Download Objectives for Community Acquired Pneumonia discussion

Facilitator Version
Module # 18 CAP and HCAP
Created by Wendy Gerstein 11/13
Objectives:
1. Be able to triage patients appropriately based on either the pneumonia severity
index (PSI) or CURB-65 score.
2. Be able to choose appropriate empiric antibiotic therapy for both CAP and HCAP.
3. List three risk factors for HCAP/HAP.
References:
1. Management of Community-Acquired Pneumonia, Halm E., Teirstein,A, NEJM
2002 347:2039-2045.
2. Fine MJ, Stone RA, Singer DE, et al. Processes and outcomes of care for patients
with community-acquired pneumonia: results from the Pneumonia Patient
Outcomes Research Team (PORT) cohort study. Arch Intern Med 1999;159: 970980.
3. Healthcare-associated pneumonia in adults: management principles to improve
outcomes. Craven DE; Palladino R; McQuillen DP Infect Dis Clin North Am 2004
Dec;18(4):939-62.
4. The Role of MRSA in Healthcare-Associated Pneumonia. Lam AP and
Wunerlink RG. Semin Respir Crit Care med 2009; 30:52-60.
CASE
HPI: Patient is a 75 yo male with history of COPD (FEV 1 70%, not on home oxygen)
and hypertension who presents to the ER with a 3-4 day history of worsening cough with
some production of greenish phlegm. He also complains of lack of energy and appetite
with decreased oral intake, and has had some chills but no obvious fever. Denies CP, but
has some SOB with exertion. He denies GI or GU symptoms, and has no headache or
neurological complaints. He denies significant weight changes or leg swelling. He is not
up to date on immunizations. He denies sick contacts, but did travel recently to southern
California to see his brother. In the ED bp 104/54, p 108, RR 20, T 37, 85% RA, 96% on
2 liters. Exam notable for crackles LLL with egophony, mild prolonged expiratory phase
bilaterally; rest of exam unremarkable. Labs significant for wbc 13,400, Na 132, K 3.8,
Cl 98, HCO3 25, Bun 20, creatinine 1.1, glucose 96. LFT’s normal, UA normal.
What is your initial assessment? Sepsis - SIRS (HR and wbc) with likely infection; new
hypoxia.
Possible sources of infection? Pneumonia (CAP), viral syndrome, bronchitis.
What is your initial management step? CXR, blood cultures, lactate, calculate PSI or
CURB-65 score (see attached sheet).
CXR shows a dense LLL infiltrate with air bronchograms.
What is your initial treatment plan? How would you determine the patient’s
severity of illness as well as the appropriate disposition?
SOB, increased cough with sputum, hypoxia and a CXR with a focal finding confirm the
clinical suspicion of community acquired pneumonia. In addition a COPD exacerbation
may be contributing to his symptoms. He is at risk for the most common CAP pathogens
which include S. pneumoniae, M. pneumoniae, H. influenza, and M. catarrhalis. In
addition his travel history raises his risk of Coccidioides immitis, and he should be tested
for it if he does not respond to CAP therapy.
Utilizing the Pneumonia Severity Index (PSI), a score of 85 {age score (75) + hypoxia
score (10) = 85} was calculated (Risk class III). Based on this score and hypoxia, patient
should be admitted for a course of IV antibiotics. His CURB-65 score is 2. Each score
has a recommended disposition (home vs. observation vs. admit vs. MICU)
Appropriate antibiotics include:
 IV ceftriaxone (or cefotaxime) and oral doxycycline.
 IV ceftriaxone and oral azithromycin.
 Moxifloxacin (check EKG for QT duration) if beta-lactam allergic.
Of note: Patients who are bacteremic with S. pneumoniae in the setting of pneumonia
have improved outcomes when treated with a b-lactam antibiotic compared to a non blactam antibiotic.
What possible outpatient medications can you use for treatment of CAP on
discharge from hospital?
With no co-morbidities present: Doxycycline, azithromycin, moxifloxacin
With co-morbidities present (such as COPD or recent antibiotic use): Moxifloxacin;
azithromycin or doxycycline plus high dose amoxicillin or augmentin.
After 2 days patient is discharged to home on oral antibiotics and oxygen and is doing
better but then 5 days after discharge he develops severe cough with purulent sputum,
high fevers, and pleuritic CP. In the ED he is noted to have fever to 38.5, p 120s, bp
90/60. 90% 5 liters, RR 25; CXR shows persistent LLL infiltrate with small effusion and
new RUL infiltrate.
What would be highest on your differential? HCAP/HAP, parapneumonic
effusion/empyema, aspiration pneumonia. Other possibilities (but less likely) include
pulmonary embolus with associated pulmonary infarct) or lung abscesses.
Can you list 3 or more risk factors for HCAP/HAP?
1. Prior antibiotic therapy in the last 3 months
2. Current hospitalization > 5 days
3. High frequency of antibiotic resistance in the community
4. Hospitalization for at least 2 days in the preceding 90 days
5. From a nursing home type living situation (not group home)
6. Recent surgery
7. Chronic dialysis
8. Invasive respiratory devices (intubation, bronchoscopy)
9. Pre-existing pulmonary disease
10. Immunosuppressive disease or therapy
11. Enteral feeding in conjunction with supine position (ICU).
What organisms are typically implicated in HCAP/HAP?
–
–
–
–
–
Resistant GNR’s (Enterobacter, Citrobacter, Klebsiella, E. coli)
Pseudomonas aeruginosa
S. aureus (MRSA)
Anaerobes (aspiration)
Aspergillosis (seen more in prolonged hospitalizations and
immunosuppressed patients)
What is your treatment plan including antibiotic coverage? Patient now has a PSI
score of at least 95 (+10 for effusion, bp is borderline), need to consider MICU or at least
step down care depending on response to IVFS; start iv antibiotics (see below), other
supportive care including IVFs, oxygen, check lactate and blood gas in addition to other
basic labs, send sputum and blood for culture, check MRSA status. In addition need to
monitor the pleural effusion, consider tap if still febrile after 24 hours of antibiotics or if
enlarging in size.
Antibiotic options include:





Piperacillin/tazobactam (Zosyn).
Cefepime plus clindamycin if concerned about anaerobes (? Aspiration risk or
poor dendition).
Levoquin (check QT) +/- clindamycin (if beta-lactam allergic)
Carbapenems if patient has history of multi-drug resistant organisms.
Vancomycin should be added to above regimens if MRSA nares positive or
patient deteriorating quickly. Can stop vancomycin once confirmed that patient is
MRSA negative and sputum/blood cultures negative.
Of note, nasal carriage of MRSA is a much higher risk factor for invasive infection
compared to skin colonization, and the most predictive risk factor for nosocomial MRSA
infection is prior antibiotic therapy (particularly flouroquinolones).
Do you need to “double cover” for possible resistant GNRs? Unless the patient has a
documented resistant organism in the past or risk factors for resistant organisms, or is
neutropenic with sepsis, there is no evidence for "double coverage."
MKSAP questions:
ID Question 30; answer D – management of mild pneumonia caused by histoplasmosis.
ID Question 47; answer A – Diagnose anthrax infection after inhalation exposure.
ID Question 50; answer C – Treatment of a patient with suspected CA-MRSA
pneumonia.
ID Question 103; answer C – choose appropriate site of care for a patient with CAP.
Predictors of morbidity and mortality in pneumonia: CURB-65 and PSI
CURB-65:

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Confusion (based upon a specific mental test or new disorientation to person, place, or time)
BUN > 19 mg/dL
Respiratory rate >30 breaths/minute
Blood pressure <90/60 mmHg
Age >65 years
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30-day mortality was 0.7, 2.1, 9.2, 14.5, and 40 percent for 0, 1, 2, 3, or 4 factors.
Patients with a CURB-65 score of 0 to 1 can probably be treated as outpatients; those
with a score of 2 should be admitted to the hospital, and those with a score of 3 or more
should be assessed for ICU care, particularly if the score is 4 or 5.
c. Regardless of predictors, early treatment with antibiotics is associated with improved clinical
outcomes. Goal is administration of appropriate antibiotics within 4 hours of triage in ER.
Pneumonia Severity Index (PSI)
Characteristic
Points Score
Demographic Factors
Age
Men: Age in years
Women: Age in years - 10
Nursing home resident
+ 10
Coexisting Illnesses
Neoplastic disease
+ 30
Liver disease
+ 20
Congestive Heart Failure
+ 10
Cerebrovascular disease
+ 10
Renal disease
+ 10
Findings on Physical
Examination
Altered mental status
+ 20
Respiratory rate ≥ 30/min
+ 20
Systolic blood pressure < 90 mm + 20
Hg
Temperature < 35° C or ≥ 40° C
+ 15
Pulse ≥ 125 beats/min
+ 10
Laboratory and Radiographic
Findings
Arterial pH < 7.35
+ 30
Blood urea nitrogen ≥ 30 mg/dl
+ 20
(11 mmol/1)
Sodium < 130 mmol/liter
+ 20
Glucose ≥ 250 mg/dl (14
+ 10
mmol/liter)
Hematocrit < 30%
+ 10
Sa02 < 90%* or Pa02 < 60 mm
+ 10
Hg
Pleural effusion
+ 10
Total PSI
Pneumonia Severity Index (PSI) is used to determine
a patient's risk of death. The total score is obtained
by adding to the patient's age (in years for men or in
years minus 10 for women) the points assigned for
each additional applicable characteristic.
(Data adapted from Fine et al. N Engl J Med 1997;
336; 243-50)
Recommendations Based on total PSI Score
Risk
Risk
Mortality Disposition
Score Class
≤ 50
I Low
0.1%
Consider outpatient or
observation status
≤ 70 II Low
0.6%
Consider observation or
admit
71-90 III Low
0.9%
Consider observation or
admit
91-130 IV Mod
9.3%
Admit, consider MICU
> 130 V High
27.0% Admit, consider MICU
Admission is recommended for Class I, II and III
patients who are hypoxemic (RA 02 sat of <90%),
and patients who have important medical or
psycho/social contraindications to outpatient care.
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to
Dr. Wendy Gerstein, Department of Medicine, VAMC (111) or give to Dr. Patrick
Rendon if at the University.
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment
below:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient
curriculum in general:
6) Please circle one:
Attending
Resident (R2/R3)
Intern
Medical student