10/2/2017. Pneumonia: Are We Missing the Mark? Objectives. Pneumonia
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1 Pneumonia: Are We Missing the Mark? LaDawna Goering, DNP, APN, ANP-BC Nick Van Hise, Pharm. D, BCPS Objectives Diagnose Pneumonia Evaluate severity of illness tools and site of care decisions Review diagnostic tests in pneumonia Examine criteria for when to utilize diagnostic testing Analyze the use of quantitative cultures, biomarkers, and antibiogram Apply guidelines for prescribing antibiotics for treatment of CAP, HAP, and VAP Describe pneumonia prevention recommendations: Smoking cessation & Flu and pneumococcal immunization Pneumonia Community Acquired Pneumonia (CAP) affects 5.6 million patients a year 6 th leading cause of death in people > 65 years of age Averages 10.6 per 1,000 per working adults aged18 64 yrs. I million hospital admissions, 10 20% require ICU 140,000 readmissions a year, 1 in 5 within 30 days 50,000 deaths annually Both influenza pneumonia & bacterial pneumonia are associated with post pneumonia cardiac events including arrhythmias, worsening heart failure, and myocardial infarction. An elder adult can take months to recover; the mortality rate /risk remains elevated for 5 years post pneumonia. 1
2 Hospital Acquired/ Ventilator Associated Pneumonias Hospital acquired pneumonia and ventilator associated pneumonia account for 22% of all HAI. Pneumonia has the highest morbidity and mortality rates of all nosocomial infections. 50% of HAP patients suffer from respiratory failure, pleural effusions, septic shock, renal failure, and empyema. VAP estimated to occur in 9 28% of mechanically ventilated patients, VAP has a mortality rate of 3 17%. VAP estimated to prolong the duration of mechanical ventilation by up to 11 days, increase hospitalization stay by 6 25 days, and increase health care cost by $12,000 to $40,000 per episode. (Kallet, 2015) Diagnosis Clinical Diagnosis Cough Fever & Chills Fatigue Sputum Shortness of Breath Pleuritic chest pain 30% of elderly do not have cough, fever, sputum, or elevated wbc Physical Exam Rales/ Bronchial breath sounds May be missing in elderly population Definitive diagnosis = Chest radiograph / CT Diagnostic testing only if alters standard management care (antibiotic coverage) Pneumonia Chest X-ray (Smithuis, 2014) 2
3 Site of Care Decision Hospital Admission most costly Inpatient care for pneumonia 25% more costly than outpatient care Costs an estimated $ billion yearly Mean all age cost per inpatient episode $11,148 $51,219 Mean all age cost per outpatient episode $2,212 Benefits of outpatient treatment include Resume to normal activity sooner 80% prefer outpatient therapy Less risk for acquired infections (Sato, Rey, Nelson & Pinsky, 2013). Severity of Illness Initial Assessment of Severity Hospital vs. Outpatient CURB 65/ CRB65 Confusion, uremia, resp rate, low, blood pressure, age 0 1 outpatient > 2 inpatient (>3 ICU) Pneumonia Severity Index (PSI) Classifies patients into 5 mortality risk classes Recommends I II outpatients III observation/ short stay IV V Hospitalization/ inpatient Site of Care Decision Considerations Complications of pneumonia Exacerbation of underlying disease Rare illness (Sickle cell, neuromuscular disease) Signs or symptoms of severe CAP Borderline score thresholds (CURB/ CRB/ PSI) Psychosocial needs Intractable vomiting Injection drug abuse Psychiatric Illness Homelessness Poor overall functional status Cognitive dysfunction Ability to take oral medication & outpatient support (IDSA & ATS, 2007 & 2016) 3
4 CURB 65/ CRB65 Severity Score Site of Care (Auble et al., 2005) PNEUMONIA SEVERITY INDEX PSI Classifications (Mandell et al., 2007) 4
5 Criteria for Severe Community Acquired Pneumonia Minor criteria Respiratory rate >30 breaths/min PaO2/FiO2 ratio <250 (ratio arterial oxygen partial pressure to fractional inspired oxygen) requires arterial blood sample Multilobar infiltrates requires CXR Confusion/disorientation Uremia (BUN level >20 mg/dl) Leukopenia (WBC count, <4000 cells/mm3 ) Thrombocytopenia (platelet count, <100,000 cells/mm3 ) Hypothermia (core temperature, <36 degrees C) Hypotension requiring aggressive fluid resuscitation Major criteria Invasive mechanical ventilation Septic shock with the need for vasopressors (IDSA & ATS, 2007 & 2016) SMART COP Severe CAP Score of 5 or > (Charles et al., 2008) Criteria for Diagnostic Testing Intensive care unit admission Failure of outpatient antibiotic therapy Cavitary infiltrates Known / suspected Leukopenia Active alcohol abuse Chronic severe liver disease Severe obstructive/structural lung disease Asplenia (anatomic or functional) Recent travel (within past 2 weeks) Positive Legionella Positive pneumococcal Pleural effusion (IDSA & ATS, 2007 & 2016) 5
6 Pneumonia Diagnostic Testing Rapid Point of Care testing Influenza A/B (rapid/ useful for antiviral treatment/ high false negative) Blood cultures (Most common isolate S. pneumoniae) Pretreatment blood cultures for Hospitalized patients Positive 20 25% inpatients Pneumococcal Pneumonia Patients with Severe CAP (Most often S. auerus, P. aeruginosa, and other gram negative bacilli) Asplenia, complement deficiencies, chronic liver disease, leukopenia. Sputum cultures (Most common S. pneumoniae) Gram stain / culture If good sample / obtained within 6 12 hrs of antibiotics Patients with Severe CAP (COPD pts/ alcoholism) higher risk gram negative pathogens / P. Aeruginosa. (IDSA & ATS, 2016) Pneumonia Diagnostic Testing Urinary antigen tests Severe CAP Legionella pneumophilia (continues to be + for weeks) S. pneumoniae (rapid test and detect after can still be detected 3 days after antibiotic therapy) Enzyme linked immunosorbent assay (ELISA) Urine sample/ detects pneumococcal cell wall polysaccharide in 77 88% patients with bacteremic pneumococcal pneumonia 64% nonbacteremic pneumonia ELISA for legionella urinary antigen + 74% Leginonella pneumopila seotype1 PCR Assay Detects Respiratory viruses including influenza, Mycoplasa Pneumoniae, Chlamydophlia pneumoniae 20 40% of CAP hospitalized patients. (IDSA & ATS, 2016) Use of Quantitative Cultures, Biomarkers Recommendations in Suspected Hospital Acquired Pneumonia (non VAP) Respiratory Cultures Consider sputum cough induction / expectoration Nasotracheal suction Blood Cultures Target antibiotic treatment to results of microbiology results Not Recommended at this time for decision on antibiotic therapy Procalcitonin (PCT) clinical criteria is recommended over the use of serum PCT + clinical criteria PCT (0.1 ug/l) used to guide antibiotic discontinuation C reactive protein (CRP) clinical criteria is recommended over the use of CRP+ clinical criteria Soluble Triggering Receptor Expressed on Myeloid Cells (strem 1) (requires bronchial lavage) clinical criteria is recommended over the use of sterm 1+ clinical criteria (IDSA & ATS, 2016) 6
7 Prescribing Antibiotics Hospitals disseminate a local antibiogram specific to their intensive care population Empiric treatment is developed to treat the distribution of local pathogens and susceptibilities for inpatients and outpatients Recommended shorter Length of therapy 7 days. Prescribing Antibiotics Hospitals disseminate a local antibiogram specific to their intensive care population. Empiric treatment should be developed to treat the distribution of local pathogens and susceptibilities. MRSA? Drug resistance?? 7 day of antimicrobial therapy / de escalation Etiology of Community Acquired Pneumonia OUTPATIENT Streptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Chlamydophila pneumoniae Respiratory viruses INPATIENT NON ICU S. pneumoniae M. pneumoniae C. Pneumoniae H. influenzae Legionella species Aspiration Respiratory viruses INPATIENT ICU S. pneumoniae Staphylococcus aureus Legionella species Gram negative bacilli H. Influenzae Potentially GNR (IDSA & ATS, 2007 & 2016) 7
8 Definitions of the different types of Pneumonia CAP: patient currently residing in the community with no specific risk factors for resistance HAP: patient residing in the hospital for at least 48 hours and develops a new infiltrate after 48 hours of admission VAP patient developing a pneumonia after at least 48 hours of being ventilated (IDSA & ATS, 2007 & 2017) Antibiotics for CAP Outpatient without comorbidities : Doxycycline Azithromycin Outpatient with comorbidities Moxifloxacin Inpatient Non ICU Ceftriaxone + Azithromycin Moxifloxacin Inpatient ICU Ceftriaxone + Azithromycin Cefepime + Azithromycin Aztreonam + Vancomycin + Azithromycin Worried about QT prolongation Switch azithromycin to doxycycline (IDSA & ATS, 2007 & 2017) Antibiotics for HAP & VAP (IDSA & ATS, 2007 & 2017) 8
9 What about GNR & MRSA When to expect MRSA on the inpatient or outpatient: Outpatients: Recurrent cellulitis Chronic indwelling catheters (PICC s, foley s, ports, etc) Living in a long term care facility with greater than 40% colonization in the home Chronic dialysis Inpatients: Same risk factors as above except, greater than 40% colonization in the ICU When to expect Multi drug resistant (MDR) gram negative rods (GNR s) Receiving chronic (2 or more antibiotics IV or oral in the last 90 days) Living in a long term care facility with known MDR organisms (IDSA & ATS, 2007 & 2017) Who remembers HCAP (Healthcare Associated Pneumonia)? Well, it no longer exists The 2017 IDSA/ATS Guideline update eliminated the term HCAP HCAP previously were defined as: Being exposed to a hospital or receiving broad spectrum abx within the previous 90 days HCAP patients now are treated as CAP patients Is that always appropriate??? NO Lets discuss (IDSA & ATS, 2007 & 2017) Vaccination Influenza updates Pneumococcal Vaccination All persons > 6 months without contraindications Season quadrivalent / trivalent influenza vaccines Live attenuated influenza vaccine not recommended this season due to ineffectiveness against H1N1 during & Pregnant women may receive vaccine. (USDHS, MMWR, 2017) Prevnar 13 / PCV13 Pneumovax 23/PPSV23 Over the age of 65 (both PCV 13 & PPSV23) PCV13 first when possible PCV 13 & PPSV23 > age of 19 Give to High risk concurrent disease/ immunocompromising conditions asplenia CSF leak cochlear implants (ACIP, 2014) 9
10 Smoking Smoking cessation = Goal for all CAP patients who smoke All smokers should be offered smoking cessation education programs, counseling, and treatment, as well as follow up. Oral Care Hospitals and several research studies have found that oral care reduces non ventilator hospital acquired pneumonia (NV HAP) rates by 40% to 60%. References Aujesky, D., Auble, T., Yealy, D., Stone, R., Obrosky, D., Meehan, T., Fine, M. (2005). Prospective comparison of three validated prediction rules for prognosis in community acquired pneumonia. American Journal of Medicine Broulette, J., Y, H., Pyenson, B., Iwasaki, K., &Sato, R. (2013). The incidence rate and economic burden of community acquired pneumonia in a working age population. American Health & Drug Benefits. 6(8) Charles, P., Wolfe, R., Whitby, M., Fine, M., Fuller, A., Stirling, R.,. Grayson,L. (2008). SMART COP: A tool for predicting the need for intensive respiratory or vasopressor support in community acquired pneumonia. Clinical Infectious Disease.47(3): Kalil, A., Metersky, M., Klompas, M., Muscedere, J., Sweeney, D., Palmer, L.,.Brozek, J. (2016). Management of adults with hospital acquired and ventilator associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinicial Infectious Diseases. 63(5). E61 e111. Retrieved from: Kallet, R. H. (2015). The vexing problem of ventilator associated pneumonia: Observations on pathophysiology, public policy, and clinical science. Respiratory Care, 60(10), doi: /respcare Mandell, L., Wunderink, R., Anzueto, A., Bartlett, J., Campbell, G.,.Whitney, C. (2007). Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the management of community acquired pneumonia in adults, Clinical Infectious Diseases, 44(2) Retrieved from: 10
11 References Musher, D. & Thorner, A. (2014). Community acquired pneumonia. New England Journal of Medicine doi /NEJMra Sato,R., Rey, G., Nelson, S. & Pinsky, B. (2013). Community acquired pneumonia episode costs by age and risk in commercially insured US adults aged>50 years. Applied Health Economics and Health Policy. 11(3) Smithuis, R. (2014). Chest X Ray Lung disease. Four pattern approach. Radiology Assistant. Retrieved from: x ray lungdisease.html Tomczyk, S., Bennett, N., Stoecker, C., Gierke, R., Moore, M., Whitney, C., Handler,S. & Philshvilli, T. (2014). Use of 13 Valent pneumococcal conjugate vaccine and 23 valent pneumococcal polysaccharide vaccine among adults aged >65 years: Recommendations of the advisory committee on immunization practices. 63(37) U.S. Department of Health and Human Services, Centers for Disease control and Prevention.(2017). Prevention and control of seasonal influenza with vaccines: Recommendations of the advisory committee on immunization practices United States, Influenza Season. (MMWR Recomm Rep 2016;65[no.RR 5]). Retrieved from Weiss, E., Essaied, W., Adrie, C., Zahar, J., & Timsit, J. (2017). Treatment of severe hospital acquired and ventilator associated pneumonia: a systematic review of inclusion and judgment criteria used in randomized controlled trials. Critical Care, doi: /s Questions 11
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