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CAP Flashcards

1
Q

Identifying CAP

A

Onset in community OR < 48h after hospitalization

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2
Q

Morbidity & Mortality

A

~10% require admission to ICU

~10% mortality (especially if antibiotics not started promptly

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3
Q

Risk factors

A

1) ≥ 65 years
2) Smoking
3) Previous hospitalization for CAP
4) Comorbidities e.g. COPD, DM, HF, immunosuppression

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4
Q

Microbiology

A

Outpatient:

1) Streptococcus pneumoniae
2) Haemophilus influenzae
3) Atypicals
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae

Inpatient, non-severe:

1) 1) Streptococcus pneumoniae
2) Haemophilus influenzae
3) Atypicals
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Legionella pneumophilia

Inpatient, severe:
1) 1) Streptococcus pneumoniae 
2) Haemophilus influenzae
3) Atypicals
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Legionella pneumophilia
4) Staphylococcus aureus
5) Other Gram-negatives e.g.
- Klebsiella pneumonia
- Burkholderia pseudomallei 
• High local incidence 
• Causes melioidosis --> pneumonia is a common presentation
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5
Q

Risk stratification - Stratification methods

A

1) Pneumonia severity index (PSI)
2) CURB-65
3) IDSA/ATS Criteria for severe CAP

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6
Q

Risk stratification - Pneumonia severity index (PSI)

1) How it works
2) Classification
3) Clinical practice

A

How it works:
Used to assess location of treatment
Use 20 variables to stratify CAP patients into 5 mortality risk classes

Classification:
Class I-II: Outpatient
Class III: Short hospitalization/observation
Class IV-V: Inpatient

Clinical practice:
Limited use due to complexity

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7
Q

Risk stratification - CURB-65

  • How it works
  • Classification
  • Clinical practice
A

How it works:
Used to assess location of treatment
Uses 5 variables to stratify CAP patients into 3 mortality risk classes (based on score)

Classification:
Score = 0-1: Outpatient
Score = 2: Inpatient
Score ≥ 3: Inpatient, consider ICU

Clinical practice:
Commonly used
- Easy to use
- Readily available parameters

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8
Q

Risk stratification - IDSA/ATS criteria for severe CAP

A

Severe CAP: ≥ 1 Major symptoms OR ≥ 3 Minor symptoms

Major symptoms:

1) Mechanical ventilation
2) Septic shock requiring vasoactive medication

Minor symptoms:

1) RR ≥ 30 bpm
2) PaO2/FiO2 ≤ 250
3) Multilobar infiltrates
4) Hypothermia - Core temperature < 36oC
5) Uremia - Urea > 7 mmol/L
6) Leukopenia - WBC < 4 x 10^9 / L
7) Hypotension requiring aggressive fluid resuscitation
8) Confusion/Disorientation

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9
Q

Management of CAP

A

Pharmacological treatment:

1) Antibiotic treatment
2) Adjunctive corticosteroid treatment
- NOT recommended

Non-pharmacological:
1) Prevention

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10
Q

Prevention

A

1) Vaccination
- Influenza –> can cause pneumonia as a complication
- Pneumococcal –> protects against S. pneumoniae

2) Smoking cessation

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11
Q

Adjunctive corticosteroid treatment

1) Treatment regimen
2) Benefits
3) Limitations
4) Clinical use

A

Treatment regimens:

1) PO Prednisolone 40mg q24h x 7 days OR
2) IV Dexamethasone 50mg q24h x 4 days

Benefits:

1) Decrease inflammation in lungs –> relieves symptoms
2) May shorten length of stay & time to clinical stability (increase rate of clinical resolution)

Limitations
1) Any impact is small & outweighed by increased risk of hypoglycemia / other ADRs

Clinical use:
NOT routinely recommended

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12
Q

Antibiotic treatment - Initiation

A

Initiate with clinical suspicion

  • I.e. Based on clinical presentation (S/Sx, radiographic findings)
  • Confirmation with cultures not needed
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13
Q

Antibiotic treatment - Treatment regimens

A

Outpatient
- Standard regimen (for ALL outpatient)

Inpatient (severe VS non-severe)

  • Standard regimen (for ALL inpatient)
  • Consider need for additional coverage: Anaerobic / MRSA / Pseudomonal coverage
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14
Q

Antibiotic treatment - Considerations when choosing antibiotics

  • Macrolides
  • Fluoroquinolones
A

Macrolides
- Avoid Erythromycin - associated with more GI side effects

Respiratory Fluoroquinolones
- NOT 1st line - Only used as alternative in penicillin allergy
- Associated with ADRs: Tendonitis, tendon rupture, neuropathy, QTc prolongation, hypoglycemia, CNS disturbances
- High risk of collateral damage
- Delay diagnosis of TB
- Reserve use for other GN infections
• Only oral option for P. aeruginosa
• Alternative against P. aeruginosa, in patients with severe penicillin allergies

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15
Q

Standard regimen for OUTpatient - Patient population

A

Organisms to cover & treatment regimen differs depending on patient population:

1) Generally healthy
2) Certain comorbidities
- Chronic heart, lung, liver, renal diseases
- DM
- Alcoholism
- Malignancy
- Asplenia

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16
Q

Standard regimen for OUTpatient - Organisms to cover

A

Generally healthy:

1) Streptococcus pneumoniae
2) Haemophilus influenzae
3) Atypicals (optional)

Certain comorbidities:

1) Streptococcus pneumoniae
2) Haemophilus influenzae
- Including ß-lactamase producing strains
3) Atypicals

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17
Q

Standard regimen for OUTpatient - Choice of antibiotics (generally healthy)

A

1st Line:

1) Amoxicillin
- Covers S. pneumoniae + H. influenzae

Alternative:

1) Levofloxacin OR Moxifloxacin
- Alternative in penicillin allergy

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18
Q

Standard regimen for OUTpatient - Choice of antibiotics (certain comorbidities)

A 
1st line: 
1) Amoxicillin-Clavulanate OR Cefuroxime
- Covers S. pneumoniae + H. influenzae 
PLUS
2) Macrolides (Clarithromycin / Azithromycin) OR Doxycycline
- Covers atypicals

Alternative:

1) Levofloxacin OR Moxifloxacin
- Alternative in penicillin allergy

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19
Q

Standard regimen for OUTpatient - Dosing

A

Amoxicillin

  • PO 1g TDS
  • Renal dose adjustment needed

Augmentin

  • PO 625 mg TDS OR PO 2g BD
  • Renal dose adjustment needed

Cefuroxime

  • PO 500 mg BD
  • Renal dose adjustment needed

Azithromycin
- PO 500 mg OD

Clarithromycin
- PO 500 mg BD

Doxycycline
- PO 100 mg BD

Levofloxacin

  • PO 750 mg OD
  • Renal dose adjustment needed

Moxifloxacin
- PO 400 mg OD

20
Q

Standard regimen for INpatient, NON-severe - Organisms to cover

A

1) S. pneumoniae
2) H. influenzae
- Including ß-lactamase producing strains
3) Atypicals

21
Q

Standard regimen for INpatient, NON-severe - Choice of antibiotics

A

1st Line:
1) Amoxicillin-Clavulanate OR Ceftriaxone
- Covers S. pneumoniae + H. influenzae
PLUS
2) Macrolides (Clarithromycin / Azithromycin) OR Doxycycline
- Covers atypicals

Alternative:

1) Levofloxacin OR Moxifloxacin
- Alternative in penicillin allergy

22
Q

Standard regimen for INpatient, NON-severe - Dosing

A

Route:

  • ß-Lactam / Fluoroquinolones: IV (may step down to PO later on)
  • Macrolides / Doxycycline: PO if possible

Amoxicillin-Clavulanate

  • IV 1.2g q8h
  • Renal dose adjustment needed

Ceftriaxone
- IV 1 - 2g q24h

Azithromycin
- PO 500 mg OD OR IV 500 mg q24h

Clarithromycin
- PO 500 mg BD OR IV 500 mg q12h

Doxycycline
- PO 100 mg BD

Levofloxacin

  • IV 750 mg q24h
  • Renal dose adjustment needed

Moxifloxacin
- IV 400 mg q24h

23
Q

Standard regimen for INpatient, severe - Organisms to cover

A

1) S. pneumoniae
2) H. influenzae
- Including ß-lactamase producing strains
3) Atypicals
4) S. aureus
5) Other GN bacteria e.g.
- Klebsiella pneumonia
- Burkholderia pseudomallei

24
Q

Standard regimen for INpatient, severe - Choice of antibiotics

A

1st Line:
1) Penicillin G OR Amoxicillin-Clavulanate
- Augmentin preferred –> additional coverage over MSSA, ß-lactamase producing strains
PLUS
2) Ceftazidime
- Covers Burkholderia pseudomallei
PLUS
3) Macrolides (Clarithromycin / Azithromycin) OR Doxycycline

Alternative:
1) Levofloxacin OR Moxifloxacin
- Alternative in penicillin allergy  
PLUS
2) Ceftazidime
- Covers Burkholderia pseudomallei 
- May be used in mild penicillin allergies
- Avoid in severe allergies --> Burkholderia not covered in such cases
25
Q

Standard regimen for INpatient, severe - Dosing

A

Route:

  • ß-Lactams / Fluoroquinolones: IV (may step down to PO later)
  • Macrolides / Doxycycline: PO if possible

Amoxicillin-Clavulanate

  • IV 1.2g q8h
  • Renal dose adjustment needed

Penicillin G

  • IV 4 million units q6h
  • Renal dose adjustment needed

Ceftazidime

  • IV 2g q8h
  • Renal dose adjustment needed

Azithromycin
- PO 500 mg OD OR IV 500 mg q24h

Clarithromycin
- PO 500 mg BD OR IV 500 mg q12h

Doxycycline
- PO 100 mg BD

Levofloxacin

  • IV 750 mg OD
  • Renal dose adjustment

Moxifloxacin
- IV 400 mg OD

26
Q

____ may require additional ____ coverage

A

Inpatient

Anaerobic / MRSA / Pseudomonal

27
Q

Anaerobic coverage - Indications

A

1) Lung abscess OR

2) Empyema

28
Q

Anaerobic coverage - Organisms to cover

A

1) Bacteroides fragilis
2) Porphyromonas spp.
3) Fusobacterium spp.
4) Prevotella spp.

29
Q

Anaerobic coverage - Treatment regimen

A

Add on:

1) Clindamycin OR
2) Metronidazole

Route: PO if possible (else IV)

Additional antibiotics only needed if standard regimen has no anaerobic activity
- I.e. Not needed if standard regimen includes Augmentin

30
Q

MRSA coverage - Indication

A

1) Prior respiratory isolation of MRSA in last 1 year OR
2) Severe CAP only: Hospitalization + Prior IV antibiotic use in last 90 days + Locally validated risk factors
- Note: Validation of risk factors usually not done in clinical practice

31
Q

MRSA coverage - Choice of antibiotics

A

1) Vancomycin OR
- Recommended
2) Linezolid

32
Q

MRSA coverage - Dosing

A

Vancomycin

  • IV 15 mg/kg q8-12h
  • Renal dose adjustment needed

Linezolid
- PO 600 mg BD OR IV 600 mg q12h

33
Q

Pseudomonal coverage - Indication

A

1) Prior respiratory isolate of P. aeruginosa in past 1 year OR
2) Severe CAP only: Hospitalization + Prior IV antibiotic use in last 90 days + Locally validated risk factors
- NOT applicable in SG - All inpatient, severe CAP will receive P. aeruginosa coverage due to Ceftazidime (originally used for Burkholderia)

34
Q

Pseudomonal coverage - Choice of antibiotics

A 
MODIFY standard regimen to include: 
1) Piperacillin-Tazobactam
- Generally 1st line anti-Pseudomonal ß-lactam in local hospitals 
OR
2) Ceftazidime 
- Poor GP coverage 
OR
3) Cefepime
OR
4) Meropenem 
- Generally reserved for ESBL-producing strains 
OR
5) Levofloxacin
- Alternative in penicillin allergy
35
Q

Pseudomonal coverage - How to modify standard regimen

A

Initial regimen:
Augmentin / Ceftriaxone + Macrolide / Doxycycline
Modified regimen:
Anti-Pseudomonal ß-lactam + Macrolide OR Doxycycline

Initial regimen:
Levofloxacin OR Moxifloxacin
Modified regimen:
Continue Levofloxacin / Switch to Levofloxacin

36
Q

Pseudomonal coverage - Dosing

A

Piperacillin-Tazobactam

  • IV 4.5g q6h
  • Renal dose adjustment needed

Ceftazidime

  • IV 2g q8h
  • Renal dose adjustment needed

Cefepime

  • IV 2g q8h
  • Renal dose adjustment needed

Levofloxacin

  • IV 750 mg q24h
  • Renal dose adjustment needed
37
Q

Duration of treatment

A

Minimum: 5 days

  • Must have achieved clinical stability
  • Most would have achieved clinical stability within 48-72h
  • Clinical stability: Afebrile, able to maintain oral intake, normal vital signs, oxygen saturation, mental status

MRSA / P. aeruginosa: 7 days

Burkholderia pseudomallei: 3 - 6 months

38
Q

Monitoring

A

Safety

1) ADRs e.g. diarrhoea, rash
2) Renal function

Efficacy

1) Clinical improvement
- Expected in 48 - 72h
- Decreased cough, chest pain, SOB, fever, WBC, tachypnea etc.
- Elderly/Multiple comorbidities may take longer
2) Radiographic findings
- Takes up to 4-6 weeks for resolution
- Not used to monitor therapeutic response
- Only repeated if clinical deterioration (especially after 72h)

39
Q

Treatment modification - When to modify

A

1) Culture results come out - Culture directed therapy
2) Clinical deterioration
3) Avoid escalating treatment in first 72h (usually takes 48-72h for improvement)
- Exception: Culture-directed / Clinical deterioration
4) Clinical improvement (usually after 48-72h) - De-escalate (e.g. oral step down)

40
Q

Treatment modification - What to modify

A

Stop empiric coverage of MRSA / P. aeruginosa after 48h if:

  • No MRSA / P. aeruginosa found in culture AND
  • Clinical improvement

Stop empiric coverage of Burkholderia pseudomallei if:

  • Not found in culture AND
  • Clinical improvement

Oral step down therapy

41
Q

Oral step down therapy - Indication

A

ALL of the following are met:

1) Hemodynamically stable (normal BP)
2) Afebrile ≥ 24h
3) Clinical improvement
4) Able to ingest PO medications
5) Normally functioning GIT

42
Q

Oral step down therapy - Benefits

A

1) Increase patient comfort & mobility
2) Decrease risk of nosocomial-associated bloodstream infections
3) Decrease phlebitis
4) Decrease preparation & administration time
5) Decrease costs
6) Facilitate discharge

43
Q

Oral step down therapy - Step down process

A

1) Clinically stable for 48 - 72h
2) Step down to PO antibiotics
3) Monitor for another day (optional)
4) Discharge to complete course at home

44
Q

Oral step down therapy - Choice of antibiotics (positive cultures available)

A

Positive cultures available:
Step down based on susceptibility results
Note: Levofloxacin is the only PO agent available for P. aeruginosa

45
Q

Oral step down therapy - Choice of antibiotics (no positive cultures available)

A 
Choose same antibiotic / same class  Should have similar coverage to standard regimen / initial IV antibiotics 
MRSA / P. aeruginosa / Burkholderia coverage NOT needed

Non-severe patients:

1) IV Augmentin OR IV Ceftriaxone - Switch to PO Augmentin OR PO Cefuroxime
2) IV Macrolides - PO available
3) IV Fluoroquinolones - PO available

Severe patients

1) IV Augmentin OR IV Penicillin G - Switch to PO Augmentin OR PO Cefuroxime
2) IV Ceftazidime - Discontinue
3) IV Macrolides - PO available
4) IV Fluoroquinolones - PO available

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