Facilitator Version

Module # 18 CAP and HCAP

Created by Wendy Gerstein 11/13

Objectives:

1.  Be able to triage patients appropriately based on either the pneumonia severity index (PSI) or CURB-65 score.

2.  Be able to choose appropriate empiric antibiotic therapy for both CAP and HCAP.

3.  List three risk factors for HCAP/HAP.

References:

1. Management of Community-Acquired Pneumonia, Halm E., Teirstein,A, NEJM 2002 347:2039-2045.

2. Fine MJ, Stone RA, Singer DE, et al. Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study. Arch Intern Med 1999;159: 970-980.

3. Healthcare-associated pneumonia in adults: management principles to improve outcomes. Craven DE; Palladino R; McQuillen DP Infect Dis Clin North Am 2004 Dec;18(4):939-62.

4. The Role of MRSA in Healthcare-Associated Pneumonia. Lam AP and Wunerlink RG. Semin Respir Crit Care med 2009; 30:52-60.


CASE

HPI: Patient is a 75 yo male with history of COPD (FEV 1 70%, not on home oxygen) and hypertension who presents to the ER with a 3-4 day history of worsening cough with some production of greenish phlegm. He also complains of lack of energy and appetite with decreased oral intake, and has had some chills but no obvious fever. Denies CP, but has some SOB with exertion. He denies GI or GU symptoms, and has no headache or neurological complaints. He denies significant weight changes or leg swelling. He is not up to date on immunizations. He denies sick contacts, but did travel recently to southern California to see his brother. In the ED bp 104/54, p 108, RR 20, T 37, 85% RA, 96% on 2 liters. Exam notable for crackles LLL with egophony, mild prolonged expiratory phase bilaterally; rest of exam unremarkable. Labs significant for wbc 13,400, Na 132, K 3.8, Cl 98, HCO3 25, Bun 20, creatinine 1.1, glucose 96. LFT’s normal, UA normal.

What is your initial assessment? Sepsis - SIRS (HR and wbc) with likely infection; new hypoxia.

Possible sources of infection? Pneumonia (CAP), viral syndrome, bronchitis.

What is your initial management step? CXR, blood cultures, lactate, calculate PSI or CURB-65 score (see attached sheet).

CXR shows a dense LLL infiltrate with air bronchograms.

What is your initial treatment plan? How would you determine the patient’s severity of illness as well as the appropriate disposition?

SOB, increased cough with sputum, hypoxia and a CXR with a focal finding confirm the clinical suspicion of community acquired pneumonia. In addition a COPD exacerbation may be contributing to his symptoms. He is at risk for the most common CAP pathogens which include S. pneumoniae, M. pneumoniae, H. influenza, and M. catarrhalis. In addition his travel history raises his risk of Coccidioides immitis, and he should be tested for it if he does not respond to CAP therapy.

Utilizing the Pneumonia Severity Index (PSI), a score of 85 {age score (75) + hypoxia score (10) = 85} was calculated (Risk class III). Based on this score and hypoxia, patient should be admitted for a course of IV antibiotics. His CURB-65 score is 2. Each score has a recommended disposition (home vs. observation vs. admit vs. MICU)

Appropriate antibiotics include:

·  IV ceftriaxone (or cefotaxime) and oral doxycycline.

·  IV ceftriaxone and oral azithromycin.

·  Moxifloxacin (check EKG for QT duration) if beta-lactam allergic.

Of note: Patients who are bacteremic with S. pneumoniae in the setting of pneumonia have improved outcomes when treated with a b-lactam antibiotic compared to a non b-lactam antibiotic.

What possible outpatient medications can you use for treatment of CAP on discharge from hospital?

With no co-morbidities present: Doxycycline, azithromycin, moxifloxacin

With co-morbidities present (such as COPD or recent antibiotic use): Moxifloxacin; azithromycin or doxycycline plus high dose amoxicillin or augmentin.

After 2 days patient is discharged to home on oral antibiotics and oxygen and is doing better but then 5 days after discharge he develops severe cough with purulent sputum, high fevers, and pleuritic CP. In the ED he is noted to have fever to 38.5, p 120s, bp 90/60. 90% 5 liters, RR 25; CXR shows persistent LLL infiltrate with small effusion and new RUL infiltrate.

What would be highest on your differential? HCAP/HAP, parapneumonic effusion/empyema, aspiration pneumonia. Other possibilities (but less likely) include pulmonary embolus with associated pulmonary infarct) or lung abscesses.

Can you list 3 or more risk factors for HCAP/HAP?

  1. Prior antibiotic therapy in the last 3 months
  2. Current hospitalization > 5 days
  3. High frequency of antibiotic resistance in the community
  4. Hospitalization for at least 2 days in the preceding 90 days
  5. From a nursing home type living situation (not group home)
  6. Recent surgery
  7. Chronic dialysis
  8. Invasive respiratory devices (intubation, bronchoscopy)
  9. Pre-existing pulmonary disease
  10. Immunosuppressive disease or therapy
  11. Enteral feeding in conjunction with supine position (ICU).

What organisms are typically implicated in HCAP/HAP?

–  Resistant GNR’s (Enterobacter, Citrobacter, Klebsiella, E. coli)

–  Pseudomonas aeruginosa

–  S. aureus (MRSA)

–  Anaerobes (aspiration)

–  Aspergillosis (seen more in prolonged hospitalizations and immunosuppressed patients)

What is your treatment plan including antibiotic coverage? Patient now has a PSI score of at least 95 (+10 for effusion, bp is borderline), need to consider MICU or at least step down care depending on response to IVFS; start iv antibiotics (see below), other supportive care including IVFs, oxygen, check lactate and blood gas in addition to other basic labs, send sputum and blood for culture, check MRSA status. In addition need to monitor the pleural effusion, consider tap if still febrile after 24 hours of antibiotics or if enlarging in size.

Antibiotic options include:

·  Piperacillin/tazobactam (Zosyn).

·  Cefepime plus clindamycin if concerned about anaerobes (? Aspiration risk or poor dendition).

·  Levoquin (check QT) +/- clindamycin (if beta-lactam allergic)

·  Carbapenems if patient has history of multi-drug resistant organisms.

·  Vancomycin should be added to above regimens if MRSA nares positive or patient deteriorating quickly. Can stop vancomycin once confirmed that patient is MRSA negative and sputum/blood cultures negative.

Of note, nasal carriage of MRSA is a much higher risk factor for invasive infection compared to skin colonization, and the most predictive risk factor for nosocomial MRSA infection is prior antibiotic therapy (particularly flouroquinolones).

Do you need to “double cover” for possible resistant GNRs? Unless the patient has a documented resistant organism in the past or risk factors for resistant organisms, or is neutropenic with sepsis, there is no evidence for "double coverage."

MKSAP questions:

ID Question 30; answer D – management of mild pneumonia caused by histoplasmosis.

ID Question 47; answer A – Diagnose anthrax infection after inhalation exposure.

ID Question 50; answer C – Treatment of a patient with suspected CA-MRSA pneumonia.

ID Question 103; answer C – choose appropriate site of care for a patient with CAP.


Predictors of morbidity and mortality in pneumonia: CURB-65 and PSI

CURB-65:

·  Confusion (based upon a specific mental test or new disorientation to person, place, or time)

·  BUN > 19 mg/dL

·  Respiratory rate >30 breaths/minute

·  Blood pressure <90/60 mmHg

·  Age >65 years

·  30-day mortality was 0.7, 2.1, 9.2, 14.5, and 40 percent for 0, 1, 2, 3, or 4 factors.

·  Patients with a CURB-65 score of 0 to 1 can probably be treated as outpatients; those with a score of 2 should be admitted to the hospital, and those with a score of 3 or more should be assessed for ICU care, particularly if the score is 4 or 5.

c. Regardless of predictors, early treatment with antibiotics is associated with improved clinical outcomes. Goal is administration of appropriate antibiotics within 4 hours of triage in ER.

Pneumonia Severity Index (PSI)
Characteristic / Points / Score
Demographic Factors
Age
Men: Age in years
Women: Age in years - 10
Nursing home resident / + 10
Coexisting Illnesses
Neoplastic disease / + 30
Liver disease / + 20
Congestive Heart Failure / + 10
Cerebrovascular disease / + 10
Renal disease / + 10
Findings on Physical Examination
Altered mental status / + 20
Respiratory rate ≥ 30/min / + 20
Systolic blood pressure < 90 mm Hg / + 20
Temperature < 35° C or ≥ 40° C / + 15
Pulse ≥ 125 beats/min / + 10
Laboratory and Radiographic Findings
Arterial pH < 7.35 / + 30
Blood urea nitrogen ≥ 30 mg/dl (11 mmol/1) / + 20
Sodium < 130 mmol/liter / + 20
Glucose ≥ 250 mg/dl (14 mmol/liter) / + 10
Hematocrit < 30% / + 10
Sa02 < 90%* or Pa02 < 60 mm Hg / + 10
Pleural effusion / + 10
Total PSI
/ Pneumonia Severity Index (PSI) is used to determine a patient's risk of death. The total score is obtained by adding to the patient's age (in years for men or in years minus 10 for women) the points assigned for each additional applicable characteristic.
(Data adapted from Fine et al. N Engl J Med 1997; 336; 243-50)
Recommendations Based on total PSI Score
Risk Score / Risk Class / Mortality / Disposition
≤ 50 / I Low / 0.1% / Consider outpatient or observation status
≤ 70 / II Low / 0.6% / Consider observation or admit
71-90 / III Low / 0.9% / Consider observation or admit
91-130 / IV Mod / 9.3% / Admit, consider MICU
> 130 / V High / 27.0% / Admit, consider MICU
Admission is recommended for Class I, II and III patients who are hypoxemic (RA 02 sat of <90%), and patients who have important medical or psycho/social contraindications to outpatient care.

Post Module Evaluation

Please place completed evaluation in an interdepartmental mail envelope and address to Dr. Wendy Gerstein, Department of Medicine, VAMC (111) or give to Dr. Patrick Rendon if at the University.

1) Topic of module:______

2) On a scale of 1-5, how effective was this module for learning this topic? ______

(1= not effective at all, 5 = extremely effective)

3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:

______

4) Was the attending involved in the teaching of this module? Yes/no (please circle).

5) Please provide any further comments/feedback about this module, or the inpatient curriculum in general:

6) Please circle one:

Attending Resident (R2/R3) Intern Medical student