KAISER PERMANENTE OHIO COMMUNITY ACQUIRED PNEUMONIA

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1 KAISER PERMANENTE OHIO COMMUNITY ACQUIRED PNEUMONIA Methodology: Expert opinion Issue Date: 8-97 Champion: Pulmonary Medicine Most Recent Update: 6-08, 7-10, 7-12 Key Stakeholders: Pulmonary Medicine, Next Update: 7-14 Pharmacy, IM RECOMMENDATION Guidelines are recommendations to support the Clinician in their decisions about the appropriate evaluation and treatment of Community Acquired Pneumonia (CAP). The guideline is not intended to replace the practitioner s clinical judgment, as the Practitioner is designing a treatment plan for each individual patient. EVALUATION CLINICAL CHARACTERISTICS Symptoms suggestive of pneumonia include fever combined with respiratory symptoms such as cough, sputum production, pleurisy, and dyspnea. Most patients have respiratory rate exceeding 20 per minute In patients with risk factors for HIV or HIV positive consider PCP (HIV related pneumonia will not be addressed in this guideline) Depending on the clinical situation the following may be appropriate: The American Thoracic Society (ATS) and the Infectious Disease Society of America (IDSA) guidelines differ on the degree of testing. The ATS maintains that positive cultures and a specific etiologic agent are difficult to obtain, whereas the IDSA emphasis is on establishing an etiologic diagnosis. To eliminate the confusion, the IDSA and ATS formed a joint committee to unify the CAP guidelines. CHEST X-RAY A chest film showing infiltrates can confirm the diagnosis of pneumonia. Normal CXR can be seen in the first 24 hours, in PCP, and profound neutropenia SPUTUM EXAMINATION Gram stain can help initial choice of antibiotics as 90% of the organisms seen on a good stain are what is cultured. However, 30-65% of the smears are negative; also, sputum cultures give a low yield. BLOOD CULTURES If the patient is admitted, 2 sets of blood cultures (obtained 10 minutes apart from separate sites) should be obtained. Blood culture is positive in only 11% of cases. HIV TESTING HIV testing is suggested in hospitalized patients between the age of 15 and 54 years of age if the HIV rate of new cases exceeds 1 case per 1000 discharges

2 SEROLOGY TESTING FOR PATIENTS ADMITTED TO HOSPITAL (to be considered) Legionella: urine antigen testing, or DFA ( direct fluorescent antibody testing) Pneumococcal urine antigen testing Mycoplasma serology Chlamydia serology SEVERITY ASSESSMENT & HOSPITALIZATION There are no firm guidelines for when patients should be admitted to the hospital, and ultimately the decision rests with the physician after an appropriate clinical assessment. There are a series of well-recognized risk factors that increase either the risk of death or the risk of a complicated course of CAP. When these factors are present, especially if multiple risk factors coexist, then hospitalization should be strongly considered. The specific hospitalization risk factors include: 1. Age > than 65 yr. 2. Vital Signs: Temperature <35 O C, or >38.3 O C Respiratory rate > 30/min Pulse >125 beats/min Systolic BP < 90 mmhg or diastolic <60 mmhg 3. Lab data: WBC < 4000 or > 30,000 po 2 < 60 mmhg on room air, pco 2 > 50 Multilobar or rapidly progressive infiltrates in the first 48 hours Creatinine > 1.2 mg/dl or BUN > 20 mg/dl ph <7.3 on an ABG 4. Co-existing diseases: Chronic renal failure, hepatic failure, congestive heart failure, diabetes mellitus, alcoholism, neoplasm, immunosuppression, altered mentation, previous hospitalization within the last year, previous pneumonia The Pneumonia Patient Outcomes Research Team (PORT) has developed a prediction rule which stratifies patients into 5 risk categories. (See attached table) The risk categories I and II are associated with a mortality of <1% and can be treated as an outpatient. Category III with a mortality of 2.8% and may require an overnight stay. Category IV and V have a mortality of 8.2% and 29% respectively and should be strongly considered for inpatient treatment. The British Thoracic Society (BTS) recommended the CURB-65 scoring system, which looks at Confusion, BUN > 20 MG/DL, Respiratory rate > 30, low Blood pressure ( systolic < 90 mmhg, diastolic < 60 mmhg), and age 65 or older. A CURB-65 score greater than 2 suggest inpatient or more intensive in-home health care services. Mortality for a score of 3 is 14.5%, for a score of 4, 40%, and for a score of 5 the mortality is 57%. Page 2 of 10

3 THERAPY* The emergence of drug resistant Streptococcus pneumoniae (DRSP) has lead to some modification of the recommendations for empiric therapy. The ATS has changed their recommendations to account for high level of penicillin resistance (MIC >2.0 ug/ml) and intermediate resistance ( ug/ml). Patients at risk for DRSP include those with antibiotic use in the last 3 months, age >65, use of immunosuppressive drugs, alcoholic abuse, and nursing home residents. The IDSA has divided empiric therapy between outpatient treatment and inpatient treatment. The inpatient treatment group is further divided between the general medical ward and the intensive care unit. The ATS also divided empiric therapy between inpatient and outpatient groups. The ATS further divided outpatients into groups with no risk factors such as cardiopulmonary disease or smoking and those with risk factors such as cardiopulmonary disease and smoking. The ATS also modifies empiric treatment if DRSP is suspected. Outpatient Group I No cardiopulmonary disease, nonsmoker Low DRSP risk Group II Cardiopulmonary disease including COPD and CHF NY Classes III and IV, smokers Low DRSP risk High DRSP risk (non-penicillin allergic) Macrolide, Azithromycin or Clairthromycin or Doxycycline 100 mg po BID Azithromycin 500 mg x 1, 250 mg po QD Or Doxycycline 100mg po BID Amoxicillin 500 mg po TID + Augmentin Azithromycin High DRSP risk (penicillin allergic) Inpatient Group III (medical ward) Low DRSP risk High DRSP risk Moxifloxacin 400 mg po QD (Antipneumococcal Fluroquinolone) Second or third generation cephalosporin IV, plus macrolide IV or doxycycline IV, Or IV Moxifloxacin alone Ceftazidime or ceftriaxone plus Page 3 of 10

4 Group IV (intensive care unit) macrolide IV, Or Moxifloxacin IV alone) (Antipneumococcal Fluroquinolone) Antipseudomonal 3 rd generation cephalosporin (e.g., ceftazidime or cefoperazone) or antipseudomonal penicillin or carbapenem, plus macrolide IV Or Fluoroquinolone IV plus an antipseudomonal 3 rd generation cephalosporin Or -lactam/ -lactamase inhibitor IV plus a macrolide IV or fluoroquinolone IV * The usual duration of antibiotic therapy is days, but may vary depending on the patient s clinical condition and response to therapy. MONITORING RESPONSE Fever decreases in 2-5 days WBC decreases in 4 days Physical findings ( i.e.. rales) resolve in > 7 days in 20-40% of patients CXR: < 50 years, 60% clear in 4 weeks; > 50 years or other concurrent illness only 20-30% clear by 4 weeks; follow-up CXR for resolution in 4 to 8 weeks Patients who fail to respond or deteriorate following initial therapy require reevaluation. Incorrect diagnosis CHF, embolus, neoplasm, sarcoidosis, drug reaction, hemorrhage Correct diagnosis Host issues: local factors (obstruction), inadequate host response, super infection, empyema Drug issues: error in drug selection, route or dose, compliance, drug reaction Pathogen issues: non-bacterial (fungi, viral), bacterial (mycobacteria), drug resistance MEMBER EDUCATION Compliance with medication; side effects of medications Members should be told to refrain from smoking Abnormal findings on chest X-rays clear much more slowly than do clinical signs of pneumonia SYSTEM SUPPORT Page 4 of 10

5 Pulmonary PROPOSED PROCESS & OUTCOME MEASURES Antibiotic use by diagnosis, hospital admissions, chest x-ray by diagnosis RATIONALE & SUMMARY OF EVIDENCE PATHOLOGY Microbial agent or cause Prevalence ( North American studies) Streptococcus pneumoniae 20-60% Haemophilus influenzae 3-10% Staphylococcus aureus 3-5% Gram negative bacillus 3-10% Miscellaneous ( Moraxella catarrhalis, 3-5% Streptococcus pyogenes, Neisseria meningitidis) Atypical Legionella Mycoplasma 10-20% 2-8% 1-6% 4-5% Chlamydia pneumoniae Virus (adenovirus, RSV, influenza) 2-15% Aspiration 6-10% Sixth leading cause of death in the United States Mortality rate of 1-5%, but as high as 25% in hospitalized patients Death usually within the first 7 days Radiographic deterioration in the setting of severe CAP has been noted to be a particularly poor prognostic feature, highly predictive of mortality. It may signify inadequately treated infection, and aggressive evaluation and initiation of broad antimicrobial therapy are necessary if there is accompanying clinical deterioration. Acute Exacerbation of Chronic Bronchitis (AECB) - No clear definition of acute bronchitis - Generally accepted as cough productive of purulent sputum <15d without clinical or radiographic evidence of pneumonia, increased sputum volume and increased shortness of breath. Etiology AECB H. Influenza up to 50% S. Pneumonia 15-20% C. Pneumonia 5% M. Catarrholes Emperic Rx for AECB Young adults: immunocompetent Doxycycline Amoxicillin Erythromycin Page 5 of 10

6 Older adults or with co-morbilities: REFERENCES Amox-clavulanate Azithromycin Fluoroquinolone 1. American Thoracic Society. Guidelines for the initial management of adults with community -acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Am Rev Respir Dis 1993;148: Bartlett JG, Mundy LM. Current concepts: community -acquired pneumonia. N Engl J Med 1995; 333: File, TM, Garan, J. et al. Guidelines for Emperic Antimicrobial Prescribing in CAP (Chest 2004; 125: ) 4. Guthrie, R. Community-Acquired Lower Respiratory Tract Infection, Etiology and Treatment, Chest; 120(6): Mandell LA, Marrie J, Grossman DF, et al. Canadian Guidelines for the Initial Management of CAP: An Evidence-Based Update by the Canadian Infectious Disease Society and Canadian Thoracic Society Clin Inf Dis 2000; 31: Ramsdell, J., Narseverje, GL., et al Management of Community Acquired Pneumonia in the Home. An American College of Chest Physician Clinical Position Statement, Chest 2005, Mandell, La., Wanderink, RG., Anqueto, A. et al. Infectious Disease Society of America / American Thoracic Society Consensus Guidelines on the Management of Community Acquired Pneumonia in Adults., Clin Inf Dis (suppl 2) S Hoare, Z., Lim, WS., Pneumonia update on diagnosis and management BMJ 2006 & 332: Lim, WS., Baudouin, SV,. et al. British Thoracic Society guidelines for the management of Community acquired pneumonia in adults: update Thorax 2009;64 (suppl III) iii1- iii Schmitt, S. Community Acquired Pneumonia Disease Management Project. Cleveland Clinic August 1, 2010 Page 6 of 10

7 Severity/Risk Algorithm Table Algorithm Patients with communityacquired pneumonia Is the patient over 50 years of age? yes no Does the patients have a history of any of the following comerbid conditions? Neoplastic disease Congestive heart failure Cerebrovascular disease Renal disease Liver disease yes Assign patient to risk classic II-V based on prediction model scoring system or curb-65 scoring system no Does the patient have any of the following abnormalities on physical examination? Alterered mental status Pulse > 12.5/minute Respiratory rate > 30/minute Systolic blood pressure < 90 mmhg Temperature <35 C or > 40 C yes no Assign patient to risk class I Page 7 of 10

8 Curb 65 Scoring System Confusion 0-1 BUN > 20mg/dl 0-1 Respiratory rate > Low Blood Pressure 0-1 Systolic < 90 Diastolic < 60 Age > Points Score 0-2 Mortality < 9% Score 3 Mortality 14.5% Score 4 Mortality 40% Score 5 Mortality 57% Page 8 of 10

9 Scoring System Pneumonia Severity Index (PSI) Patient characteristic Points assigned 1 Demographic factors Age: Males age (in yrs) Female s age (in yrs) 10 Nursing home resident +10 Comorbid Illnesses Neoplastic disease +30 Liver disease +20 Congestive heart failure +10 Cerebrovascular disease +10 Renal diseases +10 Physical examination findings Altered mental status +20 Respiratory rate > 30/minutes +20 Systolic blood pressure < 90 mmhg +20 Temperature <35 C or > 40 C +15 Pulse > 125/minutes +10 Laboratory findings ph < BUN > 10.8 mmol/l +20 Sodium < 130 meq/l +20 Glucose > 13.9 mmol/l +10 Hematocrit < 30% +10 PO 2 < 60 mmhg Pleural effusion A risk score (total point score) for a given patient is obtained by running the patient age in years (age 10 for females) and the points for each applicable patient characteristic. 2 Oxygen saturation <90% else was considered abnormal. Page 9 of 10

10 Stratification of Risk Score of PSI Risk Risk class Based on I Algorithm Low II < 70 total points III total points Moderate IV total points High V > 130 total points Table 3. Risk-class mortality rates for patients with pneumonia Validation Cohort Risk No. of No. of Mortality Recommendations class Points Patients (%) for site of care I No predictors 3, Outpatient II <70 5, Outpatient III , Inpatient (briefly) IV , Inpatient V <130 9, Inpatient Page 10 of 10