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1. Recent guidelines for
pneumonia management
Presenter : Dr Bidyut Kr Adhikary
Chairperson : Dr Dipanjan Bandyopadhyay

2. • This official clinical practice guideline was approved by the American
Thoracic Society in May 2019 and the Infectious Diseases Society of
America in August 2019
• Also Endorsed by the Society of Infectious Disease Pharmacists in July
2019
Am J Respir Crit Care Med 2019;200(7):45–67.

4. Definitions
• Pneumonia : Infection of lung tissue
• Community acquired pneumonia : Pneumonia that is acquired outside
of the hospital setting
• Hospital acquired pneumonia : pneumonia not incubating at the time
of hospital admission and occurring 48 hours or more after admission
• Ventilator associated pneumonia : pneumonia occurring >48 hours
after endotracheal intubation

5. Community acquired pneumonia (CAP)
• Infection of the pulmonary parenchyma
• Clinical presentation: indolent to fulminant
• Clinical manifestations: Fever, cough with / without sputum
production, dyspnea, pleuritic chest pain, hemoptysis
• Diagnosis: clinically and with chest radiography

6. Microbial causes of Pneumonia
Outpatients
Hospitazed patients
Non-ICU ICU
Streptococcus
pneumoniae
S. Pneumoniae S. Pneumoniae
Mycoplasma pneumoniae M. Pneumoniae Staphylococus aureus
Haemophilus influenzae Chlamydia pneumoniae Legionella spp
C. pneumoniae H. Influenzae Gram negative bacilli
Respiratory viruses Legionella spp H. Influenzae
Respiratory viruses Respiratory viruses

7. Diagnosis of CAP as per IDSA

8. Chest radiograph of pneumonia

9. Severe CAP :
ATS / IDSA
Minor criteria
• Respiratory rate > 30 breaths/min
• PaO2 / FIO2 ratio < 250
• Multilobar infiltrates
• Confusion / disorientation
• Uremia (blood urea nitrogen > 20 mg/dl)
• Leukopenia (WBC ˂4,000 cells/ml)
• Thrombocytopenia (platelet <100,000/ml)
• Hypothermia (core temperature < 36o
C)
• Hypotension requiring aggressive fluid
resuscitation
Major criteria
• Septic shock with need for
vasopressors
• Respiratory failure requiring
mechanical ventilation

10. GS and Culture of Lower Respiratory Secretion
• Obtaining sputum Gram stain and culture routinely in adults with CAP
managed in the outpatient setting not recommended
• Obtaining pretreatment GS and culture of respiratory secretions in
adults with CAP managed in the hospital setting who:
 Classified as severe CAP
 Are being empirically treated for MRSA or P. aeruginosa
 Were previously infected with MRSA or P. aeruginosa
 Were hospitalized and received parenteral antibiotics, whether
during the hospitalization event or not, in the last 90 days

11. Recommendation about Blood Cultures
• Recommend not to obtain blood cultures in adults with CAP managed
in the outpatient setting
• Suggest not to obtaining blood cultures routinely in adults with CAP
managed in the hospital setting
• Obtaining pretreatment blood cs in adults in the hospital setting who:
 Classified as severe CAP
 Are being empirically treated for MRSA or P. aeruginosa
 Were previously infected with MRSA or P. aeruginosa
 Were hospitalized and received parenteral antibiotics, whether
during the hospitalization event or not, in the last 90 days

12. Legionella and Pneumococcal Urinary Antigen
Testing
• Suggest not routinely testing urine for pneumococcal antigen in
adults with CAP except in adults with severe CAP
• Suggest not routinely testing urine for Legionella antigen in
adults with CAP except :
 In cases where indicated by epidemiological factors, such
as association with a Legionella outbreak or recent travel
 In adults with severe CAP

13. Testing for Influenza Virus at the Time of Diagnosis
• When influenza viruses are circulating in the community,
testing for influenza with a rapid influenza molecular assay
recommended
• Molecular assay preferred over a rapid influenza diagnostic
test
• Benefits of antiviral therapy : Oseltamivir
• Anti-influenza treatment be prescribed for adults with CAP
who test positive for influenza in the inpatient setting

14. Pneumonia Severity Index (PSI)

15. Class Point Mortality
Class 1 < 51 0.1 %
Class 2 51 - 70 0.6 %
Class 3 71 – 90 0.9 %
Class 4 91 – 130 9.3 %
Class 5 > 130 27 %
Pneumonia Severity Index (PSI)

16. CURB 65 score
• Calculated by giving 1 point for each of the following :
 Confusion
 Raised blood urea nitrogen (over 7 mmol/lit)
 Raised respiratory rate (30 breadths/ min)
 Low blood pressure (diastolic BP ≤ 60 mmHg or systolic BP ≤ 90 mmHg)
 Age ≥ 65 yrs
Score 0 – 1 : ˂ 3 % mortality
Score 2 : 3 -15 % mortality
Score 3 – 5 : ˃ 15 % mortality

17. Role of Chest X-ray
• In the community :
Not necessary to perform chest radiograph in patients of CAP unless:
 The diagnosis is in doubt and a chest radiograph will help in
differential diagnosis
 Progress following treatment for suspected CAP is not satisfactory
 Patient is at risk of underlying lung pathology such as lung CA

18. • In the hospital:
 All patients should have a chest radiograph as soon as possible
to confirm or refute the diagnosis
 Need not be repeated before discharge who have satisfactory
clinical recovery
 Patients with persistent signs & symptoms: CXR after 6 weeks
Role of chest X ray

19. Decision regarding place of treatment
• In addition to clinical judgement, use a validated clinical prediction rule
for prognosis to determine the need for hospitalization in adult
• Pneumonia Severity Index (PSI) preferred over the CURB-65
• CRB 65 score 0 do not require hospitalization, score 1 or 2 hospital
referral and assessment, score ≥ 3 urgent hospital admission (BTS)
• Consider medical and/or psychosocial contraindications to outpatient
therapy

20. Decision regarding ICU admission
• The PSI and CURB-65 were not designed to help select the level of
care needed by a patient who is hospitalized for CAP
• Patients with severe pneumonia as per the 2007 IDSA/ATS CAP
guidelines require ICU admission
• Patients with CURB-65 score of 4 and 5 assessed specifically for the
need of ICU care ( BTS guideline)

21. General management strategy : BTS guideline
• Oxygen therapy: maintain PaO2 at ≥ 8 kPa and Spo2 ≥ 94 %
• Repeated ABG measurements
• Assessment for volume depletion and proper use of IV fluid
• Prophylactic LMWH in patients who are not fully mobile
• Nutritional support in prolonged illness

22. Empiric antibiotic in outpatient Setting for CAP
• Healthy adults without comorbidities
 Amoxicillin 1 g three times daily or
 Doxycycline 100 mg twice daily or
 Macrolide (azithromycin 500 mg on first day then 250 mg daily or
clarithromycin 500 mg twice daily)
• Adults with comorbidities
 Combination therapy amoxicillin/clavulanate and macrolide or
doxycycline or
 Monotherapy with respiratory fluoroquinolone

23. Empiric antibiotic regimen for inpatient
• Without Risk Factors for MRSA and P. aeruginosa
 Combination therapy with a b-lactam and a macrolide
 Monotherapy with a respiratory fluoroquinolone
 Combination therapy with a b-lactam and doxycycline 100 mg
twice daily

24. • With Risk Factors for MRSA and P. aeruginosa
• Only cover empirically for MRSA or P. aeruginosa in adults with CAP if
locally validated risk factors for either pathogen are present
• Most consistent strong risk factor : Prior isolation of these organisms,
especially from the respiratory tract, and/or recent hospitalization and
exposure to parenteral antibiotics
• Need to obtain local data
• Empiric treatment options for MRSA include vancomycin or linezolid
• Empiric treatment options for P. aeruginosa include piperacillin-
tazobactam, cefepime, ceftazidime, aztreonam, meropenem or
imipenem
Empiric antibiotic regimen for inpatient

25. Recommendation regarding anaerobic coverage
• Suggest not routinely adding anaerobic coverage for suspected
aspiration pneumonia unless lung abscess or empyema is suspected
• Anaerobic bacteria do not play a major role in etiology as per several
studies
• Concern of increasing rates of C. difficile infections (frequently
associated with use of clindamycin)

26. Use of corticosteroids
• Recommend not routinely using corticosteroids in adults with non-
severe CAP
• Suggest not routinely using corticosteroids in adults with severe CAP
and severe influenza pneumonia
• Use of steroids in patients with septic shock refractory to adequate
fluid resuscitation and vasopressor support

27. Duration of Antibiotic Treatment
• Duration of antibiotic therapy should be guided by a validated
measure of clinical stability (resolution of vital sign abnormalities,
ability to eat, and normal mentation)
• Antibiotic therapy should be continued until the patient achieves
stability and for no less than a total of 5 days

28. Clinical criteria for diagnosing HAP/ VAP
• Presence of new lung infiltrate plus clinical evidence that the infiltrate
is of an infectious origin, which include
 The new onset of fever
 Purulent sputum
 Leukocytosis
 Decline in oxygenation

29. Microbiologic diagnosis of HAP & VAP
• Suggest non-invasive sampling with semiquantitative cultures to
diagnose VAP
• For patients with invasive quantitative culture results below the
diagnostic threshold for VAP, antibiotics be withheld
• Suggest that patients with suspected HAP (non-VAP) be treated
according to the results of microbiologic studies performed on
respiratory samples obtained noninvasively, rather than empirically

30. Role of BIOMARKERS AND THE CLINICAL
PULMONARY INFECTION SCORE
• Use clinical criteria alone, rather than using serum Procalcitonin plus
clinical criteria for initiating antibiotic therapy
• Use clinical criteria alone, rather than using bronchoalveolar lavage
fluid (BALF) sTREM-1 plus clinical criteria
• Use clinical criteria alone rather than using CRP plus clinical criteria
• Use clinical criteria alone, rather than using CPIS plus clinical criteria
sTREM-1 : Soluble Triggering Receptor Expressed on Myeloid Cells
CPIS : Modified Clinical Pulmonary Infection Score

31. Risk factors for Multidrug-Resistant Pathogens

32. Selection of antibiotic in VAP
• All hospitals should regularly generate and disseminate a local
antibiogram, ideally one that is specific to their intensive care
population
• Empiric treatment regimens be informed by the local distribution of
pathogens associated with VAP and their antimicrobial susceptibilities
• Patients with suspected VAP include coverage for S. aureus,
Pseudomonas aeruginosa, and other gram-negative bacilli in all
empiric regimens

33. • Include an agent active against MRSA for the empiric treatment only in
patients with any of the following:
 A risk factor for antimicrobial resistance
 Patients being treated in units where >10%–20% of S. aureus
isolates are methicillin resistant
 Patients in units where the prevalence of MRSA is not known
• For MRSA use either vancomycin or linezolid
• For empiric coverage of MSSA (and not MRSA) use a regimen including
piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or
meropenem
Selection of antibiotic in VAP

34. • Prescribing 2 antipseudomonal antibiotics from different classes for the
empiric treatment of suspected VAP only in patients with any of the
following:
 A risk factor for antimicrobial resistance
 Patients in units where >10% of gram-negative isolates are
resistant to an agent being considered for monotherapy
 Patients in an ICU where local antimicrobial susceptibility rates
are not available
 Patient with structural lung disease
• Avoid aminoglycosides & colistin if alternative agents with adequate gram-
negative activity are available
Selection of antibiotic in VAP

35. Gram-Positive Antibiotics
With MRSA Activity
Gram-Negative Antibiotics
With Antipseudomonal
Activity: β-Lactam–Based
Agents
Gram-Negative Antibiotics With
Antipseudomonal Activity: Non-β-Lactam–Based
Agents
Glycopeptides:
Vancomycin 15 mg/kg IV
q8–12h
Antipseudomonal
penicillins: Piperacillin-
tazobactam 4.5 g IV q6h
Fluoroquinolones:
Ciprofloxacin 400 mg IV q8h Levofloxacin 750 mg
IV q24h
Or Or Or
Oxazolidinones:
Linezolid 600 mg IV q12h
Cephalosporins:
Cefepime 2 g IV q8h,
Ceftazidime 2 g IV q8h
Aminoglycosides:
Amikacin 15–20 mg/kg IV q24h Gentamicin 5–7
mg/kg IV q24h Tobramycin 5–7 mg/kg IV q24h
Or Or
Carbapenems:
Imipenem 500 mg IV q6hd
Meropenem 1 g IV q8h
Polymyxins
Colistin 5 mg/kg IV × 1 (loading dose) followed by
2.5 mg × (1.5 × CrCl + 30) IV q12h (maintenance
dose)
Polymyxin B 2.5–3.0 mg/kg/d divided in 2 daily IV
doses
Or
Monobactams:
Aztreonam 2 g IV q8h

36. • All hospitals should regularly generate and disseminate a local
antibiogram, ideally one that is tailored to their HAP population
• Empiric antibiotic regimens be based upon the local distribution of
pathogens associated with HAP and their antimicrobial susceptibilities
• Patients being treated empirically for HAP prescribe an antibiotic with
activity against S. aureus
Selection of antibiotic in HAP

37. • For patients with HAP who are being treated empirically and have
either a risk factor for MRSA infection like:
 Prior intravenous antibiotic use within 90 days
 Hospitalization in a unit where >20% of S. Aureus isolates are
methicillin resistant
 Prevalence of MRSA is not known
Or
• Who are at high risk for mortality
Need for ventilatory support due to HAP
Septic shock
Selection of antibiotic in HAP (MRSA
coverage)

38. • Use vancomycin or linezolid for MRSA
• Empiric treatment for MSSA (and not MRSA) : Regimen including
piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or
meropenem
• For patients with HAP who have factors increasing the likelihood for
Pseudomonas or other gram-negative infection or a high risk for
mortality: Prescribe antibiotics from 2 different classes with activity
against P. aeruginosa
• Recommend not to use an aminoglycoside as the sole
antipseudomonal agent for empiric therapy
Selection of antibiotic in HAP

39. ROLE OF INHALED ANTIBIOTIC THERAPY in VAP
• Patients with VAP due to gram-negative bacilli that are susceptible to
only aminoglycosides or polymyxins (colistin or polymyxin B): Both
inhaled and systemic antibiotics, rather than systemic antibiotics
alone
• places a high value on achieving clinical cure and survival

40. Definitive therapy : Pseudomonas
• Patients with HAP/VAP due to P. aeruginosa, the choice of an antibiotic for
definitive (not empiric) therapy be based upon the results of antimicrobial
susceptibility testing
• Recommend against aminoglycoside monotherapy
• Recommend dual therapy using two antibiotics to which the isolate is
susceptible in patients who are in septic shock or at a high risk for death
• Others : use monotherapy

41. ESBL & Acinetobacter
• ESBL
Choice of an antibiotic for definitive therapy be based upon the results of
antimicrobial susceptibility testing and patient-specific factors
• Acinetobacter
 Treatment with either a carbapenem or ampicillin/ sulbactam if
the isolate is susceptible
 Acinetobacter species that is sensitive only to polymyxins: IV
polymyxin (colistin or polymyxin B) and adjunctive inhaled colistin
 Acinetobacter species sensitive only to colistin : Not using
adjunctive rifampicin
 recommend against the use of tigecycline

42. Length of therapy
• Recommend a 7-day course of antimicrobial therapy for both HAP &
VAP
• Antibiotic therapy be de-escalated rather than fixed
• For patients with HAP/VAP use PCT levels plus clinical criteria to guide
the discontinuation of antibiotic therapy, rather than clinical criteria
alone

43. Prevention of HAP/ VAP
• Strategies to reduce bacterial colonization:
 Selective digestive tract decontamination : High cost , increase
MDR
 Oral Chlorhexidine
 Gastric acid suppression only in indicated patients
• Strategies to reduce aspiration:
 Semi recumbent position (30o – 60o)
 Minimize sedation
 Airway clearance, early mobilization and pain control

44. • Specific measures against VAP:
 Reduce duration of mechanical ventilation
 Use NIV or HFNC
 Daily sedation interval and assessment of weaning status
 Early extubation
 Daily cuff pressure monitoring
 Changing ventilator tubing if excessively soiled
Prevention of HAP/ VAP

45. Summary
• Use of clinical judgement is important for diagnosis and management
• Generation of local antibiogram and judicious use of antibiotic
• Select antibiotic based on risk factors for MDR organisms
• Not all aspiration pneumonias require anaerobic coverage

46. Thank you