HR>100), fever (T>37.8˚C) At least one abnormal chest findings - breath sounds, rhonchi, crackles, or wheeze

Chest x- ray is required for definitive Dx CAP in Immunocompetent Adults - 2004 Update No particular sx & abnormal P.E. finding sufficiently sensitive or specific to confirm or exclude the Dx Chest x- ray is required for definitive Dx Clinical prediction rules may be utilized if CXR is not available

Diagnostic standard – Chest radiograph Assess severity CAP in Immunocompetent Adults - 2004 Update Diagnostic standard – Chest radiograph Assess severity Presence of complications pleural effusion multilobar involvement abscess May suggest possible etiology Differentiate pneumonia from other conditions In addition to confirm the diagnosis of pneumonia, an initial chest radiographic examination is essential in assessing the severity of disease and presence of complication. Finding of bilateral or multilobar involvement, progression of infiltrates within 24 hours, pleural effusion, and lung abscess are suggestive of severe disease, poor prognosis and indicate the need for hospital admission. Chest radiography may also suggest possible etiology and help in differentiating pneumonia from other conditions that my mimic it (Grade A).

LOW Risk C A P ---> Outpatient Care CAP in Immunocompetent Adults - 2004 Update Which patient will need hospital admission ? Pts w/ stable VS: RR < 30 breaths/min, PR < 125 beats/min DBP > 60 mmHg & SBP > 90 mmHg No / stable comorbid condition * No evidence of extrapulmonary sepsis No evidence of aspiration CXR: localized infiltrates; no evidence of pleural effusion nor abscess; not progressive within 24 h LOW Risk C A P ---> Outpatient Care

* Comorbid conditions include: Diabetes mellitus (DM) Neoplastic disease Neurologic disease Congestive heart failure (CHF) Coronary artery disease (CAD) Renal failure COPD Chronic liver disease Chronic alcohol abuse

Patients which will need hospital admission ? Moderate CAP: In-patients Pts w/ unstable VS: RR > 30 breaths/min, PR > 125 beats/min, Temp > 40oC or <35oC unstable comorbid condition * extrapulmonary evidence of sepsis * suspected aspiration Chest X-ray: multilobar infiltrates; pleural effusion or abscess; progression of findings to >50% in 24 hrs

*Unstable comorbid conditions include: uncontrolled diabetes mellitus (DM) active malignancies neurologic disease in evolution congestive heart failure (CHF) Class II-IV unstable coronary artery disease (CAD) renal failure on dialysis uncompensated COPD decompensated liver disease

Patients which will need hospital admission ? High Risk CAP: ICU Care Any criteria under moderate risk category plus Hemodynamic alterations and hypoperfusion (i.e. altered mental state, DBP <60 mmHg or SBP <90 mmHg, urine output <30 ml/hr) or Impending or frank respiratory failure (i.e. Hypoxemia of PaO2 <60 mmHg or acute hypercapnea of PaCO2 >50 mmHg)

*Extrapulmonary evidence of sepsis: Moderate Risk C A P: Hepatic Hematologic Gastrointestinal Endocrine High Risk C A P: CNS - altered mental state CVS - DBP <60 mmHg or SBP <90 mmHg Renal - urine output <30 ml/hr

CAP Algorithm: Management-Oriented Risk Stratification of Community-Acquired Pneumonia in Immunocompetent Adults CAP Any of the ff: 1. RR > 30/min 2. PR > 125/min 3. Temp > 40oC or <35oC 4. Extrapulmonary evidence of sepsis 5. Suspected aspiration 6. Unstable comorbid conditions* 7. CXR: multilobar, pleural effusion abscess, progression of lesion to >50% of initial within 24 hrs YES Any of the ff: 1. Shock or signs of hypoperfusion - hypotension - altered mental state - urine output <30ml/hr 2. PaO2<60mmHg or Acute hypercapnea (PaCO2>50mmHg) HIGH RISK CAP YES Intensive care MODERATE RISK CAP NO In-patient LOW RISK CAP Outpatient NO

Microbiologic studies are necessary in CAP? Moderate Risk CAP Blood CS Sputum GS CS Optional : PA for M. pneumoniae MIF for C. pneumoniae (for elderly & immunocompromised) Urine Ag Test for L. pneumophila DFA Test for L. pneumophila High Risk CAP Blood CS Sputum GS CS (ABG) PA for M. pneumoniae MIF for C. pneumoniae Urine Ag Test for L. pneumophila DFA Test for L. pneumophila

PRINCIPLES OF EMPIRICAL THERAPY Treat early; give antibiotics within 4 h of admission Cannot reliably differentiate etiology on basis of clinical findings Treat most likely pathogens S. pneumoniae; H. Influenzae Atypicals Others (local epidemiology) *Recent antibiotics, recent hospitalization, etc.

Empiric Antimicrobial Therapy in CAP Low risk: Amoxicillin, Co-trimoxazole, Macrolides (Azithromycin, Clarithromycin, Roxithromycin) Co-amoxiclav, Sultamicillin 2nd Generation Cephaloporins: Cefuroxime, Cefaclor

Empiric Antimicrobial Therapy in CAP Moderate Risk CAP: Macrolides, Antipneumococcal fluoroquinolones (PO or IV), β-lactams with β-lactamase inhibitor (IV) 2nd Generation Cephalosporins (IV) 3rd Generation Cephalosporins (Ceftriaxone, Cefotaxime, Ceftizoxime IV) Carbapenems (Ertapenem IV)

Nonpseudomonal c IV b-lactams include 2nd gen cephalosporin - cefuroxime sodium 3rd gen cephalosporins - ceftriaxone, cefotaxime those w/ anaerobic activity: cefoxitin, ceftizoxime, ertapenem d IV b-lactams w/ b-lactamase inhibitor include ampicillin-sulbactam, amoxicillin-clavulanic acid

e IV antipneumococcal fluoroquinolones include levofloxacin gatifloxacin moxifloxacin

Empiric Antimicrobial Therapy in CAP High Risk C A P With risk for P. aeruginosa: IV antipseudomonal b-lactamf +/- b-lactamase inhibitor g + IV macrolide or IV antipneumococcal FQ e +/- aminoglycoside or IV ciprofloxacin No risk for P. aeruginosa: IV nonpseudomonal b-lactam c +/- b-lactamase inhibitor d + IV macrolide OR IV antipneumococcal FQ e

Antipseudomonal f IV b-lactams include g IV b-lactams 3rd gen cephalosporin - ceftazidime 4th gen cephalosporins - cefepime, cefpirome those w/ anaerobic activity: imipenem-cilastatin, meropenem g IV b-lactams w/ b-lactamase inhibitor piperacillin-tazobactam, ticarcillin-clavulanic acid

fever declines w/in 72 hrs; temperature normalizes within 5 days How do we assess response to initial Rx ? Most patients w/ uncomplicated bacterial pneumonia will respond to treatment within 24-72 hrs fever declines w/in 72 hrs; temperature normalizes within 5 days respiratory signs, esp. tachypnea, return to normal A follow-up CXR NOT necessary to confirm that infiltrate has cleared for low-risk CAP patients

Switch Therapy to an oral agent if: How do we assess response to initial Rx ? Switch Therapy to an oral agent if: Less cough & resolution of respiratory distress Afebrile for > 24 h Etiology is not a virulent/resistant pathogen Stable co-morbid condition No life-threatening complication This will allow early hospital discharge ----> cost savings

Duration of antibiotic use based on etiology Etiologic Agent Duration of therapy (days) Most bacterial pneumonia except GNB, S. aureus, P. aeruginosa Enteric Gram (-) pathogens, S. aureus, P. aeruginosa Mycoplasma & Chlamydophilia Legionella sp. 5-7 3 (azalides) 10-14 14-21

Follow-up CXR to determine: Pneumothorax Cavitation Extension to previously uninvolved lobes Pulmonary edema; ARDS Re-assess bacteriologic studies: to determine resistance to antibiotic being given or presence of other pathogens i.e., M. TB or fungi * In elderly: S. pneumoniae & L. pneumophila may be causes of slowly resolving pneumonia

How do we prevent pneumonia? Pneumococcal vaccine Influenza vaccine Adult dose O.5 ml IM or SC one-time revaccination may be given after 5 years 0.5 ml IM once a year C.I. Serious allergic reaction to a vaccine component moderate or serious acute illness Precautions Guillain-Barre Syndrome