Community Acquired Pneumonia Evaluation and Treatment (2019) PDF

Evaluation and Treatment of Community Acquired Pneumonia Rosalie D. Bravo, MS, RN, ACNP-BC Professor Emerita Vice Chair, Academic Programs & Personnel Department of Physiological Nursing University of California San Francisco 2019 ATS/IDSA Diagnosis & Treatment of Adults with Community- Guide...

Evaluation and Treatment of Community Acquired Pneumonia Rosalie D. Bravo, MS, RN, ACNP-BC Professor Emerita Vice Chair, Academic Programs & Personnel Department of Physiological Nursing University of California San Francisco 2019 ATS/IDSA Diagnosis & Treatment of Adults with Community- Guidelines for Acquired Pneumonia. An Official Guideline of the American Thoracic Society and Infectious Disease CAP Society of America. Metlay JP, Waterer GW, Long AC, et al. Am J Respir Crit Care Med. 2019, Oct1;200 (7):e45-e67  Discuss evidence-based recommendations for diagnostic testing for community acquired pneumonia Analyze mortality risk using validated risk Objectives stratification tools to aid in designating the safest level of care Apply appropriate antibiotic stewardship principles in the management of community-acquired pneumonia, ensuring optimal antimicrobial selection Community Acquired Pneumonia - CAP An acute infection of the pulmonary parenchyma associated with a constellation of suggestive features AND accompanied by the presence of an acute infiltrate on chest radiograph. CAP develops in a patient who is NOT hospitalized or residing in a long-term facility With or without supporting microbiological data Blood Cx Wunderlink RG, Waterer GW, N Engl J Med 2014; 370:543-551  CAP facts CAP Incidence: 24.8 cases per 10,000 Jain S, et al. CDC EPIC Study Team, NEJM, 2015 Average length of stay: 5.2 days National Hospital Discharge survey 2010, CDC 13th leading cause of death (combined with influenza) in the US 2021 CDC Deaths, Final data for 2021  Historical Milestones of Pneumonia Hans Christian ABX New ABX Gram develops Resistance -Lefamulin 2019 Hippocrates Beta Lactam -Omadacycline 2018 SARS-CoV-2 Gram stain. Now describes lung pneumococcus then -Delafloxacin 2019 COVID-19 Pandemic infection Macrolide linked to PNA resistance 400BC 1884 21st 2019 Late 20th Century Century 1881 1940s PPSV23 Vaccine 1983 1945 PCN molecular Pneumococcus structure ID, purified Pneumococcal vaccine isolated by Louis & produced in bulk Pasteur & George PCV7 in 2007 Sternberg PCV13 in 2010  CAP, HAP, VAP by setting Community acquired refers to pneumonia that develops in the outpatient setting where the patient has not been associated with a healthcare environment Hospital Acquired Pneumonia refers to pneumonia that develops in a non- intubated patient within 48 hours of admission to a hospital Ventilator Associated Pneumonia is HAP that begins within 48 hours after intubation Healthcare Associated Pneumonia (HCAP) - Discontinued since 2019 guideline Wunderlink RG, Waterer GW. N Engl J Med 2014; 370:543-551; Kalil et al. Clin Infect Dis. 2016; 63(5):e61-e111  “Atypical” pneumonia or pathogens Atypical pneumonia refers to pneumonia where the presenting symptoms differ from the classic symptoms or CXR findings differ from the classic lobar opacity. Sx like productive cough, fever, weakness, atypical chest pain Atypical pathogens refers to: Mycoplasma pneumoniae Chlamydophila (Chlamydia) pneumoniae Legionella pneumophila Streptococcus pneumonia is the most common Prevention, Diagnosis, Treatment Framework Prevention Diagnosis – clinical features, CXR, diagnostic testing Risk stratification – disease severity and site of care Etiology & Risk stratification for resistant pathogens Empiric antibiotic therapy & adjunctive therapeutics Prevention- Pneumococcal Vaccinations Prevents invasive disease (bacteremia) Target groups Elderly age > 65 Immunocompromised, asplenia, sickle cell dz, alcoholism, liver disease, chronic heart disease Homophys? vaccine for children Prevention- Pneumococcal Vaccinations PCV 15 (Vaxneuvance) PCV 20 (Prevnar 20) PCV 21 (CAPVAXIVE) PPSV23 (Pneumovax23) 23-valent pneumococcal polysaccharide vaccine  PneumoRecs VaxAdvisor App for Vaccine Providers | Pneumococcal | CDC ACIP Recommendations Download this App before the Synchronous session Prevention, Diagnosis, Treatment Framework Prevention Diagnosis – clinical features, CXR, diagnostic testing Risk stratification – disease severity and site of care Etiology & Risk stratification for resistant pathogens Empiric antibiotic therapy & adjunctive therapeutics How is the diagnosis of outpatient CAP made? The patient must have the clinical features of pneumonia on history and physical exam PLUS Radiographic evidence. Obtain a CXR when CAP is suspected. Predominant symptoms of typical CAP Cough Fevers and chills Dyspnea Pleuritic chest pain Purulent sputum Baer & Columbo, 2019. Community Acquired Pneumonia, Medscape CAP Differential Diagnosis Bronchitis – acute or exacerbation of COPD COVID-19 Acute Coronary Syndrome Heart failure & pulmonary edema Pulmonary embolism Bronchogenic carcinomas Metastatic disease Radiation pneumonitis Wunderlink RG, Waterer GW. N Engl J Med 2014 Outpatient vs. Inpatient Diagnostic Testing Outpatient – Dx testing other than CXR of limited value Inpatient – Get the CXR. Other tests are of limited value except for patients with severe CAP. Get pre-treatment blood cultures and send sputum if an adequate sample can be obtained. Admission CBC, CMP, viral PCR. Severe CAP/Critically ill – CXR, Blood and sputum cultures + PCR viral tests. CBC, CMP, coagulation studies, serum lactate, PCT, urine antigen tests for legionella and pneumococcus, ABG. Metlay JP, Waterer GW, Long AC, et al. Am J Respir Crit Care Med. 2019, Oct1;200 (7):e45-e67  Diagnostic testing CXR to confirm the Dx for CAP Get a PA or lateral if pt can stand If no infiltrate, prob not PNA Image from Koo et al. RadioGraphics Vol. 38, No. 3: 719-739  Imaging Chest radiograph – Recommended CAP imaging study. Sensitive but not specific Helpful to characterize PNA Multilobar, necrotizing, pleural effusion, lobar location CT scan has better sensitivity but lack of evidence that CT scan improves outcomes c/w CXR. Good for differentiating non-pneumonia diagnoses Chest ultrasound – diagnostic potential & good for assessing pleural effusion and for guiding thoracentesis Mandell, LA, et al. Clin Infect Dis. 2007;44(suppl 2):S27–S72; Ye, X, et al. PLoS One. 2015; 10(6):e0130066 Blood cultures Only ~20% of admited patients have (+) blood Cx Send for patients with severe CAP Not recommended for low risk, non-severe CAP patients treated in the outpatient or the inpatient setting. Send for inpatients with recent hospitalization or recent antibiotic therapy (within 90 days) Send for patients that will be treated for MRSA and/or PSA Metlay JP, Waterer GW, Long AC, et al. Am J Respir Crit Care Med. 2019, Oct1;200 (7):e45-e67 Sputum culture Pros: May ID causative pathogen in severe CAP. Send if patient has severe CAP Expectorated sample in non-intubated. Recommended for patients with structural lung disease Cons: Difficult to obtain in ED. Lots of contaminants for inadequate sample & does not change treatment or outcomes for patients with non-severe CAP Metlay JP, Waterer GW, Long AC, et al. Am J Respir Crit Care Med. 2019, Oct1;200 (7):e45-e67  Urine Antigen Testing (UAT) – pts with Severe CAP/ ICU admission Pneumococcal Urine Antigen Test (UAT) – Recommended for patients with severe CAP specifically for pneumococcus: streptococcus penumonia or legionella. Quite expensive, so dont use for pts who will be sent home Legionella UAT – Recommended for severe CAP/ICU admission and patients hx recent travel (cruise ships, spas, hotels) or known outbreak Send for outpatient treatment failure Metlay JP, Waterer GW, Long AC, et al. Am J Respir Crit Care Med. 2019, Oct1;200 (7):e45-e67 Legionella - associated with hx of travel, cruise ship, spas, staying in hotels Influenza testing strongly rec!! Rapid influenza molecular assay recommended during flu season over rapid influenza diagnostic tests (antigen testing) **UCSF has specific guideline about testing for influenza during summer months Metlay JP, Waterer GW, Long AC, et al. Am J Respir Crit Care Med. 2019, Oct1;200 (7):e45-e67 SARS-CoV-2 testing Persons with signs or symptoms of COVID-19 should have diagnostic testing regardless of vaccination status. Nucleic Acid Amplification Tests (NAATs) Antigen tests  Biomarkers Procalcitonin – Is not recommended for guiding initiation of antibiotic therapy. May be useful for de-escalating antibiotic therapy Metlay JP, Waterer GW, Long AC, et al. Am J Respir Crit Care Med. 2019, Oct1;200 (7):e45-e67 In the setting of the COVID-19 surges, procalcitonin and CRP may be be useful. PCT is low in COVID-19 and high in bacterial pneumonia CRP may be high in COVID-19 and bacterial pneumonia Summary of diagnostic testing Extensive diagnostic testing is helpful for patients with risk factors for severe CAP requiring ICU admission Trend away from automatically sending blood cultures for non- severe CAP admitted to floor In most studies a specific causal diagnosis is obtained in