Community-Acquired Pneumonia (CAP) June 2016 Update

Care Process Model AUGUST 2016

DIAGNOSIS AND MANAGEMENT OF Community-Acquired Pneumonia (CAP) June 2016 Update

This care process model (CPM) is maintained by Intermountain Healthcare’s Lower Respiratory Tract Infection Team, a subgroup of the Intensive Medicine Clinical Program. The CPM summarizes and updates evaluation and treatment WHAT’S NEW in this update? recommendations for community-acquired pneumonia (CAP) in immunocompetent patients 18 years and older. (A Updated antibiotic recommendations: Pediatric CAP CPM is also available.) Recommendations are based on recent local susceptibility data and practice patterns, • Use the Drug Resistance in Pneumonia (DRIP) along with the most recent consensus guidelines of the Infectious Diseases Society of America (IDSA) and the American score to identify inpatients at risk for MRSA, MAN Thoracic Society (ATS). The guidelines do not apply to healthcare-associated pneumonia (HCAP). The concept of pseudomonas, and other bacteria resistant to HCAP will be discarded in the next consensus IDSA/ATS guidelines. usual CAP therapy. (See page 4.) • For most outpatients, prescribe doxycycline alone Why Focus ON PNEUMONIA? or azithromycin plus amoxicillin (needed to address • Pneumonia remains common, serious, and costly. In the U.S., influenza and pneumonia are the ninth leading cause of macrolide resistance) (See page 3). death overall. CDC1 Pneumonia accounts for more than 1% of adults seen in Intermountain emergency departments (EDs). Of those adult ED patients who present with pneumonia, 60% are admitted to the hospital. DEA1 GOALS • Site-of-care decisions vary widely and can dramatically affect mortality and cost of care. In one study, unaided clinical • Prompt and correct diagnosis, including a chest judgment in deciding whether to hospitalize varied more than two-fold (38% vs. 79%) among ED physicians at x-ray whenever possible Intermountain’s LDS Hospital. The variance could not be explained by severity of illness, time or day of week, or patient • Consistent use of objective, severity-of-illness demographic. Higher hospitalization rates were not associated with reduced mortality or fewer secondary admissions. DEA2 criteria (CURB-65) to guide site-of-care decisions –– Lower-risk patients treated in the outpatient setting are able to resume normal activity faster than if hospitalized. LAB • Prompt administration of appropriate antibiotics (varies by site of care and risk for resistant bacteria –– Higher-risk patients not hospitalized can result in higher mortality (both for patients hospitalized after initial outpatient [DRIP]) treatment MIN and for severely ill patients not initially admitted to the ICU NEI). • Influenza and pneumococcal vaccines for all • Diagnosis and severity assessment cannot be made consistently and accurately using only the physical exam and clinical appropriate inpatients and outpatients judgment. Chest x-ray and objective severity of illness scores (CURB-65) and pulse oximetry should be used to identify MAN,LIM • Venous thromboembolism (VTE) prophylaxis and patients with CAP who are candidates for outpatient treatment. early ambulation for all inpatients • Antibiotics should be administered as early as possible. In-hospital mortality, length of stay, and 30-day mortality decrease when antibiotics are administered within 4 to 6 hours of diagnosis. HOU Patients with moderate-to-severe CAP should receive their first dose of antibiotics before they leave the emergency room or clinic. MAN • Well-designed and implemented local treatment guidelines decrease mortality and improve other clinical outcomes. DEA3,DEA4 MEASURES Data shows that Intermountain hospitals with the highest level of compliance with this CPM and associated order sets • Compliance with antibiotic recommendations DEA3 have the lowest mortality rates. • 30-day, all-cause mortality • Length of hospital stay The inside pages of this tool provide an algorithm and associated notes and can be folded open and posted in • Appropriate site of care decisions your office or clinic. The back page summarizes antibiotic recommendations and notes, references, and resources. • Readmission rate DIAGNOSIS DIAGNOSIS ANDMANAGEMENTOF Community-Acquired Pneumonia(CAP) • • • • • • lateral film chest > Pleural effusion Severe sepsis ≤ SpO ≥ 5 cm on upright upright on 5 cm affects decisiontoadmit? 1 otherfactorpresent that 2 90% CURB-65 factors OUTPATIENT treatment 0 to1

ALGORITHM: no • • • • comorbid illness comorbid Uncontrolled available No caregiver in an immunocompetent adult presenting to physician office or ED or office physician to presenting adult immunocompetent an in Symptoms suggestive pneumonia of

yes

• • • DIAGNOSIS AND RISK ASSESSMENT RISK DIAGNOSIS AND U C 65 B R • • • ASSESS risk factors: CURB-65 CURB-65 factors: risk ASSESS lood pressure: SBP less than 90 mm Hg mm 90 than less SBP pressure: lood espiratory rate: 30 breaths or more per minute per more or breaths 30 rate: espiratory onfusion: not oriented to person, place, or time or place, person, to oriented not onfusion: RR ≥ 24 RR ≥ rate Heart ≥ 37.8ºC/100ºF Fever remia: BUN 20 mg/dL or greater or 20 mg/dL remia: BUN

years or older years • • • • Treatment algorithm.) Treatment draw draw (See antibiotic guidance below in in below guidance antibiotic (See Give the first dose of antibiotics dose first the Give Consider before transport or admission. admission. or transport before ORDER chest x-ray chest ORDER BEFORE thepatientleaves DIAGNOSE pneumonia hospital admission hospital PLAN for NON-ICU PLAN ≥ BEFORE giving antibiotic 100 bpm 100 1 of the following? the 1 of CURB-65 factors the clinicorED: new infiltrate new blood cultures (b) yes 2 • • • • Focal rales Focal Sp0 2 ; if done, done, ; if ≤ 90% (c) .

(e) infiltrate no new new no • • • • Treatment algorithm.) Treatment BEFORE giving antibiotic (See antibiotic guidance below in in below guidance antibiotic (See Give the first dose of antibiotics dose first the Give blood of cultures 2sets Draw before transport or admission. admission. or transport before BEFORE thepatientleaves (a) no hospital admission hospital

the clinicorED: org/clinicalprograms intermountainphysician. other related CPMs at at CPMs related other and and CPM Bronchitis Refer to the the to Refer Note: CURB-65 factors PLAN for ICU ICU for PLAN 3 ormore Consider influenza, bronchitis, orother diagnoses (d) .

(a) (e) (d) (c) (b) Chest x-ray (CXR). x-ray (CXR). Chest CURB-65. Symptoms Alternate diagnoses. Fever. Fever. • • • • • • • home. at rates mortality lower have and faster better get patients less-ill and treatment, hospital than costly less is significantly treatment Home home. at safely treated be 2days. about in x-ray the repeat and treatment x-ray, begin anegative despite pneumonia suspect you If film. positive subsequent a by followed is rarely x-ray anegative Conversely, CAP. has fever, leukocytosis and cough, shadow, radiographic anew with everyone not however, that mind, in Keep guidelines. international per diagnosis make to the is required scan CT or CXR apositive Either pneumonia. of diagnosis confirm to used be should chills, sweats, headache, and myalgia are less common. less are myalgia and headache, sweats, chills, Note: Note: appropriate management group. the into patient the triage and risk mortality predict accurately and quickly can here shown system scoring • • • • • • pneumonia are present. are pneumonia of symptoms or signs other no if x-ray chest require therapy. Other diagnoses to consider include: consider to diagnoses Other therapy. oseltamavir Consider community. the in present is influenza and rhinorrhea, no myalgia, severe has is febrile, patient Sweats 69% Sweats 71% Anorexia 74% Fever 72% Dyspnea Cough 86% Chills 73% Fatigue 91% Pertussis cancer Lung pneumonitis Hypersensitivity Aspiration pneumonitis chronic bronchitis of Acute exacerbation Acute bronchitis

JAC In older patients, confusion is more common; fever, fever, common; is more confusion patients, older In During influenza season, fever alone may not not may alone fever season, influenza During The simple, 5-point, CURB-65 severity risk risk severity CURB-65 5-point, simple, The About 75% of patients with pneumonia can can pneumonia with 75% patients of About pneumonia: of suggestive Whenever possible, a chest x-ray x-ray achest possible, Whenever • • • • • • Abdominal pain 16% pain Abdominal 51% Myalgia Vomiting 25% Headache 58% 16% Hemoptysis 46% pain chest Pleuritic Influenza • • • • •

LIM Travel-related infection injury lung acute with Sepsis Hantavirus tuberculosis Pneumocystis, infarction) (with embolism Pulmonary is probable if the the if is probable MET

ALGORITHM: TREATMENT (f) Dosing notes. See the Antibiotics Discussion on page 4. Antibiotic Notes Outpatient treatment Hospital treatment doxycycline •• Instruct patients to take with full (doxycycline glass of water and remain upright monohydrate for 1 hour. If not already done, If not already done, preferred) •• Has phototoxic side effect. Previously healthy AND Comorbidities (COPD, CHF, consider blood cultures draw 2 sets of blood •• Contraindicated for children under no antimicrobial use within diabetes, malignancy, or renal BEFORE starting cultures BEFORE 8 years old. the last 3 months failure) OR antimicrobial use antibiotic. Do not wait starting antibiotic. Do •• Category D in pregnancy. Use within the last 3 months for culture results before not wait for culture results azithromycin for pregnant women. giving antibiotics. before giving antibiotics. •• Doxycycline monohydrate is lower cost than other compounds Mild pneumonia Moderate pneumonia and has lower GI toxicity. Non-ICU care ICU care Antibiotics (f): Antibiotics (f): azithromycin Z-Pak dosing is obsolete. Newer dosing Antibiotics (f): is 500 mg daily for 3 days. •• Doxycycline, 100 mg Antibiotics (f): One of these: • Ceftriaxone, 1 g IV every orally twice daily for 7 days •• Ceftriaxone, 1 g IV every • ceftriaxone When stable (afebrile for 12 hours, •• Doxycycline, 100 mg 24 hours until stable, then 12 hours until stable, (doxycycline monohydrate orally twice daily for WBC improving or normal, and patient preferred) amoxicillin, 1,000 mg then amoxicillin, 1,000 7 days (doxycycline mg 3 times daily for total feeling better), switch to amoxicillin 3 times daily for a total to complete 7-day course. OR monohydrate preferred) course of 7 days course of 7 days •• Azithromycin, 500 mg OR PLUS PLUS amoxicillin If beta-lactam allergic: Monotherapy orally daily for 3 days PLUS with levofloxacin (Levaquin) •• Azithromycin, 500 mg orally •• Azithromycin, 500 mg •• Azithromycin, 500 mg amoxicillin, 1,000 mg 3 daily for 3 days 750 mg orally once daily for 5 days. times daily for 7 days IV first day, then 500 mg IV daily for 3 days (If pregnant, or allergic orally; total course 3 days, Do not combine levofloxacin with (If pregnant or allergic doxycycline or azithromycin. to doxycycline, use or doxycycline, 100 mg to doxycycline, use azithromycin.) orally twice daily for 7 days azithromycin.) cefepime Requires renal adjustment for For antibiotic alternatives, subsequent dosing. PLUS refer to the PNEUMONIA Vaccinations: For antibiotic alternatives, Ceftriaxone, 1 g IV or IM daily ICU ORDER SET (See page 4 Screen for influenza and refer to the PNEUMONIA vancomycin Requires renal adjustment for until stable, for access directions.) pneumococcal vaccines, and NON-ICU INPATIENT subsequent dosing. then amoxicillin, 1,000 mg give if appropriate (g) ORDER SET. (See page 4 orally 3 times daily for 7 days for access directions.) (g) Vaccinations. All patients should be screened for need for an influenza or pneumococcal vaccine at outpatient clinic visits or before discharge (if hospitalized). MAN,CDC2 TREATMENT Other outpatient best practices Other inpatient best practices • Influenza: All patients ≥ 6 months should have an annual influenza vaccination to ensure appropriate •• Patient education. Use Intermountain’s •• Patient education. Use protection against new antigenic types. Intermountain’s Pneumonia: Guide to Pneumonia: Prevention and Care at Home • Pneumococcal vaccines: fact sheet, available from i-printstore.com. Hospital Care fact sheet available from i-printstore.com. –– At age > 65 years, give PCV13 (Prevnar) • Follow-up visit or phone call in • –– At least 1 year later, give PPSV23 polysaccharide •• Early ambulation. Have patient sit 48 to 72 hours. vaccine (Pneumovax) in chair and/or ambulate for at least •• Follow up in 6 weeks: 20 minutes during the first 24 hours –– Then, no further pneumococcal vaccines after age 65 –– Repeat CXR in 6 weeks if smoker > 35 years of hospitalization. or for anyone age ≥ 60. If vaccine status is unknown, vaccination is –– 6-week follow-up visit: Give influenza and •• VTE prophylaxis. recommended. Both vaccines can be given pneumococcal vaccines if not already given (g). •• Provide smoking cessation advice/counseling simultaneously, but each should be given at a separate •• Provide smoking cessation advice/ (if applicable). See left for patient education information. site. Moderate-to-severe acute illness with or without a counseling (if applicable). Use •• Influenza and pneumococcal vaccines fever is a precaution for all vaccines, but the following Intermountain’s Quitting Tobacco: your before discharge. (g) are not considered precautions or contraindications journey to freedom booklet (i.e., vaccines can be given): fever, mild disease with or available from i-printstore.com. without fever, convalescence phase of an illness. DRUG RESISTANCE IN PNEUMONIA (DRIP) SCORING DRIP scoring identifies patients at risk for infection with MRSA,Pseudomonas , and other bacteria resistant RESOURCES to usual CAP therapy. (DRIP replaces the HCAP criteria, which do not accurately identify at-risk patients or The following Intermountain resources are available on improve mortality.)WEB the Pneumonia topic page at intermountainphysician.org/ clinicalprograms or intermountain.net/clinicalprograms: To calculate the DRIP score for a patient, sum the points for applicable risk factors shown in the table below. A score ≥ 4 indicates an increased risk of drug-resistant pneumonia. In such cases, consider using an anti- • Care process models. CPMs are pseudomonal betalactam (cefepime or piperacillin-tazobactam) plus a macrolide (azithromycin), and an anti- available for related diagnoses such as Bronchitis, Asthma, and COPD. A Pediatric MRSA agent (vancomycin or linezolid). Community-Acquired Pneumonia CPM is also available. Risk Factors Points • Flash cards. Adult and Pediatric CAP flash cards Antibiotic use < 60 days 2 summarize key decision points from the CPMs. Long-term care resident 2 Use Intermountain’s Tube feeding 2 e-tool for • Patient education. Patient fact sheets are available for Major Pneumonia (at Home and in the Hospital), Colds and Coughs Prior drug-resistant calculating DRIP. 2 pneumonia (DRP) (1 year) (Adult and Children/Adolescents), and other topics. A smoking cessation booklet is also available. All patient education can be Hospitalization < 60 days 1 Click here or from accessed and ordered at i-printstore.com. Chronic pulmonary disease 1 Intermountain.net, Poor functional status 1 type “DRIP” into the • Order sets. Both ICU and NON-ICU ORDER SETS are available address bar. Gastric acid suppression 1 on the Pneumonia topic page of intermountainphysician.org/ Minor Wound care 1 clinicalprograms as well as in the Clinical Forms library. MRSA colonization (1 year) 1 The materials will also appear in the iCentra EMR as suggested patient education items. ANTIBIOTICS DISCUSSION REFERENCES • Increased macrolide resistance appeared in 2013 and 2014. Macrolide resistance (azithromycin, Citations are available on the Pneumonia topic page of erythromycin, and clarithromycin) among Streptococcus pneumoniae isolates has increased at all Utah intermountainphysician.org/clinicalprograms. Intermountain hospital microbiology labs. Resistance has increased among respiratory pneumococcal isolates to 60% in northern Utah and 32% in St. George. Among blood isolates from adults, resistance is now 15% to 35% in northern Utah and 21% in St. George. LOWER RESPIRATORY INFECTION TEAM • Why has resistance increased? Increased resistance results from Z-Pak (azithromycin) prescribing for • Nathan Dean, MD • Matt Mitchell, PharmD chest colds and sinus infections and perhaps under-vaccination with PCV13 (Prevnar) in children. Children • Wayne Cannon, MD • Jan Orton, RN vaccinated with PCV13 have greatly reduced carriage of most multi-drug-resistant pneumococcal strains. • Sarah Daly, DO • David Pombo, MD Pneumococcus remains the most common and deadly bacteria that causes pneumonia. • Richard Ensign, PharmD • Jason Spaulding, MD • What antibiotics provide coverage? Pneumococcal activity remains very high for ceftriaxone and • Cody Ball, PharmD • Tony Wallin, MD amoxicillin. (Clavulanate in Augmentin contributes nothing against streptococci.) Azithromycin remains • Sharon Hamilton, RN effective for treatment of other pathogens that cause pneumonia, such asMycoplasma , Chlamydia, Haemophilus influenzae, and Moraxella. • Generic, first-line antibiotics should be used whenever possible. All recommended first-line antibiotics This CPM is based on best evidence at the time of publication. are available in generic form. They are as effective as brand-name antibiotics. It is not meant to be a prescription for every patient. Clinical • Quinolones should NOT be used as first-line therapy due to documented immune-modulating effects judgment based on each patient’s unique situation remains vital. of macrolides and lower mortality with combined therapy versus quinolone monotherapy in sicker patients. We welcome your feedback. Contact Nathan Dean, MD, at Overuse of quinolones has led to increased resistance. If a quinolone is used, the recommended dose of 801-507-4696 or [email protected]. levofloxacin (Levaquin) remains at 750 mg for 5 days; adjust subsequent doses if creatinine clearance less than 30. Longer courses increase cost, drive resistance, and increase the likelihood of secondary C. difficile.