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Community-Acquired Pneumonia (CAP) June 2016 Update

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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 AND MANAGEMENT OF Community-Acquired Pneumonia (CAP) (a) Symptoms suggestive of pneumonia: MET ALGORITHM: DIAGNOSIS AND RISK ASSESSMENT • Fatigue 91% • Pleuritic chest pain 46% Symptoms suggestive of pneumonia (a) • Chills 73% • Hemoptysis 16% • Cough 86% • Headache 58% in an immunocompetent adult presenting to physician office or ED • Dyspnea 72% • Vomiting 25% • Fever 74% • Myalgia 51% ≥ 1 of the following? • Anorexia 71% • Abdominal pain 16% Fever ≥ 37.8ºC/100ºF (b) Sp0 ≤ 90% • • 2 • Sweats 69% • Heart rate ≥ 100 bpm • Focal rales no Note: In older patients, confusion is more common; fever, • RR ≥ 24 chills, sweats, headache, and myalgia are less common. yes (b) Fever. During influenza season, fever alone may not no new Consider influenza, require chest x-ray if no other signs or symptoms of ORDER chest x-ray (c) bronchitis, or other pneumonia are present. infiltrate diagnoses (d) new infiltrate (c) Chest x-ray (CXR). Whenever possible, a chest x-ray should be used to confirm diagnosis of pneumonia. Either a positive CXR or CT scan is required to make the DIAGNOSE pneumonia diagnosis per international guidelines. Keep in mind, Note: Refer to the however, that not everyone with a new radiographic ASSESS risk factors: CURB-65 (e) Bronchitis CPM and shadow, cough, fever, and leukocytosis has CAP. other related CPMs at Conversely, a negative x-ray is rarely followed by a Confusion: not oriented to person, place, or time intermountainphysician. subsequent positive film. If you suspect pneumonia remia: BUN 20 mg/dL or greater U org/clinicalprograms despite a negative x-ray, begin treatment and repeat the Respiratory rate: 30 breaths or more per minute x-ray in about 2 days. Blood pressure: SBP less than 90 mm Hg (d) Alternate diagnoses. Influenza is probable if the 65 years or older patient is febrile, has severe myalgia, no rhinorrhea, and influenza is present in the community. Consider oseltamavir 0 to 1 2 3 or more therapy. Other diagnoses to consider include: CURB-65 factors CURB-65 factors CURB-65 factors • Acute bronchitis • Pulmonary embolism • Acute exacerbation of (with infarction) DIAGNOSIS chronic bronchitis • Pneumocystis, tuberculosis ≥ 1 other factor present that yes PLAN for NON-ICU PLAN for ICU affects decision to admit? hospital admission hospital admission • Aspiration pneumonitis • Hantavirus • Hypersensitivity pneumonitis • Sepsis with acute • ≤ SpO2 90% • No caregiver • Severe sepsis available • Lung cancer lung injury • Pleural effusion • Uncontrolled BEFORE the patient leaves BEFORE the patient leaves • Pertussis • Travel-related infection > 5 cm on upright comorbid illness the clinic or ED: the clinic or ED: lateral chest film • Consider blood cultures; if done, • Draw 2 sets of blood cultures (e) CURB-65. About 75% of patients with pneumonia can draw BEFORE giving antibiotic. BEFORE giving antibiotic. be treated safely at home. Home treatment is significantly less costly than hospital treatment, and less-ill patients no Give the first dose of antibiotics Give the first dose of antibiotics • • get better faster and have lower mortality rates at before transport or admission. before transport or admission. JAC (See antibiotic guidance below in (See antibiotic guidance below in home. The simple, 5-point, CURB-65 severity risk OUTPATIENT Treatment algorithm.) Treatment algorithm.) scoring system shown here can quickly and accurately treatment predict mortality risk and triage the patient into the appropriate management group. LIM (f) Dosing notes. See the Antibiotics Discussion on page 4. ALGORITHM: TREATMENT 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
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