Dr. Yazdan Mirzanejad (biography and disclosures)
There are five new pieces of evidence that changed my practice in management and treatment of pneumonia.
Community acquired pneumonia caused by Streptococcus Pneumonia is the 6th leading culprit of death due to infection in North America.
In the 80’s, first time resistance of Streptococcus pneumonia to Penicillin was noted in South Africa; shortly after it spread widely throughout the world, and currently it has turned into a variably sensitive, intermediate and highly resistant strain.
What changed my practice
In the 90’s, the British Thoracic Society and American Thoracic Society gathered and developed a practice guideline, which was revisited later in the late 90’s and once again in 2007 by the Infectious Diseases Society of America. By walking through guidelines derived over 10 years, there are 5 major evidences that changed my way of managing community acquired pneumonia.
What I do now
1) A quick way to assess patients for where, what and when to treat and investigate was brought into practice by the CURB-65 Severity Score for Community Acquired Pneumonia. This method has more practical utility than the pneumonia severity index (PSI) previously used.
| Confusion | Yes +1 point |
| Urea > 7mmol/L | Yes +1 point |
| Respiratory Rate ≥ 30 | Yes +1 point |
| BP: SBP < 90 mmHg or DBP ≤ 60 mmHg | Yes +1 point |
| Age ≥ 65 | Yes +1 point |
Management is guided by the score:
| CURB – 65 Score | Recommendation |
| 0-1 | Low risk, consider home treatment |
| 2 | Short inpatient hospitalization or closely supervised outpatient treatment |
| 3-5 | Hospitalize or consider intensive care admission |
http://www.mdcalc.com/curb-65-severity-score-community-acquired-pneumonia
2) Penicillin and Amoxicillin came back to Guidelines treatment of mild to moderate pneumonia due to their preserved ability to eradicate Streptococcus pneumonia in 65% of the cases. They have replaced macrolides and quinolones which previously were first choices, thus the majority of community acquired pneumonia with an intensity of mild to moderate could be easily treated with Amoxicillin +/- Doxycyciline. 1, 2, 3, 5
3) I also learned to take into consideration the numbers of co-morbidities as an important independent risk factor for severity of pneumonia presentation rather than just looking at patients’ vitals and microbiology reports. The number of co-morbidities is linearly associated with worse outcome due to poor immune response and higher rate of colonization with resistant bacteria. 2
4) The time to initiation of antibiotics is crucial to improve the outcome in moderate to severe pneumonia. Based on the evidence, antibiotic initiation within the first 6 hours is substantial to successful outcome as the delay will increase the mortality of severe sepsis by 7.8% per hour thereafter. 2, 4
5) I continue to stay current with the recommendations within the practice guidelines. The outcome of patients in the centers that consistently adopted the practice guideline recommendations has been more favorable in the past 10 years. 2
I hope this brief note can change your practice management in treatment of community acquired pneumonia as well.
References: (Note: Article requests require a login ID with the BC College of Physicians website)
- Donald E. Low, Joyce de Azavedo, et al. Antimicrobial Resistance among Clinical Isolates of Streptococcus pneumoniae in Canada during 2000, Antimicrobial Agents and Chemotherapy, May 2002, p. 1295–1301 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC127188/pdf/0963.pdf (View article with UBC)
- Lionel A. Mandell, Richard G. Wunderink, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72 (Suppl 2) (View article with CPSBC or UBC)
- M. Winters, D.M. Patrick, et al. Epidemiology of Invasive Pneumococcal Disease in BC during the Introduction of Conjugated Pneumococcal Vaccine, Canadian Journal of Public Health, January/February 2008, Vol. 99, No. 1 (View article with CPSBC or UBC)
- Anand Kumar, Cameron Haery, et al. The Duration of Hypotension before the Initiation of Antibiotic Treatment Is a Critical Determinant of Survival in a Murine Model of Escherichia coli Septic Shock: Association with Serum Lactate and Inflammatory Cytokine Levels. The Journal of Infectious Diseases 2006; 193:251–8 (View article with CPSBC or UBC)
- Anand Kumar, Ryan Zarychanski, et al. Early combination antibiotic therapy yields improved survival compared to monotherapy in septic shock: A propensity-matched analysis. Crit Care Med 2010 Vol. 38, No. 9 (View article with CPSBC or UBC)
Recommended reading:
Slides for data for susceptibility of strep pneumonia in the US and BC
http://www.ubccpd.ca/susceptibility_of_strep_pneumonia.htm
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Back to Penicillin which is a great.
good practice points
I like the idea of using Amoxil and also using Doxy
I like the simplicity of the staging of severity, when to admit, when to admit to ICU etc.
I agree that assessing for comorbidities is key to clinical outcomes
Concise, easy to follow recommendations. Nicely presented and thought – out.
Good to know that staying with Amoxil for lower risk patients is still valid. Concise risk scoring to make triaging a little easier.
consistent with current practice
Interesting that we’re back to penicillin group again.
Interesting that we’re back to amoxicillin
The CURB score is a bit vague in terms of diagnosis: What about proper clinical examination and finding: Lung signs > then WBC / CRP count / blood culture prior to treatment /CXR
Many other conditions can give a similar ‘CURB’ score and I can not trust that as an only diagnostic guideline.
Treatment choice:
Amoxycillin + Clavulanic acid 0.75-1,5g O/IV q4-6h
Amikacin 15mg/kg IV q12h
Gentamycin 5mg/kg IV q 8h00
Vancomycin 2g IV q 6-12h00
With respect to Dr.VG Lotfie-Eaton’s concerns, I would like to reply as follows:
1- CURB65 itself is a general manifestation and classifcation of systemic inflamatory response syndrome which I agree applies to various clinical scenarios, however it will be only more meaningful once the diagnosis of pneumonia is established by clinician and then it can guide the modality of therapy depends on the scores and will help with timely management plan in the right place i,e.. wards versus intensive care unit vice versa.
2- Having said that, it only serves as a guide and not an absolute measure for patient’s management purposes. The final disposition for ill patient only will be detemined by clinician and nothing to my estimate could ever replace it!
But very good point for discussion though!
Regards,
yazdan
like the CURB65, practical for hospital-based medicine..
Would a history of not having the flu shots or the pneumovax shots add an extra point when assessing risk?
In reply to Dr. J. Burke’s comment, the answer is yes, and it has two important application with it,
1- if no Vaccines and the syndrome prodromed by Coryza, sever Myalgia and other specific can bring a strong argue in favor of Viral pneumonia with influenza strain, so early treatment with Oseltamivir would be advocated and important in Survival
2- At times secondary bacterial Pneumonia can be a consequence of a primary viral pneumoniae especially influenza pneumonia, so it can direct the antibiotics therapy in favor of antibacterials and more specifically, Staphylococcus and Streptococcus pneumonia.
Regards,
yazdan
Good to know Penicilline is back as fist choice