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* For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. Terms of Use The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-forprofit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement. © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. in the clinic CommunityAcquired Pneumonia © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. Who is at increased risk for CAP? Persons with: Comorbid illness (respiratory disease; cardiovascular disease; diabetes mellitus; chronic liver disease) Immune suppression Chronic kidney disease History of splenectomy Elderly Cigarette smokers Alcoholism © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. Who should receive pneumococcal vaccination and when? All individuals aged 65 years and older Other high-risk persons regardless of age Those living in special environments (long-term care) Chronic heart disease (CHF, cardiomyopathy but not HT) Chronic lung disease (COPD but not asthma) Diabetes mellitus; Chronic liver disease Cerebrospinal fluid leaks; Cochlear implants Functional or anatomical asplenia (sickle cell disease) Immune-suppression Cigarette smoking; Alcoholism Alaskan natives or American Indians Anyone hospitalized for a medical illness © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. When to give vaccination In those without high-risk conditions: age 65 Risk factors: when risk first identified, irrespective of age How to give vaccination Timing varies by age and presence of high-risk conditions Generally: PCV-13 first (more immunogenic) PPS-23 (for additional strain coverage) 6-12 mo later In immune-compromised patients <65 years: PPS-23 only 8 weeks after PCV-13 In those who received 1 or 2 doses of PPS-23 before age 65, repeat dose at ≥65 years if ≥5 years have passed since prior dose © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. What is the role of influenza vaccination in preventing CAP and its complications? Immunize yearly All patients at increased risk for influenza complications Anyone likely to transmit the infection to high-risk patients Recombinant influenza vaccine: Use in adults age ≤49 Option: Live attenuated vaccine (intranasal) in healthy, nonpregnant adults age ≤49 Don’t give to health care workers in contact with severely immune-compromised patients Don’t give to those with immunosuppression and chronic medical conditions High-dose influenza vaccine: available for those >65 © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. CLINICAL BOTTOM LINE: Prevention... Offer pneumococcal vaccination to those at risk for CAP Immune-competent: PCV-13, then PPS-23 after 6-12 mo Immune-suppressed: PCV-13, then PPS-23 after only 8 wk If received PPS-23 previously: 1 dose PCV-13 ≥1 year after In those ≥65 who received previous doses before age 65: repeat PPS-23 vaccination after 5 years In immune-suppressed at at any age: repeat PPS-23 vaccination after 5 years Offer influenza vaccine yearly to at-risk persons © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. Which symptoms should lead clinicians to consider CAP? Pneumonia with respiratory and systemic symptoms Cough, purulent sputum, pleuritic chest pain Dyspnea, chills, fever, night sweats, weight loss Hemoptysis suggests necrotizing infection Most patients present with acute illness 1–2d in duration Older patients and those with chronic illness may develop nonrespiratory symptoms only Confusion, weakness, lethargy Falling, poor oral intake, decompensation of chronic illness Symptoms may be present for longer periods in elderly © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. Which organisms cause CAP? Streptococcus pneumoniae (pneumococcus) Haemophilus influenzae Mycoplasma pneumoniae Chlamydophila pneumoniae Legionella Influenza virus Parainfluenza virus Respiratory syncytial virus Adenovirus © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. Modifying Factors That Increase the Risk for Infection With Specific Pathogens Penicillin-resistant and drug-resistant pneumococci Age >65; beta-lactam therapy in past 3 months; alcoholism; immune-suppressive illness; multiple medical comorbid conditions; exposure to child in day care center Enteric gram-negative bacteria Residence in a nursing home; underlying cardiopulmonary disease; multiple medical comorbid conditions; recent antibiotic therapy Pseudomonas aeruginosa Structural lung disease (bronchiectasis); corticosteroid therapy; broad-spectrum antibiotic therapy for >7 d in the past month; malnutrition © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. What is the role of history and physical examination in the diagnosis of CAP? Suggests the presence of pneumonia Suggestive: fever or hypothermia, tachypnea, crackles, bronchial breath sounds on auscultation, pleural effusion Identifies risk factors for HCAP Predicts the cause Identifies those who might have less common cause Helps define severity Associated with poor outcome: Respiratory rate >30 breaths/min Diastolic BP <60 mm Hg; systolic BP <90 mm Hg Heart rate >125 beats/min Temperature <35°C or >40°C © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. When should clinicians use chest radiography? When patients have clinical features suggesting CAP To define the presence of parenchymal lung infection To identify certain pneumonia complications When diagnosis is questionable Pleural effusion, lung abscess, necrotizing pneumonia, or multilobar illness suspected Assume pneumonia in absence of radiographic infiltrate if patient has convincing history and focal physical findings To aid management if severe illness is present Confirm with decubitus film, thoracic ultrasound, or CT © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. What is the role of other laboratory tests? Outpatients: to assess oxygenation only (pulse oximetry) Inpatients: to define severity and identify cause Pulse oximetry Arterial blood gases (if CO2 retention suspected) Sputum (Gram stain and culture before therapy started) Rapid diagnostic testing of respiratory secretions with molecular methods Culture endotracheal aspirate in intubated and mechanically ventilated patients Serum levels of C-reactive protein or procalcitonin Severe pneumonia: collect 2 sets of blood cultures and test urine for Legionella and pneumococcal antigens © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. What other disorders should clinicians consider in those suspected of having CAP? Virus or an unusual bacterial pathogens Bronchoalveolar cell carcinoma Bronchiolitis obliterans with organizing pneumonia Lymphoma Pulmonary vasculitis Congestive heart failure Pulmonary embolus Hypersensitivity pneumonitis Antibiotic-induced colitis Interstitial diseases Empyema, meningitis, endocarditis Lung cancer Lymphangitic carcinoma © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. When should clinicians consider specialty consultation for diagnosis, and which types of specialists should they consult? Infectious disease To identify infectious complications of pneumonia and unusual infections Pulmonary specialist To identify inflammatory lung disease and pulmonary embolus To perform bronchoscopy and transbronchial biopsy Surgeon To perform thoracoscopic or open lung biopsy © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. CLINICAL BOTTOM LINE: Diagnosis... History helps define risk factors for specific pathogens Physical findings help define disease severity Confirm diagnosis with chest radiograph Laboratory testing has limited value Diagnosing specific pathogens early is less useful because most initial therapy is empirical If patient does not respond to initial therapy, consult specialists and consider bronchoscopy and lung biopsy © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. How should clinicians determine if a patient requires outpatient, inpatient, or ICU care? Pneumonia Severity Index or British Thoracic Society rule Guidelines support ICU care if patient: Needs assisted ventilation Has septic shock requiring vasopressors Has ≥3 of following Respiratory rate ≥30 breaths/min PaO2/ FiO2 ratio ≤250 Multilobar infiltrates, confusion or disorientation Blood urea nitrogen ≥7.1 mmol/L (20 mg/dL) Leukocyte count <4 × 109 cells/L Platelet count <100 × 109 cells/L Temperature <36°C Hypotension requiring aggressive fluid resuscitation © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. What is the role of nondrug therapies? Outpatients Oral hydration Hospitalized patients IV hydration and oxygen for hypoxemia Chest physiotherapy if >30 mL/d sputum and clearance of secretions is impaired Severely ill ICU patient Noninvasive ventilatory support Mechanical ventilation for respiratory failure © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. Which antibiotics should be prescribed for outpatients? If patient has no cardiopulmonary disease and no factors that increase infection risk with DRSP or enteric gram-negative bacteria Macrolide or doxycycline If patient has cardiopulmonary disease or factors that increase infection risk with DRSP or enteric gramnegative bacteria Antipneumococcal quinolone or combination beta-lactam + macrolide or doxycycline If patient received antibiotic in past 3 months, avoid using antibiotic of same class © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. Drug Treatment for CAP Antibiotics for community-acquired MRSA —linezolid, clindamycin, vancomycin Antipseudomonal beta-lactams —piperacillin/tazobactam, cefepime, imipenem, meropenem Cephalosporins —cefuroxime, cefpodoxime, ceftriaxone, cefotaxime Glycylcycline —tigecycline Macrolides —azithromycin, clarithromycin Penicillins —amoxicillin/clavulanate, ampicillin, ampicillin/sulbactam Quinolones —ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin Tetracyclines —doxycycline © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. How should clinicians follow patients during outpatient treatment? Patients should monitor response to therapy Measure temp orally every 8h Drink at least 1 to 2 quarts of liquid daily Report chest pain, severe or increasing shortness of breath, or lethargy Complete course of antibiotics on schedule If response satisfactory: return exam in 10-14 days Give pneumococcal and influenza vaccinations if needed Repeat chest radiograph ≥1 month after starting therapy to screen for nonresolution of infiltrates © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. How soon after admission should antibiotics be started? As soon as possible after diagnosis and before leaving the emergency department For hospitalized patients who are not in ICU IV azithromycin if no cardiopulmonary disease and no factors that increase risk for DRSP or gram-neg bacteria IV or oral quinolone or combination beta-lactam + macrolide or doxycycline if have cardiopulmonary disease or factors that increase risk for DRSP or gram-neg bacteria Individualize antibiotic choice by risk factors for MDR pathogens if patients have HCAP © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. Which antibiotics should be given to patients admitted to the ICU? Do not use empirical monotherapy Assess for risk factors for P. aeruginosa No risk factors: IV ceftriaxone or cefotaxime plus azithromycin or quinolone Risk factors: IV antipseudomonal beta-lactam plus IV quinolone effective against P. aeruginosa Risk factors (alternative): IV antipseudomonal beta-lactam combined with aminoglycoside plus IV macrolide or IV antipneumococcal quinolone If community-acquired MRSA suspected, add linezolid alone or vancomycin combined with clindamycin © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. What are the other components of ICU care for CAP? Hydration Supplemental oxygen Chest physiotherapy Ventilatory support for respiratory failure Systemic corticosteroids Especially if relative adrenal insufficiency suspected or if patient with pneumococcal pneumonia has associated meningitis Vasopressors Serum lactate measurement © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. When can clinicians switch hospitalized patients from IV to oral antibiotics? When cough, sputum production, and dyspnea improve When afebrile on 2 occasions 8 hours apart When able to receive oral medications Select oral regimen that covers all organisms isolated in blood or sputum cultures and reflects IV therapy Patients who responded to beta-lactam–macrolide combination can be continued on macrolide monotherapy unless cultures justify dual therapy © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. When should a consultation be requested for hospital patients, and who should be consulted? Infectious disease or pulmonary: Questions about initial antibiotic therapy selection or poor response to initial therapy Pulmonary or critical care: Decisions about vasopressors use, appropriate site of care, need for ventilatory support Pulmonary physician: If pleural effusion documented and decision needed about thoracentesis Pulmonary or thoracic surgical: Placement of chest tube if complicated parapneumonic effusion or empyema found on thoracentesis Thoracic surgeon: Surgical decortication for advanced and loculated pleural effusion and empyema Cardiologist: Cardiac ischemia complications or CHF © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. When can inpatients be discharged from the hospital? Once a switch to oral therapy made Once coexisting medical conditions are under control No proven benefit for continued hospital observation © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. What are the indications for follow-up chest radiography? If patient has good clinical response to therapy Repeat chest radiograph at least 4 to 6 weeks after initial therapy Radiographic resolution lags behind clinical resolution by 6 to 8 weeks, but early improvement is usually substantial If patient deteriorates despite therapy and doesn’t reach clinical stability Conduct aggressive evaluation Order early follow-up chest radiograph © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. How can patients prevent recurrent CAP? Update pneumococcal and influenza vaccinations Avoid smoking cigarettes Receive optimal therapy for comorbid illnesses Obtain care for medical conditions that predispose to recurrent infection Pursue evaluation for aspiration risk factors If pneumonia recurs in same location, consider possible bronchiectasis, aspirated foreign body, or endobronchial obstruction If patient has recurrent pneumonia or pneumonia with an unusual pathogen, consider immune deficiency © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. CLINICAL BOTTOM LINE: Treatment... Determine site of care (outpatient, hospital, or ICU) Select antibiotic therapy Deliver supportive care (oxygen, hydration) Determine need for ventilatory support Consult specialist in severe disease and for complications Transition to oral antibiotics after treatment response Delay chest radiography 4-6 weeks if responsive to therapy Monitor for comorbid illness and update vaccinations Encourage smoking cessation © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1.