Community Acquired Pneumonia Antibiotic Treatment

Question : In Adults With Cap Should A Respiratory Sample Be Tested For Influenza Virus At The Time Of Diagnosis

Recommendation

When influenza viruses are circulating in the community, we recommend testing for influenza with a rapid influenza molecular assay , which is preferred over a rapid influenza diagnostic test .

Summary of the evidence

Rapid influenza tests have become increasingly available, moving from earlier antigen-based detection tests to nucleic acid amplification tests. We were unable to identify any studies that evaluated the impact of influenza testing on outcomes in adults with CAP. In contrast, a substantial literature has evaluated the importance of influenza testing in the general population, specifically among patients with influenza-like illness . Our recommendations for influenza testing in adults with CAP are consistent with testing recommendations for the broader population of adults with suspected influenza, as summarized in the recent IDSA Influenza Clinical Practice Guideline .

Rationale for the recommendation

The benefits of antiviral therapy support testing of patients during periods of high influenza activity. During periods of low influenza activity, testing can be considered but may not be routinely performed. Of note, this testing recommendation has both therapeutic and infection-control implications in the hospital setting. Updated influenza testing recommendations are also available on the CDC website .

B Empiric Therapy For Patients Who Require Inpatient Management

• Obtain urine culture to confirm susceptibility
• First-line empiric therapy*:
• Ceftriaxone 1g IV Q24H +/- Ampicillin 2 g IV Q6H

• Step down to appropriate oral antibiotics when patient is afebrile and hemodynamically stable, based on culture and susceptibility results
• Usual duration of therapy is 7 days for uncomplicated pyelonephritis complicated infections require 10-14 days of therapy and occasionally longer, in consultation with Urology and Infectious Diseases

*Suggest coverage for extended-spectrum beta-lactamase producing organisms in the following circumstances:

• Known ESBL colonization

Diagnosis And Treatment Of Community

M. NAWAL LUTFIYYA, PH.D., ERIC HENLEY, M.D., M.P.H., and LINDA F. CHANG, PHARM.D., M.P.H., B.C.P.S., University of Illinois College of Medicine at Rockford, Rockford, Illinois

STEPHANIE WESSEL REYBURN, M.D., M.P.H., Mayo School of Graduate Medical Education, Rochester, Minnesota

Am Fam Physician. 2006 Feb 1 73:442-450.

• References

Patients with community-acquired pneumonia often present with cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain. When a patient presents with suspected community-acquired pneumonia, the physician should first assess the need for hospitalization using a mortality prediction tool, such as the Pneumonia Severity Index, combined with clinical judgment. Consensus guidelines from several organizations recommend empiric therapy with macrolides, fluoroquinolones, or doxycycline. Patients who are hospitalized should be switched from parenteral antibiotics to oral antibiotics after their symptoms improve, they are afebrile, and they are able to tolerate oral medications. Clinical pathways are important tools to improve care and maximize cost-effectiveness in hospitalized patients.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Patients with suspected community-acquired pneumonia should receive chest radiography.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Patients with suspected community-acquired pneumonia should receive chest radiography.

Overview of Community-Acquired Pneumonia

Definition

Definition

• References

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Appropriate Methods Of Causative Bacteria Detection In Inpatients

For inpatients with pneumonia, it is advisable to perform blood culture, and sputum Gram smear and culture tests before antibiotic administration as long as they are indicated. Sputum tests must be done using sputum samples obtained before antibiotic administration, and should only be performed when sufficient amounts of sputum are released, collected, transferred, and treated . For patients with moderate community-acquired pneumonia, a blood culture, Legionella, S. pneumoniae urinary antigen test, and sputum gram smear and culture must be performed . For patients with airway intubation, a test using trans-tracheal aspirate samples must be performed. For immunodeficient patients, or patients for whom common treatments have failed, invasive tests such as airway endoscopy and percutaneous pulmonary aspiration are useful .

KQ 2. For adults who may have contracted community-acquired pneumonia, is the urinary S. pneumoniae antigen test useful for selecting therapeutic antibiotics?

Question 1: In Adults With Cap Who Test Positive For Influenza Should The Treatment Regimen Include Antibacterial Therapy

Recommendation

We recommend that standard antibacterial treatment be initially prescribed for adults with clinical and radiographic evidence of CAP who test positive for influenza in the inpatient and outpatient settings .

Summary of the evidence

Bacterial pneumonia can occur concurrently with influenza virus infection or present later as a worsening of symptoms in patients who were recovering from their primary influenza virus infection. As many as 10% of patients hospitalized for influenza and bacterial pneumonia die as a result of their infection . An autopsy series from the 2009 H1N1 influenza pandemic found evidence of bacterial coinfection in about 30% of deaths .

S. aureus is one of the most common bacterial infections associated with influenza pneumonia, followed by S. pneumoniae, H. influenzae, and group A Streptococcus other bacteria have also been implicated . Given this spectrum of pathogens, appropriate agents for initial therapy include the same agents generally recommended for CAP. Risk factors and need for empiric coverage for MRSA would follow the guidelines included earlier in this document. Rapidly progressive severe pneumonia with MRSA has been described in previously healthy young patients, particularly in the setting of prior influenza however, it is typically readily identified in the nares or sputum and should be identified by following the recommendations of earlier recommendations in this guideline.

Rationale for the recommendation

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Outpatient Vs Inpatient Treatment

Choosing between outpatient and inpatient treatment is a crucial decision because of the possible risk of death.9,15,16 This decision not only influences diagnostic testing and medication choices, it can have a psychological impact on patients and their families. On average, the estimated cost for inpatient care of patients with CAP is $7,500. Outpatient care can cost as little as $150 to $350.1719 Hospitalization of a patient should depend on patient age, comorbidities, and the severity of the presenting disease.9,20

Physicians tend to overestimate a patients risk of death14 therefore, many low-risk patients who could be safely treated as out-patients are admitted for more costly inpatient care. The Pneumonia Severity Index was developed to assist physicians in identifying patients at a higher risk of complications and who are more likely to benefit from hospitalization.9,15,16 Investigators developed a risk model based on a prospective cohort study16 of 2,287 patients with CAP in Pittsburgh, Boston, and Halifax, Nova Scotia. By using the model, the authors found that 26 to 31 percent of the hospitalized patients were good outpatient candidates, and an additional 13 to 19 percent only needed brief hospital observation. They validated this model using data17 from more than 50,000 patients with CAP in 275 U.S. and Canadian hospitals.1517,21,22

Information from reference 15.

Question 1: In The Inpatient Setting Should Adults With Cap And Risk Factors For Mrsa Or P Aeruginosa Be Treated With Extended

Recommendation

We recommend abandoning use of the prior categorization of healthcare-associated pneumonia to guide selection of extended antibiotic coverage in adults with CAP .

We recommend clinicians only cover empirically for MRSA or P. aeruginosa in adults with CAP if locally validated risk factors for either pathogen are present . Empiric treatment options for MRSA include vancomycin or linezolid . Empiric treatment options for P. aeruginosa include piperacillin-tazobactam , cefepime , ceftazidime , aztreonam , meropenem , or imipenem .

If clinicians are currently covering empirically for MRSA or P. aeruginosa in adults with CAP on the basis of published risk factors but do not have local etiological data, we recommend continuing empiric coverage while obtaining culture data to establish if these pathogens are present to justify continued treatment for these pathogens after the first few days of empiric treatment .

Summary of the evidence

Unfortunately, no validated scoring systems exist to identify patients with MRSA or P. aeruginosa with sufficiently high positive predictive value to determine the need for empiric extended-spectrum antibiotic treatment. Scoring system development and validation are complicated by varying prevalence of MRSA and P. aeruginosa in different study populations. Moreover, no scoring system has been demonstrated to improve patient outcomes or reduce overuse of broad-spectrum antibiotics.

Rationale for the recommendation

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Question : In The Inpatient Setting Should Patients With Suspected Aspiration Pneumonia Receive Additional Anaerobic Coverage Beyond Standard Empiric Treatment For Cap

Recommendation

We suggest not routinely adding anaerobic coverage for suspected aspiration pneumonia unless lung abscess or empyema is suspected .

Summary of the evidence

Aspiration is a common event, and as many as half of all adults aspirate during sleep . As a result, the true rate of aspiration pneumonia is difficult to quantify, and there is no definition that separates patients with aspiration pneumonia from all others diagnosed with pneumonia. Some have estimated that 5% to 15% of pneumonia hospitalizations are associated with aspiration . Rates are higher in populations admitted from nursing homes or extended care facilities .

Patients who aspirate gastric contents are considered to have aspiration pneumonitis. Many of these patients have resolution of symptoms within 24 to 48 hours and require only supportive treatment, without antibiotics .

Studies evaluating the microbiology of patients with aspiration pneumonia in the 1970s showed high rates of isolation of anaerobic organisms however, these studies often used trans-tracheal sampling and evaluated patients late in their disease course, two factors that may have contributed to a higher likelihood of identifying anaerobic organisms . Several studies of acute aspiration events in hospitalized patients have suggested that anaerobic bacteria do not play a major role in etiology .

Rationale for the recommendation

Research needed in this area

Question 1: In The Inpatient Setting Should Adults With Cap Be Treated With Corticosteroids

Recommendation

We recommend not routinely using corticosteroids in adults with nonsevere CAP .

We suggest not routinely using corticosteroids in adults with severe CAP .

We suggest not routinely using corticosteroids in adults with severe influenza pneumonia .

We endorse the Surviving Sepsis Campaign recommendations on the use of corticosteroids in patients with CAP and refractory septic shock .

Summary of the evidence

Two randomized controlled studies of corticosteroids used for treatment of CAP have shown significant reductions in mortality, length of stay, and/or organ failure. The first study found a large magnitude of mortality benefit that has not been replicated in other studies, raising concerns that the results overestimated the true effect . In the second study, there were baseline differences in renal function between groups . Other RCTs of corticosteroids in the treatment of CAP have not shown significant differences in clinically important endpoints. Differences have been observed in the time to resolution of fever and other features of clinical stability, but these have not translated into differences in mortality, length of stay, or organ failure .

In pneumonia due to influenza, a meta-analysis of predominantly small retrospective studies suggests that mortality may be increased in patients who receive corticosteroids. This finding might reflect the importance of innate immunity in defense against influenza as opposed to bacterial pneumonia.

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History And Physical Examination

Common symptoms include fever , chills, pleuritic chest pain, and a cough producing mucopurulent sputum. Overall, physician judgment is moderately accurate for diagnosis of pneumonia, especially for ruling it out .7 Absence of fever and sputum also significantly reduces the likelihood of pneumonia in outpatients.8

High fever , male sex, multilobar involvement, and gastrointestinal and neurologic abnormalities have been associated with CAP caused by Legionella infection.9 The clinical presentation of CAP is often more subtle in older patients, and many of these patients do not exhibit classic symptoms.1 They often present with weakness and decline in functional and mental status.

The patient history should focus on detecting symptoms consistent with CAP, underlying defects in host defenses, and possible exposure to specific pathogens. Persons with chronic obstructive pulmonary disease or human immunodeficiency virus infection have an increased incidence of CAP. Patients should be asked about occupation, animal exposures, and sexual history to help identify a specific infectious agent. A recent travel history may help identify Legionella pneumonia, which has been associated with stays at hotels and on cruise ships. Influenza is often suggested on the basis of typical symptoms during peak influenza season.

D Necrotizing Skin And Soft Tissue Infection

• May be caused by Group A streptococci or mixed aerobes/anaerobes or other rare etiologies
• Urgent Infectious Diseases and Surgical consultation is strongly suggested in all suspected cases

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Duration Of Antibiotic Therapy For Outpatients And Inpatients With Cap

The optimal duration of antibiotic therapy for the treatment of CAP has yet to be definitively established. Short-term antibiotic therapy seems to be the most appropriate, given that it provides less patient exposure to the effects of antibiotics, reduces the occurrence of adverse effects, reduces the development of drug resistance by microorganisms, improves patient adherence, and can minimize length of hospital stay and financial costs. In addition, very long-term treatments favor the development of bacterial resistance and the occurrence of potentially severe adverse effects, such as infections with Clostridium difficile. However, short-term treatment should be as effective as longer-term treatments in terms of rates of mortality, complications, and disease recurrence.

Recommendations regarding the optimal duration of antibiotic therapy have changed over time, and there are discrepancies on this issue across guidelines .

Question 1: In Adults With Cap Who Are Improving Should Follow

Recommendation

In adults with CAP whose symptoms have resolved within 5 to 7 days, we suggest not routinely obtaining follow-up chest imaging .

Summary of the evidence

There are limited data on the clinical usefulness of reimaging patients with pneumonia. Most available data have evaluated whether reimaging patients detects lung malignancy not recognized at the time of treatment for pneumonia. Reported rates of malignancy in patients recovering from CAP range from 1.3% to 4% . When unsuspected nonmaligant pathology is included, the rate of abnormal findings may reach 5%.

Almost all patients with malignancy in reported series were smokers or ex-smokers. One longer-term study found 9.2% of CAP survivors in the Veterans Affairs system had a new diagnosis of cancer, with a mean time to diagnosis of 297 days. However, only 27% were diagnosed within 90 days of discharge from hospital, suggesting the yield of routine follow-up post discharge would be low .

Rationale for the recommendation

Available data suggest the positive yield from repeat imaging ranges from 0.2% to 5.0% however many patients with new abnormalities in these studies meet criteria for lung cancer screening among current or past smokers .

Research needed in this area

Further research may clarify subgroups of patients who may benefit from further radiological assessment after initial therapy for pneumonia.

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Antibiotic Resistance Of The Major Causative Bacteria Of Community

Resistance against ampicillin due β-lactamase production is common in H. influenzae. In a domestic study that analysed 544 bacterial strains, the antibiotic resistance against ampicillin, cefuroxime, clarithromycin, cefaclor, and amoxicillin/clavulanate was 58.5%, 23.3%, 18.7%, 17.0%, and 10.4%, respectively . This study did not identify bacterial strains that are resistant to levofloxacin and cefotaxime. In another study that analysed 229 bacterial strains, the antibiotic resistance against ampicillin high at 58.1%, and that against cefaclor, clarithromycin, amoxicillin/clavulanate, cefixime, and levofloxacin was 41.4%, 25.8%, 13.5%, 10.9%, and 1.3%, respectively .

Not many studies have analysed the antibiotic susceptibility of M. pneumoniae in Korea. In a study that examined M. pneumoniae isolated from respiratory organ samples of pediatric patients in 2000-2011, genes related to macrolide resistance was detected in 31.4% of the samples, and this rate was reported to increase every year . In another study using respiratory organ samples from pediatric patients, genes related to macrolide resistance were found in 17.6% of the samples of M. pneumoniae . Although the ratio of methicillin-resistant S. aureus in community-acquired S. aureus infection has been increasing in Korea, systematic research on the role of MRSA in community-acquired pneumonia is lacking .

Treatment Of Patients With Pneumonia In Icu

KQ 14. For patients who may have contracted community-acquired pneumonia and are admitted to ICU for treatment, does the β-lactam/macrolide combination therapy lead to better prognoses than the β-lactam monotherapy?

KQ 15. For patients who may have contracted community-acquired pneumonia and who are in admitted to ICU for treatment, does the β-lactam/macrolide combination therapy lead to better prognoses than the respiratory fluoroquinolone monotherapy?

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Appropriate Methods Of Causative Bacteria Detection In Outpatients

When treating outpatients with community-acquired pneumonia of low severity, tests are selectively performed according to age, underlying diseases, severity markers, epidemiological factors, and current history of antibiotic use. Sputum gram smear and culture may be performed when antibiotic-resistant bacteria or bacteria that are difficult to treat with common empirical antibiotics are suspected. If tuberculosis is suspected based on clinical or radiographic findings, a sputum stain and tuberculosis test are performed. It is also recommended to perform diagnostic tests when Legionella infection or influenza are suspected based on clinical and epidemiological findings.

Question : In Adults With Cap Should Serum Procalcitonin Plus Clinical Judgment Versus Clinical Judgment Alone Be Used To Withhold Initiation Of Antibiotic Treatment

Recommendation

We recommend that empiric antibiotic therapy should be initiated in adults with clinically suspected and radiographically confirmed CAP regardless of initial serum procalcitonin level .

Summary of the evidence

Several studies have assessed the ability of procalcitonin to distinguish acute respiratory infections due to pneumonia from acute bronchitis or upper respiratory tract infections . However, for the purposes of this guideline, the question is whether, among patients with clinically confirmed CAP, measurement of procalcitonin can distinguish patients with viral versus bacterial etiologies and guide the need for initial antibiotic therapy. Some investigators have suggested that procalcitonin levels of 0.1 g/L indicate a high likelihood of viral infection, whereas levels 0.25 g/L indicate a high likelihood of bacterial pneumonia . However, a recent study in hospitalized patients with CAP failed to identify a procalcitonin threshold that discriminated between viral and bacterial pathogens, although higher procalcitonin strongly correlated with increased probability of a bacterial infection . The reported sensitivity of procalcitonin to detect bacterial infection ranges from 38% to 91%, underscoring that this test alone cannot be used to justify withholding antibiotics from patients with CAP .

Rationale for the recommendation

Research needed in this area

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