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Pneumonia: The Forgotten Killer
William Sonnenberg, MD, FAAFP
ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.
DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.
All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.
The content of my material/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated:
• Steroids for pneumonia.
William Sonnenberg, MD, FAAFPFamily physician,Titusville, Pennsylvania; Clinical Assistant Professor of Family and Community Medicine, Penn State College of Medicine, Hershey, Pennsylvania
Dr. Sonnenberg earned his medical degree from the University of Pittsburgh and completed his family medicine residency at McKeesport Hospital in Pennsylvania. A former president of the Pennsylvania Academy of Family Physicians, he has been in private practice in the Titusville, Pennsylvania, area since 1983. In 2017, he will be a featured speaker about pneumonia and inflammatory bowel disease in four issues of the AAFP’s FP Audio™. His lectures at national meetings have been selected for publication by Audio-Digest seven times. 2017 marks his 10th time presenting at the AAFP’s annual meeting.
Learning Objectives1. Monitor the health of patients who have weakened immune systems to
mitigate risk factors that increase their risks of developing pneumonia.
2. Prescribe appropriate empiric therapy for CAP based on suspected pathogen and local susceptibility patterns.
3. Identify risk factors for multidrug pathogens in patients who have HAP, HCAP or VAP.
4. Prescribe appropriate antibiotic therapy for HAP, HCAP or VAP based on risk factors for multidrug-resistant pathogens, predominant pathogens in the clinical setting, and local susceptibility patterns.
Audience Engagement SystemStep 1 Step 2 Step 3
2
Agenda
• Identify patients at increased risk of pneumococcal disease.
• Prescribe appropriate empiric therapy for CAP based on suspected pathogen and local susceptibility patterns.
• Discuss evidence based methods to prevent CAP
Target Audience
•Alabama
• Illinois
•Maine
•Michigan
•Washington
Jim Henson
• May 4, 1990 had sore throat
• May 13, saw doctor in North Carolina, aspirin suggested
• May 15, 2am, SOB and coughing blood
• 5 am ventilator
• Died may 16 1:21 am
Maimonides and Pneumonia
• Acute fever
• Sticking pain in the chest
• Short breaths
• Serrated pulse
• Cough mostly with sputum
Epidemiology
• 8th leading cause of death in USA
• Most common infection‐related mortality
• Main cause of sepsis worldwide
• 2nd leading cause of hospitalization
• 2nd highest % of ER visits admitted
• Most in winter months
• 52,700 deaths in 2007
• $17 billion per year
Am Fam Physician. 2011 Jun 1;83(11):1299‐1306
8th Leading Cause of Death ‐ 2013
27,682
41,325
53,282
0
10,000
20,000
30,000
40,000
50,000
60,000
Prostate Cancer Breast Cancer Pneumonia
DEA
THS
3
30 Day Readmission Rate
23.5%20.0%
15.5% 14.7%
0%
5%
10%
15%
20%
25%
CHF COPD Pneumonia AMI
Agency for Healthcare Research and Quality, Feb 23, 2016
$2 Billion Cost$2 Billion Cost
Stagnation
• No mortality decrease since routine use of penicillin – 14%
• Guidelines work!
• 28,661 pneumonias, 7,719 admissions
• 30 day mortality for admitted patients
• 11.0% v 14.2% (RR 0.69)
Dean, NC et al. Am J Med. 2001 Apr 15;110(6):451‐7
Community Acquired Pneumonia
AES Poll Question #1
• Which medication does not increase the risk of pneumonia?
1. Proton pump inhibitors
2. Statins
3. Anticholinergics
4. Inhaled corticosteroids
5. Benzodiazepines
Risk Factors for CAP
• Male
• Underweight
• >65 years
• Smoking
• Alcohol
• Immunosuppression
• COPD
• HIV
• Asplenia
• Contact with children
• Bad teeth
• Crowding (>10/household)Torres A, Peetermans WE, Viegi G, Blasi F. Thorax. 2013;68(11):1057‐1065
Medications that Increase Risk
• Proton pump inhibitors
• Tumor necrosis factor‐alpha inhibitors
• Amiodarone
• N‐acetylcysteine,
• Oral or inhaled steroids
• Benzodiazepines
• EszopicloneRemington LT, Sligl WI. Community‐acquired pneumonia. Curr Opin Pulm Med. 2014;20(3):215‐224
4
PPI’s and CAP
• 463 patients, 29% using PPI’s
• Doubled risk of S. pneumoniae
• 28% v. 14%
• No increased risk for other bacteria
de Jager CPC et al. Aliment Pharmacol Ther 2012 Nov.
Inhaled Corticosteroids
•Cohort 163,514 pts, 20,344 developed severe pneumonia over 5.4 years of follow‐up
•Current use, RR 1.69
• Risk disappeared after stopping for 6 months
•Higher with fluticasone, RR 2.01
• Lower with budesonide, RR 1.17Samy Suissa, et al. Thorax. 2013;68(11):1029‐1036
Benzodiazepines and CAP
• Case controlled study over 4,900 patients
• 54% ↑ pneumonia
• 22% ↑ dying in 30 days
• 32% ↑ dying in 3 years
21
Thorax doi:10.1136/thoraxjnl‐2012‐202374
Anticholinergic and Pneumonia
•Case‐controlled study adults 64‐94, 1039 pneumonia cases
•Acute use
• 59% cases of pneumonia
• 35% of controls
• aOR = 2.55
J Am Geriatr Soc. 2015 Mar;63(3):476‐85
Symptoms
•Cough – 90%
• Fever – 80%
•Dyspnea – 66%
•Pleuritic chest pain – 50%
• Tachypnea• Most consistent sign
• Can occur 3‐4 days before other signs
Normal Vitals
• All normal vital signs associated with < 1% risk of pneumonia
• RR > 20
• HR > 100
• Temp > 37.8⁰C
Metlay JP, et al, JAMA 1997; 278:1440‐1445
5
Findings
•Rales or crackles present 75‐80% of the time
• Less than 1/3 have dullness on percussion or egophony
Physical Exam v. CXR
•52 males with lower respiratory Sx
• 24 had pneumonia on CXR
•3 physicians, blinded to Hx, labs, CXR
• Sensitivity 47% ‐ 69%
• Specificity 58% ‐ 75%
Wipf JE et al. Arch of Int Med 159(10):1082‐7
Pneumonia in Elderly
• Weaker immunity, less symptoms
• Insidious onset
• Chest pain uncommon
• Fever may be absent, 30%
• May have normal WBC
• Cough weak or absent
• Delirium common
• Sputum minimal or absent
Daniel M. Musher, M.D., and Anna R. Thorner, M.D. NEJM 2014; 371:1619-1628
Osler on Pneumonia
"In old age, pneumonia may be latent, coming on without a chill; the cough and expectoration are slight.. ..”
“In senile and alcoholic patients, the temperature may be low but the brain symptoms pronounced.”
CAP Pathogens
Typical
• S. pneumoniae
• H. influenzae
Atypical
• Mycoplasma
• Chlamydophilia pneumonia
• Legionella
• Viruses
Atypicals
• Don’t Gram Stain
• Don’t grow on routine culture
• Present in 25% of all pneumonias
• Always treat
6
Typical v. Atypical Pneumonia
Typical
• Memorable onset
• Unilateral
• Pleuritic
• Cough with purulent phlegm
• Fever, chills, sweats
• Dyspnea
• Few extrapulmonary symptoms
Atypical
• Slow onset
• “Walking pneumonia”
• Extrapulmonary symptoms• Myalgias
• Diarrhea
• Abdominal pain
• Sore throat, ear pain
• Dry cough
• Little fever, dyspnea
Pneumococcal Pneumonia
• 95% in past, now 10‐15%• Vaccines, ↓smoking
• Abrupt onset, high fever, shaking chill
• Productive cough
• Pleuritic chest pain
• 75% bacteremia
• CXR consolation, primarily RLL
Daniel M. Musher, M.D., and Anna R. Thorner, M.D. NEJM 2014; 371:1619-1628
Risk of Pneumococcal Pneumonia
• 50x higher < 2 years or > 65 years
• ≈ 1.5‐2.1 times more likely in males
• Smoking, active and passive, most important risk factor ages 18‐64
• Living with child < 6 years in daycare
• Dementia, seizure, HF, COPD, HIV, influenza
• Proton pump inhibitors
• Influenza may be responsible for 40% of cases at peak of flu seasons
Semin Respir Crit Care Med. 2005;26(6):563‐574.
Sci Transl Med 2013 Jun 26;5(191)
H. Flu Pneumonia
• Subacute onset of fever, less fulminant
• Associated with COPD
• Productive cough
• CXR patchy bronchopneumonia or RLL pneumonia
Legionella Infection
• Peaks in late summer
• Incubation 2‐10 days
• Fever > 104° F or 40° C
• Relative bradycardia
• GI – diarrhea, abnormal LFTs
• CNS symptoms – confusion, ataxia, headache, seizures
Cunha BA. Clinical features of legionnaires' disease. Semin Respir Infect. 1998;13(2):116–127
Legionella Infection Risk Factors• Male
• Long‐term smoking
• 20% travel associated• No person‐to‐person transmission
• Survives in water, biofilms
• Unused hotel rooms, long pipe runs, many water outlets
• Cooling towers, cruise ships, fountains, dipping flower pots Lancet Infect Dis, Vol 14, Iss 10, Oct 2014, Pages 1011–1021
7
Mycoplasma Pneumonia• Most common cause under 40
• Incubation 2‐3 weeks, 5‐10% develop pneumonia
• Otitis media, pharyngitis
• 20% of CAP requiring hospitalization
• 75% have normal white counts
• Burrows between cilia
• No cell wallClin Microbiol Rev. 2004; 17(4):697‐728
Chlamydophila pneumoniae• Up to 10% of all pneumonias in USA
• Most adults have been infected
• 3‐4 week incubation
• 2 week prodrome of sore throat
• Mild infiltrates
• May be severe with COPD
• Association with CAD (foam cells) and Alzheimer’s disease (ε4 allele)Blasi F, Tarsia P, Aliberti S. Chlamydophila pneumoniae. Clin Microbiol Infect 2009;15:29‐35.
Moraxella Pneumonia
• Subacute, follows chronic bronchitis
• Predilection for patients with CAD
• Productive cough
• Purulent sputum
• Chills infrequent
Community Acquired MRSA
•More antibiotic susceptibility
•More virulent
•More necrotizing pneumonia
• Linezolid may reduce toxin production better
Wunderink RG, et al. Clin Infect Dis. 2012;54(5):621.Curr Ther Res Clin Exp. 2012 Jun; 73(3): 86–102.
Hageman JC et al. Emerg Infect Dis. 2006;12(6):894
Features Suggesting CAP MRSA
• Cavitary infiltrate or necrosis
• Rapidly increasing pleural effusion
• Gross hemoptysis (not just blood‐streaked)
• Concurrent influenza
• Neutropenia
• Erythematous rash
• Skin pustules
• Young, previously healthy patient
• Severe pneumonia during summer months
N Engl J Med 2014; 370:543‐551
MRSA Pneumonia
•Multiple nodular lesions
• Some with cavitation
•Bilateral pleural effusions
8
CAP Pathogens, 2010‐2012
Jain S et al. N Engl J Med
2015;373:415‐427.
Testing
AES Poll Question #2
• What will not cause a false negative CXR?
1. Early pneumonia in first 24 hours
2. Severe neutropenia
3. Early use of antibiotics
4. Pneumocystis
Laboratory Studies
• CBC
• BMP
• LFT
• Sputum Gram Stain
• Blood cultures before antibiotics
• PCR, Urine antigen, viral studies
• IgG and IgM not useful
When to Chest X‐Ray
One Abnormal Vital Sign
• Temp > 100⁰F (37.8⁰C)
•HR > 100
•RR > 20
Two Clinical Signs
•↓ Breath sounds
•Crackles (rales)
•Absence of asthma
Ebell MH. Predicting pneumonia in adults with respiratory illness. Am Fam Physician. 2007;76(4):562
False Negative CXR’s
•Pneumocystis
• Early pneumonia
• First 24 hours
• Severe neutropenia
9
Lung Ultrasound
• Sensitivity 94%, specificity 96% in adults
• No radiation, bedside
• Pregnancy
• More accurate for pleural effusion and consolidation
G Volpicelli, M Elbarbary, M Blaivas, the International Liaison Intensive Care Med, 38 (2012), pp. 577–591
Blood Cultures
• Positive 4% ‐ 18% in CAP
• Add little
• Highly specific if positive
• Obtain in severe CAP
• Yield halved by prior antibiotic treatment
Impact of Blood Cultures
•13 studies
•Positive BC in 0% ‐ 14%
•Narrowed antibiotics 0% ‐ 3%
•Broadening 0% ‐ 1 %
Journal of Hospital Medicine 01/2009; 4(2):112 ‐ 123
Who Needs Blood Cultures?
• Cavitation
• Alcoholics
• End stage liver disease
• Critically ill
• Neutropenia
• Asplenia
• Pleural effusion
Sputum Cultures
• Useful with
• Lung cavities
• Poor response to outpatient therapy
• Pleural effusion
• ICU admissions
Sputum Studies Value
• 40% ‐ 60% unable to produce sputum
• 45% ‐ 50% inadequate because of contamination
• 80% yield with pneumococcal pneumonia
• 40% pneumonias multiple organisms, can‘t narrow antibiotics based on culture
Musher DM, et al. Clin Infect Dis 2004; 30:165‐169
10
Pulse Oximetry
• All admitted patients ‐ CMS guideline
• pO2 ≤ 90% good specificity for adverse outcomes
• Admit all hypoxic patients
• Oxygen saturation < 90%
• Arterial saturation < 60 mm Hg on room air
Primary Care Respiratory Journal (2010) 19(4): 378‐382
Limits of Pulse Oximetry• Requires normal hemoglobin
• Oxygen or carbon monoxide read the same
• Same absorption peaks (920 nm)
• False normal readings with
• Carbon monoxide poisoning
• Smoke inhalation
• Cigarette smoking
• Can be hypoxic with normal pulse oximetry
Limits of Pulse Oximetry
• Anemia will have less oxygen• Low oxygen, normal saturation
• Requires pulsating blood – low profusion• Hypothermia
• Hypotension • Vasoconstriction • Peripheral vascular disease • Low cardiac output
Other Studies
• Urine antigen for S. pneumoniae in moderate to high severity
• Urine antigen for Legionella in high severity
• PCR for mycoplasma
• Chlamydophila antigen and/or PCR detection tests when psittacosis suspected
• Viral studiesThorax 2009; 64:iii1‐iii55 doi:10.1136/thx.2009.121434
Procalcitonin
• Differentiate viral from bacterial with high sensitivity and moderate specificity
• Can guide ABX duration
• Reduced duration from 8 days to 4 days, no change in morbidity or mortality
P Schuetz, R Balk, M Briel, et al.Clin Chem Lab Med, 53 (2015), pp. 583–59
Urine Antigen Testing
•Higher yield in more severe illness
•Pneumococcal disease
• 15 minute results
• 50% ‐ 80% sensitivity, > 90% specific
• Works after ABX begun
• Legionella• Detects subgroup 1; 80%‐95% of Legionella CAP
11
Pleural Effusions
• 20% ‐ 60% of CAP
• Tap most mild to moderate effusions
• Treat transudates with antibiotics
• Repeat taps or chest tube for exudates
Inpatient or Outpatient?
AES Poll Question #3
• Factors in outpatient treatment of pneumonia include all except
1. Cost sayings
2. Higher mortality
3. Less resistant bacteria
4. Faster return to activity
Reasons to Avoid Hospitalization
•25 times greater cost
•80% prefer outpatient
• Faster return to activity
• Lower mortality
• Thromboembolic events
•Hospital resistant bacteriaATS pneumonia guidelines, 2007
Mortality of Hospitalized CAP
•14% mortality in hospitalized patients
•30% inpatient mortality in elderly
•Comorbidities
• COPD, diabetes, renal insufficiency, HF, CAD, cancer, chronic liver disease
Niederman MS et al. Am J Respir Crit Care Med. 2001; 163:1730‐1754
Port or PSI
•PORT ‐ Pneumonia Patient Outcomes Research Team
•PSI – Pneumonia Severity Index
12
PORT: Step 1: Class I or Classes II‐VPresence of:
Yes/No
> 50 years of age
Altered mental status
Pulse ≥ 125/min
Respiratory rate > 30/minute
SBP < 90
Temperature <35⁰C or ≥40⁰C
History of:
Any YES’s, proceed to Step 2
All NO’s, assign to Risk Class 1
Outpatient mortality 0.1%
Neoplastic disease
Heart failure
Cerebrovascular disease
Renal disease
Liver disease
PORT Severity IndexDemographic factors:
Age (in years) Points
• Male Age
• Female Age – 10 yrs
• Nursing home Age + 10 yrs
PORT Severity Index
Coexisting Conditions Points
• Neoplastic Disease +30
• Liver Disease +20
• CHF +10
• Cerebrovascular +10
• Renal Disease +10
PORT Severity Index
Initial Exam Findings Points
• Altered mental Status +20
• Respiratory rate >30 +20
• Systolic <90 +20
• T < 95⁰F or ≥ 104⁰F +15
• Pulse ≥ 125 +10
PORT Severity Index
Initial Lab Findings Points
• pH < 7.35 +30
• BUN > 30 +20
• Na < 130 +20
• Glucose ≥ 250 +10
• Hct < 30 +10
• APO2 < 60 or O2 < 90% +10
• Pleural effusion +10
PORT Severity Index
ScoreRisk
Class
Site of
Therapy
30 Day
Mortality
None I Outpatient 0.1%
≤70 II Outpatient 0.6%
71-90 III Inpatient 0.9-2.8%
91-130 IV Inpatient 8.2-9.3%
>130 V Inpatient 27.0-29.2%
13
CURB‐65 Scoring
• One point for each
• Confusion
• Uremia (BUN > 19)
• Respiratory Rate > 30
• Blood pressure (SBP < 90, DBP < 60)
• Age ≥ 65
British Thoracic Society
CURB‐65 Treatment SiteScore Mortality % Risk Suggested Site
0 0.6%Low Outpatient
1 2.7%
2 6.8% ModerateShort stay/
Supervised outpatient
3 14.0%Moderate to
highInpatient
4 or 5 27.8% High Inpatient/ICU
British Thoracic Society
Hospital Acquired Pneumonia
Health Care‐Associated Pneumonia
Inpatient for ≥ 2 days in previous 90 days
Nursing home or ECF
Home infusion therapy
Hemodialysis in previous 30 days
Family member with multidrug‐resistant pathogen
Immunosuppressive disease or therapy
ATS and IDSA
Inpatient Pathogens
Non‐ICU
• S. pneumoniae
• M. pneumoniae
• C. pneumoniae
• H. influenza
• Legionella species
• Aspiration
• Viruses
ICU
• S. pneumoniae
• Staphylococcus aureus
• Legionella species
• Gram‐negative Bacilli
• H. influenza
Mandell et al. Clin Infect Dis 2007;44:S27‐72
Prevention of HAP
• Hand washing
• Non invasive ventilation
• Breaks in sedation
• Assess for extubation
• Head of bed at 30⁰ to 45⁰
• Control glucose
14
Treatment of Pneumonia
Poll Question #4
• Minimum duration of treatment
1. 5 days
2. 7 days
3. 10 days
4. 14 days
Antibiotic Timing
• Antibiotics within 4 hours of arrival to hospital
• Mortality 6.8% v. 7.4%
• 0.4 day shorter LOS
• May increase pressure for misuse
• Guideline retired in 2012 in favor of prompt treatment where Dx first made
Houck PM et al. Arch Intern Med. 2004;164(6):637
IDSA Empiric Antibiotics for CAP (Outpatient)
Previously Healthy
No ABX ≤ 3 months
Macrolide
or
doxycycline
Comorbidities
ABX ≤ 3 months
Respiratory quinolone
or
β‐Lactam + Macrolide
Special Considerations
Regions with >25% high‐level macrolide‐
resistance
Respiratory quinolone
or
β‐Lactam + Doxycycline
Mandell et al. Clin Infect Dis 2007;44:S27‐72
IDSA Empiric Antibiotics for CAP (Inpatient)
Inpatients Non‐ICU
Respiratory Quinolone
or
Anti‐pneumococcal βlactam + macrolide
ICU
β lactam + Macrolide or respquinolone
or
PCN allergy – resp quinolone + aztreonam
Always more than one ABX
Mandell et al. Clin Infect Dis 2007;44:S27‐72
IDSA Empiric Antibiotics for CAP (Inpatient)
Pseudomonas Antipseudomonal β lactam + antipseudomonal quinolone
or
Antipseudomonal β lactam + aminoglycoside + azithromycin
or
Antipseudomonal β lactam (PCN allergy→ aztreonam) + aminoglycoside
+ antipseudomonal quinolone
MRSA
Add Vancomycin orLinezolid
Mandell et al. Clin Infect Dis 2007;44:S27‐72
15
Atypical Coverage for Bacteremic Pneumonia• 2,209 Medicare admissions for bacterial pneumonia
• If any atypical coverage;• ↓ 30 day mortality, OR 0.76
• ↓ 30 day readmission, OR 0.67
• Benefits confined to macrolides, not fluoroquinolones nor tetracycline's
• ↓ In-hospital mortality, OR 0.59
• ↓ 30 day mortality, OR 0.61
• ↓ 30 day readmission, OR 0.59
• Macrolides inhibit inflammatory responseMark L et al. Chest. 2007;131(2):466‐473
Macrolide Resistance
49% Nationally
Keedy K, et al. Poster presented at: 19th Annual MAD-ID Conference; May 5-7, 2016; Orlando, FL.
Macrolides in Pneumonia?
• High pneumococcal resistance
• Decrease inflammatory mediators and adhesion molecules
• Many retrospective studies show reduced morbidity and mortality
• 187 pts, crude mortality 5.6% v. 23.6% with azithromycin
• Clarithromycin probably should not be used
• Interaction with CCB’s – kidney injury, hypotension, death
• Statin interactionsShorr AF, et al. BMJ Open 2013
Fluoroquinolones Have Issues
• Hypertoxic C. diff; NAP1
• Worse than clindamycin
• Prolonged QT interval
• Tendon rupture and tendonitis
• Black box neuropathy warning
• Aortic dissection, aneurysm
Risk Factors Resistant Pneumococcus
• Age > 65 years
• β‐lactam, macrolide, or fluoroquinolone past 3‐6 months
• Alcoholism
• Comorbidities
• Immunosuppressive illness or therapy
• Exposure to child in day care
Steroids For Inpatient CAP
• Meta analysis 13 RCT trials (>2000 pts)
• 20‐60 mg prednisone or equivalent
• All‐cause mortality RR 5.3% v. 7.9%
• Only benefited severe pneumonia 7.4% vs. 22.0%
• Mechanical ventilation RR 3.1% v. 5.7%
• ARDS 0.4% vs. 3.0%
• Shortened LOS one day.
Siemieniuk RAC et al. Ann Intern Med 2015 Oct 6
16
Switch to Oral Therapy• Meet following criteria for 24 hours
• Able to ingest oral medications
• HR <100, SBP > 90 • RR < 25• O2 sat > 90%, pO2 > 60 on room air or low‐flow O2 via nasal cannula, or return to baseline O2 for pts on long‐term O2 therapy
• Return to baseline cognition• Temp < 100.9⁰F (38.3⁰C)
Lee JS, Giesler DL, Gellad WF, Fine MJ. Antibiotic therapy for adults hospitalized with community-acquired pneumonia: a systematic review. JAMA. 2016;315(6):593–602
Duration of Antibiotic Therapy
•Minimum of 5 days
•7 days if fever persists after 4 days
• Expect improvement at day 3
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44:Suppl 2:S27-S72
Response to Therapy
• Expect improvement in 3 days
• 6% ‐ 15% may not respond
• Pneumococcal pneumonia
• Cough resolves in 8 days
• Crackles clear in 3 weeks
Risk Factors for Response Failure
•Multilobar
•Cavitation
•Pleural effusion
• Liver disease
• Leukopenia
•High PSI IndexMenéndez R et al. Thorax. 2004;59(11):960
Treatment Failures, Further Evaluation
•Repeat history – travel, pet exposure
•Repeat CXR, sputum and blood cultures
•Chest CT
•Bronchoscopy
• Lung biopsy
Clin Infect Dis. 2007;44 Suppl 2:S27
Cardiac Complications
• Influenza and bacterial pneumonia
• MI and afib in 7‐10% of admitted VA patients
• Worsening heart failure in 20%
• Up regulation of cytokines
• Afib usually resolves in few weeks
Daniel M. Musher, M.D., and Anna R. Thorner, M.D. N Engl J Med 2014; 371:1619-162
17
Stable for Discharge?• Temp > 37.8⁰C
• RR > 24• HR > 100• SBP ≤ 90• O2 sat < 90% on room air
• Can‘t eat• No mental status improvement
• If one parameter of instability present at discharge then
• Death rate 14.6% v. 2.1%
• Readmission 14.6% v. 6.5%
Dagan E et al. Scand J Infect Dis. 2006;38(10):860
Follow‐up Chest X‐ray?
• CXR responses lags behind clinical response
• CXR response varies (age, #lobes)
• Under 50, no pulmonary disease; clears in 4 weeks
• Older with underlying lung disease; clears in 12 weeks
• Get follow‐up CXR with
• Pleural effusion
• Endotracheal tubeMitl RL et al. Am J Respir Crit Care Med. 1994;149(3 Pt 1):630.
Simple Recommendations
Mild CAP, no resistance Doxycycline
Moderate CAP, recent ABX use Azithromycin + high dose amoxicillin
Moderate CAP with comorbidity
Azithromycin + cefuroxime
Inpatient moderate CAP IV azithromycin + ceftriaxone
Severe inpatient CAP Cefapime + Fluoroquinolone
Prevention of Pneumonia
Why Prevent Pneumonia?
• Mortality hazard ratio for CAP 1.65
• Average age 59
• Inpatient cost $11,000 to $55,000
• Outpatient cost $1,000 to $5,600
Wyrwich KW et al. Patient Relat Outcome Meas. 2015;6:215‐223
Pneumococcal Vaccination
Hazard Ratio
CAP Hospitalization 1.21
Outpatient pneumonia 1.14
Pneumococcal bacteremia 0.58
Death from any cause 0.88
Jackson LA et al. N Engl J Med 2003;348:1747‐1755
18
Problems with Polysaccharide Vaccine
• Ineffective under age 2
• Not lifelong
• No mucosal immunity
• No protection from upper or lower tract infection
• Little herd immunity
• No help with carrier rates
Conjugated Vaccine (PCV 13)
• Mucosal immunity and longer lasting
• Adults 19 and older with
• asplenia, sickle cell disease, cerebrospinal fluid leaks, cochlear implants, or other immunosuppressing conditions
• Should get PCV13 first followed in 8 weeks by PPSV23
• If PPSV23 already given, give PCV13 one year later
Pneumococcal Vaccines
PVC13 PPSV23
Prevents bacteremia + +
Limits non‐Bacteremic pneumonia + ?
Prevents colonization +
Response in young children +
Faster immune response +
More strains +
PPSV23 blunts response to PCV13
Influenza Vaccination • 17,393 admissions for CAP in 4 year study
• November → April
• 1590 vaccinated patients significantly less likely to die (odds ratio = 0.30)
• Influenza may increase pneumococcal susceptibility by 100 fold
Spaude KA, et al.. Arch Intern Med. January 8, 2007;167:53–9
Antibiotics for Acute Respiratory Infection
• 814,000 patients, 1.5 million visits
• 65% were diagnosed with bronchitis
• Significant minor adverse side effects in treated group
• Less hospitalizations for pneumonia in antibiotic group
• NNT is 12,225Meropol SB et al. Ann Fam Med March/April 2013 vol. 11 no. 2 165‐172
19
Antibiotics for “Almost Pneumonia?”
• 2000 patients with “moderately bad” bronchitis or worse randomized to amoxicillin or placebo
• NNT 30 to prevent new or worsening symptoms
• Number needed to harm 21
• Nausea, rash, diarrhea
• One anaphylaxis
Little P et al. Lancet 13:2, p123–129,
Time for a Vitamin D Slide
• Finnish study of 1,421 subjects from 1998‐2001
• Lowest 1/3 had 2.5 risk of pneumonia than those with high levels
University of Eastern Finland. "Low vitamin D levels a risk factor for pneumonia." ScienceDaily. ScienceDaily, 30 April 2013
Other Risk Reducers
•High socioeconomic status
•Recent dental examination
• Statins
Statins and Pneumonia
• 18 studies
• RR 0.84 for CAP
• RR 0.68 short term mortality
• Dampens inflammatory response
• No benefit in VAP
Khan AR, Riaz M, Bin Abdulhak AA, et al. PLoS One. 2013;8(1):e52929Papazian L, Roch A, Charles PE, et al. JAMA 2013;310:1692‐170
Practice Recommendations
• Learn guidelines, they have potential to improve mortality
• Discharge when switched to orals
• Immunize against pneumococcal disease with both vaccines and influenza
• Be rich with nice teeth
Rocky Graziano
I quit school in the sixth grade because of pneumonia.
Not because I had it, but because I couldn't spell it.
