Community-Acquired Pneumonia

Joanna M. Delaney, D.O. Georgetown University / Providence Hospital June 8, 2007

Objectives

Describe the common pathogenesis and pathogens of pneumonia Discuss diagnosis and initial management of community acquired pneumonia (CAP) Understand features of the Pneumonia PORT Severity Index Discuss the IDSA/ATS guidelines and recommendations for final antibiotic choice Understand issues in basic management for pneumonia in children, nursing home patients, and immunocompromised patients.

Epidemiology

Unclear! Few population-based statistics on the condition alone CDC combines PNA with influenza for morbidity & mortality data

PNA & influenza = 7th leading causes of death in the US (2001) Age-adjusted death rate = 21.8 per 100,000 Mortality rate: 1-5% out-Pt, 12% In-Pt, 40% ICU Death rates increase with comorbidity and age Affects race and sex equally

Community Acquired Pneumonia

Infection

of the lung parenchyma in a person who is not hospitalized or living in a long-term care facility for 2 weeks 5.6 million cases annually in the U.S. Estimated total annual cost of health care = $8.4 billion Most common pathogen = S. pneumo (6070% of CAP cases)

Nosocomial Pneumonia
Hospital-acquired

pneumonia (HAP)

Occurs 48 hours or more after admission, which was not incubating at the time of admission

Ventilator-associated

pneumonia (VAP)

Arises more than 48-72 hours after endotracheal intubation

Nosocomial Pneumonia

Healthcare-associated pneumonia (HCAP)

Patients who were hospitalized in an acute care hospital for two or more days within 90 days of the infection; resided in a nursing home or LTC facility; received recent IV abx, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic

Guidelines for the Management of Adults with HAP, VAP, and HCAP. American Thoracic Society, 2005

Pathogenesis
Inhalation,

aspiration and hematogenous spread are the 3 main mechanisms by which bacteria reaches the lungs Primary inhalation: when organisms bypass normal respiratory defense mechanisms or when the Pt inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment

Pathogenesis
Aspiration:

occurs when the Pt aspirates colonized upper respiratory tract secretions

Stomach: reservoir of GNR that can ascend, colonizing the respiratory tract.

Hematogenous:

originate from a distant source and reach the lungs via the blood stream.

Pathogens
CAP

usually caused by a single organism Even with extensive diagnostic testing, most investigators cannot identify a specific etiology for CAP in 50% of patients. In those identified, S. pneumo is causative pathogen 60-70% of the time

Streptococcus pneumonia
Most

common cause of CAP Gram positive diplococci Typical symptoms (e.g. malaise, shaking chills, fever, rusty sputum, pleuritic hest pain, cough) Lobar infiltrate on CXR Suppressed host 25% bacteremic

Atypical Pneumonia

#2 cause (especially in younger population) Commonly associated with milder Sxs: subacute onset, non-productive cough, no focal infiltrate on CXR Mycoplasma: younger Pts, extra-pulm Sxs (anemia, rashes), headache, sore throat Chlamydia: year round, URI Sx, sore throat Legionella: higher mortality rate, water-borne outbreaks, hyponatremia, diarrhea

Viral Pneumonia
More

common cause in children

RSV, influenza, parainfluenza

Influenza

most important viral cause in adults, especially during winter months Post-influenza pneumonia (secondary bacterial infection)

S. pneumo, Staph aureus

Other bacteria

Anaerobes

Aspiration-prone Pt, putrid sputum, dental disease

Klebsiella - alcoholics Branhamella catarrhalis - sinus disease, otitis, COPD H. influenza

Gram negative

Staphylococcus aureus

IVDU, skin disease, foreign bodies (catheters, prosthetic joints) prior viral pneumonia

Diagnosis and Management

Guidelines

American Thoracic Society

Guidelines for the Management of Adults with CA (2001) Update of Practice Guidelines for the Management of CAP in Immunocompetent adults (2003)
IDSA/ATS Consensus Guidelines on the Management of CAP in Adults (March 2007)

Infectious Diseases Society of America

ATS and IDSA joint effort

Guidelines
2001

ATS & 2003 IDSA Guideline Update Expert panels Evidence-based recommendations Recommend patient stratification to identify likely pathogens and suggested empiric abx

Site of care Presence of cardiopulmonary disease Presence of modifying factors

Clinical Diagnosis
Suggestive

signs and symptoms CXR or other imaging technique Microbiologic testing

Signs and Symptoms

Fever or hypothermia Cough with or without sputum, hemoptysis Pleuritic chest pain Myalgia, malaise, fatigue GI symptoms Dyspnea Rales, rhonchi, wheezing Egophony, bronchial breath sounds Dullness to percussion Atypical Sxs in older patients

Clinical Diagnosis: CXR

Demonstrable

infiltrate by CXR or other imaging technique

Establish Dx and presence of complications (pleural effusion, multilobar disease) May not be possible in some outpatient settings CXR: classically thought of as the gold standard

Infiltrate Patterns
Pattern Lobar Patchy Interstitial Cavitary Possible Diagnosis S. pneumo, Kleb, H. flu, GN Atypicals, viral, Legionella Viral, PCP, Legionella Anaerobes, Kleb, TB, S. aureus, fungi Staph, anaerobes, Kleb

Large effusion

Clinical Diagnosis: Recommended testing

Outpatient:

CXR, sputum Cx and Gram stain not required Inpatient: CXR, Pox or ABG, chemistry, CBC, two sets of blood Cxs

If suspect drug-resistant pathogen or organism not covered by usual empiric abx, obtain sputum Cx and Gram stain. Severe CAP: Legionella urinary antigen, consider bronchoscopy to identify pathogen

Clinical Diagnosis
Assess

overall clinical picture PORT Pneumonia Severity Index (PSI)

Aids in assessment of mortality risk and disposition Age, gender, NH, co-morbidities, physical exam lab/radiographic findings

IDSA: Outpt Management in Previously Healthy Pt

Organisms: S. pneumo, Mycoplasma, viral, Chlamydia pneumo, H. flu Recommended abx:

Advanced generation macrolide (azithro or clarithro) or doxycycline Respiratory quinolone (moxi-, levo-, gemi-), OR Advanced macrolide + amoxicillin, OR Advanced macrolide + amoxicillin-clavulanate

If abx within past 3 months:

IDSA: Outpt Management in Pt with comorbidities

Comorbidities: cardiopulmonary dz or immunocompromised state Organisms: S. pneumo, viral, H. flu, aerobic GN rods, S. aureus Recommended Abx:

Respiratory quinolone, OR advanced macrolide

Recent Abx:

Respiratory quinolone OR Advanced macrolide + beta-lactam

IDSA: Inpt ManagementMedical Ward

Organisms: all of the above plus polymicrobial infections (+/- anaerobes), Legionella Recommended Parenteral Abx:

Respiratory fluoroquinolone, OR Advanced macrolide plus a beta-lactam As above. Regimen selected will depend on nature of recent antibiotic therapy.

Recent Abx:

IDSA: Inpt ManagementSevere/ICU

One

of two major criteria:

Mechanical ventilation Septic shock, OR

Two

of three minor criteria:

SBP90mmHg, Multilobar disease PaO2/FIO2 ratio < 250

Organisms:

S. pneumo, Legionella, GN, Mycoplasma, viral, ?Pseudomonas

IDSA: Inpt Management: Severe/ICU

No risk for Pseudomonas

IV beta-lactam plus either

IV macrolide, OR IV fluoroquinolone

Risk for Pseudomonas

Double therapy: selected IV antipseudomonal betalactam (cefepine, imipenem, meropenem, piperacillin/tazobactam), plus
IV antipseudomonal quinolone -OR-

Triple therapy: selected IV antipseudomonal betalactam plus IV aminoglycoside plus either IV macrolide, OR IV antipseudomonal quinolone

Switch to Oral Therapy

Four

criteria:

Improvement in cough and dyspnea Afebrile on two occasions 8 h apart WBC decreasing Functioning GI tract with adequate oral intake

If

overall clinical picture is otherwise favorable, can can switch to oral therapy while still febrile.

Management of Poor Responders

Consider

non-infectious illnesses Consider less common pathogens Consider serologic testing Broaden antibiotic therapy Consider bronchoscopy

Prevention
Smoking

cessation Vaccination per ACIP recommendations

Influenza
Inactivated vaccine for people >50 yo, those at risk for influenza compolications, household contacts of high-risk persons and healthcare workers Intranasal live, attenuated vaccine: 5-49yo without chronic underlying dz

Pneumococcal
Immunocompetent 65 yo, chronic illness and immunocompromised 64 yo

Pneumonia in Children: Dx

Symptoms

Infants: non-specific manifestations

Fever, poor feeding, irritability, vomiting, diarrhea, URI Sx, cough, respiratory distress

Older children: more specific

Fever, cough, chest pain, tachypnea, tachycardia, grunting, nasal flaring, retracting. Cyanosis usually very late.

Signs/Physical exam

RR > 60 for all ages Hypoxia Rales, wheezes, crackles, coarse breath sounds

Pneumonia in Children: Pathogens

0-4

wks: GBS, GN enterics, Listeria 4-12 wks: C. trachomatis, GBS, GN enterics, Listeria, viral (RSV/parainfluenza), B. pertussis 3 mos-4 yrs: Viral, S. pneumo, H. influenza, M. catarrhalis, Grp A Strep, Mycoplasma > 5yrs: Mycoplasma (5-15yrs), C. pneumo, S. pneumo, viral

Pneumonia in the Elderly

Prevention important Presentation can be subtle Antibiotic choice in CAP is same as other adults Healthcare associated pneumonia

Consider S. aureus (skin wounds) and GN bacteria (aspiration)

Pneumonia in Older Residents of Long-term Care Facilities. AFP 2004; 70: 1495-1500.

Pneumonia in Immunocompromised Pts

Smokers, alcoholics, bedridden, immunocompromised, elderly Common still common

S. pneumo Mycoplasma P. jirovecii Fever, dyspnea, non-prod cough (triad 50%), insidious onset in AIDS, acute in other immunocompromised Pts CXR: bilateral interstitial infiltrates Steroids for hypoxia TMP-SMZ still first line

Pneumocystis Carinii Pneumonia

New Guideline

IDSA/ATS 2007 Guideline

Hospital Admission Decision

CURB-65 criteria (confusion, uremia, RR, low BP, age 65 yrs or greater) or PSI can be used to ID candidates for outpt management Acknowledges the low yield and infrequent positive impact on clinical care Outpt testing for etiologic Dx remain optional Inpt testing for etiologic Dx recommended for specific indications

Diagnostic Testing

Antimicrobial therapy: essentially unchanged

Summary
Use

overall clinical presentation to guide therapy The admission decision is an art of medicine decision Use risk factors and guidelines to assist with clinical judgement

References
American Thoracic Society. Guidelines for the Management of Adults with Community-acquired Pneumonia. Am J Respir Crit Care Med 2001 Vol. 163:1730-1754. Mandell LA, Bartlett JG, Dowell SF, File TM Jr, Musher DM, Whitney C. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis 2003 Dec 1;37(11):1405-33. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27-72.

Arch Ped Adol Med 1995; 149: 283-7.