Diagnosis, Empiric Management and Prevention of CAP

1. Diagnosis, Empiric Management and Prevention of CAP

2. Pneumonia • Acute infection of the pulmonary parenchyma accompanied by symptoms of acute illness accompanied by abnormal chest findings. • Third leading cause of morbidity (2001) and mortality (1998) in Filipinos based on the Philippine Health Statistics (DOH). • CPG is a joint statement from PSMID, PCCP and PAFP.

3. 2004 CAP Guidelines in Immunocompetent Adults CAP definition: • Lower respiratory tract infection • Acute onset of within 24 hrs to 2 wks • Patient with : • cough • Tachypnea (RR>20), tachycardia (HR>100), fever (T>37.8˚C) • At least one abnormal chest findings - breath sounds, rhonchi, crackles, or wheeze

4. CAP in Immunocompetent Adults - 2004 Update • No particular sx & abnormal P.E. finding sufficiently sensitive or specific to confirm or exclude the Dx • Chest x- ray is required for definitive Dx • Clinical prediction rules may be utilized if CXR is not available

5. CAP in Immunocompetent Adults - 2004 Update • Diagnostic standard – Chest radiograph • Assess severity • Presence of complications • pleural effusion • multilobar involvement • abscess • May suggest possible etiology • Differentiate pneumonia from other conditions

6. LOW Risk C A P ---> Outpatient Care CAP in Immunocompetent Adults - 2004 Update Which patient will need hospital admission ? • Pts w/ stable VS: • RR < 30 breaths/min, PR < 125 beats/min • DBP > 60 mmHg & SBP > 90 mmHg • No / stable comorbid condition * • No evidence of extrapulmonary sepsis • No evidence of aspiration • CXR: localized infiltrates; no evidence of pleural effusion nor abscess; not progressive within 24 h

7. * Comorbid conditions include: • Diabetes mellitus (DM) • Neoplastic disease • Neurologic disease • Congestive heart failure (CHF) • Coronary artery disease (CAD) • Renal failure • COPD • Chronic liver disease • Chronic alcohol abuse

8. Patients which will need hospital admission ?Moderate CAP: In-patients • Pts w/ unstable VS: • RR > 30 breaths/min, • PR > 125 beats/min, • Temp > 40oC or <35oC • unstable comorbid condition * • extrapulmonary evidence of sepsis * • suspected aspiration • Chest X-ray: multilobar infiltrates; pleural effusion or abscess; progression of findings to >50% in 24 hrs

9. *Unstable comorbid conditions include: • uncontrolled diabetes mellitus (DM) • active malignancies • neurologic disease in evolution • congestive heart failure (CHF) Class II-IV • unstable coronary artery disease (CAD) • renal failure on dialysis • uncompensated COPD • decompensated liver disease

10. Patients which will need hospital admission ?High Risk CAP: ICU Care Any criteria under moderate risk category plus • Hemodynamic alterations and hypoperfusion (i.e. altered mental state, DBP <60 mmHg or SBP <90 mmHg, urine output <30 ml/hr)or • Impending or frank respiratory failure (i.e. Hypoxemia of PaO2 <60 mmHg or acute hypercapnea of PaCO2 >50 mmHg)

11. *Extrapulmonary evidence of sepsis: Moderate Risk C A P: • Hepatic • Hematologic • Gastrointestinal • Endocrine High Risk C A P: • CNS - altered mental state • CVS - DBP <60 mmHg or SBP <90 mmHg • Renal - urine output <30 ml/hr

12. Any of the ff: 1. RR > 30/min 2. PR > 125/min 3. Temp > 40oC or <35oC 4. Extrapulmonary evidence of sepsis 5. Suspected aspiration 6. Unstable comorbid conditions* 7. CXR: multilobar, pleural effusion abscess, progression of lesion to >50% of initial within 24 hrs Any of the ff: 1. Shock or signs of hypoperfusion - hypotension - altered mental state - urine output <30ml/hr 2. PaO2<60mmHg or Acute hypercapnea (PaCO2>50mmHg) YES YES HIGH RISK CAP Intensive care NO MODERATE RISK CAP NO LOW RISK CAP In-patient Outpatient Algorithm: Management-Oriented Risk Stratification of Community-Acquired Pneumonia in Immunocompetent Adults CAP

13. Microbiologic studies are necessary in CAP? Moderate Risk CAP Blood CS Sputum GS CS Optional : PA for M. pneumoniae MIF for C. pneumoniae (for elderly & immunocompromised) Urine Ag Test for L. pneumophila DFA Test for L. pneumophila High Risk CAP Blood CS Sputum GS CS (ABG) PA for M. pneumoniae MIF for C. pneumoniae Urine Ag Test for L. pneumophila DFA Test for L. pneumophila

14. PRINCIPLES OF EMPIRICAL THERAPY • Treat early; give antibiotics within 4 h of admission • Cannot reliably differentiate etiology on basis of clinical findings • Treat most likely pathogens • S. pneumoniae; H. Influenzae • Atypicals • Others (local epidemiology) *Recent antibiotics, recent hospitalization, etc.

15. Empiric Antimicrobial Therapy in CAP • Low risk: Amoxicillin, Co-trimoxazole, Macrolides (Azithromycin, Clarithromycin, Roxithromycin) • Co-amoxiclav, Sultamicillin • 2nd Generation Cephaloporins: Cefuroxime, Cefaclor

16. Empiric Antimicrobial Therapy in CAP • Moderate Risk CAP: Macrolides, Antipneumococcal fluoroquinolones (PO or IV), β-lactams with β-lactamase inhibitor (IV) • 2nd Generation Cephalosporins (IV) • 3rd Generation Cephalosporins (Ceftriaxone, Cefotaxime, Ceftizoxime IV) • Carbapenems (Ertapenem IV)

17. cIV b-lactams include 2nd gen cephalosporin - cefuroxime sodium 3rd gen cephalosporins - ceftriaxone, cefotaxime those w/ anaerobic activity: cefoxitin, ceftizoxime, ertapenem dIV b-lactams w/ b-lactamase inhibitor include ampicillin-sulbactam, amoxicillin-clavulanic acid Nonpseudomonal

18. eIV antipneumococcal fluoroquinolones include levofloxacin gatifloxacin moxifloxacin

19. No risk for P. aeruginosa: IV nonpseudomonal b-lactam c +/- b-lactamase inhibitor d + IV macrolide OR IV antipneumococcal FQe With risk for P. aeruginosa: IV antipseudomonal b-lactamf +/- b-lactamase inhibitor g + IV macrolide or IV antipneumococcal FQ e +/- aminoglycoside or IV ciprofloxacin Empiric Antimicrobial Therapy in CAPHigh Risk C A P

20. Antipseudomonal f IV b-lactams include 3rd gen cephalosporin - ceftazidime 4th gen cephalosporins - cefepime, cefpirome those w/ anaerobic activity: imipenem-cilastatin, meropenem gIV b-lactams w/ b-lactamase inhibitorpiperacillin-tazobactam, ticarcillin-clavulanic acid

21. How do we assess response to initial Rx ? Most patients w/ uncomplicated bacterial pneumonia will respond to treatment within 24-72 hrs • fever declines w/in 72 hrs; temperature normalizes within 5 days • respiratory signs, esp. tachypnea, return to normal A follow-up CXR NOT necessary to confirm that infiltrate has cleared for low-risk CAP patients

22. How do we assess response to initial Rx ? Switch Therapy to an oral agent if: • Less cough & resolution of respiratory distress • Afebrile for > 24 h • Etiology is not a virulent/resistant pathogen • Stable co-morbid condition • No life-threatening complication This will allow early hospital discharge ----> cost savings

23. Duration of antibiotic use based on etiology

24. Follow-up CXR to determine: • Pneumothorax • Cavitation • Extension to previously uninvolved lobes • Pulmonary edema; ARDS Re-assess bacteriologic studies: to determine resistance to antibiotic being given or presence of other pathogens i.e., M. TB or fungi * In elderly: S. pneumoniae & L. pneumophila may be causes of slowly resolving pneumonia

25. Pneumococcal vaccine Influenza vaccine How do we prevent pneumonia? Adult dose O.5 ml IM or SC one-time revaccination may be given after 5 years 0.5 ml IM once a year C.I. Serious allergic reaction to a vaccine component moderate or serious acute illness Precautions Guillain-Barre Syndrome