How Do I Think About Pneumonia?

1. How Do I Think About Pneumonia? Resident’s Thursday School 07/25/2013 J Rush Pierce Jr, MD, MPH Division of Hospital Medicine, UNM

2. Outline • Review resources • Case based discussion that will cover • Diagnosis • Treatment • Based on • IDSA/ATS CAP (2007) guidelines • HCAP/VAP/HAP (2005) guidelines How Do I Think About Pneumonia?

3. Resources • Guidelines available • UNMH site (https://hospitals.health.unm.edu/intranet/Index.cfm) • IDSA website – guidelines available for download to Palm or iPhone (http://www.idsociety.org/Content.aspx?id=9088) • Up-to-Date (varies some from guidelines) • Sanford Guide – generally follows guidelines • Adult Community-Acquired Pneumonia Order Set How Do I Think About Pneumonia?

4. Don’t forget: You can copy-paste this slide into other presentations, and move or resize the poll. How Do I Think About Pneumonia?

5. Case 1 • 65 y/o male smoker has 2 days of chills, dyspnea, and purulent sputum. He has no risk factors for HIV, donates blood 3x/year (most recently one month ago) and does not take any medications. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA. Examination shows no abnormalities. CXR is read as “minimal streaking at lung bases, atelectasis vs. early pneumonia” • Should I treat with antibiotics? How Do I Think About Pneumonia?

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7. Does this patient have pneumonia? • Hx: • PE: VS most useful in predicting severity • CXR is gold standard - may be normal in up to 7% on admission; assume pneumonia present if convincing hx and focal PE • Suspected pneumonia with neg CXR – consider f/u CXR or CT (more sensitive) How Do I Think About Pneumonia?

8. Thinking about pneumonia: 4 steps • Put into initial clinical classification • Decide site of care • Tests for etiology • Initial empiric therapy How Do I Think About Pneumonia?

9. Step 1:Initial clinical classification • Major immunodeficiency • Tuberculosis (suspected or established) • Relatively normal hosts without TB (location at time of infection) • Community-acquired (CAP) • Healthcare-associated (HCAP) or Hospital acquired (HAP) – includes ventilator-acquired (VAP) How Do I Think About Pneumonia?

10. Case 2 • 55 y/o homeless man from Mexico has 2 days of chills, night sweats, dyspnea, and purulent sputum without hemoptysis. He has not lost weight. He has no risk factors for HIV, takes no medications, and is not diabetic. Exam reveals T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right base. • Should I order airborne isolation? How Do I Think About Pneumonia?

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12. When to suspect TB(Intern Survival Guide) • If two or more sxs • Hemoptysis • Cough > 2 weeks • Night sweats • Wt loss > 10 # in 3 mos • If suspicious CXR (any of these) • Upper lobe infiltrates • Miliary pattern • Cavitary lesions • Nodular infiltrate Response to suspected TB Order airborn isolation and CXR Order AFB smears, cultures (does not have to be qAM!) How Do I Think About Pneumonia?

13. Step 1:Initial clinical classification • Major immunodeficiency • Tuberculosis (suspected or established) • Relatively normal hosts without TB (location at time of infection) • Community-acquired (CAP) • Healthcare-associated (HCAP) or Hospital acquired (HAP) – includes ventilator-acquired (VAP) How Do I Think About Pneumonia?

14. CAP vs HCAP/VAP/HCAP • Healthcare-associated pneumonia (HCAP) • In hospital > 1 day within past 90 days • Nursing home/SNF/LTAC • Dialysis or outpt hosp within past 30 days • IV antibiotics or chemo, wound care within 30 days • (Family member with MDRO) • HAP– occurs > 48 hrs after admission & not incubating at time of admission • VAP – occurs more than 48 – 72 hrs after intubation How Do I Think About Pneumonia?

15. Case 2 • The patient has never been hospitalized, resides at home, does not take dialysi, has not received chemotherapy, and his spouse has not been sick How Do I Think About Pneumonia?

16. Step 1:Initial clinical classification • Major immunodeficiency • Tuberculosis (suspected or established) • Relatively normal hosts without TB (location at time of infection) • Community-acquired pneumonia (CAP) • Healthcare-associated pneumonia (HCAP) or Hospital acquired pneumonia (HAP) – includes ventilator-acquired (VAP) How Do I Think About Pneumonia?

17. Thinking about pneumonia: 4 steps • Put into initial clinical classification • Decide site of care • Tests for etiology • Initial empiric therapy How Do I Think About Pneumonia?

18. Case 3 • 65 y/o male smoker has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. He has felt and eaten poorly. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right apex. He is not confused. WBC = 15K, H/H = 14.5/42, Na = 128, K = 3.5, Cl = 105, CO2 = 20. BUN/creat = 32/1.4. CXR shows RUL infiltrate. • Can I send this patient home? How Do I Think About Pneumonia?

19. www.meddean.luc.edu How Do I Think About Pneumonia?

20. Don’t forget: You can copy-paste this slide into other presentations, and move or resize the poll. How Do I Think About Pneumonia?

21. Pneumonia Severity Index (PSI) How Do I Think About Pneumonia?

22. CURB-65 • Developed by British Thoracic Society • Confusion, BUN >20, Respiratory rate >30, BP <90 syst or <60 diast, age >64 • Score = 0 – 1 OUTPT • Score = 2 WARD • Score = 3 ICU • Other subjective factors = safely and reliably take oral meds, availability of support services How Do I Think About Pneumonia?

23. ICU admission = one major or 3 minor How Do I Think About Pneumonia?

24. Thinking about pneumonia: 4 steps • Put into initial clinical classification • Decide site of care • Tests for etiology • Initial empiric therapy How Do I Think About Pneumonia?

25. Case 3 - continued • 65 y/o male smoker has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. He drinks alcohol everyday. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right base. He is not confused. WBC = 15K, H/H = 14.5/42, Na = 128, K = 3.5, Cl = 105, CO2 = 20. BUN/creat = 32/1.4. CXR shows RUL infiltrate. • What etiologic tests do I order? How Do I Think About Pneumonia?

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27. Diagnostic tests for etiology • Why not etiologic tests for everyone? • Outpt – Get SaO2; Routine tests for etiology are optional • Inpt - Blood and sputum cultures recommended for most (but not all) • ICU - blood and sputum cultures, and Legionella and pneumococcal UAT How Do I Think About Pneumonia?

28. How Do I Think About Pneumonia?

29. How Do I Think About Pneumonia?

30. Thinking about pneumonia: 4 steps • Put into initial clinical classification • Decide site of care • Tests for etiology • Initial empiric therapy How Do I Think About Pneumonia?

31. Case 4 • 24 y/o previously healthy female has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 92% RA, crackles at the right base. CBNC and Chem 7 normal. CXR = early RLL pneumonia • What antibiotics should I order? How Do I Think About Pneumonia?

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33. Empiric Rx of outpatient CAP • Healthy and no antibiotics in past 3 months • Macrolide OR doxycycline • If cardiopulmonary dz, Beta-lactam rx in past 3 mos, alcoholism, immunosuppressive rx, or exposure to child in day-care • Respiratory quinolone OR • beta – lactam (high dose amoxicillin or Augmentin) + macrolide or doxycycline • Duration of rx = 7 days (may be less with good response or if use azithro) How Do I Think About Pneumonia?

34. Outpatient RX of CAP • Candidates for outpt therapy • Low PSI or CURB-65 • Not crazy • Likely to be compliant, can get meds and F/U • Follow-up • Return if T > 101 or fail to resolve fever in 48 hours • Outpatient visit in 10 – 14 days • CXR in 1 – 2 months How Do I Think About Pneumonia?

35. Case 3 - continued • 65 y/o male smoker has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. He has felt and eaten poorly. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right base. He is not confused. WBC = 15K, H/H = 14.5/42, Na = 128, K = 3.5, Cl = 105, CO2 = 20. BUN/creat = 32/1.4. CXR shows RUL infiltrate • What antibiotics do you order? How Do I Think About Pneumonia?

36. Don’t forget: You can copy-paste this slide into other presentations, and move or resize the poll. How Do I Think About Pneumonia?

37. Empiric Rx of inpatient CAP – no special considerations • Inpatient – ward: • respiratory quinolone OR • (ceftriaxone or ceftazidime) + (azithro or doxy) • ICU – • (ceftriaxone or ceftazidime) + (IV azithro or respiratory quinolone) • If PCN allergic use aztreonam + respiratory quinolone How Do I Think About Pneumonia?

38. Empiric inpatient Rx of CAP – special considerations • Pseudomonas • suggestive gram stain, bronchiectasis, freq exacs of COPD + prior antibiotic rx • Regimens: • (Zosyn or merepenam) + cipro OR • (Zosyn or merepenam or aztreonam) + aminoglycoside + respiratory quinolone • MRSA • suggestive gram stain, ESRD, IVDU, prior influenza, prior antibiotics espquinolones, or much MRSA in community • Regimen: Add linezolid OR vancomycin How Do I Think About Pneumonia?

39. Case 3 - continued • 65 y/o male 2 days ago with RUL pneumonia and treated with ceftriaxone and azithromycin. On rounds is feeling better, eating, not confused. T = 37.9, HR = 102, BP = 105/75, RR = 12, SaO2 = 88% on room air • When I can I switch to an oral regimen and what regimen? • When can the pt go home? How Do I Think About Pneumonia?

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41. Switching to oral • If specific pathogen identified, switch to narrow spectrum therapy • When clinically improving, hemodynamically stable, able to take orals, switch to oral rx – if no pathogen, often azithro alone • Duration = at least 5 days, and until afebrile for two days, and have only one sign of clinical instability. If pathogen is Pseudomonas treat at least 14 days How Do I Think About Pneumonia?

42. Timing of discharge Readmission rate or death: no instability = 10%; 1 instability = 14%; 2+ instabilities = 46% How Do I Think About Pneumonia?

43. Pneumonia – before they go home • Smoking cessation • Vaccination How Do I Think About Pneumonia?

44. CAP – What’s New • Increasing recognition of viral pathogens • Consideration of environmental exposures as risk factor for CAP • Use of PCR (and other tests) to guide initial antibiotic choice • Use of inflammatory markers to help with diagnosis and guide therapy • Vaccine efficacy How Do I Think About Pneumonia?

45. Questions? How Do I Think About Pneumonia?

46. Empiric therapy of HCAP/HAP/VAP with MDR risk factors cefepime, ceftazadime, imipenam, or Zosyn PLUS ciprofloxacin, levofloxacin, or aminoglycoside • If MRSA concerns add linezolid or vancomicin How Do I Think About Pneumonia?

47. Switching to oral therapy for HCAP/HAP/VAP Pseudo: if sens cipro + Aug/doxy/clinda MRSA: sensitivities cipro + Aug/doxy/clinda OR moxi How Do I Think About Pneumonia?

48. Aspiration • When to use: observed/suspected aspiration + fever or leucocytosis or infiltrate • Regimens: • Unasyn + (doxy OR azithro) Augmentin or clinda • Respiratory quinolone How Do I Think About Pneumonia?

49. Non-responding pneumonia – definition (15%) • Progressive pneumonia on CXR with clinical deterioration, acute respiratory failure and/or shock occurring in first 72 hours • Delay in achieving clinical stability • Median time = 3 days • ¼ require > 5 days • Non-resolution of infiltrate > 30 days after hospitalization [different problem] How Do I Think About Pneumonia?

50. Clinical response to non-responding pneumonia • Reevaluate initial microbiologic results – consider UAT • Reassess risk factors for infection with unusual organism • Repeat blood cultures for worsening pneumonia or clinical deterioration • Look for secondary infections (catheter, urinary, skin) • Get CT to R/O PTE, thoracentesis to R/O empyema, bronchoscopy to R/O unusual pathogens How Do I Think About Pneumonia?