1. How Do I Think About Pneumonia? Resident’s Thursday School 07/25/2013 J Rush Pierce Jr, MD, MPH Division of Hospital Medicine, UNM

2. Outline Review resources Case based discussion that will cover – Diagnosis – Treatment Based on – IDSA/ATS CAP (2007) guidelines – HCAP/VAP/HAP (2005) guidelines How Do I Think About Pneumonia?07/25/20132

3. Resources Guidelines available – UNMH site (https://hospitals.health.unm.edu/intranet/Index.cfm)https://hospitals.health.unm.edu/intranet/Index.cfm – IDSA website – guidelines available for download to Palm or iPhone (http://www.idsociety.org/Content.aspx?id=9088)http://www.idsociety.org/Content.aspx?id=9088 Up-to-Date (varies some from guidelines) Sanford Guide – generally follows guidelines Adult Community-Acquired Pneumonia Order Set How Do I Think About Pneumonia?07/25/20133

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5. Case 1 65 y/o male smoker has 2 days of chills, dyspnea, and purulent sputum. He has no risk factors for HIV, donates blood 3x/year (most recently one month ago) and does not take any medications. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA. Examination shows no abnormalities. CXR is read as “minimal streaking at lung bases, atelectasis vs. early pneumonia” Should I treat with antibiotics? 07/25/2013How Do I Think About Pneumonia?5

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7. Does this patient have pneumonia? Hx: PE: VS most useful in predicting severity CXR is gold standard - may be normal in up to 7% on admission; assume pneumonia present if convincing hx and focal PE Suspected pneumonia with neg CXR – consider f/u CXR or CT (more sensitive) How Do I Think About Pneumonia?07/25/20137 SensitivitySpecificity Fever/chills85% Dyspnea70% Purulent sputum50% Any of above70 – 90%40 – 50%

8. Thinking about pneumonia: 4 steps 1.Put into initial clinical classification 2.Decide site of care 3.Tests for etiology 4.Initial empiric therapy How Do I Think About Pneumonia?07/25/20138

9. Step 1: Initial clinical classification 1.Major immunodeficiency 2.Tuberculosis (suspected or established) 3.Relatively normal hosts without TB (location at time of infection) Community-acquired (CAP) Healthcare-associated (HCAP) or Hospital acquired (HAP) – includes ventilator-acquired (VAP) How Do I Think About Pneumonia?07/25/20139

10. Case 2 55 y/o homeless man from Mexico has 2 days of chills, night sweats, dyspnea, and purulent sputum without hemoptysis. He has not lost weight. He has no risk factors for HIV, takes no medications, and is not diabetic. Exam reveals T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right base. Should I order airborne isolation? 07/25/2013How Do I Think About Pneumonia?10

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12. When to suspect TB (Intern Survival Guide) If two or more sxs – Hemoptysis – Cough > 2 weeks – Night sweats – Wt loss > 10 # in 3 mos If suspicious CXR (any of these) – Upper lobe infiltrates – Miliary pattern – Cavitary lesions – Nodular infiltrate Response to suspected TB Order airborn isolation and CXR Order AFB smears, cultures (does not have to be qAM!) How Do I Think About Pneumonia?07/25/201312

13. Step 1: Initial clinical classification 1.Major immunodeficiency 2.Tuberculosis (suspected or established) 3.Relatively normal hosts without TB (location at time of infection) Community-acquired (CAP) Healthcare-associated (HCAP) or Hospital acquired (HAP) – includes ventilator-acquired (VAP) How Do I Think About Pneumonia?07/25/201313

14. CAP vs HCAP/VAP/HCAP Healthcare-associated pneumonia (HCAP) – In hospital > 1 day within past 90 days – Nursing home/SNF/LTAC – Dialysis or outpt hosp within past 30 days – IV antibiotics or chemo, wound care within 30 days – (Family member with MDRO) HAP– occurs > 48 hrs after admission & not incubating at time of admission VAP – occurs more than 48 – 72 hrs after intubation How Do I Think About Pneumonia?07/25/201314

15. Case 2 The patient has never been hospitalized, resides at home, does not take dialysi, has not received chemotherapy, and his spouse has not been sick 07/25/2013How Do I Think About Pneumonia?15

16. Step 1: Initial clinical classification 1.Major immunodeficiency 2.Tuberculosis (suspected or established) 3.Relatively normal hosts without TB (location at time of infection) Community-acquired pneumonia (CAP) Healthcare-associated pneumonia (HCAP) or Hospital acquired pneumonia (HAP) – includes ventilator-acquired (VAP) How Do I Think About Pneumonia?07/25/201316

17. Thinking about pneumonia: 4 steps 1.Put into initial clinical classification 2.Decide site of care 3.Tests for etiology 4.Initial empiric therapy How Do I Think About Pneumonia?07/25/201317

18. Case 3 65 y/o male smoker has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. He has felt and eaten poorly. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right apex. He is not confused. WBC = 15K, H/H = 14.5/42, Na = 128, K = 3.5, Cl = 105, CO2 = 20. BUN/creat = 32/1.4. CXR shows RUL infiltrate. Can I send this patient home? 07/25/2013How Do I Think About Pneumonia?18

19. www.meddean.luc.edu 07/25/201319How Do I Think About Pneumonia?

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21. Pneumonia Severity Index (PSI) How Do I Think About Pneumonia?07/25/201321

22. CURB-65 Developed by British Thoracic Society Confusion, BUN >20, Respiratory rate >30, BP 64 – Score = 0 – 1 OUTPT – Score = 2 WARD – Score = 3 ICU  Other subjective factors = safely and reliably take oral meds, availability of support services How Do I Think About Pneumonia?07/25/201322

23. ICU admission = one major or 3 minor How Do I Think About Pneumonia?07/25/201323

24. Thinking about pneumonia: 4 steps 1.Put into initial clinical classification 2.Decide site of care 3.Tests for etiology 4.Initial empiric therapy How Do I Think About Pneumonia?07/25/201324

25. Case 3 - continued 65 y/o male smoker has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. He drinks alcohol everyday. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right base. He is not confused. WBC = 15K, H/H = 14.5/42, Na = 128, K = 3.5, Cl = 105, CO2 = 20. BUN/creat = 32/1.4. CXR shows RUL infiltrate. What etiologic tests do I order? 07/25/2013How Do I Think About Pneumonia?25

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27. Diagnostic tests for etiology Why not etiologic tests for everyone? Outpt – Get SaO2; Routine tests for etiology are optional Inpt - Blood and sputum cultures recommended for most (but not all) ICU - blood and sputum cultures, and Legionella and pneumococcal UAT How Do I Think About Pneumonia?07/25/201327

28. How Do I Think About Pneumonia?07/25/201328

29. How Do I Think About Pneumonia?07/25/201329

30. Thinking about pneumonia: 4 steps 1.Put into initial clinical classification 2.Decide site of care 3.Tests for etiology 4.Initial empiric therapy How Do I Think About Pneumonia?07/25/201330

31. Case 4 24 y/o previously healthy female has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 92% RA, crackles at the right base. CBNC and Chem 7 normal. CXR = early RLL pneumonia What antibiotics should I order? 07/25/2013How Do I Think About Pneumonia?31

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33. Empiric Rx of outpatient CAP Healthy and no antibiotics in past 3 months – Macrolide OR doxycycline If cardiopulmonary dz, Beta-lactam rx in past 3 mos, alcoholism, immunosuppressive rx, or exposure to child in day-care – Respiratory quinolone OR – beta – lactam (high dose amoxicillin or Augmentin) + macrolide or doxycycline Duration of rx = 7 days (may be less with good response or if use azithro) How Do I Think About Pneumonia?07/25/201333

34. Outpatient RX of CAP Candidates for outpt therapy – Low PSI or CURB-65 – Not crazy – Likely to be compliant, can get meds and F/U Follow-up – Return if T > 101 or fail to resolve fever in 48 hours – Outpatient visit in 10 – 14 days – CXR in 1 – 2 months How Do I Think About Pneumonia?07/25/201334

35. Case 3 - continued 65 y/o male smoker has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. He has felt and eaten poorly. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right base. He is not confused. WBC = 15K, H/H = 14.5/42, Na = 128, K = 3.5, Cl = 105, CO2 = 20. BUN/creat = 32/1.4. CXR shows RUL infiltrate What antibiotics do you order? 07/25/2013How Do I Think About Pneumonia?35

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37. Empiric Rx of inpatient CAP – no special considerations Inpatient – ward: – respiratory quinolone OR – (ceftriaxone or ceftazidime) + (azithro or doxy) ICU – – (ceftriaxone or ceftazidime) + (IV azithro or respiratory quinolone) – If PCN allergic use aztreonam + respiratory quinolone How Do I Think About Pneumonia?07/25/201337

38. Empiric inpatient Rx of CAP – special considerations Pseudomonas – suggestive gram stain, bronchiectasis, freq exacs of COPD + prior antibiotic rx – Regimens: – (Zosyn or merepenam) + cipro OR – (Zosyn or merepenam or aztreonam) + aminoglycoside + respiratory quinolone MRSA – suggestive gram stain, ESRD, IVDU, prior influenza, prior antibiotics esp quinolones, or much MRSA in community – Regimen: Add linezolid OR vancomycin How Do I Think About Pneumonia?07/25/201338

39. Case 3 - continued 65 y/o male 2 days ago with RUL pneumonia and treated with ceftriaxone and azithromycin. On rounds is feeling better, eating, not confused. T = 37.9, HR = 102, BP = 105/75, RR = 12, SaO2 = 88% on room air When I can I switch to an oral regimen and what regimen? When can the pt go home? 07/25/2013How Do I Think About Pneumonia?39

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41. Switching to oral If specific pathogen identified, switch to narrow spectrum therapy When clinically improving, hemodynamically stable, able to take orals, switch to oral rx – if no pathogen, often azithro alone Duration = at least 5 days, and until afebrile for two days, and have only one sign of clinical instability. If pathogen is Pseudomonas treat at least 14 days How Do I Think About Pneumonia?07/25/201341

42. Timing of discharge Readmission rate or death: no instability = 10%; 1 instability = 14%; 2+ instabilities = 46% How Do I Think About Pneumonia?07/25/201342

43. Pneumonia – before they go home Smoking cessation Vaccination How Do I Think About Pneumonia?07/25/201343

44. CAP – What’s New Increasing recognition of viral pathogens Consideration of environmental exposures as risk factor for CAP Use of PCR (and other tests) to guide initial antibiotic choice Use of inflammatory markers to help with diagnosis and guide therapy Vaccine efficacy How Do I Think About Pneumonia?07/25/201344

45. Questions? 07/25/2013How Do I Think About Pneumonia?45

46. Empiric therapy of HCAP/HAP/VAP with MDR risk factors cefepime, ceftazadime, imipenam, or Zosyn PLUS ciprofloxacin, levofloxacin, or aminoglycoside If MRSA concerns add linezolid or vancomicin How Do I Think About Pneumonia?07/25/201346

47. Switching to oral therapy for HCAP/HAP/VAP Pseudo: if sens cipro + Aug/doxy/clinda MRSA: sensitivities cipro + Aug/doxy/clinda OR moxi How Do I Think About Pneumonia?07/25/201347

48. Aspiration When to use: observed/suspected aspiration + fever or leucocytosis or infiltrate Regimens: – Unasyn + (doxy OR azithro) Augmentin or clinda – Respiratory quinolone How Do I Think About Pneumonia?07/25/201348

49. Non-responding pneumonia – definition (15%) Progressive pneumonia on CXR with clinical deterioration, acute respiratory failure and/or shock occurring in first 72 hours Delay in achieving clinical stability – Median time = 3 days – ¼ require > 5 days Non-resolution of infiltrate > 30 days after hospitalization [different problem] How Do I Think About Pneumonia?07/25/201349

50. Clinical response to non- responding pneumonia Reevaluate initial microbiologic results – consider UAT Reassess risk factors for infection with unusual organism Repeat blood cultures for worsening pneumonia or clinical deterioration Look for secondary infections (catheter, urinary, skin) Get CT to R/O PTE, thoracentesis to R/O empyema, bronchoscopy to R/O unusual pathogens How Do I Think About Pneumonia?07/25/201350