Pneumonia Lisa G. Winston, MD University of California, San Francisco San Francisco General Hospital Community Acquired Pneumonia (CAP): definition At least 2 new symptoms New infiltrate on chest x-ray and/or abnormal chest exam No hospitalization or other nursing facility prior to symptom onset Fever or hypothermia Cough Rigors and/or diaphoresis Chest pain Sputum production or color change Dyspnea Healthcare-Associated Pneumonia Terminology Healthcare-associated pneumonia (HCAP) Hospital-acquired pneumonia (HAP) – in hospital at least 2 days Ventilator-associated pneumonia (VAP) – on ventilator at least 2 days Guidelines published 2005 by ATS and IDSA Definitions and treatment recommendations
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18 Winston Pneumonia - UCSF CME · Sputum production or color change Dyspnea Healthcare-Associated Pneumonia Terminology Healthcare-associated pneumonia (HCAP) Hospital-acquired pneumonia
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Pneumonia
Lisa G. Winston, MD
University of California, San Francisco
San Francisco General Hospital
Community Acquired Pneumonia (CAP): definition
At least 2 new symptoms
New infiltrate on chest x-ray and/or abnormal chest exam
No hospitalization or other nursing facility prior to symptom onset
Fever or hypothermia Cough
Rigors and/or diaphoresis Chest pain
Sputum production or color change Dyspnea
Healthcare-Associated Pneumonia
Terminology
Healthcare-associated pneumonia (HCAP)
Hospital-acquired pneumonia (HAP) – in hospital at least 2 days
Ventilator-associated pneumonia (VAP) – on ventilator at least 2 days
Inpatient therapy, concern for community methicillin-resistant Staphylococcus aureus (MRSA): Add vancomycin or linezolid to regimen you
would select otherwise
*Consider as a routine measure for patients admitted to the ICU – Gram strain of respiratory specimen (sputum or tracheal aspirate) can be very helpful
Treatment of Hospital-Acquired Pneumonia (HAP)
Guidelines stratify patients by intensity of healthcare exposure into two categories
> 5 days in the hospital or risk factors for drug resistant organisms
Risk factors per guidelines include antibiotics or prior hospitalization within 90d, residence in a nursing home, dialysis, immunosuppression
< 5 days in the hospital and no risk factors
Treatment of Hospital-Acquired Pneumonia (HAP)
Initial, empirical therapy for early onset, no drug resistance risk factors
Ceftriaxone or
Levofloxacin or moxifloxacin or
Ampicillin/sulbactam or
Ertapenem
Am J Respir Crit Care Med 2005:388-416
Treatment of Hospital-Acquired Pneumonia (HAP)
Cefepime or ceftazidime
Or
Imipenem or meropenem
Or
Piperacillin/ tazobactam
Ciprofloxacin or levofloxacin
Or
Amikacin or gentamicin or tobramycin
Initial, empirical therapy for late onset or drug resistance risk factors
Linezolid or vancomycin + +
Am J Respir Crit Care Med 2005:388-416
Length of Therapy
7 – 10 days has been standard for most patients but may not be necessary
Shorter course with azithromycin or high dose levofloxacin
Meta-analysis that patients with mild to moderate disease can be treated with 7 days or less
Li et al. Am J Med. 2007;120(9):783-90
Length of Therapy
For VAP, 8 days compares favorably to 15 days – may want to extend with non-fermenting Gram negatives, e.g. Pseudomonas aeruginosa
Chastre et al, JAMA 2003;290(19):2588-98
Switch to Oral Therapy
Reduces costs, shortens length of stay, may reduce complications
As soon as improving clinically, able to take POs, GI tract functioning Usually within 3 days; no need to observe in hospital
Narrow spectrum agent if organism identified (usually S. pneumoniae)
Empirical therapy: macrolide, doxycycline, antipneumococcal fluoroquinolone, or combination therapy
Prevention
There are steps patients and providers can take….
Prevention Influenza vaccine
Pneumococcal vaccine ~ 60% effective for pneumococcal bacteremia in
immunocompetent adults
Few side effects
Can be given simultaneously
Give prior to hospital discharge Standing orders facilitate
Prevention
Smoking, with or without COPD, is a significant risk factor
Do gastric acid-suppressive drugs, especially proton pump inhibitors, increase risk for CAP?
Risk may only be associated with drugs that are recently started, not with long-term use; may not be causal Sarkar et al, Ann Intern Med, 2008;149(6)391-98
Prevention
Elderly patients with dementia appear to have increased risk for all-cause mortality when treated with both atypical and typical antipsychotic medications
Much of this risk may be due to pneumonia
Dutch case-control study showed a dose-dependent association of atypical and typical antipsychotic drugs with CAP in older patients
??? Increased risk of aspiration through mouth dryness, impaired swallowing and/or sedation
Trifiro et al, Ann Intern Med, 2010;152(7):418-25.