Putting Your CAP on in the Hospital Updates to the Pneumonia Guidelines · 2020. 1. 14. · Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity

Putting Your CAP on in the Hospital Updates to the Pneumonia Guidelines

Vicky Shah, PharmD, BCPSAssistant Professor of Pharmacy Practice

Wilkes University Nesbitt School of Pharmacy

Disclosure SlideThe presenter for this activity has been required to disclose all relationships with any proprietary entity producing health care goods or services, with the exemption of non-profit or

government organizations and non-health care related companies.

No significant financial relationships with commercial entities were disclosed by any of the speakers.

Learning Objectives

Discuss different types of

pneumonia

Explain risk factors, diagnosis

and clinical presentations of

pneumonia

Identify updated treatments for

pneumonia

Updated October 2019

Community Acquired Pneumonia

4

The Infectious Diseases Society of America (IDSA)

The American Thoracic Society

(ATS)

New 2019 CAP

Guidelines

5Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al.; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society

consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44:S27–S72.

Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol 2011;64:395–400.

Major Changes

Health Care-Associated Pneumonia

(HCAP)

Diagnostic Changes

Outpatient Antibiotic

Recommendations

Inpatient Antibiotic Recommendations

Additional Coverage

Recommendations

Corticosteroid Use Recommendations

Newer Agents

6Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., ... & Griffin, M. R. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the

American Thoracic Society and Infectious Diseases Society of America. American journal of respiratory and critical care medicine, 200(7), e45-e67.

PneumoniaInfection where the air sacs of the lung get inflamed

due to bacterial or viral infection

7

McLuckie, A., ed. (2009). Respiratory disease and its management. New York: Springer. p. 51. ISBN 978-1-84882-094-4.

Health Care-Associated Pneumonia (HCAP)

Major Update



Types of Pneumonia

9

Type of Pneumonia Definition

Community Acquired Pneumonia (CAP) Pneumonia developing in patients with no contact to a medical facility

Healthcare-Associated Pneumonia (HCAP)

Pneumonia developing in patients not in medical facility but two or more risk factors for multidrug resistant pathogens:

• Recent hospitalization ≥ 2 days within past 90 days• Nursing home or long-term care patients

• Recent antibiotic use, IV therapy, wound care, or chemotherapy within past 30 days

• Hemodialysis patient within past 30 days• Contact with family member who has multidrug resistant pathogen

infection

Hospital Acquired Pneumonia (HAP) Pneumonia developing ≥ 48 hours after admission

Ventilator Associated Pneumonia (VAP)Pneumonia developing ≥ 48 hours after intubation and mechanical

ventilation

Aspiration Pneumonia (AP)Pneumonia developing in alcoholic patients or patients who have trouble

swallowing

Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., ... & Griffin, M. R. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the


Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., ... & El Solh, A. A. (2016). 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, 63(5), e61-e111.

Pathophysiology

Inhaled or aerosolized particles enter the lung through breathing

Bacteria enter the lung via the bloodstream from an extrapulmonary site of infection

Aspiration of oropharyngeal contents

10

McLuckie, A., ed. (2009). Respiratory disease and its management. New York: Springer. p. 51. ISBN 978-1-84882-094-4.

EpidemiologyOne of the most common causes of infectious

death in the United States

Increased hospitalizations and re-hospitalizations

Risk Factors

11

Marrie TJ, Huang JQ. Epidemiology of community-acquired pneumonia in Edmonton, Alberta: an emergency department-based study. Can Respir J 2005; 12:139.

Ramirez JA, Wiemken TL, Peyrani P, et al. Adults Hospitalized With Pneumonia in the United States: Incidence, Epidemiology, and Mortality. Clin Infect Dis 2017; 65:1806.

Jain S, Self WH, Wunderink RG, et al. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med 2015; 373:415.

Kalil AC, Metersky ML, Klompas M, et al. 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. Clin Infect Dis 2016; 63:e61.

Clinical Presentation

12

Symptom Frequency

Symptom Frequency

Cough 79–91%

Fatigue 90%

Fever 71–75%

Shortness of Breath 67–75%

Sputum 60–65%

Chest Pain 39–49%

Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. p. 480. ISBN 978-0-07-148480-0.

Hoare Z, Lim WS (May 2006). "Pneumonia: update on diagnosis and management" (PDF). BMJ. 332 (7549): 1077–79. doi:10.1136/bmj.332.7549.1077. PMC 1458569. PMID 16675815.

Nair GB, Niederman MS (November 2011). "Community-acquired pneumonia: an unfinished battle". The Medical Clinics of North America. 95 (6): 1143–61. doi:10.1016/j.mcna.2011.08.007. PMID 22032432.

"Pneumonia (Fact sheet N°331)". World Health Organization. August 2012. Archived from the original on 30 August 2012.

Darby J, Buising K (October 2008). "Could it be Legionella?". Australian Family Physician. 37 (10): 812–15. PMID 19002299.

Ortqvist A, Hedlund J, Kalin M (December 2005). "Streptococcus pneumoniae: epidemiology, risk factors, and clinical features". Seminars in Respiratory and Critical Care Medicine. 26 (6): 563–74. doi:10.1055/s-2005-925523.

PMID 16388428.

Etiology

13

Bacterial Pathogens

• Gram Positives

• Gram Negatives

• Atypical Pathogens

• Anaerobes

Viruses

Fungi

Differential Diagnosis

• Tuberculosis

• Influenza

• COPD Exacerbation

• CHF Exacerbation

• Bronchitis

Johansson N, Kalin M, Tiveljung-Lindell A, et al. Etiology of community-acquired pneumonia: increased microbiological yield with new diagnostic methods. Clin Infect Dis 2010; 50:202.



Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., ... & El Solh, A. A. (2016). 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, 63(5), e61-e111.

Common PathogensGram-Positive

Pathogens

Staphylococcus aureus

Streptococcus species

Gram-Negative

Pathogens

Klebsiella pneumoniae

Pseudomonas aeruginosa

Haemophilus influenzae

Moraxella catarrhalis

Atypical Pathogens

Legionella pneumophila

Mycoplasma pneumoniae

Chlamydia pneumoniae

Anaerobic Pathogens

Bacteriodes species

14

Johansson N, Kalin M, Tiveljung-Lindell A, et al. Etiology of community-acquired pneumonia: increased microbiological yield with new diagnostic methods. Clin Infect Dis 2010; 50:202.



Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., ... & El Solh, A. A. (2016). Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice


Diagnosis

Demonstration of infiltrates on chest imaging in a patient with clinical presentation of pneumonia

• Chest X-ray

• Sputum Cultures

• Blood Cultures

• Complete Blood Count

• Physical Examination

• Computed Tomography

15Marchello, CS; Ebell, MH; Dale, AP; Harvill, ET; Shen, Y; Whalen, CC (2019). "Signs and Symptoms That Rule out Community-Acquired Pneumonia in Outpatient Adults: A Systematic Review and Meta-Analysis". Journal of the

American Board of Family Medicine : JABFM. 32 (2): 234–247. doi:10.3122/jabfm.2019.02.180219. PMID 30850460.

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of

America. Am J Respir Crit Care Med 2019; 200:e45.

Severity of PneumoniaOutpatient Vs. Inpatient

Pneumonia Severity

Index CURB-65

16Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58:377.



Pneumonia Severity Index (PSI)

17Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58:377.



CURB-65

18

Symptom Points

Confusion 1

Urea > 20 mg/dL 1

Respiratory Rate ≥ 30 breaths/minute 1

SBP < 90 mm Hg or DBP ≤ 60 mm Hg 1

Age ≥ 65 1

Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58:377.



Severity

19

CURB-65

Score Location of Therapy

0 Outpatient

1 Outpatient

2 Outpatient OR Inpatient

3 Inpatient

4 Inpatient ICU

5 Inpatient ICU

Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58:377.



Pneumonia Severity Index (PSI)

Risk Class (Points) Recommendation Site of Care

I (<50) Outpatient

II (51-70) Outpatient

III (71-90) Outpatient OR Inpatient

IV (91-130) Inpatient

V (>130) Inpatient

Severe Community Acquire PneumoniaOne Major Criterion or Three or More Minor Criteria

Major Criteria

• Septic Shock with need for vasopressors

• Respiratory failure requiring mechanical ventilation

Minor Criteria

• Respiratory rate ≥ 30 breathes/minute

• PaO2/FiO2 ratio ≤ 250

• Multilobar infiltrates

• Confusion/disorientation

• Uremia (BUN) ≥ 20 mg/dL

• Leukopenia (WBC) ≤ 4,000 cells/microliter

• Thrombocytopenia (Platelets) ≤ 100,000

• Hypothermia (core temperature) ≤ 36OC

• Hypotension requiring aggressive fluid resuscitation

20



Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., ... & El Solh, A. A. (2016). 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, 63(5), e61-e111.

Diagnostic ChangesMajor Update



Diagnostic Considerations

Sputum/Blood Cultures

Urinary Antigen Testing for Legionella

Influenza Virus Testing

Procalcitonin

Repeat X-Rays



Sputum/Blood CulturesOutpatient Setting – NOT recommended to obtain sputum/blood

Gram Stain and Cultures routinely in adults with CAP

Inpatient Setting – RECOMMENDED obtaining Gram Stain and Cultures of respiratory secretions/blood in adults with CAP who

are:

• Classified as severe CAP, especially if intubated

• Being treated empirically for MRSA or Pseudomonas aeruginosa

• Previously infected with MRSA or Pseudomonas Aeruginosa, especially those with prior respiratory tract infections

• Hospitalized and received parenteral antibiotics within the last 90 days23



Urinary Antigen Testing for Legionella

NOT recommended unless:

• Severe CAP

• Patient is near a Legionella outbreak or has recent travel to

area with outbreak24



Influenza Virus TestingRECOMMENDED testing for influenza with a rapid influenza

molecular assay, which is preferred over a rapid influenza diagnostic test

Empiric antibiotics should be initiated but discontinued once Influenza testing comes back

Follow CDC recommendations and hospital specific recommendations



Procalcitonin

NOT recommended to determine need for initial

antibacterial therapy



Repeat X-Rays

NOT recommended if patient is clinically

improving



Non-Pharmacologic TherapyOxygen

Bronchodilators (Albuterol)

Chest Physiotherapy

Adequate Hydration

Nutritional Support

Fever Control

Symptom Control28

Prevention of Pneumonia

29

Influenza Vaccine Pneumococcal

Vaccine

Outpatient Antibiotic Recommendations

Major Update



Empiric Treatment – OutpatientClinical Setting Empirical Treatment

Previously healthy and no

antibiotic therapy in past 3 months

Amoxicillin 1 gram three times daily

Doxycycline 100mg twice daily

Azithromycin 500mg on day then 250mg daily for four days

Clarithromycin 500mg twice daily

Clarithromycin Extended Release 1000mg

*** ONLY IN AREA WITH PNEUMOCOCCAL RESISTANCE TO

MACROLIDES IS <25% ***



Empiric Treatment – OutpatientClinical Setting Empirical Treatment

Comorbidities (Diabetes,

heart/lung/liver/renal disease,

alcoholism, malignancy, asplenia)

Amoxicillin/Clavulanate or Cephalosporin

PLUS

Macrolide

Amoxicillin/Clavulanate or Cephalosporin

PLUS

Doxycycline

Respiratory Fluoroquinolone (My Good Lungs)

Moxifloxacin

Gemifloxacin

Levofloxacin



Why is Ciprofloxacin not considered a respiratory fluoroquinolone?

33

Inpatient Antibiotic Recommendations

Major Update



Empiric Treatment – Inpatient NON-ICU

Clinical Setting Empirical Treatment

Non-ICU

Ampicillin/Sulbactam OR Cefotaxime OR Ceftriaxone OR Ceftaroline

PLUS

Macrolide


Moxifloxacin

Gemifloxacin

Levofloxacin


PLUS

Doxycycline



Empiric Treatment – Inpatient Severe ICU

Clinical Setting Empirical Treatment

Severe ICU


PLUS

Macrolide


PLUS


Moxifloxacin

Gemifloxacin

Levofloxacin



Additional Coverage Recommendations

Major Update



Anaerobic Coverage

NOT recommended to add coverage against anaerobes in SUSPECTED aspiration

pneumonia unless patient has lung abscess or empyema



Corticosteroid Use Recommendations

Major Update



Corticosteroid Use

NOT recommended for use UNLESS

patient has sepsis



Newer AgentsMajor Update



Lefamulin & Omadacycline

FDA approved for Community Acquired Pneumonia

Randomized Clinical Trials published after guidelines were released

Individual clinicians and institutions can determine use of agents until next guideline update



UpdatesTopics Current Guidelines Previous Guidelines

HCAP o Term Removed o Included in HAP/VAP

Diagnostic Changes

o Cultures for severe CAP and MRSA/Pseudomonas Empiric Coverage

o Imaging not recommended if patient improving

o Procalcitonin not recommended

o Urinary Antigen only recommended for severe CAP and outbreaks

o Cultures not mentioned

o Imaging not discussed

o Procalcitonin not discussed

o Urinary Antigen only recommended for severe CAP

Outpatient Antibiotic

Recommendations

o Amoxicillin recommended as 1st line therapy for outpatient without

comorbidities or risk factors for resistant pathogens

o Amoxicillin without Clavulanate and ampicillin without sulbactam not

recommended for patients with comorbidities

o Macrolides are alternative options for outpatients without

comorbidities or risk factors for resistant pathogens

o Amoxicillin not recommended

o Amoxicillin and Ampicillin were options for patients

with comorbidities

o Macrolides recommended as first line therapy

Inpatient Antibiotic

Recommendations

o Cefuroxime was removed as a treatment option and replaced with

Ceftaroline

o Cefuroxime was recommended and Ceftaroline was

not FDA approved yet

Additional Coverage

o One pseudomonas agent is recommended for empiric coverage

o Not recommended to add anaerobic coverage for suspected

aspiration pneumonia unless patient has empyema or lung abscess

o Two pseudomonas agents are recommended

o Anaerobic coverage was recommended for all

suspected aspiration pneumonia patients

Corticosteroid Use o Not recommended o Not discussed

Newer Agents o Not added to guidelines o Not discussed



Hospital Acquired PneumoniaVentilator Associated Pneumonia

Updated 2016

44

Major Guideline Updates

Removal of the concept of Health Care Associated

Pneumonia (HCAP)

Larger emphasis on local institutions

collecting data and creating antibiogram

Decrease the unnecessary use of dual gram-negative and empiric MRSA

coverage

Shorter duration of therapy

45Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., ... & El Solh, A. A. (2016). Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice


Removal of the Concept of Health Care Associated Pneumonia (HCAP)

Major Update



Types of Pneumonia

Type of Pneumonia Definition

Community Acquired Pneumonia (CAP)Pneumonia developing in patients with no contact to a

medical facility

Healthcare Associated Pneumonia (HCAP)

Pneumonia developing in patients not in medical facility but two or more risk factors for multidrug resistant pathogens:

• Recent hospitalization ≥ 2 days within past 90 days• Nursing home or long-term care patients• Recent antibiotic use, IV therapy, wound care, or

chemotherapy within past 30 days• Hemodialysis patient within past 30 days• Contact with family member who has multidrug resistant

pathogen infection

Hospital Acquired Pneumonia (HAP) Pneumonia developing ≥ 48 hours after admission

Ventilator Associated Pneumonia (VAP)Pneumonia developing ≥ 48 hours after intubation and

mechanical ventilation

Aspiration Pneumonia (AP)Pneumonia developing in alcoholic patients or patients who

have trouble swallowing



Larger Emphasis on Local Institutions Collecting Data and Creating Antibiogram

Major Update



Antibiogram Example



Decrease the Unnecessary Use of Dual Gram-Negative and Empiric MRSA

CoverageMajor Update



Risk Factors for Multidrug Resistant PathogensRisk Factors for MDR VAP

• Prior IV antibiotic use within 90days

• Septic Shock at time of VAP

• Acute Respiratory Distress Syndrome preceding VAP

• Five or more days of hospitalization prior to the occurrence of VAP

• Acute renal replacement therapy prior to VAP onset

Risk Factors for MDR HAP

• Prior IV antibiotic use within 90 days

Risk Factors for MRSA HAP/VAP


Risk Factors for MDR Pseudomonas HAP/VAP




Empiric Therapy

Patients with no risk factors for MDR should cover

Pseudomonas and MSSA

Decision to cover MRSA or double cover for

Pseudomonas should be guided by patient’s clinical

stability, risk factors for MDR and local antibiograms



Empiric Treatment



Empiric Therapy

54

Not at high risk of mortality and no factors

increasing likelihood of MRSA

Not at high risk of mortality but with factors

increasing likelihood of MRSAHigh risk of mortality

Zosyn

OR

Cefepime

OR

Levofloxacin

OR

Carbapenem

Zosyn

OR

Cefepime or Ceftazidime

OR

Levofloxacin or Ciprofloxacin

OR

Carbapenem

OR

Aztreonam

Zosyn

OR

Cefepime or Ceftazidime

OR

Carbapenem

OR

Aztreonam

PLUS PLUS

Vancomycin

OR

Linezolid

Levofloxacin or Ciprofloxacin

OR

Aminoglycoside

PLUS

Vancomycin

OR

Linezolid

OR

MSSA Coverage

Kalil, Andre C., et al. "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 63.5 (2016): e61-e111.

If dual pseudomonas coverage is needed, which of the following combinations would you

recommend?A. Cefepime PLUS Zosyn

B. Levofloxacin PLUS ZosynC. Ceftriaxone PLUS ImipenemD. Cefepime PLUS Ertapenem

55

Shorter Duration of TherapyMajor Update



Duration of Therapy

7 days

57Kalil, Andre C., et al. "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 63.5 (2016): e61-e111.

Aspiration PneumoniaUpdated 2019

58

What patients are at highest risk for obtaining aspiration pneumonia?

59

Etiology

Anaerobic pathogens

• Bacteriodes and oral anaerobes

Streptococcus species



Treatment

Beta-Lactam/Beta-Lactamase Inhibitor Combinations

Clindamycin

Carbapenems

Metronidazole (Combined with Beta Lactam)



References▪ Darby J, Buising K (October 2008). "Could it be Legionella?". Australian Family Physician. 37 (10): 812–15. PMID 19002299.

▪ Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol

2011;64:395–400.

▪ Hoare Z, Lim WS (May 2006). "Pneumonia: update on diagnosis and management" (PDF). BMJ. 332 (7549): 1077–79. doi:10.1136/bmj.332.7549.1077. PMC 1458569.

PMID 16675815.

▪ Johansson N, Kalin M, Tiveljung-Lindell A, et al. Etiology of community-acquired pneumonia: increased microbiological yield with new diagnostic methods. Clin Infect Dis

2010; 50:202.

▪ Jain S, Self WH, Wunderink RG, et al. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med 2015; 373:415.

▪ Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., ... & El Solh, A. A. (2016). 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, 63(5), e61-e111.

▪ Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation

study. Thorax 2003; 58:377.

▪ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al.; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases

Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44:S27–S72.

▪ Marchello, CS; Ebell, MH; Dale, AP; Harvill, ET; Shen, Y; Whalen, CC (2019). "Signs and Symptoms That Rule out Community-Acquired Pneumonia in Outpatient Adults: A Systematic

Review and Meta-Analysis". Journal of the American Board of Family Medicine : JABFM. 32 (2): 234–247. doi:10.3122/jabfm.2019.02.180219. PMID 30850460.

▪ Marrie TJ, Huang JQ. Epidemiology of community-acquired pneumonia in Edmonton, Alberta: an emergency department-based study. Can Respir J 2005; 12:139.

▪ McLuckie, A., ed. (2009). Respiratory disease and its management. New York: Springer. p. 51. ISBN 978-1-84882-094-4.

▪ Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., ... & Griffin, M. R. (2019). Diagnosis and treatment of adults with community-acquired

pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. American journal of respiratory and critical

care medicine, 200(7), e45-e67.

▪ Nair GB, Niederman MS (November 2011). "Community-acquired pneumonia: an unfinished battle". The Medical Clinics of North America. 95 (6): 1143–61.

doi:10.1016/j.mcna.2011.08.007. PMID 22032432.

▪ Ortqvist A, Hedlund J, Kalin M (December 2005). "Streptococcus pneumoniae: epidemiology, risk factors, and clinical features". Seminars in Respiratory and Critical Care Medicine.

26 (6): 563–74. doi:10.1055/s-2005-925523. PMID 16388428.

▪ "Pneumonia (Fact sheet N°331)". World Health Organization. August 2012. Archived from the original on 30 August 2012.

▪ Ramirez JA, Wiemken TL, Peyrani P, et al. Adults Hospitalized With Pneumonia in the United States: Incidence, Epidemiology, and Mortality. Clin Infect Dis 2017; 65:1806.

▪ Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. p. 480. ISBN 978-0-07-148480-0.

What Questions Do You Have?

[email protected]

63

● Last slide – Include the survey/evaluation link(s) and the deadline for

completion to receive credit.

Putting Your CAP on in the Hospital Updates to the Pneumonia Guidelines · 2020. 1. 14. · Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity

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