Pneumonia: The Forgotten Killer

Transcription

1 Pneumonia: The Forgotten Killer David Glenn Weismiller, MD, ScM, FAAFP Department of Family and Community Medicine University of Nevada, Las Vegas School of Medicine

2 Disclosure Statement 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 conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree 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.

3 Learning Objectives 1. Discuss the diagnostic and risk factor approaches to common types of pneumonia. 2. Describe empiric therapy of pneumonia for outpatients and inpatients. 3. Explain the use and ACIP recommendations for pneumonia vaccines.

4 Community Acquired Pneumonia (CAP) Leading cause of infection-related death 20% require hospitalization 60% of these are > 65 yrs old Mortality rate is <5% for those treated as outpatients Up to 25% for those requiring hospitalization Up to 50% when ICU is needed

5 CAP Diagnosis History Cough 90% Sputum production 66% Dyspnea 66% Pleuritic chest pain 50% Fever/chills Malaise/weakness Smoking history Travel history Physical examination Fever Tachycardia Hypoxia Tachypnea Crackles Bronchial breath sounds Consolidation (dullness to percussion, egophony, tactile fremitus)

6 CAP Work-Up CXR confirms the clinical diagnosis Lobar consolidation, effusions suggest bacterial etiology Bilateral interstitial infiltrates suggest viral etiology May exclude illnesses that mimic CAP False negative Dehydration Elderly patients Repeat in hours if clinical suspicion high

7 CAP Work-Up Sputum for gram stain and culture (SOR B) Done prior to Rx only if good quality (few squamous epithelial cells) and rapidly processed in a microbiology lab Not sensitive but fairly specific May be useful to exclude Staph. aureus or gram negative rods Misleading in those with COPD Blood cultures (x 2) (SOR A) Collect prior to antibiotic therapy Most helpful in those with severe or atypical CAP Positive in 5-14% of cases S. pneumoniae accounts for 2/3 of positive cultures

8 1. A 68 year old female is admitted to the ICU with severe CAP. Her urine should be tested for which one of the following antigens? A. Chlamydia B. Mycoplasma C. Legionella D. Pseudomonas

9 CAP Work-Up Initial treatment is usually empiric Influenza A & B rapid antigen if in season Legionella, and S. pneumo urinary antigen testing (UAT) can be done if failed outpt Rx.; consider TB testing If intubated Endotracheal aspirate should be sent for culture

10 2. A 16 year old male presents to the ED with a 3 day history of fever (101.5) and a productive cough. His parents smoke in the home. What is the most likely pathogen causing his illness? A. Streptococcus pneumoniae B. Mycoplasma pneumoniae C. Haemophilus influenzae D. Chlamydia pneumoniae

11 CAP Etiology Most common pathogens Streptococcus pneumoniae 20-60% Mycoplasma pneumoniae 1-40% Chlamydia pneumoniae 4-10% Legionella 2-10% Haemophilus influenzae 3-10% Moraxella catarrhalis 1-5 % Virus & anaerobes 2-15%

12 CAP Etiology Less common pathogens Staphylococcus Gram negative bacilli (3-10%) Pneumocystis Mycobacterium tuberculosis Other causes Aspiration (6-10%)

13 CAP Modifying Factors Pediatric patients Age 4 mo to 4 yrs Most common pathogen RSV Peak incidence 2-7 mo of age Age 5-18 yrs Most common pathogen Mycoplasma pneumoniae Treat with a macrolide

14 CAP Modifying Factors Increased risk for drug-resistant S. pneumoniae (DRSP) Age > 65 Beta-lactam Tx in last 3 mo ETOH abuse Immunosuppressive illness Multiple medical comorbidities Chronic heart, lung, liver, or renal disease, DM, malignancies, asplenia, immunosuppressed conditions Exposure to children in a day care center

15 CURB-65 Clinical Factors Severity Scores for CAP Points Confusion 1 Uremia (BUN >19mg/dl or 7mmol/L) 1 Respiratory Rate >30/min 1 Blood Pressure: SBP <90 or DBP <60 1 Age >65 1

16 CURB-65 Severity Scores for CAP Curb-65 Score Death % Recommendation Low risk (consider home treatment) Low risk Higher risk (consider hospitalization) 3 14 High risk (hospitalize) 4 or Severe (consider ICU)

17 ICU Admission Decision Patients with either 1 of the major criteria or 3 of the minor criteria Major criteria Need for mechanical ventilation Septic shock Minor criteria PaO2/FiO2 ratio < 250 RR > 30/min Confusion Multilobar infiltrates SBP < 90 mm Hg despite fluid resuscitation BUN > 20 mg/dl Leukopenia (< 4000 cells/mm3) Thrombocytopenia (< 100,000 cells/mm3) Hypothermia (< 36 degrees Celsius) Hyponatremia (< 130 meq/l) Arterial ph < 7.3

18 3. 55 year old male presents with a 4-day history of productive cough, fever at home and a CXR showing a RLL infiltrate. He received Clindamycin 2 months ago for dental work. The appropriate choice for outpatient treatment is? A. Levofloxacin B. Azithromycin C. Cefuroxime D. Augmentin

19 CAP and Drug-Resistant S. pneumo (DRSP) In the US, most penicillin resistance is intermediate and not highly resistant Definitions Sensitive = MIC < 2 mg/l Intermediate = MIC of 4 mg/l Resistance = MIC > 8 mg/l

20 CAP and DRSP BIRP criteria (pts at high risk for drugresistant pneumonia) B: Broad spectrum antibiotics within past 3 mo I: Immunosuppression R: Resident of a NH or poor functional status P: Prior hospitalization within past 3 mo

21 Treatment Categories (2010 IDSA) 1. Outpatient If healthy, low risk for DRSP, no antibiotics in past 3 months 2. Outpatient with comorbidities COPD, CHF, DM, renal, liver, malignancy, immunosuppression, recent antibiotics in past 3 months or macrolide resistance

22 Treatment Categories (2010 IDSA) 3. Inpatient (Non ICU) 4. ICU Expanded coverage including Gm negatives associated with aspiration Extensive coverage (Staph, Legionella, Gram neg, H. flu)

23 CAP Principles to Guide Therapy Give 1 st dose rapidly and before leaving ED All pts should be treated for atypical pathogens (i.e. Mycoplasma) and pneumococcus Plus other pathogens based on risk factors Monotherapy with macrolides should be limited to pt with no cardiopulmonary disease or recent antibiotics Anti-pseudomonal Rx should be used for those with pseudomonal risk factors MRSA Rx should be used only if increased risk No ICU admit should receive monotherapy

24 CAP Treatment 1. Outpatient, previously healthy, no risk for DRSP infection Macrolides (SOR A) Azithromycin Clarithromycin Erythromycin OR Doxycycline (SOR B)

25 CAP Treatment 2. Outpatient with comorbidities or recent abx Respiratory fluoroquinolone (SOR A) Moxifloxacin, gemifloxacin, or levofloxacin OR Beta-lactam PLUS a macrolide* (SOR A) High-dose amoxicillin (1gm TID) or Amox/clavulanate (2g BID) preferred Alternatives include ceftriaxone, cefpodoxime, cefuroxime *Doxycycline can be an alternative to the macrolide

26 CAP Treatment 3. Inpatient (Non-ICU) Respiratory fluoroquinolone (IV or PO) (SOR A) OR Beta-lactam (IV or IM) Cefotaxime, ceftriaxone, and ampicillin/sulbactam Ertapenem for selected pts PLUS Macrolide* (IV or PO) (erythro, clarithro, azithro) *Doxycycline may be substituted (SOR C)

27 4. Inpatient (ICU) Beta-lactam (IV) CAP Treatment Cefotaxime, ceftriaxone, or ampicillin/sulbactam PLUS Azithromycin OR Fluoroquinolone (SOR A) (If PCN allergic fluoroquinolone and aztreonam recommended)

28 CAP Treatment Reduce time to first antibiotic dose (SOR B) Before leaving the ED Switching from IV to PO (SOR B) Hemodynamically stable Improving clinically Able to take PO and normal functioning GI tract

29 CAP Treatment Discharge from hospital (SOR B) Clinically stable No other active medical problems Safe environment for continued care Inpatient observation is not necessary while receiving PO Rx

30 CAP Treatment CAP patients should be treated For a minimum of 5 days (SOR A) Until afebrile for hrs Until at least all but 1 CAP associated sign of clinical stability (SOR B) Temp < 37.8 C HR < 100 BPM RR < 24 BrPM SBP > 90 mm hg O2 Sats > 90% po2 > 60 mm Hg on Rm air Ability to maintain oral intake Normal mental status (Halm and Fine, JAMA)

31 CAP Prevention Proven interventions: Smoking cessation (SOR C) Immunizations Pneumococcal (SOR B) Influenza (SOR A) Respiratory hygiene measures (SOR C) Masks and gloves for symptomatic patients

32 Hospital-Acquired Pneumonia (HAP) 2016 update Healthcare-associated pneumonia term HCAP is now retired HAP-Defined as acquired in hospital after 48 hrs or more after admission VAP-Ventilator-assoc. pneumonia (48 hrs or more after intubation)

33 HAP Risk Criteria Treatment should be guided by LOCAL antibiogram (unique to each hospital) High risk for Multidrug-Resistance (MDR) Prior intravenous antibiotic use within 90 days Septic shock at time of VAP ARDS preceding VAP Five or more days of hospitalization prior to the occurrence of VAP Acute renal replacement therapy prior to VAP onset

34 HAP Treatment Low Risk of Mortality, low MRSA risk Piperacillin-tazobactam 4.5g IV q 6h OR Cefipime 2g IV q 6h OR Levofloxacin 750 mg IV daily OR Imipenem 500 mgiv q 6h or Meropenem 1 g IV q 8h

35 HAP Treatment Low Risk of Mortality, HIGH MRSA risk Piperacillin-tazobactam 4.5g IV q 6h OR Cefipime 2g IV q 6h or ceftazidime 2 g IV q 8h OR Levofloxacin 750 mg IV daily or ciprofloxacin 400 IV q 8h OR Imipenem or Meropenem or Aztreonam (PCN allergy) PLUS Vancomycin 15mg/kg IV q8h or Linezolid IV

36 HAP Treatment HIGH Risk of Mortality, HIGH MRSA risk TWO of the following Piperacillin-tazobactam 4.5g IV q 6h OR Cefipime 2g IV q 6h or ceftazidime 2 g IV q 8h OR Levofloxacin 750 mg IV daily or ciprofloxacin 400 IV q 8h OR Imipenem or Meropenem or Aminoglycoside or Aztreonam PLUS Vancomycin 15mg/kg IV q8h or Linezolid IV

37 CAP Prevention: Pneumococcal S. pneumoniae consequences: Vaccination 19,000 preventable deaths per year due to pneumonia, bacteremia, and meningitis PCV-13 Pneumococcal Conjugate vaccine (Prevnar 13) T-cell response PPSV23 Pneumococcal Polysaccharide vaccine (Pneumovax) 23 serotypes that cause 80% of invasive pneumococcal disease B-cell response 96% drop in pneumonia caused by susceptible strains

38 4. You see an otherwise healthy 43 year old with new-onset Type 2 DM. When discussing vaccination for prevention of pneumonia, which of the following statements is most correct? A. PCV13 now then PPSV23 in 12 months B. PCV13 now and PPSV23 at age 65 C. PPSV23 now and again after age 65 D. PPSV23 at age 65

39 Conjugate Vaccine (PCV13) Primary series at 2, 4, 6 months, booster months Previously unvaccinated children need 1 dose of PCV13 Immunocompromised children up to age 18 need 1 dose of PCV13 (even if previously vaccinated with PCV7) Adults > 19 with CSF leaks, cochlear implants, functional asplenia, sickle cell, or immunosuppression need 1 dose All adults > 65 who have not previously received a dose of PCV13 need 1 dose

40 Polysaccharide Vaccine (PPSV) 23 Single dose at age > 65 years Indications for single dose for those 2-64 years of age: Chronic cardiac disease (especially cyanotic congenital and failure) Cirrhosis, chronic liver disease, alcoholism Cochlear implants, cerebrospinal fluid leak Diabetes Chronic lung disease, asthma, cigarette smoker Residents of chronic care institutions Indications for 2 doses 5 years apart ages 2-64 Chronic renal disease (renal failure and nephrotic syndrome) Asplenia, sickle cell Immunocompromised (HIV, congenital, leukemia/lymphoma, multiple myeloma, drugs or radiation, organ transplant)

41 How to Give Both Vaccines CDC recommends BOTH pneumococcal vaccines for adults >65 yrs Age 2-18 Give 1 dose of PPSV23 at least 8 weeks after the final dose of PCV13. (If immune compromise or asplenia, should receive a 2 nd dose of PPSV23 5 years after the first PPSV23) Age at high risk give PCV13 first followed by PPSV23 at least 8 weeks later Age > 65 give PCV13 first, followed by PPSV23 1 year later (min 8 weeks if immunocompromised) If your patient has received any doses of PPSV23, the dose of PCV13 should be given at least 1 year later If given PPSV23 prior to age 65, give 1 dose after 5 years or >65 yrs

42 Risk Group Immune Competent Functional or Anatomic Asplenia Immune Compromised Medical Condition PCV13 PPSV23 Chr Dz (heart, lung, liver) + Diabetes + Alcoholism + Cigarette smoking + CSF leaks + + Cochlear implants + + Sickle cell; congenital or acquired asplenia HIV, cancer, CRF, organ transplant, immunosuppression 2 nd PPSV23 After 5 yrs

43 Viral Lung Infections (Influenza) Abrupt onset of respiratory/constitutional symptoms (cough, fever, myalgia, headache, malaise, sore throat, and rhinitis) Aerosol spread in winter, incubation ~2 days, lasting 3-7 days Rapid tests available, but false-negative rate is high Antiviral meds should be started ASAP (ideally within 48 hours) for severe cases, hospitalized patients, or those at high risk: Chronic disease (e.g., Asthma, COPD, DM, CHD, etc.) Immunosuppression (HIV, AIDS, Cancer) Pregnancy Age <5 or >65

44 Antivirals for Influenza Oseltamivir (Tamiflu) preferred (SOR: A) Adults: 75 mg po BID x 5 days (QD x 7 days for *prophylaxis) Childhood dose with oral suspension is weight dependent Zanamivir (Relenza) except in asthma, COPD (SOR: A) Adults and children >7: 2 inhalations BID x 5 d (QD x 7d for prophylaxis) Peramavir (Rapivab) Adults: 600 mg IV infusion once *Chemoprophylaxis considered for recent exposure in high-risk patients and recommended for outbreaks in an institutional setting

45 Thank you!

46

47 Answers 1. C 2. B 3. A 4. C

48 References Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults Clinical Infectious Diseases. 2007;44:S27-S72. l f+html /child-immunization-schedule.pdf