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Cap/vap Topic Discussion

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Definitions

Pneumonia: Inflammation of the lung most often caused by infection with bacteria, viruses, and other microorganisms or inhalation of substances such as food, liquid, gas, or dust

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Clinical Presentation

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Diagnosis

  • New infiltrate on imaging with clinical signs/symptoms
  • Chest x-ray (gold standard)
  • CT or ultrasound
  • Other testing:
  • Sputum grain stain and culture
  • Urine antigen assay – S. pneumoniae and Legionella
  • Blood cultures
  • Bronchoscopy

Common Etiologies

[pic 3][pic 4]

Curb-65 Severity Score for CAP

Prognostic Variables

Criteria

Score

Confusion

Disorientation to person, place, or time

1

Urea

BUN > 20 mg/dL

1

Respiratory Rate

> 30 breaths/min

1

Blood Pressure

SBP < 90 mmHg or DBP < 60 mmHg

1

Age

> 65 years of age

1

0-1: Treat as outpatient

2: Treat as inpatient

> 3: Often admitted to ICU

PORT Pneumonia Severity Index

  • Stratifies patients into 5 individual mortality risk classes
  • Generally preferred compared to CURB-65 due to validation
  • More time consuming, therefore not utilized as often as CURB-65
  • Several calculators available online

Comorbidities and Risk Factors for Antimicrobial Resistance

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Treatment Duration (OSUWMC) 

  • CAP: 5 days
  • HAP: 8 days
  • VAP: 8 days
  • 14 days if caused by S. aureus, Pseudomonas spp., Acinetobacter spp. Stenotrophomonas spp., and Burkholderia

Treatment Duration (IDSA)

  • CAP: Minimum 5 days
  • Patient should be afebrile for 48-72h before discontinuation
  • HAP/VAP: 7 days preferred

COMMUNITY ACQUIRED PNEUMONIA TREATMENT

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Outpatient Empiric Treatment:

  • Previously healthy + No Abx prior 3 months
  • Macrolide: clarithromycin or azithromycin
  • Tetracycline: doxycycline
  • Comorbidities, high risk of S. pneumoniae macrolide resistance, or Abx therapy in previous 3 months
  • Respiratory fluoroquinolone (levofloxacin, moxifloxacin)
  • Macrolide (or doxycycline) + B-lactam
  • High dose amoxicillin, amoxicillin/clavulanate, cephalosporin (ceftriaxone, cefuroxime, cefpodoxime)

Drug

Dose

Respiratory Fluoroquinolones

-Levofloxacin 750 mg PO daily

-Moxifloxacin 400 mg PO daily

Macrolide

-Azithromycin 500 mg PO x 1 day, then 250 mg PO daily x  2-5 days (alternative 500 mg PO x 3 days)

-Clarithromycin 500 mg x 1 day then 250 mg daily x 2-5 days

Tetracycline

-Doxycycline 100 mg PO BID

β-lactam

-Amoxicillin 1g PO TID

-Amoxicillin/clavulanate 2 g PO BID

-Ceftriaxone 1-2g IV Q24H

-Cefpodoxime 200 mg PO BID

-Cefuroxime 500 mg PO BID

Inpatient Empiric Treatment:

  • Inpatient, non-ICU
  • Respiratory fluoroquinolone alone OR
  • Macrolide or doxycycline PLUS Beta-lactam
  • Ampicillin, cefotaxime, ceftriaxone, ertapenem
  • PCN allergic patients: respiratory fluoroquinolone or aztreonam are recommended
  • Inpatient, ICU
  • Respiratory fluoroquinolone OR azithromycin PLUS
  • Beta-lactam
  • Ampicillin/sulbactam, cefotaxime, ceftriaxone, ertapenem
  • Inpatient, ICU - P. aeruginosa
  • Risk factors: chronic PO steroids, severe underlying pulmonary disease, prior abx therapy, smoking
  • Beta-lactam + fluoroquinolone OR
  • Fluoroquinolone: ciprofloxacin or levofloxacin
  • Beta-lactam: Zosyn, cefepime, meropenem, imipenem
  • Fluoroquinolone + aminoglycoside + azithromycin OR
  • Aminoglycoside: tobramycin, amikacin
  • Beta-lactam + fluoroquinolone + aminoglycoside
  • Inpatient, ICU – MRSA
  • Risk factors: ESRD, IVDU, prior Abx therapy, prior influenza
  • Linezolid OR
  • Vancomycin
  • NOT daptomycin!

HOSPITAL-ACQUIRED & VENTILATOR-ASSOCIATED PNEUMONIA TREATMENT

[pic 7]

  • All patients
  • S. aureus + P. aeruginosa + other gram-negative bacilli coverage
  • Zosyn OR cefepime OR levofloxacin
  • Imipenem and meropenem also included in guidelines but typically not used
  • MRSA coverage
  • Risk factors: prior IV Abx within 90 days, in a unit with > 20% MRSA isolates or prevalence not known, or high risk of mortality
  • One of the agents mentioned above PLUS vancomycin OR linezolid
  • Pseudomonas double coverage
  • Risk factors: prior IV Abx within 90 days, high risk of mortality, structural lung disease
  • Risk for methicillin-resistant Pseudomonas and other GNB
  • One of the agents mentioned above under “All patients” PLUS an aminoglycoside
  • Amikacin, gentamicin, tobramyci

Procalcitonin

  • Procalcitonin is a serum biomarker that helps distinguish bacterial infection from other causes of infection or inflammation
  • In healthy patients, procalcitonin is synthesized in thyroid neuroendocrine cells and the protein is not released into the blood until it is cleaved into calcitonin
  • In the presence of bacterial infection, procalcitonin synthesis is induced in nearly all tissue and is released into the bloodstream
  • Can be used in conjunction with clinical judgement for guiding antibiotic therapy
  • More helpful for discontinuing antibiotics instead of starting treatment
  • Trends in procalcitonin are more valuable than absolute quantity

References

  1. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O'grady NP, Bartlett JG, Carratalà J, El Solh AA. 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. Clinical Infectious Diseases. 2016 Jul 14;63(5):e61-111.
  2. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O'grady NP, Bartlett JG, Carratalà J, El Solh AA. 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. Clinical Infectious Diseases. 2016 Jul 14;63(5):e61-111.
  3. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A prediction rule to identify low-risk patients with community-acquired pneumonia. New England journal of medicine. 1997 Jan 23;336(4):243-50.

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