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Pneumonia Updates - Diagnostics (Part I)

Matthew DeLaney, MD and Rick Pescatore, DO
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Matthew and Rick discuss the new IDSA updates regarding the diagnosis, disposition and treatment of patients with possible community acquired pneumonia.

 

Pearls:

  • When considering influenza, patients should be tested using NAAT rather than diagnosed clinically.

  • Patients with test proven influenza and infiltrates on CXR should receive oseltamivir, regardless of duration of symptoms, in addition to appropriate antibiotics

  • Patients should be risk stratified using a clinical decision tool, preferably PSI/PORT score,  to determine who is likely to benefit most from hospital admission.

  • Procalcitonin is no longer recommended in the initial evaluation of patients with possible pneumonia. 



  • At the end of 2019, the American Thoracic Society (ATS) and the Infectious Disease Society of America (IDSA) released the first update of the treatment guidelines for community acquired pneumonia (CAP) in >10 years. 

  • IDSA now recommends more routine testing for influenza using nucleic acid amplification testing (NAAT) for influenza because of enhanced sensitivity of NAAT compared to older antigen based testing (>90% vs. ~50% sensitivity). 

    • The IDSA now recommends that patients with test proven influenza and an infiltrate on CXR receive oseltamivir (regardless of duration of symptoms) in addition to appropriate antibiotics.

    • 30% of deaths from influenza come from bacterial co-infection. 

  • IDSA recommends risk stratifying patients with a Pneumonia Severity Index (PSI)/PORT score and recommends against relying heavily on a CURB-65 score to determine which patients will benefit from hospitalization. 

      • Several questions on the PSI rely on lab testing which may not be available in UC, however, the parameters give guidance to factors associated with higher risk of adverse outcomes in patients with pneumonia.

    • https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap

    • Clinical gestalt and assessment are also critical. Patients who appear ill and/or show signs of respiratory distress should be referred immediately to an ED.

      • The guidelines also discuss major and minor criteria suggesting need for ICU admission including need for intubation, hypotension, tachypnea, and multilobar infiltrates.

  • Multilobar pneumonia is a concerning finding and an independent predictor of poor outcome. 

    • All patients with multilobar pneumonia should be referred to an ED for further evaluation.

  • These guidelines suggest that, based on the low quality of evidence supporting utility, procalcitonin is no longer recommended in the diagnosis or treatment of CAP.

    • There may be some limited utility in specific patients (mostly hospital inpatients) however, so this test is probably not going away, but having access to PCT testing from UC shouldn’t be a priority. 

 

References:

  1. Metlay JP, et al. 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. PubMed PMID: 31573350

  1. https://www.thennt.com/nnt/corticosteroids-treating-pneumonia/

  2. Eliakim-Raz N, et al. Empiric antibiotic coverage of atypical pathogens for community-acquired pneumonia in hospitalized adults. Cochrane Database Syst Rev.  2012 Sep 12;(9):CD004418. doi: 10.1002/14651858.CD004418.pub4. Review.PubMed PMID: 22972070.

 

James L. -

Great episode and update.

For the PSI/PORT score, my UC does not have the capability to do a stat ABG. Any recommendations for using the calculator in this case?

Mike W., MD -

Hi James and thx for the comment. If you don't have access to ABG (and most uc's do not and I will say that I basically only do VBG and almost NEVER do an ABG). So I would not try and use just 'part' of the score... good luck!
M

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