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Community Acquired Pneumonia - Guideline Update

Devang Patel, MD, Matthew DeLaney, MD, FACEP, FAAEM, and Neda Frayha, MD
00:00
27:42

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We have been waiting and waiting and waiting for the new community acquired guidelines. And here they are! Infectious Diseases expert Dr. Devang Patel joins Matt DeLaney and Neda Frayha for a conversation on CAP in general and the new guidelines in specific.

Pearls:

  • The latest guidelines for community acquired pneumonia now includes amoxicillin or doxycycline for 5-7 days as first-line treatment given the rising rates of macrolide resistance and less emphasis on coverage of atypical pneumonia pathogens.

 

  • Review of pathophysiology:

    • Lower respiratory tract often preceded by an upper respiratory tract infection, that inhibits ability to clear mucus and pathogens invade the lungs

    • Other risk factors:

      • Smoking

      • Elderly

      • Immune compromise (ie: infection, steroids, cancer)

    • Pathogens:

      • Typical - strep pneumo, haemophilus, staph aureus

      • Atypical (more common) - influenza, parainfluenza, mycoplasma, chlamydia pneumoniae, legionella, coccidioidomycosis (in the southwest)

      • EPIC Study (2015) - study to determine pneumonia pathogens using all the tools we have available (culture, PCR)

        • 62% no pathogen detected

        • 22% viral - most were rhinovirus which does not cause lower respiratory tract infections but predisposes to pneumonia

        • Strep pneumonia was the number one bacterial pathogen

        • Bottomline: we still don’t know what causes most pneumonias but just that our patients get better with antibiotics

      • Differentiating between typical v. atypical pneumonias - there’s no good way to know viral versus bacterial → default is to treat as bacterial pneumonia with antibiotics

  • Diagnosis:

    • Clinical features (cough, fever, sputum production, pleuritic chest pain, crackles)

    • Guidelines recommend a chest x-ray

    • For outpatient uncomplicated pneumonia, don’t get blood or sputum cultures

    • For severe cases (those with risk factors for multidrug resistance, MRSA, or pseudomonas) you still want to get blood and sputum cultures

    • Pearls:

      • No more healthcare-associated pneumonia

      • Emphasis on CURB-65 to assess severity of who does NOT need to be admitted

      • Procalcitonin is NOT endorsed as a way to determine who gets antibiotics and who doesn’t

  • Treatment:

    • Increasing strep pneumo resistance to macrolides so no more monotherapy with macrolide (azithromycin) unless resistance is less than 20% in the area

    • First-line in non-hospitalized adult is amoxicillin or doxycycline for 5-7 days

    • Steroids recommended not use but may be considered in septic shock

  • Commentary from Dr. Patel (ID specialist):

    • Not a major change in practice other than to consider not covering atypicals in an otherwise healthy person

 

REFERENCES:

  1. Metlay JP, Waterer GW, Long AC, et al on behalf of the American Thoracic Society and Infectious Diseases Society of America. Diagnosis and Treatment of Adults with Community-Acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST. https://www.atsjournals.org/doi/10.1164/rccm.201908-1581ST 

  2. Jain S, Self WH, Wunderink RG, et al for the CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med 2015; 373:415-427.

Postma DF, van Werkhoven CH, van Elden LJR, et al for the CAP-START Study Group. Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med 2015; 372:1312-1323.

Lori-Ann L. -

Just to clarify, podcast and notes stated that macrolides can be used to treat CAP if resistance is lower than 20% in the area, but the quiz stated 25%. Small detail, but it confused me.

Also wanted to share this great interactive map on resistance rates of common pathogens. https://resistancemap.cddep.org/CountryPageSub.php?country=United+States

Neda F., MD -

Thanks for letting us know, and thanks for sharing that map! -- Neda

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