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ID8 Infectious Diseases
Respiratory Infections
Toronto Notes 2019
Table 10. IDSA/ATS Community Acquired Pneumonia Treatment Guidelines 2007
Setting
Outpatient
Inpatient
Circumstances
Previously well
No antibiotic use in last 3 mo
Comorbidities2
Antibiotic use in last 3 mo (use different class)
Ward ICU
Treatment
β-lactam1, Macrolide2 OR Doxycycline
β-lactam1 ± Macrolide2
OR Respiratory fluoroquinolone4
β-lactam1 ± Macrolide2
OR Respiratory fluoroquinolone4
β-lactam4 + (Macrolide1 OR Respiratory fluoroquinolone3)
Lobar Pneumonia
*Given different regional resistance patterns, therapy should be based on local epidemiology and site-specific recommendations **Refers to empiric treatment to be started. Appropriate antibiotic therapy should be tailored if pathogen is identified
1. β-lactam: cefotaxime, ceftriaxone, ampicillin-sulbactam
2. Macrolide: use azithromycin orclarithromycin
3. Comorbidities: chronic heart, lung, liver, or renal disease, DM, alcoholism, malignancy, asplenia, immunocompromised 4. Respiratory fluoroquinolone: moxifloxacin, gemifloxacin, levofloxacin
IDSA: Infectious Diseases Society of America
ATS: American Thoracics Society
Table 11. IDSA/ATS Hospital-Acquired (HAP) and Ventilator-Associated (VAP) Pneumonia Clinical Practice Guidelines 2016
Bronchopneumonia
Setting
Clinically suspected HAP (non-VAP) with no increase in likelihood of MRSA and not at high risk of mortality
Clinically suspected HAP (non-VAP) with increasing likelihood of MRSA and not at high risk of mortality
Clinically suspected HAP (non-VAP) with high risk of mortality or recipient of IV antibiotics in last 90 d
Clinically suspected VAP in units where empiric MRSA coverage and double antipseudomonal/ Gram-negative coverage are appropriate
Treatment
One of: piperacillin-tazobactam
OR cefepime
OR levofloxacin
OR imipenem or meropenem
One of:
piperacillin-tazobactam
OR cefepime or ceftazidime
OR levofloxacin or ciprofloxacin OR imipenem or meropenem OR aztreonam*
PLUS one of:
vancomycin or linezolid for MRSA coverage
Two of the following (avoid 2 β-lactams): piperacillin-tazobactam
OR cefepime or ceftazidime
OR levofloxacin or ciprofloxacin
OR imipenem or meropenem
OR aztreonam*
OR amikacin or gentamicin or tobramycin
PLUS either MRSA or MSSA coverage:
MRSA: vancomycin or linezolid
OR MSSA: piperacillin-tazobactam, cefepime, levofloxacin, imipenem, meropenem
One of:
β-lactam/β-lactamase inhibitor (piperacillin/tazobactam)
OR antipseudomonal cephalosporin (cefepime or ceftazidime) OR antipseudomonal carbapenem (imipenem or meropenem) OR monobactam (aztreonam*)
PLUS one of:
antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin) OR aminoglycoside (amikacin, gentamicin, or tobramycin)
OR polymyxins (colistin or polymyxin B)
PLUS one of:
vancomycin or linezolid for MRSA coverage
Interstitial Pneumonia
©Stuart Jantzen 2012
Figure 6. Lobar, broncho, and interstitial pneumonia
Does This Adult Patient Have Pneumonia? From The Rational Clinical Examination JAMA 2009; http://www.jamaevidence.com/ content/3485708
Study: Systematic review of articles assessing the sensitivity and specificity of clinical exam maneuvers for the diagnosis of adult community acquired pneumonia. Results: The presence of fever or immunosuppression had a positive likelihood ratio (+LR) of 2, while a history of dementia had a +LR of 3; however, these traits are not confirmatory. The presence of an abnormality in any vital sign, including tachycardia, tachypnea, or fever had a +LR ranging from 2-4, which was not significantly affected by different cut-points. The absence of vital sign abnormality had a –LR ranging from 0.5-0.8. The combination of respiratory rate <30/min, heart rate <100/min, and temperature <37.8°C had a –LR of 0.18. Findings on chest exam raised the likelihood
of diagnosis, but were uncommonly seen in studies.
For example, presence of asymmetric respirations essentially confirmed the diagnosis, but was only present in 4% of patients. In patients with a clinical diagnosis, but normal radiograph, only ~10% will develop radiographic findings in 72 h.
Conclusions: Evidence suggests no single item on clinical history or physical exam is sufficient to rule inoroutpneumoniawithoutchestx-ray.Vitalsign abnormalities were correlated with a diagnosis of pneumonia. Findings on chest exam significantly raised the likelihood of pneumonia, but were uncommonly seen in studies.
**Refers to empiric treatment to be started. Appropriate antibiotic therapy should be tailored if pathogen is identified
* Available in Canada through special access
Risk factors for mortality include need for ventilatory support due to pneumonia and septic shock need for ventilatory support due to pneumonia and septic shock
Risk factors for MDR VAP: prior IV antibiotic use within 90 days, septic shock at time of VAP, ARDS preceding VAP, 5+ days of hospitalization prior to VAP onset, acute renal replacement therapy prior to VAP onset
Risk factors for MDR HAP, MRSA VAP/HAP or MDR pseudomonas VAP/HAP: Prior IV antibiotic use within 90 days
Note: Indications for MRSA coverage includes IV antibiotic treatment during the prior 90 days and treatment in a unit where prevalence of MRSA of S. aureus isolates is not known or is >20%
Note: These guidelines may be less applicable in Canada given lower rates of antibiotic resistance among common nosocomial pathogens
Prevention
• PublicHealthAgencyofCanadarecommendsthefollowing
■ vaccine for influenza A and B annually for all ages ≥ 6 mo
■ pneumococcal polysaccharide vaccine (Pneumovax®) for all adults >65 yr and in younger patients
24 mo of age and older at high risk for invasive pneumococcal disease (e.g. functional or anatomic
asplenia, congenital or acquired immunodeficiency)
■ pneumococcalconjugatevaccine(Prevnar-13®)forallchildren<5yr,andforchildrenand
adolescents at high risk for invasive pneumococcal disease who are 5-17 yr and who have not previously received Prevnar-13® (CDC recommends giving Prevnar-13® to all adults at high risk for invasive pneumococcal disease)