Pneumonia Current Challenges

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Pneumonia Current Challenges

• Clare Colligan
• Antibiotic / Clinical Governance Pharmacist
• NHS Forth Valley

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Aims

• Quickly review the diagnosis and aetiology of
  pneumonia
• Discuss severity assessments
• Consider suitable
• antibiotic regimes
• Discuss the challenges
• around treating the
• infection but
• preventing HCAI
• Raise awareness of
• SNAP CAP care bundle

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Community Acquired Pneumonia

• Diagnosis difficult clinically
• CXR Gold standard
• 29 of hospitalised patients treated for CAP had
  no CXR changes
• Plus symptoms of LRTI
• New focal signs chest signs on examination
• At least one systemic feature
• Sweating , fever, shivers, aches pains, temp
  gt380C
• No other explanation for illness

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How common / serious is it?

• Incidence
• 5-11 per 1000 adult population
• 22-44 admitted to hospital
• 1.2-10 cared for in ITU setting
• Mortality
• Hospitalised patients 5.7-10
• ITU patients - gt30

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Aetiology
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Severity Assessment

• Several PSI, CURB-65
• CURB 65
• Confusion (AMT8)
• Urea gt 7mmol/l
• RR 30 breaths per min
• BP lt 90 syst or 60 diast
• Age 65 years
• Score 1 for each
• Remember clinical judgement / co-morbidities
  social circumstances

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Severity vs mortality

• CURB 65 scores

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Antibiotic Management CAP

• Majority of therapy is empirical cover Strep.
  pneumo
• Non severe (CURB 65 0 or 1)
• Amoxicillin 500mg tds orally or
• Doxycycline 200mg stat then 100mg od daily or
• Clarithromycin 500mg bd
• Course length 7 days BTS (ATS 5days)
• Oral route

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Antibiotic Management CAP

• Moderate (CURB 65 2)
• Atypical cover is required
• Add clarithromycin 500mg bd to amoxicillin
• (or single therapy with doxycycline or
  levofloxacin)
• Course length 7 days
• Oral route
• IV route only if oral route compromised

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Antibiotic Management CAP

• Severe (CURB 65 3 - 5)
• Need to include staph. aureus / gm ve cover
  not common but carry a high mortality
• Intravenous treatment prompt to ensure high
  blood/lung concentrations
• Course length at least 10 days, 14 days for
  atypical

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Antibiotic Management CAP

• CURB 65 3 - 5
• IV co-amoxiclav 1.2g tds clarithromycin 500mg
  bd
• Or IV BZP 1.2g qds levofloxacin 500mg bd (or
  ciprofloxacin 400mg bd IV)
• Or IV Cefuroxime 1.5g tds (or ceftriaxone 2g od
  or cefotaxime 1g tds) IV clarithromycin 500mg
  bd
• (Allergy to penicillin and 2nd/3rd generation
  cephalosporins vancomycin ciprofloxacin
  local)

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Dilemma Antimicrobial stewardship vs clinical
care

• Risk of clinical deterioration vs risk of over
  treating with broad spectrum abx.
• Most deaths occur shortly after admission
• Senior review essential is it CAP? Is it
  severe?
• De-escalate therapy
• Stop treatment if not infective! record
  indication in case notes
• Micro results
• IV to oral switch reduce risk of SABs
• Limit risk of CDAD/MRSA by appropriate therapy

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SNAP CAP

• Scottish National Audit Programme Community
  Acquired Pneumonia
• Care bundle to be implemented in all boards
• Oxygen saturations 94-98, CURB 65 recorded,
  antibiotics within 4 hours, antibiotics follow
  local policy, CURB 65 0 or 1 discharged if
  appropriate, CURB 65 3-5 admitted and IV
  antibiotics

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Other factors to consider

• Risk of aspiration community or hospital?
• Often normal flora from oropharynx
• Need gm-ve anaerobic cover
• Peptostreptococcus, Fusobacterium. Prevotella
• Broad spectrum /- metronidazole
• Amoxicillin gentamicin metronidazole
• Co-amoxiclav
• Ciprofloxacin metronidazole (no strep pneumo
  cover)
• MRSA HCAI
• Post flu severe CAP ?add flucloxacillin
• Mycoplasma epidemic years use macrolide in non
  severe?

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Pandemic Flu

• Need to ensure S.aureus cover
• Non-severe co-amoxiclav, doxycycline or
  clarithromycin or moxifloxacin
• Severe as for severe CAP
• IV co-amoxiclav macrolide or
• IV cefuroxime or cefotaxime macrolide (not
  ceftriaxone less activity vs S.aureus)

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HAP hospital acquired pneumonia

• Definition occurs 48 hours after admission
  was not incubating at time of admission
• Diagnosis no universally accepted clinical
  criteria
• Purulent tracheal secretions new or persistent
  infiltrates on CXR
• ?O2 requirements
• Temp gt 38.3oC
• WCC gt1010 or lt 4x109

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HAP - concepts

• Effects 0.5-1 of inpatients most common HCAI
  contributing to death
• Early and late onset
• gt48 hours but lt 5 days
• gt 5 days
• Microbiological profile different
• Early onset
• More likely to be community like bacteria
• Late onset
• More likely to be due to more resistant organisms
• Course length no greater than 8 days

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HAP antibiotics

• Early onset no previous anitbiotics / risk
  factors
• Co-amoxiclav or cefuroxime
• Early onset previous antibiotics and/or risk
  factors
• Ceftriaxone, cefotaxime, piperacillin/tazobactam
  or fluroquinolone
• Late onset need to look at unit/local
  resistance/incidence (e.g pseud, klebsiella)
• Locally piperacillin/tazobactam gentamicin
• Not all isolates require treatment clinical
  picture!

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• Questions?