Pneumonia UpdateJohn M. MacKay Jr. MD

Vice-Chair

Department of Emergency Medicine

Paul L. Foster School of Medicine

Texas Tech HSC, El Paso

Pneumonia Update

• CAP

– Adults

– Kids

• Influenza

• Core Measures

CAP Adults

• Classic Diagnosis easy

• However,

– Subtle in the Elderly ( may only be confused)

– 15 % may be missed on x-ray by radiologist

– 10 % rate of radiologist disagreement

– Culture related diagnosis not very helpful

– Implementation of Core measures may be helpful, but has had unexpected consequences

– Use of severity scores and indexes has resulted in arguments against admissions where clearly warranted

CAP Adult

• CAP

– Decisions• Is it Really CAP ?

• Inpatient vs. Outpatient, floor vs. ICU

• Current Antibiotic guidelines

• Risk for Treatment Failure

• Invasive vs. Non-invasive support

• Influenza ?

CAP Adult

• Is it really CAP ?

– Health Care Associated Pneumonias

• Unclear if the nursing home patient is community or hospital

• Some recommend Pseudomonas/MRSA coverage

• Caveat– Easy to overtreat

• Look at past treatment, presence of COPD or recent antibiotics for Help in decision making

• Look at community MRSA patterns, clinical pattern and x-ray

CAP Adults

• In patient vs. Outpatient

• Floor vs. ICU

– Use one of the scores

– Add common sense

– Be prepared to argue with the consultant

– Some hospitals have ICU requirements for non-invasive ventilation

CAP Adult

• Antibiotics

– Simple outpatient

• Azithromycin or Doxycycline or respiratory fluoroquinolone

– Complex outpatient

• Respiratory Fluoroquinolone, second generation cephalosporin or Augmentin and macrolide

• Antibiotics (cont)

– Simple Inpatient

• Respiratory fluoroquinolone or 2nd generation cephalosporin and macrolide

– Complex Inpatient and ICU

• Above– May substitute ertrapenenem for 2nd generation

cephalosporin

– May need pseudomonal or MRSA coverage

CAP Adult

• Other considerations in Adults

– Ventilation

• Many recommend trial of non-invasive ventilation

• CPAP and Bi-PAP may require closer observation than usually done

– Influenza Testing

• Usually in patients you will treat as outpt if positive

• May be necessary to cohort in epidemic seasons

• Almost always in ICU, often for inpatients

• Almost always for atypical appearance on x-ray

CAP kids

• Pediatric Issues

– To x-ray or not x-ray

– To admit or not admit

– To Treat or not to treat

– To do “tests” or not to do tests

CAP kids

• To x-ray or not to x-ray

– Outpatient

• Not necessary if diagnosis clear and clearly outpatient

• Necessary if possibly admitted or with complications or failed treatment

– Inpatient

• Get the x-ray

– Follow up

• Generally not necessary unless getting worse or recurrent

CAP kids• To admit or not admit

– Admit

• < 3 months

• Hypoxia or respiratory distress

• Increased virulent organisms, especially MRSA

• Social issues

– ICU

• Invasive or non-invasive respiratory support

• Shock

• Persistent hypoxia

• Altered mental status

CAP kids

• To Treat or not to treat

– Outpatient

• Antibiotics not routinely required for pre-school aged children with CAP– Amoxicillin if you suspect bacterial

• Macrolides for school aged kids and adolescents with CAP

• Influenza antiviral therapy where appropriate for CAP with possible pneumonia before testing results are back

CAP kids• To Treat or not to treat

– Inpatient

• Ampicillin or Pen-G to infants and school aged kids

• 3rd generation cephalosporin to not fully immunized kids or where resistance patterns weird

• Macrolide if considerations warrant

• Add vancomycin or clindamycin if it looks like staph aureus

CAP kids

• Tests

– Blood Cultures

• Outpatients if treatment failure or not immunized

• Inpatients if moderate to severe or not improving

– Sputum

• If they can get you some easily

– Viral pathogens including influenza

• Yes

– Others

• Inpatient yes otherwise no unless very complex

CAP Influenza

• CDC

– Says we are down to sporadic Cases

– However…..

CAP Influenza

• Probably should test based on local patterns

– Probably still should cohort in urban areas with non private rooms

– Probably should test with atypical patterns

– Our experience says the Influenza A has tapered off with ongoing Influenza B

Pneumonia Core Measures

• Here to stay

– Not all the science is hard core

– Changed from 4 hour door to antibiotics to 6

– Too early antibiotics may have caused people to get too broad in treatment

– Consistent approach, earlier identification and methodologies have somewhat improved outcomes, but not as much as expected

References

• Community-Acquired Pneumonia, Richard G. Wunderink, M.D., and Grant W. Waterer, M.B., B.S., Ph.D. N Engl J Med 2014; 370:543-551February 6, 2014DOI: 10.1056/NEJMcp1214869

• Bacterial Pneumonia Treatment & Management, Nader Kamangar, MD, Annie Harrington MD.Chief Editor: Zab Mosenifar, MD :Medscape

• S27-S72:Lionel A. Mandell, Richard G. Wunderink,Antonio Anzueto, John G. Bartlett,G. Douglas Campbell, Nathan C. Dean, Scott F. Dowell, Thomas M. File Jr., Daniel M. Musher, Michael S. Niederman, Antonio Torres,and Cynthia G. WhitneyInfectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults:In Clinical Infectious Diseases,Volume 44, supplement 2,

• Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, Stockwell JA, Swanson JT. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011 Oct;53(7):e25-76. [340 references]