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Antibiotic StewardshipECHO

AIM Statement: promote appropriate use of antibiotics to improve patients safety and

outcomes

Case-Based Community- Acquired Pneumonia (CAP) Guideline Update

10/17/2019Marshall Renna, Pharm.D.

Esther Zhang, Pharm.D.

Conflicts of Interest

• None

Learning Objectives

• Given a patient case, employ the most appropriate therapy for outpatient CAP

• Based on patient specific information, illustrate risk factors for drug resistant pathogens and need for empiric broad-spectrum antibiotics

• Given a patient case, employ the most appropriate therapy for inpatient non-severe CAP

• Given a patient case, employ the most appropriate therapy for inpatient severe CAP

Highlight of What’s New

Diagnostics Treatment

Sputum and blood cultures

2007 IDSA/ATS Criteria for

Defining Severe CAP

(1 major or > 3 minor)

MinorRR > 30 bpm

Pa02/FiO2 ratio < 250

Multilobar infiltrates

Confusion/disorientation

BUN > 20

WBC < 4000

PLT < 100,000

Temp < 36o C

Hypotension requiringfluids

MajorSeptic shock w/ vasopressors

Intubated

• ONLY in Severe CAP OR broad empiric coverage• Prior cultures w/

resistant organism• IV antibiotics in the

last 90 days

Patient Case

• A 62 yo F w/ a PMH significant for COPD presents to the ED with a 2 day history of cough, SOB, and subjective fever and chills

• Home meds: Albuterol, budesonide/formoterol, atorvastatin, tiotroprium, pantoprazole

• On physical exam: • Temp = 101 degrees F, BP 110/72, HR 89, RR 17, O2 sat is 97% on 3L

NC• Diffuse wheezing and rhonchi throughout

• Labs: WBC is 6.1, PLT 180, SCr 0.8, BUN 12

• Read as “patchy basilar opacity could be atelectasis or infection”

The patients procalcitonin comes back negative at <0.05, should antibiotics be initiated? 1. Yes2. No

Procalcitonin

Clinically suspected and radiographically confirmed CAP

Disregard procalcitonin

Initiation Reduce duration in setting of prolonged average length of treatment

Useful if average length of stay exceed 5 – 7 days

Cessation

Outpatient Therapy

• Amoxicillin OR• Doxycycline* OR• Macrolide - If local pneumococcal

resistance is less than 25%

No comorbidities or risk factors for Pseudomonas

or MRSA

• Combination therapy with amoxicillin/clavulanate or cephalosporin

• AND macrolide or doxycycline• OR monotherapy with respiratory

fluoroquinolone

With comorbidities (chronic heart, lung,

liver, or renal disease; DM; alcoholism;

malignancy; asplenia)

http://ir.melinta.com/static-files/663314fb-823b-484c-9f40-6d1726cbeee1

Streptococcus pneumoniae Resistance to Macrolides in the U.S.

Patient Case

• A 40 yo male presents to the ED in September with a 3 day history of fever, chills, cough, SOB, sputum production and right sided chest pain.

• PMH significant for tobacco use (cigarettes, 0.5 packs per day)• No home medications• On physical exam:

• Temp = 98.6 degrees F, BP 137/102, HR 108, RR 18, O2 sat is 95% on 2L NC

• Decreased breath sounds, rales• Labs: WBC is 18.2, PLT 270, SCr 1.16, BUN 22

The patient in admitted to the medicine floor, which of the following is an appropriate initial treatment regimen?

A. Ciprofloxacin 400mg IV BIDB. Piperacillin-tazobactam 4.5 gm Q6H + vancomycinC. Azithromycin IV 500mg daily + ceftriaxone 1gm IV dailyD. Ceftriaxone 1gm daily + metronidazole 500mg IV Q8H

Non-Severe Inpatient Treatment(No Pseudomonas or MRSA Risk Factors)

1st line

• B-lactam + macrolide• Ampicillin/sulbactam

or ceftriaxone + azithromycin

1st line

• Fluoroquinolone monotherapy

• Levofloxacin

Alternative

• B-lactam + doxycycline

The patient in admitted to the medicine floor, which of the following is an appropriate initial treatment regimen?

A. Ciprofloxacin 400mg IV BIDB. Piperacillin-tazobactam 4.5 gm Q6H + vancomycinC. Azithromycin IV 500mg daily + ceftriaxone IV dailyD. Ceftriaxone IV daily + metronidazole 500mg IV Q8H

Macrolide

Respiratory Quinolone

Severe Inpatient Treatment

(No Pseudomonas or MRSA Risk

Factors)

Severe pneumonia - 1 major or > 3 minor

B-lactam

No doxy anywhere!

HCAP MRSA and Pseudomonas Risk FactorsRisk Factor Management Non-

SevereManagement Severe

Prior respiratory isolation of MRSA

Add MRSA coverage and obtain nasal PCR for deescalation

Add MRSA coverage and obtain nasal PCR for deescalation

Prior respiratory isolation of Pseudomonas aeruginosa

Add coverage and obtain culture for deescalation

Add coverage and obtain culture for deescalation

Recent hospitalization AND receipt of IV antibiotics and local risk factors for MRSA

Obtain culture and nasal PCR but WITHHOLDcoverage unless results are positive for either

Add coverage and obtain nasal PCR and cultures for deescalation or need for continuation

Recent hospitalization AND receipt of IV antibiotics and local risk factors for P. aeruginosa

Obtain cultures, initiate coverage only if positive

Add coverage and obtain cultures for deescalation or need for continuation

HCAP MRSA and Pseudomonas Risk FactorsRisk Factor Management Non-

SevereManagement Severe

Prior respiratory isolation of MRSA

Add MRSA coverage and obtain nasal PCR for deescalation

Add MRSA coverage and obtain nasal PCR for deescalation

Prior respiratory isolation of Pseudomonas aeruginosa

Add coverage and obtain culture for deescalation

Add coverage and obtain culture for deescalation

Recent hospitalization AND receipt of IV antibiotics and local risk factors for MRSA

Obtain culture and nasal PCR but WITHHOLDcoverage unless results are positive for either

Add coverage and obtain nasal PCR and cultures for deescalation or need for continuation

Recent hospitalization AND receipt of IV antibiotics and local risk factors for P. aeruginosa

Obtain cultures, initiate coverage only if positive

Add coverage and obtain cultures for deescalation or need for continuation

• Cover MRSA and/or Pseudomonas IF...• Prior respiratory culture was positive for MRSA or

PseudomonasOR

• Severe CAP with risk factors for resistance (i.e. recent IV antibiotics)

• Obtain respiratory culture and/or MRSA nasal PCR IF…• Initiated on anti-MRSA or Pseudomonas therapy

OR• Risk factors for resistance, regardless of severity

Aspiration Pneumonia – To Cover or Not to Cover

• Anaerobic coverage (metronidazole) not recommended unless:• Lung abscess• Empyema

Patient Case

• 55 yo female with poorly controlled diabetes and recent flu symptoms presents to the ED septic with a 2 day history of progressive fatigue, cough, and SOB. Pt was recently hospitalized out of state where she was treated w/ IV antibiotics for PNA

• PMH significant for T2DM (last A1c 12.9), HTN, hypothyroid• Home meds include atorvastatin 10mg HS, empagliflozin 10mg

daily, glipizide-metformin 5-500mg BID, HCTZ 12.5 daily, losartan 50mg daily, sitagliptin 100mg daily, dessicated thyroid 180mg daily

Patient Case Continued

• On PE:• T = 100.4 degrees F, BP 92/54, HR 124 bpm, RR 40 BPM, O2 sat 82%

on RA• Decreased air movement in all lung fields

• Labs: WBC 14.4, PLT 213, SCr 0.79, BUN 22, LA 4.1, procal 0.8• Respiratory status worsens and pt is intubated, on pressors, and

admitted to the ICU

Which of the following is an appropriate initial treatment regimen?

A. Piperacillin-tazobactam 4.5gm Q6H + azithromycin 500mg IV daily + vancomycin +oseltamivir

B. Ciprofloxacin 400mg IV Q12H + ceftazidime 2gm IV Q8H + oseltamivir

C. Ceftriaxone IV 1gm daily + azithromycin 500mg IV daily + oseltamivir

D. Cefepime IV 2gm Q8H + vancomycin + metronidazole 500mg Q8H + oseltamivir

Which of the following is an appropriate initial treatment regimen?

A. Piperacillin-tazobactam 4.5gm Q6H + azithromycin 500mg IV daily + vancomycin +oseltamivir

B. Ciprofloxacin 400mg IV Q12H + ceftazidime 2gm IV Q8H + oseltamivir

C. Ceftriaxone IV 1gm daily + azithromycin 500mg IV daily + oseltamivir

D. Cefepime IV 2gm Q8H + vancomycin + oseltamivir

For how long?

• “No less than a total of 5 days” – most clinically stable within 48-72 hours

• 7 days for MRSA or Pseudomonas CAP

• Don’t repeat CXR if sx resolve within 5 – 7 days

Summary• Blood and sputum cultures only in severe CAP, or for de-

escalation • Ignore procalcitonin when initiating therapy• Avoid macrolides monotherapy for outpatient CAP• Out with HCAP term, in with CAP with MRSA and

Pseudomonas risk factors• Macrolide recommended over doxycycline for non-severe inpt

Learning Objectives

• Given a patient case, employ the most appropriate therapy for outpatient CAP

• Based on patient specific information, illustrate risk factors for drug resistant pathogens and need for empiric broad-spectrum antibiotics

• Given a patient case, employ the most appropriate therapy for inpatient non-severe CAP

• Given a patient case, employ the most appropriate therapy for inpatient severe CAP

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References

1. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia: and official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019;200(7):e45-e67