Robert L. Keith MD FCCP Associate Professor of Medicine Division of Pulmonary Sciences & Critical Care Medicine Denver VA Medical Center University of Colorado Denver How do we define pneumonia? Fever Sputum production Radiographic infiltrate Dilemmas in CAP management Use of Immunomodulatory Agents Duration of Treatment Need for follow-up imaging Smoking cessation counseling at time of CAP Performance Measures for CAP management
Dilemma #1: Use of Immunomodulatory Agents 51 yo male presents with 10-14 d of cough, SOB, fever, anorexia PMH: Htn, Gout, EtOH abuse PE: T=101.1, 115/72, 83% on RA Crackles in R mid lung WBC=13.7 Immunomodulatory Agents: Do they improve CAP outcome? Observation: Mortality from invasive pneumococcal pneumonia remains at 20% (2/3rds die within 1 week of admission) Inflammatory Events may be responsible for many of the poor outcomes in severe CAP Could immunomodulatory agents that suppress the immune response improve outcome?
Which agent improves CAP outcome: a. Macrolides b. Statins c. Steroids d. NSAIDs e. None of the above Immunomodulatory Agents 1. Macrolides: critical part of many treatment pathways. Concentrated in phagocytic cells and inhibit neutrophils and cytokine production 2. Statins: immunomodulatory and dampen the immune response. Meta-analysis 47% less mortality. Severe CAP & ARDS trials in progress 3. Steroids: have been studied. Multiple RCTs and no effect on mortality. Recent study showed 4d of dexamethasone decreased LoS by 1d. 4. NSAIDs: no evidence to support use. Overall, there may be a role for these in selected patients with severe CAP.
Dilemma #2: Duration of Treatment How long should patients be treated for CAP? Case: 57 yo male with malaise, dry cough, and altered mental status. PMH: Htn, gout, ESRD-on dialysis PE: confused male, T-101.7, 88/45, 85%-RA Pulm: crackles ant, upper R chest WBC: 12.8 Duration of Treatment How long should this patient be treated with antibiotics? 1. 14 days 2. 10 days 3. 7 days 4. 5 days after he is afebrile
Duration of Treatment for CAP Traditional treatment duration has been 10-14d 2 recent meta-analyses have concluded that short courses (<7d) are as effective as longer courses (FQ, azithro, or other abx) Evidence based treatment: should treat for a minimum of 5d if afebrile for 48h, no more than one CAPassociated sign of clinical instability Longer duration if initial treatment not active against identified pathogen or if complicated by extrapulmonary infection (meningitis, endocarditis, empyema) Still need to treat L. pneumophila for 14d CAP associated signs of clinical instability and CAP complications Dilemma #3: Follow-up Imaging Question: Should a CXR be repeated after documented pneumonia to show resolution? Case: 78 yo with persistent cough, productive of yellow sputum, and worsening SOB PE: 36.5, 126/75, 83% on RA Pulm: crackles in R base, soft exp wheeze Ext: no edema WBC: 7.1
Should CXR infiltrates be followed to resolution? (i.e. could I be missing a lung cancer?)
Follow-up Imaging Conclusions: Incidence of new lung cancer: 1.1% at 90d, 1.7% at 1 year and 2.3% at 5 years Characteristics independently associated with new lung cancer diagnosis: male sex, age>50, current smoking Bottom Line: Follow-up imaging (90d CXR) in subjects at increased risk of lung cancer (diff study in male veterans found 5 years incidence of 9.2%) Dilemma #4:Smoking Cessation Counseling when CAP is diagnosed This is a Joint Commission and CMMS performance measure in many systems to monitor the quality of care Case: 58 yo male presents with SOB, cough, fever and sputum production. He currently smokes 2ppd PE: T-100.8, 96/53, 93% on 2L O2 Pul: crackles in L upper Cor: tachy, no m/g/r Should this pt receive smoking cessation counseling?
Smoking Cessation Counseling Performance measure: Hospitalized CAP patients with a history of smoking within the last year, how many received advice or counseling 10 RCT (compared advice to no invervention) Conclusion: inpt cessation counseling w/o outpt follow-up did not improve quit rates (15.9% vs. 15.6%) RR 1.05, 95% CI 0.90-1.22 Other CAP Performance Measures Which of the Following Measures have been shown to be effective with high quality evidence? 1. Pnemococcal Vaccination 2. Blood cultures 3. Antibiotics administration within 6 hours 4. Use of guideline compliant antibiotics 5. Influenza Vaccination
Pneumococcal Vaccination Performance Measure: Identify pts > 65yo hospitalized with CAP and vaccinate prior to discharge 15 RCTs Meta-analysis: Vaccination decreased incidence of pneumococcal pneumonia & invasive disease Quality of evidence: low Blood Cultures Performance Measure: Patients admitted or transferred to ICU w/in 24h of admission for CAP 2 retrospective cohort studies (compared those with cultures to those without) Negative blood cultures associated with improved survival and those with blood cultures drawn were more stable at 48h Quality of evidence: low Blood cx do help determine guidelines (community wide resistance patterns) Antibiotic within 6 hours Performance Measure: Proportion of adult CAP patients who receive first dose of antibiotics within 6h of hospital arrival Most prior studies examined a 4h timepoint Extrapolated data has shown abx within 6h associated with shorter hospital stay, and possibly decreased mortality Quality of evidence: low
Guideline-Compliant Antibiotics Performance Measure: Proportion of adult CAP patients who receive an initial antibiotic regimen c/w guidelines in first 24h of hosp. 2 retrospective and 6 observational studies Studies consistently show decreased mortality. Quality of evidence: moderate IDSA/ATS Guidelines:Outpatient Treatment Recommendations for Empiric Antibiotic Selection Group I No cardiopulmonary disease + no modifying factors Advanced-generation macrolide (azithromycin or clarithromycin), Moxifloxacin, or Doxycycline* Group II Cardiopulmonary disease +/- other modifying factors β-lactam + (macrolide or doxycycline*), or Respiratory fluoroquinolone ATS Guidelines: Hospitalized Patients Antibiotic Selection In-patients, non-icu: Respiratory FQ or β-lactam + macrolide ICU: No risks for Pseudomonas aeruginosa IV β-lactam +IV macrolide (azithromycin) or IV fluoroquinolone ICU: Risks for P aeruginosa Selected IV antipseudomonal β-lactam + IV antipseudomonal quinolone or Selected IV antipseudomonal β-lactam + IV aminoglycoside + IV macrolide or IV nonpseudomonal fluoroquinolone
Influenza Vaccination Performance Measure: the proportion of CAP patients (age >50) hospitalized October-March and vaccinated if necessary 26 RCTs Meta-analysis: Influenza vaccination decreases lab-confirmed cases of symptomatic influenza, and influenza-like illnesses Quality of evidence: high Other CAP Performance Measures Which of the Following Measures have been shown to be effective with high quality evidence? 1. Pnemococcal Vaccination 2. Blood cultures 3. Antibiotics administration within 6 hours 4. Use of guideline compliant antibiotics 5. Influenza Vaccination Maintaining Success for Tomorrow Know your community prevalence of atypical/resistant pathogens Know your patient host competence / co-morbidities. Up to 10% of patients may not respond. Know when to start appropriate antibiotic therapy and when to stop Advise patients to finish entire course of therapy Baquero F. J Chemother. 1999;11:35-43.