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9/28/2020
1
A New Feather in Your CAP? Applying 2019 Community
Acquired Pneumonia Guidelines to Practice
Carrie Vogler, PharmD, BCPS
Clinical Associate Professor
Beth Cady, PharmD, BCPS
Assistant Professor
SIUE School of Pharmacy Images from subscription unless otherwise indicated
Objectives
• Compare the differences in presentation, risk factors, and treatment between community acquired pneumonia and hospital acquired pneumonia.
• Interpret tests, labs, and imaging ordered for a patient with community acquired pneumonia.
• Select appropriate drug, dose, and duration for a patient presenting with community acquired pneumonia.
Conflict of Interest
• Carrie Vogler has no conflicts of interest to disclose.
• Beth Cady has no conflicts of interest to disclose.
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CAP Causes ChronologicallyOLD Guidelines Suggest New Evidence Suggests
Streptococcus pneumoniae Virus
Atypicals (ie-Mycoplasma, Chlamydia, Legionella)
Virus
Atypicals Virus
Atypicals Streptococcus pneumoniae
H. influenzae ……maybe a tiny bit atypical
M. catarrhalis But also….HARD to isolate a pathogen!
N Engl J Med. 2015;373(5):415–427.
Tests, Labs, and Imaging, OH MY!
• Determine outpatient status: PSI over CURB-65
• !!Cultures!!! (Blood and Sputum)• NOT needed UNLESS
• 1. SEVERE PNA
• 2. Concern for Pseudomonas aeruginosa (PSA) or MRSA
• Chest imaging – must be indicative of PNA
• Urinary antigen test (pneumococcal and/or legionella)• NOT needed unless SEVERE PNA OR legionella outbreak
Am J Respir Crit Care Med. 2019;200(7):e45–e67
Am J Respir Crit Care Med. 2019;200(7):e45–e67
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Out(patient) With the OLD!
•Azithromycin
•Doxycycline
•Levofloxacin
In (but still OUT-patient) With the NEW!
‡ Comorbidities include chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia
Am J Respir Crit Care Med. 2019;200(7):e45–e67
Case #1
• Mr. Topper is a 45 year old male with a past medical history of seizures (that are controlled by medications) and no allergies. He comes to the urgent care clinic complaining of cough (with sputum production), chest pain, fevers, fatigue, and shortness of breath for the past few days. His lungs sounds are diminished and a quick chest xray shows opacities consistent with community acquired pneumonia. He does not need to be admitted to the hospital, but the physician would like to start antimicrobial therapy for CAP.
• What medication would you recommend starting in Mr. Topper?
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Case #2
• Betty Bonnet is a 73 year old female who goes to her PCP complaining of symptoms of pneumonia. She has a past medical history of CHF and DM. She has had no recent hospital stays and is otherwise rather healthy. She reports an allergy to pineapple. The physician diagnoses her with community acquired pneumonia and would like to initiate antibiotic therapy in her. She can be treated as an outpatient.
• What medication do you want to start in Ms. Bonnet?
Case #3
• Sam Sombrero, a 64 year old male with ESRD, presents to the urgent care clinic after feeling sick for a few days. The physician diagnoses him with community acquired pneumonia that can be treated on an outpatient basis. The doctor asks about allergies and Sam reports that he cannot take penicillin because the last time he did, his throat closed up and he was hospitalized because of it.
• What medication do you recommend starting in Sam Sombrero?
AdministrationDRUG DOSE MONITORING
Amoxicillin 1g PO TID Allergies, N/V/D, renal function
Doxycyline 100mg PO BID Photosensitivity, N/V/D, not for children < 7yo
Azithromycin 500mg PO x 1 day, then 250mg daily QT prolongation, interactions, N/V/D
Clarithromycin 500mg PO BID OR ER 1000mg PO daily Same as azithromycin
Amoxicillin/ clavulanate
500mg/125mg PO TID OR 875mg/125mg PO BID OR 2000mg/125mg PO BID
Same as amoxicillin
Cefpodoxime 200mg PO BID Same as amoxicillin
Cefuroxime 500mg PO BID Same as amoxicillin
Levofloxacin 750mg PO daily QT prolongation, glucose levels, tendon rupture, C. difficile, altered mental status, renal function
Moxifloxacin 400mg PO daily Same as levofloxacin (except renal function)
Gemifloxacin 320mg PO daily Same as levofloxacinAm J Respir Crit Care Med. 2019;200(7):e45–e67
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Inpatient CAP (No MRSA/Pseudomonas Risk Factors)
Non-Severe SevereB-lactam* + macrolide^*amp-sulbactam ^azithromycin, cefotaxime clarithromycinCeftarolineceftriaxone
B-lactam* + macrolide^
Respiratory fluoroquinolone#
#levofloxacin, moxifloxacin
B-lactam* + Respiratory fluoroquinolone#
B-lactam* + doxycyclineIF documented allergy/contraindication to above
Am J Respir Crit Care Med. 2019;200(7):e45–e67
Case #4
• Lena Lid, a 56 YOF, is admitted to the hospital with complaints of coughing, wheezing, sputum production, fevers, and is having trouble breathing. She is diagnosed with pneumonia and has had no recent hospitalizations and has no history of infections. She is admitted to the general floor and is diagnosed with a non-severe infection. Her PMH is significant for a cefdinir allergy (reaction is nausea/vomiting) and she is otherwise healthy.
• What antibiotics do you recommend starting in Lena?
• Do you recommend obtaining blood and sputum cultures in her?
DOSESDRUG DOSE MONITORING
Ampicillin/sulbactam 1.5-3g IV Q6H Allergies, N/V/D, renal function
Cefotaxime 1-2g IV Q8H Same as ampicillin/sulbactam
Ceftriaxone 1-2g IV daily Allergies, N/V/D
Ceftaroline 600mg IV Q12H Same as amp/sulbactam
Azithromycin 500mg daily QT prolongation, N/V/D, drug interactions
Clarithromycin 500mg BID Same as azithromycin
Levofloxacin 750mg daily QT prolongation, glucose levels, tendon rupture, C. difficile, altered mental status, renal function
Moxifloxacin 400mg daily Same as levofloxacin (except renal function)
Am J Respir Crit Care Med. 2019;200(7):e45–e67
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Where Does This Leave HCAP?
• How do we determine MRSA/PSA risk factors?
• Great Question-NO SIMPLE RULE!
• But this may help...• Previous MRSA/PSA infection
• Recent hospitalization (90 days) w/ IV antibiotics
• "Locally validated risk factors"
Am J Respir Crit Care Med. 2019;200(7):e45–e67
Not Exactly "DRIP"ping With Evidence....
• DRIP Score helps predict risk of MRSA/PSA
Antimicrob Agents Chemother. 2016;60(5):2652–2663. Published 2016 Apr 22
Major Risk Factors (2 points each)
Minor Risk Factors (1 point each)
Results:
• Antibiotic use within previous 60 days
• Residence in a long-term-care facility
• Tube feeding • Prior infection with a DRP (1 yr)
• Hospitalization within previous 60 days
• Chronic pulmonary disease • Poor functional status• Gastric acid suppression • Wound care• MRSA colonization (1 yr)
• Score of > 4 Revealed:• Sensitivity: 0.76• Specificity: 0.91• Positive Predictive Value
(PPV): 0.73 • Negative Predictive Value
(NPV): 0.92
IF MRSA, Pseudomonas aeruginosa (PSA)Therapy Initiated• MRSA:
• Vancomycin• Linezolid
• PSA:• Piperacillin/Tazobactam• Cefepime, Ceftazidime• Imipenem, Meropenem• Aztreonam
• Get BLOOD and SPUTUM cultures and MRSA PCR nasal swab• Stop MRSA therapy if PCR is negative• De-escalate after 48 hours if cultures are negative for MRSA/PSA
Am J Respir Crit Care Med. 2019;200(7):e45–e67
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DOSESDRUG DOSE MONITORING
Vancomycin 15mg/kg IV Q12H
Adjust dose based on levels, renal function
Linezolid 600mg Q12H Bone marrow suppression
Piperacillin/ tazobactam 4.5g IV Q6H Allergies, N/V/D, renal function
Cefepime 2g IV Q8H Same as piperacillin/tazobactam (pip/tazo)
Ceftazidime 2g IV Q8H Same as pip/tazo
Imipenem 500mg IV Q6H Same as pip/tazo, seizures
Meropenem 1g IV Q8H Same as pip/tazo, seizures
Aztreonam 2g IV Q8H Same as pip/tazo
Am J Respir Crit Care Med. 2019;200(7):e45–e67
Mr. Fedora….
• JA Fedora is a 62 year old male with a past medical history of HTN, DMII (last A1C was 9.6 last month), and multiple diabetic foot infections, presents to the ER with complaints of chest tightness, cough (with green-tinged sputum), fever, chills, fatigue. He was recently admitted to the hospital last month with a diabetic foot infection and was treated with IV vancomycin (for MRSA) and ceftriaxone (for E. coli) for 2 weeks. He is admitted to the floor (he’s not septic and this is not a severe infection). The physician asks for your help in initiating antibiotics for community acquired pneumonia.
• What antibiotics do you recommend starting in him (he has no allergies)?
2 hours later…..
• Mr. Fedora’s nasal MRSA PCR returns and is negative.
• What do you want to do with this antibiotic therapy?
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Aspiration Pneumonia: Should We Be “All About Anaerobes”?
•NO(t really)!*
•Only if empyema/lung abscess suspected
*Evidence is low quality and recommendation is conditional
Am J Respir Crit Care Med. 2019;200(7):e45–e67
CAP Medication Duration of Therapy
•5 days (with clinical improvement)
• Resolution of vital sign abnormalities• Ability to eat• Normal mentation
•7 days if proven MRSA or PSA
• In agreement with HAP/VAP guidelinesAm J Respir Crit Care Med. 2019;200(7):e45–e67
What About the NEW KIDS (DRUGS) ON THE BLOCK?• Omadacycline
• Aminomethylcycline: Tetracycline-like (with higher barrier to resistance)• OPTIC trial: Noninferior to moxifloxacin for CAP (duration 7-14 days)• LOAD: 200mg IV x 1 OR 100mg IV q12H x 1 day• MAINTENANCE: 100mg IV Q24H or 300mg PO daily• Favorable safety profile• Not enough evidence for 2019 guidelines
• Lefamulin• Pleuromutilin – novel ribosomal inhibitor• LEAP 1 and 2 trials: Noninferior to moxifloxacin for CAP (duration 5 days)• IV 150mg Q12H; ORAL 600mg Q12H• Favorable safety profile• Not enough evidence for 2019 guidelines
N Engl J Med. 2019;380(6):517–527(LEAP 1) Trial. Clin Infect Dis. 2019;69(11):1856–1867(Leap 2) JAMA. 2019;322(17):1661–1671
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Our Team Challenge to YOU to Improve Patient Care
• RESEARCH OPPORTUNITIES:• Develop an institutional Pseudomonas aeruginosa and MRSA screening tool
• Students - reach out to inpatient pharmacists and offer to work with them
• Pharmacists - pair up with a student and work to develop a way to analyze retrospective data
• ID Pharmacists - work with pharmacists/students on data analysis and screening tool development
• EVERYONE - Gain invaluable research experience
• TEACHING OPPORTUNITIES• EVERYONE - teach YOUR teammates
• Host an educational session at your institution about the new CAP guidelines
• Create a flyer on updated recommendations
Summary
• Compare the differences in presentation, risk factors, and treatment between community acquired pneumonia and hospital acquired pneumonia.
• Interpret tests, labs, and imaging ordered for a patient with community acquired pneumonia.
• Select appropriate drug, dose, and duration for a patient presenting with community acquired pneumonia.
Carrie Vogler, PharmD, BCPS
Beth Cady, PharmD, BCPS
SIUE School of Pharmacy
What Questions Can We Answer for You?
A New Feather in Your CAP? Applying 2019 Community Acquired
Pneumonia Guidelines to Practice
