Antibiotics For Community Acquired Pneumonia In Adults

Formulations Of These Recommendations

The recommendations for treatment have been made on the basis of assessing a matrix of laboratory, clinical, pharmacokinetic and safety data, interpreted in an informed manner. While this remains an unsatisfactory basis for making robust evidence-based recommendations, it highlights the need for appropriate, prospective, randomised controlled studies designed to address the many key questions that will enable the management of CAP to be placed on a sounder basis. The responsibility for this presents a challenge to medical practitioners, healthcare systems, grant-giving bodies and industry. We have also only considered antibiotics licensed and available in the UK at the time we prepared these guidelines.

Currently, within the UK, control of hospital-acquired infection by C difficile, MRSA and pathogens with extended β-lactamase activity is a priority of local and strategic health authorities. In line with the principles of prudent use of antibiotics, the current guidelines have been modified to discourage unnecessary use of broad-spectrum antibiotics, especially cephalosporins and fluoroquinolones. The development of refined techniques for severity stratification have enabled a strategy of targeted antibiotic escalation, which should restrict the use of empirical potent broad-spectrum therapy to those cases in which it is necessary.

EMPIRICAL THERAPY

A Studies Of Cause And Effect

â¡ Was assignment of patients to treatment truly randomised?

â¡ Was the planned therapy concealed from those recruiting patients before enrolment?

â¡ Were all patients who entered the study accounted for?

â¡ Were patients analysed in the groups to which they were initially randomised?

â¡ Were patients and doctors blind to the therapy given?

â¡ Were groups treated the same way, apart from the therapy?

â¡ Were the groups similar at the start of the trial?

What Arrangements Should Be Made For Follow

It is usual practice to arrange âroutineâ hospital clinic follow-up and repeat the chest radiograph at around 6 weeks after discharge. However, there is no evidence on which to base a recommendation regarding the value of this practice in patients who have otherwise recovered satisfactorily. It is also not known whether there is any value in arranging clinical follow-up in a hospital clinic rather than with the patientâs general practitioner. The main concern is whether the CAP was a complication of an underlying condition such as lung cancer .

At discharge or at follow-up, patients should be offered access to information about CAP. In one study of 200 patients who had recently recovered from CAP, a patient information leaflet was judged to be very helpful by the majority of patients. A patient information leaflet on CAP is available on request from British Lung Foundation Headquarters and British Lung Foundation UK regional offices.

Recommendations

• Clinical review should be arranged for all patients at around 6 weeks, either with their general practitioner or in a hospital clinic.

• At discharge or at follow-up, patients should be offered access to information about CAP such as a patient information leaflet.

• It is the responsibility of the hospital team to arrange the follow-up plan with the patient and the general practitioner.

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Empirical Antibiotic Choice For Adults Hospitalised With High Severity Cap

Mortality is greatly increased in those with high severity pneumonia . The illness may progress before microbiological information is available.

Preferred and alternative initial treatment regimens are summarised in and mostly include combination therapy with broad-spectrum β-lactams and a macrolide. While S pneumoniae remains the predominant pathogen, S aureus and Gram-negative enteric bacilliâalthough uncommonâcarry a high mortality, hence the recommendation for broad-spectrum β-lactam regimens in those with high severity CAP. Patients hospitalised with CAP caused by Legionella spp are more likely to have high severity pneumonia. For these reasons, the initial empirical antibiotic regimen should also always capture this pathogen within its spectrum of activity. Specific antibiotic recommendations for treating confirmed legionella infection are provided in Section 8.20. The near universal availability of L pneumophila urine antigen testing means that a rapid diagnosis of L pneumophila serogroup 1 infection can often be made early in the course of the admission. However, the urine antigen test may be negative on admission and is also insufficiently sensitive to exclude Legionnairesâ disease, so empirical therapy for Legionnairesâ disease should not be discontinued based solely on a negative antigen test.

Recommendations

Cap In Elderly Patients: Are Risk Factors And Clinical Features Different

The classic symptoms and signs of pneumonia are less likely in elderly patients and non-specific features, especially confusion, are more likely. Comorbid illness occurs more frequently in older patients with CAP and two studies have found the absence of fever to be more common than in younger patients with CAP.

There is a high incidence of aspiration in elderly patients who present with CAP compared with controls . Case-controlled studies of pneumonia acquired in nursing homes have shown that both aspiration and pre-existing comorbid illnesses were more common in nursing home-acquired pneumonia than in others with CAP. The in-patient mortality rate for nursing home-acquired pneumonia was higher than that for age matched patients with non-nursing home-acquired pneumonia. The relationship between aetiology of CAP and the age of the patient is discussed in Section 3.

Summary

• Elderly patients with CAP more frequently present with non-specific symptoms and have comorbid disease and a higher mortality, and are less likely to have a fever than younger patients.

• Aspiration is a risk factor for CAP in elderly patients, particularly nursing home residents.

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South African Guideline For The Management Of Community

Tom H. Boyles1, Adrian Brink1,2, Greg L. Calligaro3, Cheryl Cohen4,5, Keertan Dheda3, Gary Maartens6, Guy A. Richards7, Richard van Zyl Smit3, Clifford Smith8, Sean Wasserman1, Andrew C. Whitelaw9,10, Charles Feldman11 South African Thoracic Society, Federation of Infectious Diseases Societies of Southern Africa

1Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town 3Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town 4Centre for Respiratory Disease and Meningitis, National Institute for Communicable Diseases , 6Division of Clinical Pharmacology, Department of Medicine, University of Cape Town 7Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University 11Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand , South Africa

Correspondence to:

Submitted Apr 11, 2017. Accepted for publication Apr 20, 2017.

doi: 10.21037/jtd.2017.05.31

What Are The Epidemiological Patterns Of Pathogens Causing Cap And Is This Information Useful To The Clinician

Streptococcuspneumoniae

S pneumoniae occurs most commonly in the winter . Outside the UK, epidemics have occurred in overcrowded settings .

Legionella species

Legionella infection was most common between June and October, with a peak in August and September in the UK between 1999 and 2005. Fifty percent of UK cases are related to travel, 93% of these relating to travel abroad. Clusters of cases are linked to Mediterranean resorts, especially France, Greece, Turkey and Spain, but only 23% of cases occur in clusters. Epidemics occur related to water-containing systems in buildings.

Mycoplasmapneumoniae

Epidemics spanning three winters occur every 4 years in the UK, as shown in . The apparent decline in reports is probably related to decreased use of complement fixation testing rather than a true decline in frequency.

Laboratory reports to the Health Protection Agency Centre for Infections of infections due to Mycoplasma pneumoniae in England and Wales by date of report, 1990â2008 .

Chlamydophilapneumoniae

Chlamydophilapsittaci

Infection is acquired from birds and animals but human to human spread may occur. Epidemics are reported in relation to infected sources at work . Only 20% of UK cases have a history of bird contact.

Coxiellaburnetii

Cases are most common in April to June, possibly related to the lambing and calving season. Epidemics occur in relation to animal sources , but a history of occupational exposure is only present in 7.7% of cases.

Staphylococcusaureus

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How Does The Aetiology Differ In Certain Geographical Areas

Specific studies suggest a higher frequency of certain pathogens in some geographical areas as described in the 2001 BTS guidelines . A global study found a frequency of atypical pathogens of 20â28% of cases in different regions of the world. A similar figure of 23.5% was found in a multicentre South Asian study.

Pathogens which are more common as a cause of community acquired pneumonia in certain geographical regions

Studies from Chile and Nicaragua report a similar pathogen spectrum to previous European studies.

Evidence of legionella infection was found in 31.7% of non-consecutive pneumonia cases in Trinidad and 5.1% of 645 consecutive cases in Brazil. An incidence of 5.2% for C pneumoniae was found by the same group, with a frequency of 8.1% being found in a Canadian study. In 62% of these cases an additional pathogen was also found.

An outpatient study in Arizona found evidence of coccidioidomycosis in 29% of 55 cases.

Studies from south and east Asia found high frequencies of S pneumonia,C pneumonia and Gram-negative bacteria and Haemophilus influenzae in Thailand. In China, H influenzae was the predominant pathogen in one study, but S pneumoniae and M pneumoniae in another.S pneumoniae followed by H influenzae predominated in Japan, and S pneumoniae followed by M pneumoniae in Taiwan.

S pneumoniae and Klebsiella pneumoniae were found to be the most frequent causes of CAP in the ICU on an Indian Ocean island.

Severely Ill Patients With Cap

Mortality is in the region of 12% for hospitalised CAP but > 30% among those admitted to the ICU .

Obvious reasons for referral are the need for mechanical ventilation and the presence of septic shock. Otherwise patients with a CURB-65 of â¥3 should be evaluated for ICU admission. Clinical judgment, however, is important as elderly or immunocompromised patients may warrant ICU admission even with lower scores .

Organisms that cause severe CAP are similar to those that cause less severe disease S. pneumoniae, Legionella spp., S. aureus and K. pneumoniae and viruses such as influenza . However, other organisms are important to consider especially in the right clinical or geographical context: influenza H5N1 and H7N3, SARS and MERSCoV, Hantavirus, P. jirovecii, enteric gram-negative bacilli , MSSA or MRSA , and M. tuberculosis.

Potentially useful interventions include those that are relevant to any patient with severe sepsis and mechanical ventilation should be utilised to restore adequate oxygenation without causing lung injury .

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Types Of Antibiotics For Pneumonia

There are multiple types of antibiotics that work in slightly different ways. Some are more commonly used to treat pneumonia than others based on things like:

• The bacteria causing infection
• The severity of the infection
• If youre in a patient group at greatest risk from pneumonia

The types of antibiotics that your doctor might typically prescribe for pneumonia include the following:

Antibiotics prescribed for children with pneumonia include the following:

• Infants, preschoolers, and school-aged children with suspected bacterial pneumonia may be treated with amoxicillin.
• Children with suspected atypical pneumonia can be treated with macrolides.
• Children allergic to penicillin will be treated with other antibiotics as needed for the specific pathogen.
• Hospitalized, immunized children can be treated with ampicillin or penicillin G.
• Hospitalized children and infants who are not fully vaccinated may be treated with a cephalosporin.
• Hospitalized children with suspected M. pneumoniae or C. pneumoniae infection may be treated with combination therapy of a macrolide and a beta-lactam antibiotic .
• Hospitalized children with suspected S. aureus infections might be treated with a combination of Vancocin or clindamycin and a beta-lactam.

What Microbiological Investigations Should Be Performed In Patients With Suspected Cap In The Community

Recommendations

• For patients managed in the community, microbiological investigations are not recommended routinely.

• Examination of sputum should be considered for patients who do not respond to empirical antibiotic therapy.

• Examination of sputum for Mycobacterium tuberculosis should be considered for patients with a persistent productive cough, especially if malaise, weight loss or night sweats, or risk factors for tuberculosis are present.

• Urine antigen investigations, PCR of upper or lower respiratory tract samples or serological investigations may be considered during outbreaks or epidemic mycoplasma years, or when there is a particular clinical or epidemiological reason.

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Failure Of Initial Empirical Therapy

In those patients who fail to respond to initial empirical therapy, several possibilities need to be considered, the first of which is whether the correct diagnosis has been made. Clinical and radiographic review is recommended for patients managed in the community and in hospital to look for secondary diagnoses or complications of CAP such as pleural effusion/empyema, lung abscess or worsening pneumonic shadowing. This aspect is considered in detail in Section 9.

The initial empirical antibiotic regimen may need to be reassessed. However, compliance with and adequate absorption of an oral regimen should first be considered.

Microbiological data should be reviewed and further specimens examined with a view to excluding less common pathogens such as S aureus, atypical pathogens, Legionella spp, viruses and Mycobacteria spp. It should also be noted that mixed infections can arise in approximately 10% of patients hospitalised with CAP. In the absence of any microbiological indicators of infection, the management of those failing initial empirical therapy will vary according to the severity of illness at reassessment. In patients with low severity pneumonia managed in the community, a macrolide could be substituted for amoxicillin. However, when the patientâs condition has deteriorated, admission to hospital should be considered.

Recommendations

Reviewing Severity Status After Initial Assessment In Hospital

Summary

• Regular and structured clinical review and reassessment of disease severity facilitates the stepping down and stepping up of antibiotic management.

Recommendations

• Regular assessment of disease severity is recommended for all patients following hospital admission. The âpost takeâ round by a senior doctor and the medical team provides one early opportunity for this review.

• All patients deemed at high risk of death on admission to hospital should be reviewed medically at least 12-hourly until shown to be improving.

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Diagnosis And Treatment Of Adults With Community

American Journal of Respiratory and Critical Care Medicine, Volume 200, Issue 7, 1 October 2019, Pages e45-e67, 01 October 2019

Joshua P. Metlay, Grant W. Waterer, Ann C. Long, Antonio Anzueto, Jan Brozek, Kristina Crothers, Laura A. Cooley, Nathan C. Dean, Michael J. Fine, Scott A. Flanders, Marie R. Griffin, Mark L. Metersky, Daniel M. Musher, Marcos I. Restrepo, and Cynthia G. Whitney on behalf of the American Thoracic Society and Infectious Diseases Society of America

When To Contact A Medical Professional

• Cough that brings up bloody or rust-colored mucus
• Breathing symptoms that get worse
• Chest pain that gets worse when you cough or breathe in
• Fast or painful breathing
• Night sweats or unexplained weight loss
• Shortness of breath, shaking chills, or persistent fevers
• Signs of pneumonia and a weak immune system
• Worsening of symptoms after initial improvement

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C Studies Of Diagnosis

â¡ Was the finding or result compared with a 24 carat gold standard for diagnosis?

â¡ Was the finding or result determined blind to the gold standard?

â¡ Was the gold standard determined blind to the finding or test result?

â¡ Was the gold standard determined in all cases, not just those with an abnormal result?

Antibiotic Stewardship And The Individual Clinicians Responsibility To Prevent The Overuse Of Antibiotics When Managing Cap

The choice of antibiotic regimen has consequences beyond the management of the individual patient. The inappropriate application of CAP guidelines to community acquired lower respiratory tract infections other than pneumonia and hospital acquired pneumonia leads, in turn, to inappropriate and potentially excessive antibiotic use. Too loose an interpretation of âsevere pneumoniaâ also contributes to the overprescribing of macrolides and β-lactams, especially when administered parenterally, in the management of hospitalised patients with CAP.

Overuse of antibiotics in CAP increases the cost of management and, particularly in relation to quinolones and cephalosporins, serves as a driver for health care-associated infections, including MRSA and C difficile infection. The avoidance of inappropriate or excessive use of antibiotics is specifically discussed in Section 8.18. Proper patient selection for treatment and the correct use of antimicrobial agents are emphasised in this document.

In particular, these guidelines stress that the use of empirical broad-spectrum antibiotics is initially recommended only in patients with high severity CAP. This group of patients comprise approximately one-third of all patients admitted to hospital with confirmed CAP. Regular review and the prompt âde-escalationâ to narrow-spectrum antibiotics based on early microbiological investigations are also emphasised.

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What Are The Optimum Antibiotic Choices When Specific Pathogens Have Been Identified

In routine clinical practice, only about one-third to one-quarter of patients with CAP admitted to hospital will be defined microbiologically. Of these, some such as mycoplasma, chlamydophila and C burnetii infection will be diagnosed late in the illness on the basis of seroconversion, reducing the opportunity for early targeted therapy. Among patients managed in the community, very few will be microbiologically defined.

When a pathogen has been identified, specific therapy as summarised in is proposed. In transferring patients from empirical to pathogen-targeted therapy, the regimen and route of administration will be determined by the continued need for parenteral therapy and known drug intolerance. Hence, provides preferred and alternative regimens for intravenous or oral administration. However, it should be remembered that approximately 10% of infections will be of mixed aetiology, although many such co-pathogens will be viral and hence not influenced by antibiotic choice. These recommendations are again based on a synthesis of information which includes in vitro activity of the drugs, appropriate pharmacokinetics and clinical evidence of efficacy gleaned from a variety of studies. The choice of agent may be modified following the availability of sensitivity testing or following consultation with a specialist in microbiology, infectious disease or respiratory medicine.

Recommendations

Appropriate Methods Of Causative Bacteria Detection In Inpatients

For inpatients with pneumonia, it is advisable to perform blood culture, and sputum Gram smear and culture tests before antibiotic administration as long as they are indicated. Sputum tests must be done using sputum samples obtained before antibiotic administration, and should only be performed when sufficient amounts of sputum are released, collected, transferred, and treated . For patients with moderate community-acquired pneumonia, a blood culture, Legionella, S. pneumoniae urinary antigen test, and sputum gram smear and culture must be performed . For patients with airway intubation, a test using trans-tracheal aspirate samples must be performed. For immunodeficient patients, or patients for whom common treatments have failed, invasive tests such as airway endoscopy and percutaneous pulmonary aspiration are useful .

KQ 2. For adults who may have contracted community-acquired pneumonia, is the urinary S. pneumoniae antigen test useful for selecting therapeutic antibiotics?

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