Community-Acquired Pneumonia Current & Future State Brad - PDF document

Community-Acquired Pneumonia Current & Future State Brad Sharpe, M.D. Professor of Clinical Medicine Department of Medicine UCSF sharpeb@medicine.ucsf.edu I have no relevant financial relationships to disclose. 1. In 1898, William Osler described community-acquired pneumonia as: a. An ailment that often leads to suffocation and death. b. A friend of the aged. c. A common and mortal disease which can be diagnosed by simple observation and percussion of the chest. d. Bad. Really bad. CAP: A Practical Approach 1

1. In 1898, William Osler described community-acquired pneumonia as: a. An ailment that often leads to suffocation and death. b. A friend of the aged. c. A common and mortal disease which can be diagnosed by simple observation and percussion of the chest. d. Bad. Really bad. CAP: A Practical Approach "Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those ‘cold gradations of decay’ so distressing of himself and to his friends.“ -- William Osler, M.D., 1898 CAP: A Practical Approach 2

“Brad, pneumonia sucks.” -- Mary R. Sharpe November 2011 CAP: A Practical Approach Update in CAP CAP: A Practical Approach 3

Roadmap • Background • Etiology • Diagnosis • Treatment • Prevention CAP: A Practical Approach Specific Goals: • Describe the most common causes of community-acquired pneumonia in the outpatient setting • Order appropriate diagnostic tests for CAP • Initiate appropriate antibiotics in the treatment of community-acquired pneumonia (CAP) • State the optimal duration of therapy in CAP • State the benefits and need for preventative measures for CAP CAP: Current & Future 4

Caveats • Will not talk about healthcare-associated pneumonia (HCAP) • Will not discuss admission decision (complex) • Syllabus or specific questions: (sharpeb@medicine.ucsf.edu) Community-Acquired Pneumonia Roadmap • Background • Etiology • Diagnosis • Treatment • Prevention CAP: A Practical Approach 5

CAP: Background • 5 million cases/year in the U.S. • 80% of CAP is treated outpatient • Sixth leading cause of death • Inpatient mortality 10-35% • Outpatient mortality < 1% CAP: A Practical Approach CAP: Background • Some evidence that quality of care for African-Americans with CAP is worse • Higher mortality among Caucasians Mortensen EM, et al. BMC Health Serv Res . 2004;4:20. CAP: A Practical Approach Mayr FB, et al. Crit Care Med . 2010;38:759. 6

CAP: Background Cough 90%* Dyspnea 66% Sputum 66% Pleuritic chest pain 50% * Yet, only 4% of all visits for cough are pneumonia Halm EA, Teirstein AS. N Engl J Med 2002;347(25):2039. CAP: A Practical Approach Clinical Presentation: Geriatrics • Less “classic” presentations 10% have NONE of the classic signs or symptoms • • Up to 35% will not have fever • Up to 50% will have altered mental status • Up to 50% will have “asthenia” Mehr DR, et al. J Fam Prac 2001;50(11):1101. Riquelme R, et al. Am J Respir Crit Care Med 1997;156:1908. Sund-Levander M, et al. Scand J Inf Dis . 2003;35:306. Simoneti AF , et al . Ther Adv ID . 2014;2:3. Community-Acquired Pneumonia 7

Roadmap • Background • Etiology • Diagnosis • Treatment • Prevention CAP: A Practical Approach “Typical” vs. “Atypical” • Typical organisms ♦ S. pneumoniae, H. influenzae, M. catarrhalis, etc . CAP: A Practical Approach 8

“Typical” vs. “Atypical” • Atypical organisms ♦ M. pneumoniae, C. pneumoniae, Legionella spp, etc. CAP: A Practical Approach “Typical” vs. “Atypical” • Classic teaching is not supported by the literature • Some general trends • S. pneumoniae in older pts, co-morbidities • Mycoplasma in patients < 50 years old • Bilateral hazy opacities more likely to be atypical (but not always) CAP: A Practical Approach 9

“Typical” vs. “Atypical” • Classic teaching is not supported by the literature • Some general trends • But - no history, exam, laboratory, or radiographic features predict organism • “Walking pneumonia” • “Classic lobar pneumonia” CAP: A Practical Approach Etiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient File TM. Lancet 2003;362:1991. CAP: A Practical Approach 10

Microbiology of CAP Jain S, et al. NEJM. 2015. Community-Acquired Pneumonia Microbiology of CAP • Prospective study of 2320 patients with CAP admitted to 5 hospitals • All extensive diagnostic evaluation Blood cultures, sputum cultures • Urine antigen for S. pneumoniae & Legionella • Nasopharyngeal PCR for viruses, • Chlamydophila , Mycoplasma Some serologic testing • Jain S, et al. NEJM. 2015. Community-Acquired Pneumonia 11

Microbiology of CAP Jain S, et al. NEJM. 2015. Community-Acquired Pneumonia Microbiology of CAP Jain S, et al. NEJM. 2015. Community-Acquired Pneumonia 12

Microbiology of CAP 1) Rhinovirus 2) Influenza 3) Streptococcus pneumoniae Jain S, et al. NEJM. 2015. Community-Acquired Pneumonia Microbiology of CAP • No pathogen detected in > 60% of patients Real-world ~ 80-90% • • Many possible explanations Mainly viruses? • Inadequate diagnostic testing • Jain S, et al. NEJM. 2015. Community-Acquired Pneumonia 13

Etiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient File TM. Lancet 2003;362:1991. CAP: A Practical Approach Etiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient • Resp. viruses • S pneumoniae • Resp. viruses • S pneumoniae • Legionella • S pneumoniae • M pneumoniae • H influenzae • M pneumoniae • C pneumoniae • GNRs • C pneumoniae • H influenzae • S aureus • H influenzae • Resp. viruses (?) • Legionella spp File TM. Lancet 2003;362:1991. CAP: Current & Future Metlay JP , et al. JAMA 1997;278(17):1440. 14

Take Home Points 1) 2) 3) 4) 5) Community-Acquired Pneumonia Take Home Points 1) Cover typical and atypical bacteria 2) 3) 4) 5) Community-Acquired Pneumonia 15

Roadmap • Background • Etiology • Diagnosis • Treatment • Prevention CAP: A Practical Approach 2. A 65-year old man presents to urgent care complaining of subjective fever, chills, and productive cough x 3 days. He reports mild shortness of breath. His temperature is 38.6 o C, RR 20, O 2 saturation 95% on RA. He has crackles at the right base on lung exam. You should: a. Treat for community-acquired pneumonia. b. Send him for a PA and lateral CXR. c. Send him for blood and sputum cultures. d. Prescribe sudafed and robitussin and send him home. e. Perform trans-tracheal aspiration f. B and C CAP: A Practical Approach 16

2. A 65-year old man presents to urgent care complaining of subjective fever, chills, and productive cough x 3 days. He reports mild shortness of breath. His temperature is 38.6 o C, RR 26, O 2 saturation 95% on RA. He has crackles at the right base on lung exam. You should: a. Treat for community-acquired pneumonia. b. Send him for a PA and lateral CXR. c. Send him for blood and sputum cultures. d. Prescribe sudafed and robitussin and send him home. e. Perform trans-tracheal aspiration f. B and C CAP: A Practical Approach Diagnosis of CAP 1) Select clinical features (e.g. cough, fever, sputum, pleuritic chest pain) AND 2) Infiltrate by CXR or other imaging IDSA/A TS Guidelines. CID . 2007;44:S27-72. CAP: A Practical Approach 17

Chest Radiograph – Gold Standard • All expert guidelines state should have positive CXR to make diagnosis ● History & exam not good enough (50% sensitive) • In outpt setting, should see an infiltrate. ● Order CXR if you are concerned about CAP ● If CXR negative, likely should not treat for CAP • In the inpatient setting, can see pneumonia with a negative CXR (~30%) Metlay J. Ann Intern Med . 2003. Community-Acquired Pneumonia Chest Radiograph – Gold Standard? • Should (generally) order CXR in all patients with suspected pneumonia. • In the hospital, a positive CXR is not necessary to treat as CAP (but consider other diagnoses) . Community-Acquired Pneumonia 18

2. A 65-year old man presents to urgent care complaining of subjective fever, chills, and productive cough x 3 days. He reports mild shortness of breath. His temperature is 38.6 o C, RR 26, O 2 saturation 95% on RA. He has crackles at the right base on lung exam. You should: a. Treat for community-acquired pneumonia. b. Send him for a PA and lateral CXR. c. Send him for blood and sputum cultures. d. Prescribe sudafed and robitussin and send him home. e. Perform trans-tracheal aspiration f. B and C CAP: A Practical Approach 2. A 65-year old man presents to urgent care complaining of subjective fever, chills, and productive cough x 3 days. He reports mild shortness of breath. His temperature is 38.6 o C, RR 26, O 2 saturation 95% on RA. He has crackles at the right base on lung exam. You should: a. Treat for community-acquired pneumonia. b. Send him for a PA and lateral CXR. c. Send him for blood and sputum cultures. d. Prescribe sudafed and robitussin and send him home. e. Perform trans-tracheal aspiration f. B and C CAP: A Practical Approach 19