ACTIVITY DISCLAIMER. Pneumonia: The Forgotten Killer DISCLOSURE. William Sonnenberg, MD, FAAFP. Audience Engagement System Step 1 Step 2 Step 3

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1 ACTIVITY DISCLAIMER Pneumonia: The Forgotten Killer William Sonnenberg, MD, FAAFP The 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. DISCLOSURE It 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, FAAFP Family 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 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 marks his 10th time presenting at the AAFP s annual meeting. Learning Objectives 1. 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 System Step 1 Step 2 Step 3 1

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 8 th Leading Cause of Death th leading cause of death in USA Most common infectionrelated mortality Main cause of sepsis worldwide 2 nd highest % of ER visits admitted Most in winter months 52,700 deaths in 2007 $17 billion per year DEATHS 60,000 50,000 40,000 30,000 20,000 10,000 27,682 41,325 53,282 2 nd leading cause of hospitalization Am Fam Physician Jun 1;83(11): Prostate Cancer Breast Cancer Pneumonia 2

3 30 Day Readmission Rate 25% 20% 15% 10% 5% 0% 23.5% 20.0% 15.5% 14.7% CHF COPD Pneumonia AMI Agency for Healthcare Research and Quality, Feb 23, 2016 $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 Apr 15;110(6):451 7 AES Poll Question #1 Community Acquired Pneumonia 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) Medications that Increase Risk Proton pump inhibitors Tumor necrosis factor alpha inhibitors Amiodarone N acetylcysteine, Oral or inhaled steroids Benzodiazepines Eszopiclone Torres A, Peetermans WE, Viegi G, Blasi F. Thorax. 2013;68(11): Remington LT, Sligl WI. Community acquired pneumonia. Curr Opin Pulm Med. 2014;20(3):

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 1.17 Samy Suissa, et al. Thorax. 2013;68(11): Benzodiazepines and CAP Case controlled study over 4,900 patients 54% pneumonia 22% dying in 30 days 32% dying in 3 years Anticholinergic and Pneumonia Case controlled study adults 64 94, 1039 pneumonia cases Acute use 59% cases of pneumonia 35% of controls aor = 2.55 Thorax doi: /thoraxjnl J Am Geriatr Soc Mar;63(3): 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:

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): 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 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. Daniel M. Musher, M.D., and Anna R. Thorner, M.D. NEJM 2014; 371: 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 5

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: Risk of Pneumococcal Pneumonia 50x higher < 2 years or > 65 years times more likely in males Smoking, active and passive, most important risk factor ages 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 H. Flu Pneumonia Subacute onset of fever, less fulminant Associated with COPD Productive cough CXR patchy bronchopneumonia or RLL pneumonia Semin Respir Crit Care Med. 2005;26(6): Sci Transl Med 2013 Jun 26;5(191) 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 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 Cunha BA. Clinical features of legionnaires' disease. Semin Respir Infect. 1998;13(2):

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 wall Clin Microbiol Rev. 2004; 17(4): 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: 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 Jun; 73(3): Hageman JC et al. Emerg Infect Dis. 2006;12(6):894 Features Suggesting CAP MRSA MRSA Pneumonia 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 Multiple nodular lesions Some with cavitation Bilateral pleural effusions N Engl J Med 2014; 370:

8 CAP Pathogens, Testing Jain S et al. N Engl J Med 2015;373: 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 False Negative CXR s Pneumocystis Early pneumonia First 24 hours Severe neutropenia Ebell MH. Predicting pneumonia in adults with respiratory illness. Am Fam Physician. 2007;76(4):562 8

9 Lung Ultrasound Sensitivity 94%, specificity 96% in adults No radiation, bedside Pregnancy More accurate for pleural effusion and consolidation Blood Cultures Positive 4% 18% in CAP Add little Highly specific if positive Obtain in severe CAP Yield halved by prior antibiotic treatment G Volpicelli, M Elbarbary, M Blaivas, the International Liaison Intensive Care Med, 38 (2012), pp Impact of Blood Cultures 13 studies Positive BC in 0% 14% Narrowed antibiotics 0% 3% Broadening 0% 1 % Who Needs Blood Cultures? Cavitation Alcoholics End stage liver disease Critically ill Neutropenia Asplenia Journal of Hospital Medicine 01/2009; 4(2): 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:

10 Pulse Oximetry All admitted patients CMS guideline po 2 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): 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 studies Thorax 2009; 64:iii1 iii55 doi: /thx 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 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 10

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 bacteria ATS pneumonia guidelines, 2007 Mortality of Hospitalized CAP Port or PSI 14% mortality in hospitalized patients 30% inpatient mortality in elderly Comorbidities COPD, diabetes, renal insufficiency, HF, CAD, cancer, chronic liver disease PORT Pneumonia Patient Outcomes Research Team PSI Pneumonia Severity Index Niederman MS et al. Am J Respir Crit Care Med. 2001; 163:

12 PORT: Step 1: Class I or Classes II V Presence of: > 50 years of age Altered mental status Pulse 125/min Respiratory rate > 30/minute SBP < 90 Temperature <35⁰C or 40⁰C History of: Neoplastic disease Heart failure Cerebrovascular disease Renal disease Liver disease Yes/No Any YES s, proceed to Step 2 All NO s, assign to Risk Class 1 Outpatient mortality 0.1% PORT Severity Index Demographic 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 > Systolic < T < 95⁰F or 104⁰F +15 Pulse PORT Severity Index Initial Lab Findings Points ph < BUN > Na < Glucose Hct < APO 2 < 60 or O 2 < 90% +10 Pleural effusion +10 PORT Severity Index Score Risk Class Site of Therapy 30 Day Mortality None I Outpatient 0.1% 70 II Outpatient 0.6% III Inpatient % IV Inpatient % >130 V Inpatient % 12

13 CURB 65 Scoring One point for each Confusion Uremia (BUN > 19) Respiratory Rate > 30 Blood pressure (SBP < 90, DBP < 60) Age 65 CURB 65 Treatment Site Score Mortality % Risk Suggested Site 0 0.6% Low Outpatient 1 2.7% 2 6.8% Moderate Short stay/ Supervised outpatient % Moderate to high Inpatient 4 or % High Inpatient/ICU British Thoracic Society British Thoracic Society Health Care Associated Pneumonia Hospital Acquired 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 Mandell et al. Clin Infect Dis 2007;44:S27 72 ICU S. pneumoniae Staphylococcus aureus Legionella species Gram negative Bacilli H. influenza Prevention of HAP Hand washing Non invasive ventilation Breaks in sedation Assess for extubation Head of bed at 30⁰ to 45⁰ Control glucose 13

14 Poll Question #4 Treatment of Pneumonia Minimum duration of treatment 1. 5 days 2. 7 days days 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 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 macrolideresistance Respiratory quinolone or β Lactam + Doxycycline Houck PM et al. Arch Intern Med. 2004;164(6):637 Mandell et al. Clin Infect Dis 2007;44:S27 72 IDSA Empiric Antibiotics for CAP (Inpatient) IDSA Empiric Antibiotics for CAP (Inpatient) Inpatients Non ICU ICU Pseudomonas MRSA Respiratory Quinolone or Anti pneumococcal β lactam + macrolide β lactam + Macrolide or resp quinolone or PCN allergy resp quinolone + aztreonam Always more than one ABX Antipseudomonal β lactam + antipseudomonal quinolone or Antipseudomonal β lactam + aminoglycoside + azithromycin or Antipseudomonal β lactam (PCN allergy aztreonam) + aminoglycoside + antipseudomonal quinolone Add Vancomycin or Linezolid Mandell et al. Clin Infect Dis 2007;44:S27 72 Mandell et al. Clin Infect Dis 2007;44:S

15 Atypical Coverage for Bacteremic Pneumonia 2,209 Medicare admissions for bacterial pneumonia If any atypical coverage; 30 day mortality, OR day readmission, OR 0.67 Benefits confined to macrolides, not fluoroquinolones nor tetracycline's In-hospital mortality, OR day mortality, OR day readmission, OR 0.59 Macrolides inhibit inflammatory response Mark L et al. Chest. 2007;131(2): 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 Fluoroquinolones Have Issues Hypertoxic C. diff; NAP1 Worse than clindamycin Prolonged QT interval Tendon rupture and tendonitis Black box neuropathy warning Aortic dissection, aneurysm Statin interactions Shorr AF, et al. BMJ Open 2013 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) 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 15

16 Switch to Oral Therapy Meet following criteria for 24 hours Able to ingest oral medications HR <100, SBP > 90 RR < 25 O 2 sat > 90%, po 2 > 60 on room air or lowflow O 2 via nasal cannula, or return to baseline O 2 for pts on long term O 2 therapy Return to baseline cognition Temp < 100.9⁰F (38.3⁰C) 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 Lee JS, Giesler DL, Gellad WF, Fine MJ. Antibiotic therapy for adults hospitalized with community-acquired pneumonia: a systematic review. JAMA. 2016;315(6): 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 Index Menéndez 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 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 Clin Infect Dis. 2007;44 Suppl 2:S27 Daniel M. Musher, M.D., and Anna R. Thorner, M.D. N Engl J Med 2014; 371:

17 Stable for Discharge? Temp > 37.8⁰C RR > 24 HR > 100 SBP 90 O 2 sat < 90% on room air Can t eat No mental status improvement Dagan E et al. Scand J Infect Dis. 2006;38(10):860 If one parameter of instability present at discharge then Death rate 14.6% v. 2.1% Readmission 14.6% v. 6.5% 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 tube Mitl RL et al. Am J Respir Crit Care Med. 1994;149(3 Pt 1):630. Simple Recommendations Mild CAP, no resistance Moderate CAP, recent ABX use Moderate CAP with comorbidity Inpatient moderate CAP Severe inpatient CAP Doxycycline Azithromycin + high dose amoxicillin Azithromycin + cefuroxime IV azithromycin + ceftriaxone 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: 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:

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 12,225 Meropol SB et al. Ann Fam Med March/April 2013 vol. 11 no

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 Time for a Vitamin D Slide Finnish study of 1,421 subjects from Lowest 1/3 had 2.5 risk of pneumonia than those with high levels Nausea, rash, diarrhea One anaphylaxis Little P et al. Lancet 13:2, p , 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):e52929 Papazian L, Roch A, Charles PE, et al. JAMA 2013;310: Practice Recommendations Rocky Graziano 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 I quit school in the sixth grade because of pneumonia. Not because I had it, but because I couldn't spell it. 19

20 Questions Contact Information William R. Sonnenberg, MD 20