Community Acquired Pneumonia Guideline Update

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Primary Care RAP show. Earn CME on your commute while getting the latest practice-changing primary care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/PCRAPPOD

We have been waiting and waiting and waiting for the new community acquired guidelines. And here they are! Infectious Diseases expert Devang Patel,MD joins Matt DeLaney, MD and Neda Frayha, MD 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 mon