2016 Update On CAP

CME LECTURE 2016
General data
G.M.G
68 year old female
Filipino
Roman Catholic
From Guadalupe, Cebu City
Chief complaints: Cough and Dyspnea
Past medical history
Hypertensive for 20 years

UBP: 120/80mmHg HBP:140/90mmHG
tab 16mg Candesartan(Candez)
tab 25mg Carvedilol(Carvid
Personal and social history

Known cigarette smoker for 25 years
consuming 25pack/year
Occasional alcoholic beverage drinker
No history of illicit drug use
No known food and drug allergies
Family history
(+) Hypertension,
(+)Diabetes Mellitus,
(+)Bronchial Asthma
History of present illness

Problem #1: Cough and Dyspnea
One week PTA
Onset of cough, (+) greenish sputum
Undocumented fever and chills
Took Carbocysteine 30mg/tab 1 tab with no
relief
Condition tolerated, no consult done
(-) dyspnea, (-) hemoptysis, (-) body malaise,
(-) anorexia, (-) night sweats, (-) sore throat

5 days PTA
On and off fever (temperature not taken)
Persistence of productive cough with
greenish sputum
No improvement nor worsening of
symptoms
Condition tolerated
No consult done

Two days PTA
Productive cough and fever persisted
Now associated with dyspnea, body
malaise, anorexia and insomnia
(-) hemoptysis, (-) chest pain, (-) sore throat
(-)orthopnea, (-)exertional dyspnea
Persistence of symptoms prompted
admission
PHYSICAL EXAM on admission
Conscious, coherent, cooperative

In respiratory distress, febrile
BP = 120/80 mmHg
T = 38 C
HR = 120 bpm
RR = 32 cpm
O2 saturation = 98%
PHYSICAL EXAM
SKIN:
good mobility and turgor,

HEENT:
pink palpebral conjunctiva, anicteric

sclerae, nasal septum at midline, no alar
flaring, sinuses non-tender, non-hyperemic
tonsillopharyngeal wall
PHYSICAL EXAM
NECK :
supple,
trachea
at
midline,
no
lymphadenopathies,
CHEST & LUNGS:
equal chest expansion, increased tactile

fremitus and (+)rales heard over right lower
lung field)
(-)intercostal retractions
CVS:
PMI visible at 6th LICS AAL, 2.5cm in
diameter, bounding, (+) heaves, Heart rate:
114bmp, (+) systolic and diastolic murmur,
Grade IV, no extra heart sounds
ABDOMEN:
Flabby, NABS, soft, nontender, no

organomegaly
PHYSICAL EXAM
GUT:
(-) KPS, bilaterally

EXTREMITIES:
CRT < 2 s, strong peripheral pulses, no

edema
NEUROLOGIC EXAM:
All within normal limits
Diagnostic,Empiric Management and

Prevention of Community-Acquired
Pneumonia In Immunocompetent Adults
2016 UPDATE
Changes Emerged in 2016

update
Multiple international societies had published
and revised their guidelines of the
management of patients with CAP
New organism had emerged and
development of resistance had increased
over time among respiratory pathogens
Changes emerged in 2016

Update
The influx and efflux of antimicrobial agents
used in the treatment had likewise posed a
threat to the rapid rise of antimicrobial
resistance. The use, misuse, abuse, and
overuse had also shaken the market of
antimicrobial agents.
Should antibiotics be initiated for the

empiric treatment of community-acquired
pneumonia(CAP)?
Patient should receive initial therapy as

soon as possible after the diagnosis is
established.
Antibiotics, the mainstay for the
treatment of pneumonia.
The 2004 PCPG for CAP recommended a
maximum four-hour window from
diagnosis to antimicrobial initiation.
Showed a reduced in-hospital mortality when

antimicrobial therapy was initiated w/I the
first four hours of admission and diagnosis of
CAP.
LOW RISK CAP

Stable Vital Signs
RR <30/min
PR <125/min
SBP >90 mmHg
DBP >60 mmHg
Temp >36C or <40C
No altered mental state of acute

onset
N0 suspected aspiration
No or stable co-morbid conditions
Chest X ray
- Localized infiltrates
- No evidence of pleural effusion
MODERATE RISK CAP

Unstable Vital Signs:
RR >30/min
PR >125/min
SBP <90 mmHg
DBP <60 mmHg
Temp <36C or >40C
Altered mental state of acute onset

Suspected Aspiration
Unstable/Decompensated comorbid
condition
- uncontrolled diabetes mellitus
- Active malignancies
- Neurologic disease in evolution
- Congestive heart failure (CHF)
class II-IV
- Unstable coronary artery disease
- Renal failure on dialysis
- Uncompensated COPD
- Decompensated liver disease
HIGH RISK CAP

Any of the clinical feature of Moderate Risk CAP plus any of the following:
Severe Sepsis
Septic Shock
Need for Mechanical Ventilation
What INITIAL antibiotics are recommended

for the EMPERIC treatment of communityacquired pneumonia?
LOW RISK Emperic

Treatment
For low risk w/o comorbid illness,
AMOXICILLIN still remains the standard drug
of choice, use of extended macrolides may
also be considered
For low risk with comorbid illness, Beta
lactam and Beta Lactam inhibitor
combination(BLIC) or second generation
cephalosporin w/ or without extended
macrolides are recommended.
LOW RISK Emperic Treatment
For patients who have completed first-line

treatment (BLIC and 2nd gen cephalosporin)
with no response, an extensive work up
should be done
Work up may include sputum gram stain and
culture
Moderate Risk CAP Emperic

Treatment
Combination of an IV non-antipseudomonal
B-Lactam(BLIC, cephalosporin) w/ either an
extended macrolides or a respiratory
fluoroquinolone as initial treatment
High Risk CAP Emperic Treatment

w/o Risk of P. aeruginosa
Combination of an IV non-antipseudomonal
B-lactam(BLIC, cephalosporin or
carbapenem) w/ either an IV extended
macrolide or an IV respiratory
fluoroquinolone
High Risk CAP Emperic Treatment

w/ Risk of P. aeruginosa
Combination of an IV antipneumococcal,
antipseudomonal B-Lactam(BLIC,
cephalosporin or carbapenem)
w/ an extended macrolide and aminoglycoside
or
IV ciprofloxacin ir high dose IV levofloxacin
EMPERIC ANTIMICROBIAL THERAPY WITH USUAL

RECOMMENDED DOSAGE IN 50-60KG ADULTS WITH NORMAL
LIVER AND RENAL FUNCTION
RISK
STRATIFICATIO
N
LOW RISK CAP
POTENTIAL
PATHOGEN
EMPIRIC
THERAPY
Streptococcus
pneumoniae
Haemophilus influenzae
Chlamydophila
pneumoniae
Mycoplasma pneumoniae
Moraxella Catarrhalis
Enteric Gram-negative
bacilli
(among those with comorbid illness)
WITHOUT CO MORBID
ILLNESS
Amoxicillin 1gm TID
OR
Extended macrolides.
Azithromycin 500 mg OD
OR Clarithromycin 500
mg BID

RISK
STRATIFICATIO
N
LOW RISK CAP
POTENTIAL
PATHOGEN
EMPIRIC
THERAPY
Streptococcus
pneumoniae
Chlamydophila
pneumoniae
Mycoplasma pneumoniae
bacilli
(among those with comorbid illness)
WITH STABLE COMORBID ILLNESS

Beta-lactam/Betalactamase inhibitor
combination (BLIC) OR 2nd
GEN ORAL Cephalosprorin
+/- extended macrolides
Co-Amoxiclav 1gm BID or
Sultamicillin 750mg BID
or
Cefuroxime Axetil 500mg
BID
+/Azithromycin 500 mg OD
or
Clarithromycin 500 mg

RISK
STRATIFICATIO
N
MODERATE RISK
CAP
POTENTIAL
PATHOGEN
EMPIRIC
THERAPY
Streptococcus
pneumoniae
Chlamydophila
pneumoniae
Mycoplasma
pneumoniae
bacilli
Legionella pneumophila
Anaerobes (among those
with risk of aspiration)
IV non-antipseudomonal Blactam (BLIC,

cephalosporin)
+ extended macrolides or
respiratory
fluoroquinolones (PO)
Ampicillin-Sulbactam 1.5
gm q6h IV or
Cefuroxime 1.5 g q8h IV or
Ceftriaxone 2g OD
+
Azithromycin 500mg OD
PO or
Clarithromycin 500mg BID
PO or
Levofloxacin 500mg OD PO

RISK
STRATIFICATIO
N
MODERATE RISK
CAP
POTENTIAL
PATHOGEN
EMPIRIC
THERAPY
Streptococcus
pneumoniae
Chlamydophila
pneumoniae
Mycoplasma
pneumoniae
bacilli
If aspiration pneumonia is
suspected and, a regimen
containing ampicillinsulbactam and/or
moxifloxacin is used, there
is no need to add another
antibiotic for additional
anaerobic coverage. If
another combination is
used may add clindamycin
to the regimen to cover
microaerophilic
streptococci
Clindamycin 600mg q8h IV
or
Ampicillin-Sulbactam 3g

RISK
STRATIFICATIO
N
HIGH RISK CAP
POTENTIAL
PATHOGEN
EMPIRIC
THERAPY
Streptococcus
NO RISK FOR P.
pneumoniae
aeruginosa
IV non-antipseudomonal
Chlamydophila
Beta-lactam + IV extended
pneumoniae
macrolides or IV respiratory
Mycoplasma
flouroquinolones
pneumoniae
Ceftriaxone 2 gm OD or
Ertapenem 1gm OD
bacilli
+
Azithromycin dihydrate
500mg OD IV or
Levofloxacin 500 mg OD IV
Staphylococcus aureus
or
Pseudomonas
Moxifloxacin 400mg OD IV
aeruginosa

RISK
STRATIFICATIO
N
HIGH RISK CAP
POTENTIAL
PATHOGEN
EMPIRIC
THERAPY
Streptococcus
pneumoniae
Chlamydophila
pneumoniae
Mycoplasma
pneumoniae
bacilli
Anaerobes (among
those with risk of
aspiration)
Pseudomonas
aeruginosa
RISK FOR P. aeruginosa

IV antipneumococcal
antipseudomonal B-lactam
(BLIC, cephalosporin or
carbapenem) + IV
extended macrolides +
aminoglycoside
Piperacillin-tazobactam
4.5gm q6h or
Cefepime 2gm q8-12h or
Meropenem 1g q8h8
+
Azithromycin dihydrate
500mg OD IV
+
Gentamicin 3mg/kg OD or
Amikacin 15mg/kg OD

RISK
STRATIFICATIO
N
HIGH RISK CAP
POTENTIAL
PATHOGEN
EMPIRIC
THERAPY
Streptococcus
pneumoniae
Chlamydophila
pneumoniae
Mycoplasma
pneumoniae
bacilli
Pseudomonas
aeruginosa
RISK FOR P. aeruginosa

OR
IV antipneumococcal
antipseudomonal B-lactam
(BLIC, cephalosporin or
carbapenem) + IV
cipfroxacin/high dose
levofloxacin
Piperacillin-tazobactam
4.5gm q6h or
Cefepime 2gm q8-12h or
Meropenem 1g q8h8
+
Levofloxacin 750mg OD IV
or
Ciprofloxacin 400mg q8-

RISK
STRATIFICATIO
N
HIGH RISK CAP
POTENTIAL
PATHOGEN
EMPIRIC
THERAPY
Streptococcus
pneumoniae
Chlamydophila
pneumoniae
Mycoplasma
pneumoniae
bacilli
Pseudomonas
aeruginosa
IF MRSA pneumonia is
suspected, add
Vancomycin 15mg/kg q812h
OR
Linezolid 600mg q12h IV
OR
Clindamycin 600mg q8h IV
How can response to initial

therapy be assessed?
Temperature, respiratory rate, heart rate,
blood pressure, oxygen saturation, inspired
oxygen concentration should be monitored
to assess response to therapy.
Response to therapy is expected within 2472hours of initiating treatment. Failure of
response after 72hours of treatment is an
indication to repeat Chest radiograph.
Follow-up of cultures blood and sputum are

not indicated in patients who respond to
treatment.
What should de-escalation of

emperic antibiotic therapy be done?
De-escalation of initial emperic broadspectrum antibiotic or combination

parentheral therapy to a single narrow
spectrum parenteral or oral agent based on
available laboratory data is recommended
once the patient is clinically improving is
hemodynamically stable and has a
functioning GI tract.
INDICATION FOR STEAMLINING OF

ANTIBIOTIC THERAPY
1. Resolution of fever for > 24 hours
2. Less cough and resolution of respiratory distress (normalization of
respiratory rate)
3. Improving white blood cell count, no bacteremia.
4. Etiologic agent is not a high-risk (virulent/resistant) pathogen e.g
Legionella, S. aureus, or Gram-negative enteric bacilli
5. No unstable comorbid condition or life- threatening complication such
as myocardial infarction, congestive heart failure, complete heart block,
new atrial fibrillation, supraventricular tachycardia, etc.
6. No sign of organ dysfunction such as hypotension, acute mental
changes, BUN to creatinine ration of >10:1, hypoxemia, and metabolic
acidosis
7. Patient is clinically hydrated, taking oral fluids and is able to take oral
medications.
Which oral antibiotics are recommended

for de-escalation or switch therapy from
parenteral antibiotics?
Choice of antibiotics following initial

parenteral therapy
Available culture result

Antimicrobial spectrum
Efficacy
Safety and cost
When switching to oral antibiotics, either the

same agent as the parenteral antibiotics or
an antibiotic from the same drug class
should be used.
ANTIBIOTIC DOSAGE OF ORAL

AGENTS FOR STEAMLINING OR
SWITCH THERAPY
ANTIBIOTIC
Amoxicillin-clavulanic
acid
Azithromycin
Cefixime
Cefuroxime axetil
Cefpodoxime proxetil
Levofloxacin
Moxifloxacin
Sultamicillin
DOSAGE
625 mg TID or 1 gm
BID
500 mg OD
200 mg BID
500 mg BID
200 mgw BID
500-750 mg OD
400 mg OD
750 mg BID
How long is the duration of

treatment of CAP?
Low Risk uncomplicated bacterial pneumonia
5-7 days
Moderate Risk Bacterial pneumonia

7-10 days
Moderate Risk and High Risk CAP or those

with suspected or confirmed Gram Negative
28 days if associated with bacteremia
M. pneumoniae and C. pneumoniae

10-14 days
L. pneumoniae
14-21 days
A 5-day course of Oral or IV therapy for lowrisk CAP

10-day course of IV for Legionella pneumonia
is possible with new agents such as azalides
Patient should be afebrile for 48 to 72 hours
with no signs of clinical instability before
discontinuation of treatment.
DURATION OF ANTIBIOTIC USE

BASED ON ETIOLOGY
ETIOLOGIC AGENT
Most bacterial pneumonias

except enteric Gram-negative
pathogens S. aureus (MSSA and
MRSA), and P. aeruginosa
DURATION OF THERAPY
(DAYS)
5-7 days
3-5 days for S. Pneumoniae
MSSA community-acquired
pathogens, S. aureus (MSSA and pneumonia
a. non-bacteremic 7 14 days
MRSA), and P. aeruginosa
b. Bacteremic longer up to 21
days
MRSA community-acquired
pneumonia
c. non-bacteremic 7 21 days
d. Bacteremic longer up to 28
days
DURATION OF ANTIBIOTIC USE

BASED ON ETIOLOGY
ETIOLOGIC AGENT
Mycoplasma and
Chlamydophilia
Legionella
DURATION OF THERAPY
(DAYS)
10 14 days
14 21 : 10
(azalides)
What should be done for patient who are not

improving after 72hours of empiric antibiotic
therapy?
The lack of a response to seemingly

appropriate treatment in a patient with CAP
should lead to a complete reappraisal, rather
than simply to selection of alternative
antibiotics.

therapy?
The clinical history, physical examination

and the results of all available investigations
should be reviewed. The patient should be
reassessed for possible resistance to the
antibiotics being given or for the presence of
other pathogens. Treatment should then be
revised according to culture result.

therapy?
Follow-up chest radiograph is recommended

to investigate for other conditions such as
pneumothorax, cavitation, and extension to
previously uninvolved lobes, pleural effusion,
pulmonary edema and ARDS. For an
underlying mass, bronchiectasis, loculation,
pulmonary abscesses, a CT scan would
provide more information

therapy?
Obtaining additional specimens for

microbiologic testing should be considered.
REASON FOR A LACK OF RESPONSE TO

TREATMENT OF CAP
Correct organism but inappropriate antibiotic choice or dose
Resistance of organism to selected antibiotic
Wrong Dose (e.g in a patient who is morbidly obese or has fluid overload)
Antibiotics not administered
Correct organism and correct antibiotic but infection is loculated (e.g.,
most commonly empyema)
Obstruction (e.g., lung cancer, foreign body)
Incorrect identification of causative organism
No identification of causative organism and empirical therapy directed
toward wrong organism
Non-infectious cause
Drug-induced fever
Presence of an unrecognized, concurrent infection
When can a hospitalized patient

with CAP be discharged?
In the absence of any unstable coexisting
illness or other life threatening complication,
the patient may be discharged once
clinically stable and oral therapy is initiated.
A repeat chest radiograph prior to hospital
discharge is not needed in a patient who is
clinically improving.
When can a hospitalized patient

with CAP be discharged?
A repeat chest radiograph is recommended
during a follow-up visit, approximately 4-6
weeks after hospital discharge to establish a
new radiographic baseline and to exclude
the possibility of malignancy associated with
CAP, particularly in older smokers.
RECOMMENDED HOSPITAL
DISCHARGE CRITERIA
During the 24 hours before discharge, the
patient should have the following
characteristics (unless this represents the
baseline status):
1. Temperature of 36 37.5 C
2. Pulse <100/min
3. Respiratory rate between 16-24/minute
4. Systolic BP >90mmHg
5. Blood oxygent saturation >90%
6. Functioning gastrointestinal tract
What other information should be

explained and discussed with patient?
Explain to patients with CAP that after

starting their symptoms are expected to
steadily improve, although the rate of
improvement will vary with the severity of
the pneumonia..
What other information should be

explained and discussed with patient?
Most people can expect that by:

1 week: fever should be resolved
4 weeks: chest pain and sputum production
should have substantially reduced
6 weeks: cough and breathlessness should
have substantially reduced
3 months: most symptoms should have
resolved but fatigue may still be present
6 months: most people will feel back to normal.
PHYSICAL EXAM on admission
Conscious, coherent, cooperative

In respiratory distress, febrile
BP = 120/80 mmHg
T = 38 C
HR = 120 bpm
RR = 32 cpm
O2 saturation = 98%
PHYSICAL EXAM
CHEST & LUNGS:
equal chest expansion, increased tactile

fremitus and (+)rales heard over right lower
lung field)
(-)intercostal retractions
CVS:
PMI visible at 6th LICS AAL, 2.5cm in
diameter, bounding, (+) heaves, Heart rate:
114bmp, (+) systolic and diastolic murmur,
Grade IV, no extra heart sounds
CLINICAL FORMULATION
Problem 1: Cough and Dyspnea
PRIMARY IMPRESSION:
Community Acquired Pneumonia
Moderate Risk
Hypertensive Cardiovascular Disease not
in Failure
What antibiotics?
Piptaz
azith
After 3 days?
Resolution of fever
Stable vital signs
Sputum culture: S. Pneumoniae sensitive to
piptaz, co-amox, cefu
Streamline?
Co-amox
Thank you

2016 Update On CAP

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CME LECTURE 2016

Past medical history

Hypertensive for 20 years

Personal and social history

History of present illness

History of present illness

History of present illness

PHYSICAL EXAM on admission

Conscious, coherent, cooperative

good mobility and turgor,

pink palpebral conjunctiva, anicteric

equal chest expansion, increased tactile

Flabby, NABS, soft, nontender, no

(-) KPS, bilaterally

CRT < 2 s, strong peripheral pulses, no

All within normal limits

Diagnostic,Empiric Management and

Changes Emerged in 2016

Changes emerged in 2016

Should antibiotics be initiated for the

Patient should receive initial therapy as

Showed a reduced in-hospital mortality when

LOW RISK CAP

No altered mental state of acute

MODERATE RISK CAP

Altered mental state of acute onset

HIGH RISK CAP

What INITIAL antibiotics are recommended

LOW RISK Emperic

LOW RISK Emperic Treatment

For patients who have completed first-line

Moderate Risk CAP Emperic

High Risk CAP Emperic Treatment

High Risk CAP Emperic Treatment

IV ciprofloxacin ir high dose IV levofloxacin

EMPERIC ANTIMICROBIAL THERAPY WITH USUAL

EMPERIC ANTIMICROBIAL THERAPY WITH USUAL

WITH STABLE COMORBID ILLNESS

EMPERIC ANTIMICROBIAL THERAPY WITH USUAL

IV non-antipseudomonal Blactam (BLIC,

EMPERIC ANTIMICROBIAL THERAPY WITH USUAL

EMPERIC ANTIMICROBIAL THERAPY WITH USUAL

EMPERIC ANTIMICROBIAL THERAPY WITH USUAL

RISK FOR P. aeruginosa

EMPERIC ANTIMICROBIAL THERAPY WITH USUAL

RISK FOR P. aeruginosa

EMPERIC ANTIMICROBIAL THERAPY WITH USUAL

How can response to initial

Follow-up of cultures blood and sputum are

What should de-escalation of

De-escalation of initial emperic broadspectrum antibiotic or combination

INDICATION FOR STEAMLINING OF

Which oral antibiotics are recommended

Choice of antibiotics following initial

Available culture result

When switching to oral antibiotics, either the

ANTIBIOTIC DOSAGE OF ORAL

How long is the duration of

Moderate Risk Bacterial pneumonia

Moderate Risk and High Risk CAP or those

M. pneumoniae and C. pneumoniae

A 5-day course of Oral or IV therapy for lowrisk CAP

DURATION OF ANTIBIOTIC USE