Alphabet Soup: Evaluation and Management of CAP, HAP and VAP

ZACHARY HARTSELL, MHA, PA-C

Disclosures

This presentation has no current affiliation or financial arrangements.

This presentation does not discuss off-label uses of products.

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Objectives

1. Differentiate the following: community-acquired, hospital-acquired, ventilator-associated and aspiration pneumonias.

2. Review the diagnostic tools available for hospitalized patients with pneumonia.

3. Identify when a patient should be admitted.

4. Utilize non-invasive ventilation strategies when appropriate.

5. Discuss the appropriate treatment of each type of pneumonia.

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Classifications of Pneumonia

*There is no longer a healthcare-associated pneumonia (HCAP)classification.*

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Community-acquired pneumonia (CAP)

Hospital-acquired pneumonia (HAP)

Ventilator-associated pneumonia (VAP)

Pneumonia Guidelines

Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. CID 2007:44 (Suppl 2)

◦ Update was anticipated Summer 2018…..Uncertain release.

Management of Adults with Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the IDSA and ATS. CID 2016:1-43.

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CAP

Most common type of pneumonia

Not HAP or VAP

Etiologies◦ S. pneumoniae, mycoplasma, staph, viral

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CAP: Atypical Pneumonia

Legionella◦ Temp >102.2, diarrhea/GI symptoms, dry cough◦ Hyponatremia, elevated LDH◦ Treatment: macrolides, fluoroquinolones, β-lactams

Chlamydia pneumoniae ◦ Serologic testing /PCR◦ Treatment: doxycycline or macrolides

◦ Fluoroquinolones are an alternative.

Mycoplasma Pneumonia ◦ “Walking pneumonia”, young college students◦ Serum mycoplasma IgM Abs◦ Treatment: macrolides, tetracyclines

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HAP

Pneumonia not present at the time of admission and occurring ≥48 hours after admission◦ NOT associated with mechanical ventilation

Common Pathogens◦ Aerobic gram (-) bacilli: E.Coli, Pseudomonas

aeurginosa, Klebsiella Pneumoniae, Acinetobacter◦ G+ Cocci: MSSA, MRSA◦ Anaerobic ◦ Polymicrobial

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VAP

Develops 48 hours after intubation

Microbiology similar to HAP

◦ ↑ rate of GNB (Pseudomonas)

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HAP & VAP

HAP and VAP accounts for ≈22% of all hospital-acquired infections.

HAP and VAP ↑ mortality, resource utilization, and LOS.◦ VAP prolongs mechanical ventilation by 7-11 days

◦ ↑ hospitalization by 11-13 days

◦ ↑ hospital costs by >$40,000/patient

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Where to treat?

Outpatient

Inpatient◦ Medical/surgical floor

◦ +/- Intermediate/Step-down Floor

◦ ICU

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Clinical Predictor Tools

Pneumonia Severity Illness (PSI)

British Thoracic Society (BTS) Criteria AKA “CURB 65”

A-DROP (Age, Dehydration, Respiratory failure, Orientation, Pressure (shock))

Severe Community Acquired Pneumonia (SCAP)

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A Word of Caution…

Other reasons for admission NOT scored:

◦ Exacerbation of co-morbid condition

◦ Unable to take PO medications

◦ Unable to receive outpatient care

◦ Cognitive impairment

◦ Substance abuse

Clinical predictor tools should NOT replace clinical judgment!

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ICU Admission

Late admission to ICU significantly ↑ 30 day mortality

Severe CAP Criteria ◦ Direct ICU admission when:

Any 1 major criteria or any 3 minor criteria

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Criteria for Severe CAP

Major Criteria◦ Need for invasive mechanical ventilation◦ Septic shock with need for vasopressors

Minor Criteria◦ Respiratory rate ≥ 30 breaths/min◦ PaO2/FiO2 ratio ≤ 250◦ Multilobar infiltrates◦ Confusion/disorientation◦ Uremia (BUN≥20)◦ Leukopenia (WBC <4,000)◦ Thrombocytopenia (Platelets <100,000)◦ Hypothermia (Core temp <36oC)◦ Hypotension requiring aggressive fluid resuscitation

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Criteria for Severe CAP

Other factors to consider◦ Alcohol withdrawal syndrome

◦ Hypo/hyperglycemia

◦ Hyponatremia

◦ Metabolic acidosis

◦ Elevated lactate level

◦ Cirrhosis

◦ Asplenia

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Testing

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X-ray vs. CT Scan

CXR = ALWAYS?

CT Chest = Maybe?

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Blood Cultures

Pretreatment BCs are recommended when: ◦ Admitted to ICU

◦ Cavitary infiltrates

◦ Leukopenia/ immunosuppressed

◦ Liver disease

◦ Asplenia

In other hospitalized patients, BC are optional.

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Sputum Cultures

Low sensitivity (<10-50%)

↑ rates of false positive/poor quality samples

Performing cultures after antibiotics ↓ yield by 50%

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Respiratory Pathogen Panel

Seasonal viral and bacterial testing◦ Viral: influenza A&B, RSV, parainflueza, rhinovirus,

coronovirus

◦ Bacterial: S.pneumo, C.pneumo, Mycoplasma, S. aureus, L. pneumophilia, and bordetella pertussis

Technique is everything!

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Urine Antigens

S. Pneumonia Ag and Legionella Ag

Benefits◦ Rapid

◦ Higher sensitivity rates than cultures

◦ Valid even after antibiotics

Limitations◦ Need a lab

◦ No antibiotic sensitivity

◦ Usually doesn’t change course of care

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Procalcitonin

Helpful when (-) or extremely (+)◦ <0.1mcg/L no antibiotics◦ >0.25mcg/L antibiotics

Do NOT delay antibiotics!

No change in mortality with using PCT.

The new HAP/VAP guidelines recommend using clinical criteria alone (not PCT) for determining whether to initiate antibiotics

However, they recommend using PCT with de-escalation.

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Additional Diagnostic Testing

ABG

Fungal serology- Depends on Location ◦ Coccidiomycosis, histoplasmosis

MRSA swab ◦ Helpful with de-escalation of antibiotics

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Treatment

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Non-invasive Ventilation StrategiesTiming is critical…the earlier the better!◦ Bilevel positive airway pressure

(BiPAP)

◦ High flow nasal canula

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BiPAP

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INDICATIONS CONTRAINDICATIONS

• Hypercapnea and acidosis• Cardiogenic pulmonary edema• COPD exacerbation• Weaning and post-extubation failure• Post surgical period• Obesity hypoventilation syndrome• Neuromuscular disorders• Poor alveolar oxygen exchange

o PaO2/FiO2 <200

• Impaired neurological state• Respiratory arrest• Shock or severe cardiovascular

instability• Excessive airway secretions• Vomiting• Facial lesions/trauma• Agitation

High Flow Nasal Cannula

Improves work of breathing

Enhances gas exchange

Greatly decreased intubation rates in hypoxemic respiratory failure

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Time to Antibiotic

Antibiotics should be given as soon as the diagnosis is made…try to minimize delays.

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CAP

Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. CID 2007:44 (Suppl 2)

Adapt treatment regimens for local trends

Best predictor of a good outcome is the right site of care.

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Uncomplicated OP CAP

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Select One

High Local Macrolide Resistance

Doxycycline

Combination beta-lactam/macrolise or

Fluoroquinolone

Low Local Macrolide Resistance

Currently Nowhere in US

Macrolide- azithromycin or Clarithromycin

OR

Docycycline

Inpatient or Complicated OP CAP

ICU: Consider pseudomonas and/or MRSA coverage

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Select One

Respiratory fluoroquinolone

Levofloxacin

Moxifloxacin

B-lactam PLUS Macrolide

B-lactam Cefotaxime, ceftriaxone, ampicillin, ertapenem for selected

patients

+Macrolide Azithromycin

(or doxycyline)

OR

Risk Factors for Pseudomonas

Prior use of antibiotics

H/O Pseudomonas w/in 1year

Longer hospital stay

Mechanical ventilation

Malignancy

Immunosuppression (including HIV/AIDS)

Cystic Fibrosis

Alcoholism

COPD

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Risk Factors for MRSA

End stage renal disease

IV drug abuse

Prior antibiotic use

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Multidrug Resistance Risk Factors

Antimicrobial therapy in the last 90 days

Current hospitalization of ≥5 days

High rate of antimicrobial resistance in community

Immunosuppressive disease or therapy

Recent chemotherapy

Recent wound care

Hemodialysis

Residing in nursing home or LTC facility

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If high risk of MDR/MRSA/Pseudomonas….

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Select one of these

IV Antipseudomonal

β lactam

Cefepime

Ceftazidime

Imipenem/ Cilastatin

Meropenem or Doripenem

Pipercillin/ Tazobactam

AND one of these

IV Antipseudomonal Quinolone

Ciprofloxacin

Levofloxacin

IV Aminoglycoside

Amikacin

Gentamicin

Tobramycin

AND one of these

Anti-MRSA

Linezolid

Vancomycin

HAP & VAP New Guidelines

Management of Adults with Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the IDSA and ATS. CID 2016:1-43.

Emphasis on all hospitals regularly generating a localantibiogram

Mostly focus on a patient population with a normal immune system

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First Line

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VAP HAP

Empirically cover for S. aureus, pseudomonas and other GNB with:

• Pipercillin/tazobactam• Cefepime• Levofloxacin• Imipenem or meropenem

Empirically cover for S. aureus with:

• Pipercillin-tazobactam• Cefepime• Levofloxacin• Imipenem or meropenem

Oxacillin, nafcillin or cefazolin are preferred agents for treating MSSA once it has been isolated.

MRSA Coverage

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VAP HAP

Cover for MRSA empirically IF:• A risk factor for antimicrobial resistance

• Prior IV antibiotic use within 90d• Septic shock at the time of VAP• ARDS preceding VAP• ≥5 days of hospitalization prior to

occurrence of VAP• Acute renal replacement therapy prior

to VAP onset• Patient in a unit where >10-20% of S. aureus

isolates are MRSA• When the prevalence of MRSA is not known

Cover for MRSA empirically IF:• Prior IV antibiotic use within 90

days of hospitalization • In a unit where ≥20% of S. aureus

isolates are MRSA• When the prevalence of MRSA is

not known• Patients who are high risk of

mortality

Pseudomonas Coverage

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VAP HAP

Double cover for Pseudomonas IF:• Risk factors for antimicrobial resistance

(see last slide)• Unit where >10% of Gram negative

isolates are resistant to an agents being considered for monotherapy

• ICU where local antimicrobial susceptibility rates are not available.

*Otherwise ok to use just one empiric anti-pseudomonal

Double cover for Pseudomonas IF:• Prior IV antibiotic use w/in 90 d• High risk of mortality (need ventilator

support due to HAP and/or septic shock)

*Otherwise ok to use just one empiric anti-pseudomonal

If a patient has structural lung disease, increasing risk of gram (-) infection, provide double coverage.

Anti-Pseudomonal Antibiotics

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Gram (-) antibiotics w/anti-pseudomonal activity : β-lactam based agents

Gram (-) antibiotics w/anti-pseudomonal activity: Non-β-lactam based agents

Anti-pseudomonal Penicillin• Piperacillin-tazobactamCephalosporin• Cefepime• CeftazidimeCarbapenem• Imipenem• MeropenemMonobactam• Aztreonam

Fluoroquinolone• Ciprofloxacin• LevofloxacinAminoglycoside• Amikacin• Gentamycin• TobramycinPolymyxin• Colistin• Polymycin B

Other Recommendations…

Consider adjunctive inhaled antibiotic therapy as a treatment of last resort for HAP/VAP patients who are not responding to IV antibiotics alone

For Enterobacter species not susceptible to cephalosporins → use carbapenems

In carbapenem-resistant pathogens that are only sensitive to polymycins, recommend IV polymicin B with adjunctive inhaled colistin.

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Fluoroquinolone Warning!

FDA safety warning

◦ Can cause side effects that involve the tendons, muscles, joints, nerves and the CNS

◦ Can increase risk of retinal detachment, and neurotoxicity in the elderly.

◦ Not recommended for use for sinusitis, bronchitis, and uncomplicated UTIs

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Duration of Treatment: CAP

Shorter duration therapy leads to

◦ ↓ antibiotic resistance

◦ ↓ complications

◦ ↓ cost

◦ ↑ patient compliance

◦ Minimum treatment 5 days

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Duration of Treatment: HAP/VAP

Used to be 14-21 days but now 7 day course◦ Early de-escalation if possible

◦ Only recommend longer duration of therapy if patient is not improving clinically

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When can I switch my patients to PO?

Clinically stable

Able to tolerate oral medications

Working GI tract

Not necessary to observe patients after switching to PO

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Take Home Points

Choosing the right site of care for patients with pneumonia directly correlates with improved outcomes.

Identify patients with high risk of MRSA, Pseudomonas and other MDR organisms and treat them accordingly.

The new recommendations no longer have a designation for “healthcare-associated” pneumonia

Hospitals should frequently update their antibiogram, and antibiotics should be chosen based on this.

Use BiPAP and HFNC when appropriate to provide respiratory support.

New recommendations favor shorter treatment for pneumonia unless patient is not getting better.

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References

Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. CID 2007:44 (Suppl 2)

Andre C. Kalil, Mark L. Metersky, Michael Klompas, John Muscedere, Daniel A. Sweeney, Lucy B. Palmer, Lena M. Napolitano, Naomi P. O'Grady, John G. Bartlett, Jordi Carratalà, Ali A. El Solh, Santiago Ewig, Paul D. Fey, Thomas M. File, Jr, Marcos I. Restrepo, Jason A. Roberts, Grant W. Waterer, Peggy Cruse, Shandra L. Knight, and Jan L. Brozek .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 2016 : ciw353v1-ciw353.

Johnstone J et al. Viral infection in adults hospitalized with community-acquired pneumonia. Chest. 2008; 134(6)

Mueller et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. The cochran collaboration. 2012; issue 9.

Ampel NM. Coccidiodomycosis: A review of recent advances. Clin Chest Med. 2009; 20: 241-251

Scalera NM and File TM. How long should we treat community acquired penumonia? Curr opinInfect Dis. 2007; 20:177-181

Syyjala H, Broas M, Suramo I, et al. High resolution comupted tomography for diagnosis of community-aquired pneumonia. Clinical Infectious Disease. 1998: 27:358-63

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