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PNEUMONIACOMMUNITY-ACQUIRED

PNEUMONIA IN ADULTSSarah Kamara MSN, APRN,

AGACNP-BC, FNP-C

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• To discuss the recommendations and guidelines as

outlined by the Infectious Diseases Society of

America and American Thoracic Society’s

guidelines on the management of community

acquired pneumonia

CAP:

OBJECTIVE

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• CAP is defined as an acute infection of the

pulmonary parenchyma in a patient who has

acquired the infection in the community as

distinguished from hospital-acquired

(nosocomial) pneumonia

• An infection of the lower respiratory tract

CAP:

Definition

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• Seventh leading cause of death in the US along

with influenza

• 915,900 episodes in adults 65 and older

• More than 60,000 deaths per year

• $8.4-10 billion spent yearly on treatment

• Higher in men and blacks as compared to women

and Caucasians

• Seasonal, occurs more during the winter months

• Strep pneumoniae is the most common causative

agent

CAP:

Epidemiology

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• Age ≥65 years

• COPD and/or smoking

• Malnutrition

• Alcohol consumption

• Immunosuppression

• Underlying lung disease

• Altered mental status

• Aspiration

CAP:

Risk Factors

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• Cough (typically productive)

• Fever with chills and sweats

• Shortness of breath, dyspnea

• Tachycardia, tachypnea,

• Chest pain (typically pleuritic)

• Crackles/rhonchi on lung exam

• Leukocytosis

• Headache

• Fatigue

CAP:

Clinical Presentation

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• Streptococcus pneumoniae (most common)

• Haemophilus influenzae

• Staphylococcus aureus

• Pseudomonas aeruginosa

• Legionella pneumoniae

• Mycoplasma pneumoniae atypical pathogens

• Chlamydophila pneumoniae

• Respiratory viruses (Influenza, RSV, parainfluenza,

human metapneumovirus

CAP:

Common Etiologies

Etiologies

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1. Severity of Illness

-CURB-65 (confusion, uremia, respiratory rate,

hypotension, age 65 years or greater)

-Score ≥ 2 = more intensive treatment

2. Prognostic Models

-PSI(Pneumonia severity Index)

3. Ability to tolerate oral medications

4. Availability of outpatient support/resources

Hospital Admission Criteria

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Scoring criteria

CAP: CURB65 Criteria

Score Risk Disposition

0 or 1 1.5% mortality Outpatient care

2 9.2% mortality

Inpatient vs.

observation

admission

≥ 3 22% mortality

Inpatient

admission with

consideration for

ICU admission

with score of 4 or

5

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• Septic Shock

• Invasive Mechanical Ventilation

• 3 of the minor criteria as listed

-RR ≥ 30

-PaO2/FiO2 ratio ≤ 250

-Multilobar pneumonia

-Uremia (BUN ≥ 20 mg/dl)

-Leukopenia (<4000), Thrombocytopenia (<100k)

-Hypothermia (<36ºC)

-Hypotension

ICU Admission Criteria

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• Chest xray: Infiltrate or consolidation

• Blood cultures x 2

• Lactic acid, CBC, CMP

• Sputum gram stain and cultures

• Urine legionella pneumophila and streptococcus

pneumoniae

• If clinical suspicion of CAP, but negative CXR,

consider CT chest or repeat CXR in 24-48 hours

CAP:

Work-up

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CAP:

Diagnosis and Imaging

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Diagnosis and imaging

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• At least 50% of all cases are among adults 65

years and older

• Those living in a long term care facility have a 30%

risk of pneumonia over a period of 2 years

• Most common pathogens are streptococcus

pneumoniae, H. influenza, Moraxella catarrhalis, klebsiella and staph aureus

Clinical PEARLS in the

Elderly

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Clinical findings

• Classic, expected signs may be absent

• Weakness, decreased ADL

• Tachypnea and or/SOB

• Tachycardia

• Fever with productive cough

• Confusion or mental status change

Clinical PEARLS in the

Elderly

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Chest x-ray findings

• May have multiple presentations based on the

offending pathogen

• Bacterial pneumonia can present with either

bronchopneumonia or lobar pneumonia

• Viral pneumonia may present as bilateral

interstitial infiltrates

Clinical PEARLS in the

Elderly

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Outpatient TreatmentOutpatient TreatmentOutpatient TreatmentOutpatient Treatment

Previously healthy, no use of antibiotics within the

previous 3 months, no risk for drug resistant to strep

pneumoniae

-Macrolide (azithromycin, clarithromycin or

erythromycin)

OR

-Doxycycline

CAP:

Outpatient Treatment

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Comorbidities Comorbidities Comorbidities Comorbidities or use of antibiotics within the previous or use of antibiotics within the previous or use of antibiotics within the previous or use of antibiotics within the previous

3 3 3 3 months, risk for drug resistant strep pneumoniaemonths, risk for drug resistant strep pneumoniaemonths, risk for drug resistant strep pneumoniaemonths, risk for drug resistant strep pneumoniae

Antipneumococcal fluoroquinolone

-levofloxacin, moxifloxacin, gemifloxacin

OR

Beta-lactam plus a macrolide

-Amoxicillin, amoxicillin/clavulanate

cefpodoxime, cefuroxime

Doxycycline as an alternative to a macrolide

CAP:

Outpatient Treatment

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Antipneumococcal fluoroquinolone

-Levofloxacin, gemifloxacin, maxifloxacin

Beta lactam plus a macrolide

-Ceftrioxone, cefataxime, ampicillin, ertapenem

• Doxycycline as an alternative to a macrolide

• Respiratory fluoroquinolone as an alternative for

PCN allergic patients

CAP: Inpatient (Non-ICU)

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• B-lactam plus macrolide or an antipneumococcal

fluoroquinolone

• Fluoroquinolone or aztreonem recommended for

PCN allergic patients

• If concern for pseudomonas infection, use an

antipseudomonal b-lactam plus either ciprofloxacin or levaquin

CAP: Inpatient (ICU)

TREATMENT

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Pseudomonas consideration cont.

• B-lactam plus an aminoglycoside and azithromycin

• B-lactam plus aminoglycoside and a

fluoroquinolone

• If CA-MRSA is a concern, add vancomycin or

linezolid

CAP: Inpatient (ICU)

Treatment

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• Adjust antibiotic once culture results are available

• Treat influenza A positive patients with oseltamivir

or zanamivir within 48 hours of onset

• Oseltamivir and zanamivir not recommended for

uncomplicated influenza with onset >48 hours

• Droplet precaution if influenza positive

• Test for H5N1 infection with known exposure

• Treat suspected H5N1 infection with oseltamivir

and ABX targeting S. Pneumoniae and S. aureus

Pathogen Directed

Therapy

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• Should be started in the ED

• Within one hour with s/s of sepsis

Time to first antibiotic

dose

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• Temperature <37.8C

• Heart rate <100 beats/min

• Respiratory rate <24 breaths/min

• Systolic blood pressure >90 mm Hg

• Arterial oxygen saturation >90% or pO2 >60 mm

Hg on room air

• Ability to maintain oral intake

• Normal mental status

CAP: Criteria for clinical

stability

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• Minimum of 5 days of antibiotic

• Afebrile for 48-72 hours

• No more than 1 CAP-associated sign of clinical

instability before discontinuation of therapy

• Longer duration may be needed based on culture

results or complication by extra pulmonary

infections such as meningitis or endocarditis

CAP: Duration of Therapy

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Switch to oral antibiotic when…

-Hemodynamically stable

-Clinically improving

-Able to tolerate po

-Have normal GI tract function

CAP: IV to Oral Abx

Therapy

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• Clinically stable

• No other active medical problems

• Safe environment for continued care

CAP: Discharge Criteria

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• Pneumonia vaccines for age 65 or greater or high

risk diseases

• One-time revaccination after 5 years for adults

>65, if the first vaccine was received before age

65, asplenia and immunocompromised persons

• Yearly influenza vaccines

• Smoking cessation

• Respiratory hygiene measures

CAP: Pneumonia

Prevention

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• Amy is a 66 yo female with diabetes who presents

to the ED with fever, cough, sputum production,

and pleuritic chest pain. She denies associated

N/V/D. Vital signs: T100.7, RR 24, BP 110/70, P 100, Spo2 90 on RA. Exam: A&O x 4, left basilar

rhonchi. Cxray: left lower lobe infiltrate. Labs: WBC

14k, gluc 215, BUN 27, cr 1.2.

• Should Amy be admitted?

CAP:

Case Study

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• CURB-65 criteria

– Confusion

– Uremia (BUN >20)

– Respiratory rate (RR >30)

– Blood pressure (SBP <90 or DBP < 60)

– Age 65 years or greater

• Amy’s score = 2…Recommend admission

CAP: Case Study

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• What additional work-up would you recommend?

CAP:Case study

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CAP:Case Study

• Blood cultures x 2

• Sputum Gram stain and culture

• Consider urinary pneumococcal antigen

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• Amy has no drug allergies.

• What antibiotic treatment would you recommend?

CAPCase Study

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• Respiratory quinolone alone

orororor

• Beta-lactam ++++ macrolide or doxycycline

• If Amy tells you that she took ciprofloxacin for a UTI

last month, how would that change your rx choice?

CAP:Case Study

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• Amy rapidly improves with antibiotics and

hydration. After two days of hospitalization, she is

afebrile with normal vital signs. She continues to

tolerate oral medications without problem.

• When can you discharge Amy?

• How many more days of antibiotic therapy does she require?

CAPCase Study

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• Amy can be discharged today on po abx to

complete a total of 5 days of abx therapy.

CAP:Case Study

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• Unfortunately, we are not done with Amy…

• Approximately a month after discharge, Amy falls and breaks her leg. She requires casting, which limits her mobility. She begins to note increasing shortness of breath, low grade fever, and a return of her cough, prompting her to present to her primary care provider for further evaluation.

CAP:Case Study

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• Amy is sent for CT angiogram of the chest which is

negative for pulmonary embolus, but does show a

new infiltrate in her right lower lobe with some

areas of cavitation.

• Should Amy be re-admitted to the hospital?

• What antibiotics should she receive?

CAPCase Study

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• Amy now has HCAP and is at risk for resistant

pathogens, such as Pseudomonas and MRSA.

• She should be admitted for IV abx.

• Rx with beta-lactam (piperacillin-tazobactam,

cefepime, imipenem, or meropenem) +

ciprofloxacin or levofloxacin + vancomycin or linezolid.

CAPCase Study

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• Not all patients with CAP require hospitalization

• Outpatients should be stratified by drug-resistant pneumococcus risk, comorbidities, and prior abxuse in the past 3 months

• Inpatients should be stratified by severity of illness and Pseudomonas/MRSA risk

• Patients should be treated with a minimum of 5 days of abx

CAPConclusion

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• Mandell, L.A., Wunderink, R.G., Anzueto, A., Barlett, G., Campbell, G., Dean, N.C., Dowell, S.F., File, T.M., Musher, D.M., Niederman,

M.S., Torres, A., Whitney, C.G. (2007). Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, Vol 44, Pg S27-S92. Retrieved from

http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_By_Organ_System-

81567/Lower/Upper_Respiratory/Community-Acquired_Pneumonia_(CAP)/

• Kaysin, A., Viera, A.J. (2016) Nov 1;94(9):698-706. Community-Acquired Pneumonia in Adults: Diagnosis and Management Retrieved from https://www.aafp.org/afp/2016/1101/p698.pdf

References

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Any Questions???

CAP:Conclusion