Dr. Greg Mints on Community Acquired Pneumonia November 14, 2006
Posted by rajkmd in Uncategorized.trackback
This is in relation to the following post
Greg Mints – November 14, 2006[Edit]
2. I believe that posting other hospital’s guidelines may be useful for some residents, but will result in data overload and confusion among others. Whoever posts similar documents in the future may want to consider including a commentary by one of our local specialists in the matter along with the original posting. I think such a commentary should be specifically solicited post factum in this instance as well.
3. I do not agree with several recommendations put forth in the paper. In general, for cases of suspected aspiration there seems to be very little need for anything beyond the usual Ceftriaxone in the usual dose, since most anaerobes in the mouth are expected to be sensitive. That said, ampicillin/sulbactam (Unasyn) would be a reasonable, but a bit too broad. There is certainly no reason to use Zosyn, as suggested in these guidelines, unless the patient is believed to be at high risk for pseudomonal infection (ex.: recent h/o hospitalization).
4. As a rule, there is no need to observe patients in the hospital once they have been switched to PO Abx, i.e. “If you are well enough to be on PO antibiotics, you are well enough to be home”. The paper seems to suggest otherwise.
5. Bellevue’s recommended oral equivalent of Ceftriaxone is Cefpodoxime, a 3rd generation cephalosporin with in-vitro antibacterial spectrum similar to that of Ceftriaxone.
6. I strongly oppose switching patients from i.v. Ceftriaxone to PO Levaquin. We MUST limit patient exposure to multiple classes of Abx, especially since quinolone resistance is on the rise and resistance to one member in this class of Abx usually means resistance to all (or most) of them.
7. Finally, I urge the practitioners not to over-use the PORT score. As with any clinical prediction rule, one must know whether a particular score is applicable to a particular patient.
a. If memory serves, the score has been validated principally in identifying low-risk patients, who may not need to be admitted. Its performance in identifying all other groups is less well known.
b. Chronic pulmonary diseases are not included in the scoring system. This is important, since patients with COPD, asthma and cystic fibrosis may all have worse prognosis simply because of poorer reserve, and may need to be admitted despite a low PORT score. In addition some of these are characterized by microbiological epidemiology different from the usual community-acquired pneumonia (ex.: pseudomonas is cystic fibrosis, etc.)
c. Immunocompromized patients are a separate population altogether. Among such patients PORT score has not been tested (as far as I know). In my personal experience, patients on chronic steroids and those with AIDS can do quite poorly despite low scores. I therefore strongly advise against the use of PORT score in such patients.
In response to the New York-Presbyterian Hospital (NYPH) guidelines for empiric management of community-acquired pneumonia (CAP):
The original study of the PORT score (NEJM 336:243, 1997) was validated in more than 28,000 patients predominantly in hospital emergency rooms, and the severity of illness ranged from not so sick (0.1% mortality, Class I) to very sick (29.3% mortality, Class V). Beware that the PORT score, which has evolved into the Pneumonia Severity Index (PSI), was derived to determine expected mortality for a given clinical profile. This rule has then been prospectively studied to ask the question, can the PSI determine the need for hospitalization and reduce costs, and its performance hasn’t been great. American Thoracic Society (ATS) guidelines from 2001 emphasize its limits, resting the decision to hospitalize on your clinical judgment. Thus, I strongly agree with Dr. Mints (and the ATS 2001 guidelines and the Infectious Disease Society of America (IDSA) 2003 guidelines) that over-reliance on clinical prediction rules generally, and specifically for pneumonia, is risky and in no way replaces clinical judgment. That said, by knowing the PSI criteria, we as residents may better appreciate our tools for evaluating the severity of an infection. It may surprise you to learn that hyponatremia, hyperglycemia, and a BUN of >30 add +50 to your points.
I share Dr. Mints’ chagrin that the suggested coverage for microbes associated with aspiration (i.e anaerobes) is pip/tazo and not amp/sulbactam. In my review of the 2001 ATS guidelines, they suggest high dose ampicillin, amp/sulbactam, or “other active beta-lactams” – which sounds consistent with Mints’ comment that anaerobes are likely still susceptible to ceftriaxone. Also, in our practice at Bellevue, we tend to avoid the use of fluoroquinolones when there is a question of TB infection, as levofloxacin is an important component of our armamentarium against drug-resistant TB.
To me, the NYPH guidelines do not seem to suggest a need to observe patients on PO antibiotics. Rather, they apply discharge criteria that are identical to the IDSA 2003 guidelines (temp 36hrs without antipyretics, pulse 90 ,O2sat >90%, taking POs). If these criteria are met, these NYPH guidelines suggest no reason to hold-up discharge.
One principle of CAP therapy not mentioned in the NYPH guide is the IDSA guideline to initiate antibiotic therapy within 4 hours (this is a national hospital “quality of care” measure).
Generally, when I have questions about management of CAP, I turn to the ATS and IDSA websites, which publish their guidelines as PDFs for free. IDSA plans to update their CAP recommendations in the spring of 2007.