Philippine Clinical Practice Guidelines for Community-Acquired Pneumonia (CAP) 2016 Update PDF

Philippine Clinical Practice Guidelines Community-Acquired Pneumonia Clinical Practice Guidelines Diagnosis, Empiric...

Philippine Clinical Practice Guidelines Community-Acquired Pneumonia Clinical Practice Guidelines Diagnosis, Empiric Management and Prevention of Community-Acquired Pneumonia in Immunocompetent Adults 2016 Update Treatment Joint Statement of PSMID PCCP PAFP PCR O B I O L O GY I CR AN M D R FO IN FE C S O C I ETY T IO US DI S NE PI EA IP S IL ES PH -- -1 - 970 A D-- Philippine Copyright 2016  2016 Update COMMUNITY-ACQUIRED PNEUMONIA INTRODUCTION Internationally, community-acquired pneumonia (CAP) remains the leading cause of death from an infectious disease. It is the sixth leading cause of death overall and is a major cause of morbidity and mortality. Since the last publication of Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management, and Prevention of Community-acquired Pneumonia (CAP) in Immunocompetent Adults in 2010, several changes had emerged: Multiple international societies had published and revised their guidelines of the management of patients with CAP. New organisms had emerged and development of resistance had increased over time among respiratory pathogens. The influx and efflux of antimicrobial agents used in the treatment had likewise posed a threat to the rapid rise of antimicrobial resistance. The use, misuse, abuse and overuse had also shaken the market of antimicrobial agents. It is for these reasons that a long overdue update on the management of CAP is needed. There is a need to standardize care by providing management strategies based on best available evidences. The evidences may be the same; however, regional differences, causative agents, antibiotic resistance rates, drug licensing, healthcare structure and available resources may vary. Recommendations made by one national organization may therefore not be applicable to other countries TREATMENT When should antibiotics be initiated for the empiric treatment of community-acquired pneumonia (CAP)? Patients should receive initial therapy as soon as possible after the diagnosis is established. Antibiotics, the mainstay for the treatment of pneumonia, should be initiated as soon as a diagnosis of CAP is made. The 2004 PCPG for CAP recommended a maximum four-hour window 1 Community-Acquired Pneumonia from diagnosis to antimicrobial initiation. This recommendation was based on studies that showed a reduced in-hospital mortality when antimicrobial therapy was initiated within the first four hours of admission and diagnosis of CAP. The 2007 IDSA ATS Guidelines, however, found an internal inconsistency in outcomes between the group that received antibiotics within the first two hours and the group which received antibiotics two to four hours after diagnosis. Although therapy within 4 hours of arrival to the hospital has been associated with reduced mortalities in some studies, undue emphasis on early therapy could lead to unnecessary use of antibiotics and associated complications. For these reasons, the present guideline maintains its position to not recommend a specific time interval between diagnosis and antibiotic administration for patients. Reference: 1. Bordon J, et al. Early administration of the first antimicrobials should be considered a marker of optimal care of patients with community-acquired pneumonia rather than a predictor of outcomes. International Journal of Infectious Diseases 17 (2013) e293–e298. 2. Gattarello S et al. Improvement of antibiotic therapy and ICU survival in severe non-pneumococcal community- acquired pneumonia: a matched case–control study. Critical Care (2015) 19:335. doi: 10.1186/s13054-015- 1051-1. 3. Mandell, Lionel A et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. CID 2007; 44 (Suppl 2): S27-72. 4. Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management, and Prevention of Community- acquired Pneumonia (CAP) in Immunocompetent Adults : 2004 Update. 5. Simonetti A, et al. Timing of antibiotic administration and outcomes of hospitalized patients with community- acquired and healthcare-associated pneumonia. Clinical Microbiology and Infection. 2012; 18(11):1149-1155. 2  2016 Update What initial antibiotics are recommended for the empiric treatment of community-acquired pneumonia? For low-risk CAP without comorbid illness, AMOXICILLIN remains the standard drug of choice. Use of extended macrolides may also be considered For low-risk CAP with stable comorbid illness, β-lactam with β-lactamase inhibitor combinations (BLIC) or second generation cephalosporins with or without extended macrolides are recommended. For patients who have completed first-line treatment (BLIC or 2nd generation cephalosporin) with no response, an extensive work up should be done to identify the factors for failure of response. Work-up may include doing sputum Gram stain and culture. For moderate-risk CAP, a combination of an IV non- antipseudomonal β-lactam (BLIC, cephalosporin) with either an extended macrolide or a respiratory fluoroquinolone is recommended as initial antimicrobial treatment. For high-risk CAP without risk for Pseudomonas aeruginosa, a combination of an IV non-antipseudomonal β-lactam (BLIC, cephalosporin or carbapenem) with either an IV extended macrolide or an IV respiratory fluoroquinolone is recommended as an initial antimicrobial treatment. For high-risk CAP with risk for P. aeruginosa, a combination of an IV antipneumococcal, antipseudomonal β-lactam (BLIC, cephalosporin or carbapenem) with an extended macrolide and aminoglycoside OR a combination of an IV antipneumococcal, antipseudomonal β-lactam (BLIC, cephalosporin or carbapenem) and an IV ciprofloxacin or high dose IV levofloxacin. 3 Community-Acquired Pneumonia Table 1. Empiric Antimicrobial Therapy for CAP WITH USUAL RECOMMENDED DOSAGES IN 50-60 KG ADULTS WITH NORMAL LIVER AND RENAL FUNCTIONS RISK POTENTENTIAL EMPIRIC STRATIFICATION PATHOGEN THERAPY Low-risk CAP Stable Vital signs Streptococcus pneumoniae Without co-morbid illness RR 60 mm Hg Moraxella catarrhalis Azithromycin 500 mg OD Temp >36oC or 30/min Haemophilus influenzae β-lactamd PR > 125/min Chlamydophila pneumoniae (BLIC, cephalosporin) Temp < 36oC or > 40oC Mycoplasma pneumoniae + extended macrolidesa or SBP10:1, hypoxemia, and metabolic acidosis 7. Patient is clinically hydrated, taking oral fluids and is able to take oral medications Which oral antibiotics are recommended for de-escalation or switch therapy from parenteral antibiotics? The choice of oral antibiotics following initial parenteral therapy is based on available culture results, antimicrobial spectrum, efficacy, safety and cost. In general, when switching to oral antibiotics, either the same agent as the parenteral antibiotic or an antibiotic from the same drug class should be used. 15 Community-Acquired Pneumonia TABLE 3. ANTIBIOTIC DOSAGE OF ORAL AGENTS FOR STREAMLINING OR SWITCH THERAPY ANTIBIOTIC DOSAGE Amoxicillin-clavulanic acid 625 mg TID or 1 gm BID Azithromycin 500 mg OD Cefixime 200 mg BID Cefuroxime axetil 500 mg BID Cefpodoxime proxetil 200 mgw BID Levofloxacin 500 - 750mg OD Moxifloxacin 400 mg OD Sultamicillin 750 mg BID Reference: 1. Ramirez JA. Clinical stability and switch therapy in hospitalised patients with community-acquired pneumonia: are we there yet? Eur Respir J 2013; 41: 5–6 How long is the duration of treatment for CAP? Duration of treatment is 5 to 7 days for low risk uncomplicated bacterial pneumonia. (Strong recommendation, Moderate to Very Low Quality of Evidence NICE guidelines 2014) Treatment duration for moderate risk bacterial pneumonia is 7-10 days (Strong recommendation, Low Quality of Evidence, NICE guidelines 2014) For moderate-risk and high-risk CAP or for those with suspected or confirmed Gram-negative, S. aureus or P. aeruginosa pneumonia, treatment should be prolonged to 28 days if with associated bacteremia. A treatment regimen of 10 to 14 days is recommended for Mycoplasma and Chlamydophila pneumonia while Legionella pneumonia is treated for 14 to 21 days. 16  2016 Update A 5-day course of oral or IV therapy for low-risk CAP and a 10-day course of IV for Legionella pneumonia is possible with new agents such as the azalides, which possess a long half-life and achieve high tissue levels that prolong its duration of effect. Patients should be afebrile for 48 to 72 hours with no signs of clinical instability before discontinuation of treatment. Table 4. Duration of Antibiotic Use BASED ON ETIOLOGY ETIOLOGIC AGENT Duration of therapy (days) Most bacterial pneumonias 5-7 days except enteric Gram- negative pathogens S. aureus 3-5 (azalides) for S. pneumoniae (MSSA and MRSA), and P. aeruginosa Enteric Gram-negative MSSA community-acquired pathogens, S. aureus (MSSA pneumonia and MRSA), and P. aerugi- a. non-bacteremic - 7-14 days nosa b. bacteremic - longer up to 21 days MRSA community-acquired pneumonia a. non-bacteremic - 7-21 days b. bacteremic - longer up to 28 days Pseudomonas aeruginosa a. non-bacteremic - 14-21 days b. bacteremic - longer up to 28 days Mycoplasma and 10 - 14 days Chlamydophila Legionella 14-21; 10 (azalides) Reference: 1. Aliberti, Stefano et al. Duration of Antibiotic Therapy in Hospitalised Patients with Community-acquired Pneumonia. Eur Respir J 2010; 36: 128-134. 17 Community-Acquired Pneumonia 2. Aliberti, Stefano et al. How to Choose the Duration of Antibiotic Therapy in Patients with Pneumonia. Current Opinion April 2015; 28 (2): 177-184. 3. Choudhury G et al. Seven-day antibiotic courses have similar efficacy to prolonged courses in severe community-acquired pneumonia – a propensity-adjusted analysis Clin Microbiol Infect, 17 (2011), pp. 1852-1858. 4. Lim, WS. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009;64:iii1-iii55. doi:10.1136/thx.2009.121434 5. Lim, WS et al. British Thoracic Society community acquired pneumonia guideline and the NICE pneumonia guideline: how they fit together. Thorax 2015;0:1–3. doi:10.1136/thoraxjnl-2015-206881 6. National Institute for Health and Care Excellence (NICE) Pneumonia - Diagnosis and management of Community and Hospital-acquired Pneumonia in Adults. December 2014. 7. Niederman, Michael S.. Community-acquired Pneumonia. Ann Intern Med. 2015;163(7):ITC1. doi:10.7326/ AITC2015100603. 8. Pinzone R et al. Review Article Duration of Antimicrobial Therapy in Community Acquired Pneumonia: Less Is More. The Scientific World Journal Volume 2014: 1-8. 9. Scalera NM, et al. Determining the duration of therapy for patients with community-acquired pneumonia. Curr Infect Dis Rep 2013;15:191-5. 10. Stefano A et al. How to choose the duration of antibiotic therapy in patients with pneumonia. Curr Opinion Infect Dis 2015, 28: 177-84. What should be done for patients who are not improving after 72 hours of empiric antibiotic therapy? The lack of a response to seemingly appropriate treatment in a patient with CAP should lead to a complete reappraisal, rather than simply to selection of alternative antibiotics. 18  2016 Update The clinical history, physical examination and the results of all available investigations should be reviewed. The patient should be reassessed for possible resistance to the antibiotics being given or for the presence of other pathogens such as M. tuberculosis, viruses, parasites or fungi. Treatment should then be revised according to culture result. Follow-up chest radiograph is recommended to investigate for other conditions such as pneumothorax, cavitation and extension to previously uninvolved lobes, pleural effusion, pulmonary edema and ARDS. For an underlying mass, bronchiectasis, loculation , pulmonary abscesses, a CT scan would provide more information. Obtaining additional specimens for microbiologic testing should be considered. TABLE 5. REASONS FOR A LACK OF RESPONSE TO TREATMENT OF CAP Correct organism but inappropriate antibiotic choice or dose Resistance of organism to selected antibiotic Wrong dose (e.g., in a patient who is morbidly obese or has fluid overload) Antibiotics not administered Correct organism and correct antibiotic but infection is loculated (e.g., most commonly empyema) Obstruction (e.g., lung cancer, foreign body) Incorrect identification of causative organism No identification of causative organism and empirical therapy directed toward wrong organism Non-infectious cause Drug-induced fever Presence of an unrecognized, concurrent infection References 1. Musher DM et al. Community-Acquired Pneumonia N Engl J Med 2014;371:1619-28. 19 Community-Acquired Pneumonia 2. Welte T et al. Managing CAP patients at risk of clinical failure. Respiratory Medicine 2015;109:157-169, When can a hospitalized patient with CAP be discharged? In the absence of any unstable coexisting illness or other life threatening complication, the patient may be discharged once clinically stable and oral therapy is initiated. A repeat chest radiograph prior to hospital discharge is not needed in a patient who is clinically improving. A repeat chest radiograph is recommended during a follow-up visit, approximately 4 to 6 weeks after hospital discharge to establish a new radiographic baseline and to exclude the possibility of malignancy associated with CAP, particularly in older smokers. Table 6. Recommended hospital discharge criteria During the 24 hours before discharge, the patient should have the following characteristics (unless this represents the baseline status): 1. Temperature of 36-37.5oC 2. Pulse < 100/min 3. Respiratory rate between 16-24/minute 4. Systolic BP >90 mmHg 5. Blood oxygen saturation >90% 6. Functioning gastrointestinal tract Reference: 1. Aliberti S et al. Criteria for clinical stability in hospitalized patients with community-acquired pneumonia Eur Respir J 2013; 42: 742–749. 2. Robinson S et al. Patient Outcomes on Day 4 of Intravenous Antibiotic Therapy in Non Intensive Care Unit Hospitalized Adults With Community-Acquired Bacterial Pneumonia. Infectious Diseases in Clinical Practice November 2014; 22: 320-325. 20  2016 Update What other information should be explained and discussed with the patient? Explain to patients with CAP that after starting treatment their symptoms are expected to steadily improve, although the rate of improvement will vary with the severity of the pneumonia. Most people can expect that by: 1 week: fever should have resolved 4 weeks: chest pain and sputum production should have substantially reduced 6 weeks: cough and breathlessness should have substantially reduced 3 months: most symptoms should have resolved but fatigue may still be present 6 months: most people will feel back to normal. Reference 1. Aliberti S Peyrani P Filardo G Mirsaeidi M Amir A Blasi F Ramirez JA. Association between time to clinical stability and outcomes after discharge in hospitalized patients with community-acquired pneumonia. Chest 2011 Aug 140 (2) 482-8. 2. El Moussaoui R et al. Long-term symptom recovery and health-related quality of life in patients with mild-to- moderate-severe community-acquired pneumonia. Chest. 2006; 130(4):1165-1172. 3. National Institute for Health and Care Excellence (NICE) Pneumonia - Diagnosis and management of Community and Hospital-acquired Pneumonia in Adults. December 2014. 21 Community-Acquired Pneumonia Community-acquired Pneumonia Task Force 2016 Chair - Manolito L. Chua, MD, FPSMID Co-Chair - Mari Rose A. De Los Reyes, MD, FPSMID Members: Remedios F. Coronel, MD, FPSMID Benilda B. Galvez, MD, FPCP, FPCCP Alice Genuino, MD, FPAFP Ryann Jeanne Ceralvo, MD, FPAFP Anna Guia Limpoco, MD, FPAFP Claudette Mangahas, MD, FPCP, FPCCP Leonardo Joseph Obusan, MD, FPCR Ma. Belle R. Siasoco, MD, FPCP, FPCCP Rontgene M. Solante, MD, FPCP, FPSMID Ma. Lourdes A. Villa, MD, FPCP, FPSMID Advisers- Mary Ann D. Lansang, MD, FPCP, FPSMID (Chair, PSMID Standards of Care Committee) Mediadora C. Saniel, MD, FPSP, FPSMID, FIDSA (Chair, DOH NagComm) 22 Philippine Practice Guidelines Group - Infectious Diseases Philippine Society of Microbiology and Infectious Diseases No. 116 9th Avenue, Cubao Quezon City 1109 Philippines