Community Acquired Pneumonia (CAP) Last revised January 2016 by Michelle Le

Objectives Diagnosis of CAP Level of care assessment Therapeutic recommendations

Case Vignette A 68 y/o Vietnamese male presented to the ED with SOB and productive coughing for 2 days. Reports poor oral intake since onset due to nausea and intermittent vomitting. His wife had similar symptoms 1 week ago which improved with an unknown antibiotic. Patient is requesting to go home with antibiotic. He previously had tongue swelling and skin rash with use of augmentin. Reports good health otherwise so he has not seen his PCP for past 5 years. Denies chest pain, swelling of extremities, or diarrhea. His vital signs are T 38.5 C, P 76, BP 128/82, spO2 94%, RR 16. Patient is alert and oriented. Crackles were heard over left lower lung field. Labs showed WBC 14, BUN 20 mg/dL. Chest X-ray had a consolidation in left lower lobe.

Case Vignette What is the best way to further manage this patient? A. Send home with oral azithromycin B. Send home with oral levofloxacin C. Admit to medicine floor with iv levofloxacin D. Admit to medicine floor with iv ceftriaxone and po azithromycin E. Admit to ICU with iv ceftriaxone and iv azithromycin Don’t worry... We will revisit this case at the END of our mini-lecture!

Definitions – Pneumonia (PNA) Community acquired PNA (CAP) Infection of lung parenchyma in pt who is not hospitalized or living in a long-term care facility for ≥2 weeks Hospital-acquired PNA (HAP) Occurs ≥48 hours after admission; not intubating on admission Healthcare-associated PNA (HCAP) Non-hospitalized pt with extensive healthcare contact and ≥1 criteria from below: IV therapy, wound care, or IV chemotherapy within the prior 30 days Residence in a nursing home or other long-term care facility Hospitalization in acute care hospital for ≥2 days within the prior 90 days Attendance at a hemodialysis clinic within the prior 30 days Ventilator-associated PNA (VAP) Arises >48-72 hours after endotracheal intubation -Demonstrable infiltrate by CXR or other imaging technique is required for the diagnosis of pneumonia (Moderate recommendation; level III evidence) The radiographic appearance of PNA may include lobar consolidation, interstitial infiltrates, and/or cavitation -In outpatients with CAP diagnostic tests are optional (Moderate recommendation; level III evidence)

Severity of PNA CURB-65 criteria Severity-of-illness scores can help guide whether a pt needs hospital admission and should always be supplemented with clinical judgement CURB-65 criteria Confusion Urea >19 mg/dL Respiratory rate ≥30 Blood pressure (SBP <90 or DBP ≤60) ≥65 year old ≥2 criteria then needs hospital admission and ≥3 criteria may need ICU level of care Can also use Pneumonia Severity Index (PSI) instead of CURB-65 -Severity-of-illness scores can help guide whether a pt needs hospital admission (Strong recommendation; level I evidence) -≥2 criteria then needs hospital admission (Moderate recommendation; level III evidence)

CAP Pathogens -Most common cause in all 3 scenarios: Strept pneumo -Only in ICU setting: Staph, GNRs

CAP Treatment - Outpatient No comorbidities or recent antibiotics use 1st line: azithromycin (Z-Pak) 2nd line: doxycycline Have comorbitidies or antibiotic use in last 3 months Preferred: moxifloxacin OR levofloxacin Alternative: augmentin + azithromycin All oral medications

CAP Treatment - Inpatient Non-ICU moxifloxacin OR levofloxacin azithromycin + [unasyn OR zosyn OR ceftriaxone OR meropenem] ICU Preferred: azithromycin + [unasyn OR zosyn OR ceftriaxone OR meropenem] Alternative: moxifloxacin OR levofloxacin If has PCN allergy aztreonam + [moxifloxacin OR levofloxacin] Non-ICU: either regimens are good -moxifloxacin OR levofloxacin -azithromycin + [iv unasyn OR iv zosyn OR ceftriaxone OR meropenem]

Case Vignette A 68 y/o Vietnamese male presented to the ED with SOB and productive coughing for 2 days. Reports poor oral intake since onset due to nausea and intermittent vomitting. His wife had similar symptoms 1 week ago which improved with an unknown antibiotic. Patient is requesting to go home with antibiotic. He previously had tongue swelling and skin rash with use of augmentin. Reports good health otherwise so he has not seen his PCP for past 5 years. Denies chest pain, swelling of extremities, or diarrhea. His vital signs are T 38.5 C, P 76, BP 128/82, spO2 94%, RR 16. Patient is alert and oriented. Crackles were heard over left lower lung field. Labs showed WBC 14, BUN 20 mg/dL. Chest X-ray had a consolidation in left lower lobe.

Case Vignette What is the best way to further manage this patient? A. Send home with oral azithromycin B. Send home with oral levofloxacin C. Admit to medicine floor with iv levofloxacin D. Admit to medicine floor with iv ceftriaxone and po azithromycin E. Admit to ICU with iv ceftriaxone and iv azithromycin

Case Vignette What is the best way to further manage this patient? A. Send home with oral azithromycin B. Send home with oral levofloxacin C. Admit to medicine floor with iv levofloxacin D. Admit to medicine floor with iv ceftriaxone and po azithromycin E. Admit to ICU with iv ceftriaxone and iv azithromycin The patient has CURB-65 score of 2 which requires inpatient treatment but not severe enough for ICU setting (also bc does not have at least 3 minor or 1 major criteria for ICU). He previously had severe allergic reaction to augmentin (a penicillin abx) so levofloxocin (a fluoroquinolone) is better for treatment. He has been able to tolerate oral intake so iv medications will be best.

Summary CAP: infection of lung parenchyma in pt who is not hospitalized or living in a long-term care facility for ≥2 weeks CURB-65 and Pneumonia Severity Index (PSI) are severity-of-illness scores which help guide level of care in conjuction with clinical judgement Appropriate antibiotic regimen will provide coverage for both Strept pneumoniae and atypical pathogens

References Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388. Schuetz P, Christ-Crain M, Thomann R, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA 2009; 302:1059.