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 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 Sources • Guidelines for Community-Acquired Pneumonia ♦ IDSA/ATS Consensus Guidelines 2007 (IDSA = Infectious Disease Society of America) (ATS = American Thoracic Society) ♦ BTS: British Thoracic Society • Updated Literature Review CAP: A Practical Approach 4

Caveats • Will not talk about healthcare-associated pneumonia (HCAP) • Will not discuss admission decision (complex) • Syllabus (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 • Viruses more common in older patients • Mycoplasma in patients < 50 years old 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 • S pneumoniae (30-50%) • S pneumoniae • S pneumoniae • Resp. viruses (10-30%) • M pneumoniae • Legionella spp • M pneumoniae • C pneumoniae • H influenzae • H influenzae • H influenzae • GNRs • C pneumoniae • Legionella spp • S aureus • Resp. viruses File TM. Lancet 2003;362:1991. CAP: A Practical Approach 10

Etiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient • S pneumoniae (30-50%) • S pneumoniae • S pneumoniae • Resp. viruses (10-30%) • M pneumoniae • Legionella spp • M pneumoniae • C pneumoniae • H influenzae • H influenzae • H influenzae • GNRs • C pneumoniae • Legionella spp • S aureus • Resp. viruses File TM. Lancet 2003;362:1991. CAP: A Practical Approach Etiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient • S pneumoniae (30-50%) • S pneumoniae • S pneumoniae • Resp. viruses (10-30%) • M pneumoniae • Legionella spp • M pneumoniae • C pneumoniae • H influenzae • H influenzae • H influenzae • GNRs • C pneumoniae • Legionella spp • S aureus • Resp. viruses File TM. Lancet 2003;362:1991. CAP: A Practical Approach 11

Etiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient • S pneumoniae (30-50%) • S pneumoniae • S pneumoniae • Resp. viruses (10-30%) • M pneumoniae • Legionella spp • M pneumoniae • C pneumoniae • H influenzae • H influenzae • H influenzae • GNRs • C pneumoniae • Legionella spp • S aureus • Resp. viruses File TM. Lancet 2003;362:1991. CAP: A Practical Approach Etiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient • S pneumoniae (30-50%) • S pneumoniae • S pneumoniae • Resp. viruses (10-30%) • M pneumoniae • Legionella spp • M pneumoniae • C pneumoniae • H influenzae • H influenzae • H influenzae • GNRs • C pneumoniae • Legionella spp • S aureus • Resp. viruses File TM. Lancet 2003;362:1991. CAP: A Practical Approach 12

CA-MRSA • Community-acquired MRSA (CA-MRSA) • Rare: ~ 5% of all CAP • Key clinical scenarios: • Post-influenza • Young, necrotizing, rapidly progressive CAP: A Practical Approach CA-MRSA Clinical Features % of Patients • Shock 50-100% • Multi-lobar 50-100% • Necrotizing 33-100% • Leukopenia 25-100% • Ventilated 50-100% • Mortality ~ 40% Lancet . 2009. CAP: A Practical Approach 13

Etiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient • S pneumoniae (30-50%) • S pneumoniae • S pneumoniae • Resp. viruses (10-30%) • M pneumoniae • Legionella spp • M pneumoniae • C pneumoniae • H influenzae • H influenzae • H influenzae • GNRs • C pneumoniae • Legionella spp • S aureus • Resp. viruses File TM. Lancet 2003;362:1991. CAP: A Practical Approach Roadmap • Background • Etiology • Diagnosis • Treatment • Prevention CAP: A Practical Approach 14

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 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 15

Diagnosis of CAP 1) Select clinical features (e.g. cough, fever, sputum, pleuritic chest pain) AND 2) Infiltrate by CXR or other imaging IDSA/ATS Guidelines. CID . 2007;44:S27-72. CAP: A Practical Approach 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 16

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 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 17