Narrator - Dr. Abel 00:00 Welcome to heloise the show, an educational podcast covering a real life five star review from the IT, pharmacy topics, search for helix therapy, discussion place your review the Narrator - ? 00:11 podcast is to suggest an episode or contact us online. Thank you for listening. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes, not professional advice should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk. Episode 106 I'm your co host, Dr. Kane. Dr. Khyati Patel 00:35 I'm Dr. Patel, and today with us, we have Dr. Christy Bertram. She's an infectious disease clinical pharmacist and assistant professor at our University College of Pharmacy. So welcome, Dr Unknown Speaker 00:45 Bertram, thank you for the introduction. I'm excited to be here. Dr. Sean Kane 00:48 And the title of today's episode is it's finally here, the 2019 IDSA CAP Guidelines. So Dr. Bertram, why don't you tell us why we're so excited about these guidelines finally being here. What was the wait? Sure. Speaker 1 01:01 So we've actually been waiting a very long time for these updated guidelines, since 2007 Dr. Sean Kane 01:06 Oh my, 2007 certainly nothing has changed in the pneumonia world since 2007 Unknown Speaker 01:11 nothing at all. Nope. Dr. Sean Kane 01:14 Kudos to IDSA for finally publishing them. Maybe next time we can get them a little bit sooner, though, right? That would be great. So what's new with these guidelines? Terms of formatting? I believe that there was kind of a formatting change that is pretty readily apparent when you start going through that document. Dr. Khyati Patel 01:29 Yeah, I think the grade format is a little bit different, the strong and B recommendation and the level of evidence, but now the summarization of the recommendation, and it's in those like 16 pico style questions. So like, I like those guidelines. When I look at that, it poses a question and then it answers the question and provides, like, the supporting, you know, evidence behind how they're answering this question. I love that. Dr. Sean Kane 01:51 So an example that might be, you know, should we use corticosteroids in patients with severe community-acquired pneumonia? So the PICO would be like the patient, intervention, comparison, and outcome. And you know, this is a pretty big change from some of the older guideline formats, where they just kind of gave a bunch of recommendations and then kind of explained each one later on. Speaker 1 02:12 I've noticed a trend that IDSA is moving more towards these grade formatted guidelines, and I do think it is much more user friendly. Dr. Sean Kane 02:19 Probably my favorite aspect of this guideline document is its length, or lack of length, really. So it's about 23 pages. And you know, if you even exclude the references, it's only 17 pages. You again contrast that to something like the Napp asthma guidelines that are like 400 plus pages. This is a very digestible document for the typical clinician that just wants to know what's new and what's recommended in the case of pneumonia, for example. To be clear, in this roughly 30 to 40 minute episode, we're only going to cover aspects of that 17 page document for the listeners. If you want to see the full 23 pages in action, we'll have a link at our show notes, HelixTalk.com this is episode 106 so why don't we go ahead and jump in with some of the bigger changes that really made it to the forefront of our radar, enough that we wanted to talk about them during the episode Dr. Khyati Patel 03:11 and before when we jump into those changes, maybe we should talk about some of the common definitions that the guidelines talking about, so we don't have to keep like mentioning that over and over again. But here we have severity of the community prior pneumonia defined, and it's nothing different than what the 2007 guidelines had defined the treatment. However, obviously it's a little bit different than non severe cap. Yeah, one Speaker 1 03:34 of the other biggest, biggest changes were the risk factors that were updated for MRSA and anti pseudomonal coverage with cap. So the guidelines no longer endorse the term h cap or healthcare associated pneumonia, and this was first introduced to us in the 2005 IDSA ATS guidelines for the treatment of hap and VAP. So this represents definitely a huge change with the removal of this term, Dr. Sean Kane 03:59 and kind of not a substitute, per se, but somewhat of a substitute to that H cap definition is now they these new guidelines recognize certain patients are at risk for MRSA and pseudomonas, and for those patients, again, you might pick alternative therapy. So what are some of the criteria that would put you in that camp? Speaker 1 04:18 So the guidelines specifically mentioned the use of locally validated risk factors, so having each institution look at the prevalence of both MRSA and Pseudomonas within the local epidemiology and figure out whether or not certain risk factors are more prevalent in their specific population. So at Northwestern Memorial Hospital, where I practice, we do have a published, locally validated risk factor assessment. So really, we have step one of our algorithm to look at expanded gram negative risk factors that may require patients to receive something like an anti pseudomonal Beta lactam instead. So our gram negative risk factors include patients that are immunosuppressed. So. With hematologic diseases, those receiving high doses of corticosteroids, or those patients that are neutropenic, any non ambulatory patient, so those in a wheelchair or chronically bedridden, would be considered as a risk factor, any patient receiving tube feeds or gastric acid suppression with a PPI or an h2 blocker, and then again, any patient receiving antibiotics within the previous 90 days, or hospitalized within the previous 90 days, would be a risk. So our algorithm states that if a patient has three or more of these risk factors, then we would put the patient on an anti pseudomonal agent, looking at our gram positive side, our locally validated MRSA specific risk factors include if the patient is on dialysis, so hemodialysis or peritoneal dialysis, those with prior MRSA colonization or infection, our patients with congestive heart failure and again, any hospitalization in the previous 90 days or use of antibiotics in the previous 90 days. And if patients have two or more of these risk factors, then we would consider adding something like vancomycin or linezolid for MRSA coverage. The guidelines did identify two major criteria that are pretty much across the board in all institutions: prior respiratory culture with MRSA or Pseudomonas, or recent hospitalization with IV antibiotic use within the previous 90 days. Dr. Khyati Patel 06:24 And you're also going to hear the word comorbidities, right? So how are these guidelines defining comorbidities? Is looking at any kind of chronic diseases on top of them, having pneumonia, so for example, heart failure or COPD or cirrhosis, kidney, pretty much anything, diabetes, cancer, you know, etc. Why do we worry about these comorbidities? Because these patients have poor outcomes, because they have other comorbidities, and plus they have other exposure to health care, and increases their exposure to or risk of getting these resistant bugs that Dr. Bartram just talked about. Dr. Sean Kane 06:59 So in terms of one of the recommendations they you know, most of the initial several recommendations deal with diagnostic testing for community acquired pneumonia. And we'll start off with the blood and sputum culture. And if you think about it, you know, in my neck of the woods, in these critically ill patients, they all essentially have severe cap based on the severe cap definition. So we get blood and sputum on almost everyone. So for me, that's just a given, right? But not everyone is severe cap, and not everyone is in the ICU with their pneumonia. So in terms of the spectrum of community acquired pneumonia, when are we getting these blood and sputum cultures? Dr. Khyati Patel 07:34 So on the outpatient basis, the guidelines recommend don't do either of them. Now on the inpatient setting, it depends on the patient you have in front of you, and so some of the examples of those would be Speaker 1 07:46 so any patient with severe community acquired pneumonia should obtain both a sputum and a blood culture. If you are empirically covering for MRSA or Pseudomonas. So those are resistant pathogens, you should obtain cultures if the patient does have a history of either of those, you should also be obtaining cultures. However, if the patient does not meet any of these criteria, the routine sputum and blood cultures are actually not recommended. Dr. Sean Kane 08:11 And I thought that was interesting, because even for someone who's not severe, but let's say they have enough comorbidities that, based on their curb 65 or pneumonia Severity Index score that you would admit them. It's so easy to get a blood culture, so I was a little bit surprised that you wouldn't get a blood culture on that more comorbid type patient that does have kind of run of the mill cap, but is just more deconditioned. Speaker 1 08:33 I think one of the major considerations here is that the rate of positive blood cultures is so low — it's only about 9% (a little higher with Strep pneumo). Overall the yield is low, and it does run the risk of false positives, such as a coagulase-negative staph, which can lead to additional unnecessary antibiotic therapy. Dr. Sean Kane 08:56 And I see that all of the time on the inpatient setting, where you get one out of two gram positive cocci that grow in a blood culture bottle, so you add on some vancomycin, then it takes three days for that to speciate as staph epi or something like that. Then you're treating the bug and now you've exposed them to a nephrotoxic agent. You've gotten drug levels. You've wasted everyone's time with pharmacokinetic, adjusting of the vancomycin dose. So that makes sense, right? If the yield is low enough, and there's potential harm in getting it, because you add other stuff in response to that result, maybe that's not an unreasonable thing to not to do, then, right? Dr. Khyati Patel 09:31 And it's obviously a good recommendation. Moving on from the sputum and blood culture, they also recommend, I'm testing for a urine antigen. That's something is new, not commonly, obviously done on the outpatient setting, but we want to know a little bit more about what that testing represents. Speaker 1 09:49 Yeah, so we typically do these for our inpatients. The guidelines did update their recommendation, saying that we should only be using these specific tests for patients that do have severe. Ear cap, or in the case of Legionella, those patients that may have been exposed in a potential Legionella outbreak area. So really, these tests are very specific, but they're not very sensitive. So what that means is that we can rule in something like Strep pneumo or Legionella if the test is positive; however, if the test is negative, we cannot necessarily rule that out, so it is helpful in that aspect. But again, this affects not as many of our patients, so that is why we don't recommend it across the board for everyone. Dr. Sean Kane 10:33 And again, on the ICU setting, where most of these patients will have severe cap, we do routinely get this. And one thing I like about it is that you can get that urine antigen even after antibiotics are given, because urine antigen is not impacted by receipt of antibiotics. Versus a culture, especially a blood culture, you can basically kill all the bacteria in that blood sample you've collected from the patient. Now nothing grows. But if the urine antigens are collectible, you know, if a patient can make urine, those are still going to be positive for days after you initiate antibiotic therapy. Dr. Khyati Patel 11:04 So moving on from the diagnostics, let's jump right into the recommendation of therapies, especially the community acquired outpatient based therapy. Dr. Sean Kane 11:14 So if I had pneumonia, what do the current guidelines say I should get? Assuming I am not severe, I'm going to stay at home, and I have no comorbidities, and I don't have any risk factors for MRSA or pseudomonas, what would be a typical regimen for me. Speaker 1 11:28 So the new guidelines actually prefer mono therapy with a beta lactam. Specifically, they mention amoxicillin or doxycycline. But really the best data here is with amoxicillin, we would use the high dose amoxicillin, so that would be one gram by mouth three times a day. Dr. Khyati Patel 11:43 And that's very different, because amoxicillin was never in the picture. It was always either use Doxy or use a macrolide to cover for the atypicals. Dr. Sean Kane 11:53 So how about that macrolide? Where did the macrolide go in these new guidelines? And typically, when we're talking about macrolides, we're thinking azithromycin, although chlorythromycin is also an option as well, Dr. Khyati Patel 12:03 so it's one of the alternative recommendation now, and it's not one of the preferred ones, as Dr. Bertram talked about. So really, we know why that's the case, because it's related to the increased resistance. And the guidelines even go out on a limb and say, if you only use it, if your geographic resistant rate is less than 25% so otherwise, you almost always assume that it's increased. And I think you look at the local antibiogram as well as look at the local resistant patterns, and I know you have an example to add over here. Dr. Bertram, yeah, so Speaker 1 12:36 there was a study back in 2014 unfortunately, we don't have much more updated data than this, but it looked at the distribution of macrolide resistance rates for strep pneumo across the United States. And really it found that across the entire US, there was very high rates of macrolide resistance, greater than that 30% cut off that the guidelines recommend, specifically here in the Midwest, macrolide resistance was about 44.6% and high level macrolide resistance was as high as 33.9% so it does not seem that macrolides would be an effective therapy here, at least in the United States. Dr. Sean Kane 13:12 So what we're saying is that that Z pack, which is so easy to prescribe and give and even to take as a patient, probably is not the best option for most patients given this increasing resistance problem, at least in the US and definitely in the Midwest, right? Dr. Khyati Patel 13:27 So those were the patients without any comorbidities or any risk for resistant organisms — but what about patients with comorbidities (cirrhosis, diabetes, heart failure)? What are the recommendations there? Speaker 1 13:41 So the recommendations are very similar to the previous guidelines. They recommend a beta-lactam with beta-lactamase protection — for example, amoxicillin/clavulanate (Augmentin) or a cephalosporin. Cefpodoxime and cefuroxime are the ones specifically mentioned. With this beta-lactam you should use it in combination with a macrolide or doxycycline. The second option is a respiratory fluoroquinolone. So again, this respiratory means that it has strep pneumonia coverage. So our two major ones that we think of are levofloxacin and moxifloxacin. Gemifloxacin also covers strep pneumo however, it has been on shortage and isn't readily available in the United States anymore. So really, our beta lactam plus macrolide or Doxy or our respiratory fluoroquinolone remain our top choices. So I Dr. Sean Kane 14:38 was a little bit surprised that in these non severe outpatient but comorbid patients that they would still add the macrolide or the doxycycline for atypical coverage. Typically, when you have an atypical bug like Legionella, you're sick enough that you warrant hospitalization, and for those patients, we would add atypical coverage. The guidelines do address this. They say they. At the evidence they didn't feel it was strong enough and consistent enough that they would withhold a typical coverage. So we still do have that, although I would say that you may encounter some practitioners that don't feel the need to do that, the guidelines do recommend it, though, Dr. Khyati Patel 15:14 yeah, and none of these option one or option two that we discussed have any coverage for the MRSA or the pseudomonas, because again, the risk factors for these patients are not addressed. And again, if they have risk factors for MRSA and PSA, they're sick enough to be treated in the hospital and not on the outpatient basis, exactly. Speaker 1 15:33 So really, it's only our fluoroquinolones there that do cover Pseudomonas. But again, like you mentioned, these patients will be typically sick enough to require inpatient therapy. So I Dr. Sean Kane 15:42 want to go a little bit deeper on some of these specific agents, because I think it's important that we don't just think about the regimen, but kind of the why behind it and some of the nuances of it. So, Dr. Bertram, you already mentioned that amoxicillin dose of one gram tid, that's a big dose. What is a typical like strep throat kind of dose? And why are we giving these bigger doses? Speaker 1 16:02 Yeah, so typically you'll see much smaller doses of anywhere from 250 to 500 milligrams, usually only twice a day. So the rationale behind using this higher dose is really to overcome any resistance to strep pneumo if it's present. Amoxicillin is a very well tolerated antibiotic, usually with less side effects in some of our other agents. So even though we're using this high dose, patients typically tolerate it well. Dr. Sean Kane 16:26 And then another thing to think about is that penicillin allergic patient, statistically, in the US, about 10% of patients will claim that they have a penicillin allergy. I am one of them, but unfortunately, most of us are liars. So Dr. Bertram, how often in a penicillin allergic patient, if you skin test them, are they actually truly allergic to penicillin? Yeah. Speaker 1 16:45 So this comes up all the time, and we actually started at my institution graded challenges to try and help de label these patients with penicillin allergies. However, it is reported that about 10% of the population has a penicillin allergy, but when these patients are actually skin tested or perform the graded challenge, in reality, only 90 to 95% are not allergic, so only about 5% are truly penicillin allergic. Dr. Sean Kane 17:11 So this is actually a fairly rare circumstance that people are truly penicillin allergic, although on the outpatient side, especially if you think about it, you're not going to skin test that patient to not give them amoxicillin, you're just going to give them doxycycline and be done with it. Right, right, right. Well, let's talk about doxycycline. So what is typical dosing for that? And are there any nuances to that choice in terms of community-acquired pneumonia? Dr. Khyati Patel 17:33 So it's an easy peasy 100 milligrams, you know, two times a day, so not a whopping dose like amoxicillin, it is. So it's regardless of the indication, the way the renal function. But again, amoxicillin is kind of like the preferred over doxycycline. Dr. Sean Kane 17:46 And this is based on data, right? Yeah — there is more in vitro data supporting doxycycline, while we have really good in vivo data for amoxicillin for community-acquired pneumonia. That is correct. How about that macrolide? So we already talked about how macrolide resistance is high in the U.S., which makes macrolides a less-preferred monotherapy for community-acquired pneumonia. What are some of the regimens that you might see in terms of macrolide for CAP? Speaker 1 18:14 So typically, we'll do our standard z pack dosing, especially in the outpatient setting. So that's just a five day course. The patient receives 500 milligrams on that first day, and then 250 milligrams every day after, for a total of four additional days on the inpatient side, we'll typically go with the higher intravenous dosing of 500 milligrams daily. Dr. Sean Kane 18:33 So I'm going to just get up on my stump for a second and say, I don't understand why clarithromycin is even a thing anymore. Dr. Bertram, I know you've talked about some of the potential beneficial effects of azithromycin (an immunomodulatory effect). Clarithromycin doesn't have that same data and has more drug interactions and side effects (metallic taste); dosing is usually BID and the duration is typically longer. So why is clarithromycin still a thing? Speaker 1 19:12 That is a great question. Honestly, in clinical practice, we don't use it very often. The biggest indication that I see it still used is that h pylori infection. But other than that, we have never used it for pneumonia, as far as I'm aware, Dr. Khyati Patel 19:25 and probably we should keep it that way. Dr. Sean Kane 19:29 So I know you mentioned, for those more comorbid patients that we're wanting to have beta-lactamase coverage, we might consider Augmentin (amoxicillin-clavulanate). What is that clavulanate doing — both good and bad? Speaker 1 19:41 So the clavulanate component really protects against beta-lactamase — which is common with H. influenzae and Moraxella catarrhalis. However, the clavulanate may also predispose to more adverse effects, specifically diarrhea, so that's something to counsel patients about. Dr. Khyati Patel 20:00 And then we also have, for the same patient population, cephalosporins — the two mentioned in the guidelines (both given twice daily) are cefpodoxime (3rd gen) and cefuroxime (2nd gen). Dr. Sean Kane 20:16 And you know, you might select these in that penicillin allergic patient that did not have a severe reaction. So when I was in college, I had strep throat and I had a penicillin allergy. Whether it was true or not true, I don't know, but I was perfectly fine having a cephalosporin because it was free at the local drugstore pharmacy, and I was a poor college student, and I was willing to take that risk. And generally, especially given the data we have about true penicillin allergies and the data about cross reactivity, this is a pretty safe bet, unless the patient had a very severe allergic reaction to penicillin in the past. Dr. Khyati Patel 20:49 And last but not least, we have the respiratory fluoroquinolones. "Respiratory" refers to Streptococcus pneumoniae coverage — the two are levofloxacin or moxifloxacin. The FDA labeling includes several rare but serious warnings (aortic dissection/rupture, tendonitis/tendon rupture, QTc prolongation, peripheral neuropathy, CNS effects, etc.). Speaker 1 21:20 So definitely a lot of precautions that we need to take into consideration before using these fluoroquinolones agents. However, they do have quite a bit of data supporting their efficacy for community acquired pneumonia, so that's really why we still see them recommended as first line in these guidelines. But from a stewardship perspective, if we can, we'll prefer to switch our patients to the beta lactam macrolide regimen and avoid those fluoroquinolones, if at all possible. And I did Dr. Sean Kane 21:45 think it was interesting, the guidelines made a specific comment saying we recognize the laundry list of potential rare but serious side effects. But to your point, Dr. Bertram, they said we've got really good efficacy data for these agents, and those side effects are really rare, and at least, in my opinion, a lot of those are probably at least contributed by improper dosing, especially for renal dysfunction. So you have this little old lady that you're giving 750 of Levaquin every single day to that has a clearance of 20. She's going to have a higher predisposition to getting some of these side effects, especially the cognitive and neuro type side effects. So I get it both sides. I understand why we should be avoiding them, and I understand why they're still in the guidelines. Dr. Khyati Patel 22:29 So moving on from your outpatient treatment, let's talk about when those patients kind of present on the inpatient side. How do we treat the community acquired pneumonia? So this, again, kind of divides itself into non severe and severe. And so what are some of the treatment options for the non severe cap? Speaker 1 22:46 So our non severe cap looks pretty much identical to our outpatients with comorbidities. So again, we have two different options. Option one would be a beta lactam, but in this situation, they recommend a macrolide. We don't have that either or of the macrolide or edoxie. It's macrolide. And then option two is our respiratory fluoroquinolones, like we discussed, Dr. Sean Kane 23:08 In terms of that beta-lactam/macrolide combo, the typical regimen you'll see is ceftriaxone (Rocephin) — an IV third-generation cephalosporin — combined with azithromycin. The guidelines also reference other parenteral agents including Unasyn (ampicillin-sulbactam), cefotaxime (a third-generation cephalosporin), and ceftaroline (a fifth-generation cephalosporin). Speaker 1 23:50 Yeah — ceftriaxone is probably the most common we see in practice (once daily, no renal adjustment). Some institutions use Unasyn (ampicillin-sulbactam), but it is dosed more frequently. Cefotaxime was recommended but has been on shortage. Ceftaroline has expanded coverage (including MRSA) and may provide unnecessary additional coverage in many CAP cases. Dr. Sean Kane 24:25 So you mentioned that we don't have macrolide or Doxy for our atypical coverage. Is there a scenario where you might pick Doxy for these patients? Speaker 1 24:33 So it is less preferred, but if a patient does have an allergy to a macrolide or if they have severe QTc prolongation, we could substitute doxycycline for atypical coverage. Dr. Sean Kane 24:45 So then moving on to that more severe community acquire pneumonia patient who's in the hospital. We basically have really similar therapy here. So option one is that beta lactam macrolide basically identical to what we had for non severe cap. And then option two, and I'm actually a little bit surprised about this. One is beta lactam plus respiratory fluoroquinolone. So you're getting your atypical coverage with that respiratory fluoroquinolone, and you're actually kind of getting, if you will, double strep pneumo coverage between your respiratory fluoroquinolone and your beta lactam. So any thoughts on that? Dr. Bertram, Speaker 1 25:14 so this is not something that we see very commonly. Typically, we'll see the beta lactam plus the macrolide route. But there have been some studies comparing the two, looking at beta lactam plus macrolide versus beta lactam plus respiratory fluoroquinolone, and they have shown equal results as far as mortality goes. So I think that's really why either is still recommended as first line. Dr. Khyati Patel 25:36 So those are our patients without any high risk organisms, right? So let's bring it to the patients who have either the MRSA or Pseudomonas. How do we provide that coverage so they have a history of MRSA? We kind of talked about it earlier — adding vancomycin would be helpful, or even linezolid (Zyvox). But the recommendation is, whenever possible, we should be thinking about de‑escalation, especially looking at those sputum cultures as well as the blood cultures when they come up. Speaker 1 26:06 And another potential de escalation opportunity, in particular for MRSA, is obtaining what's called a MRSA nasal PCR. So really what this is, is just a swab of the patient's nasal passages, and this has been shown to have a very, very high negative predictive value. So if this test comes back negative, we can effectively rule out MRSA pneumonia and discontinue MRSA therapy for our patient. Dr. Sean Kane 26:32 So what about that patient with a history of Pseudomonas or deserving of pseudomonal coverage? What are we doing different for these patients? Speaker 1 26:39 So we'll change our beta-lactam to one that covers Pseudomonas — for example, piperacillin-tazobactam, cefepime, or ceftazidime — or use a carbapenem (meropenem, imipenem). For those with a severe beta‑lactam allergy, we can use aztreonam; note aztreonam covers gram-negatives only, so add vancomycin or linezolid for gram-positive coverage. Dr. Sean Kane 27:06 So these are patients that typically had a history of Pseudomonas or MRSA and were empirically initiating therapy for those patients. What about the patient who has just been in the hospital within the last 90 days that had IV antibiotics within the last 90 days, are we empirically giving these patients, there's anti MRSA, antiseminal coverage, or are we doing something different for them? Speaker 1 27:28 That's a great question. So the guidelines do address this, and they state that if the patient does not have severe cap, we do not need to empirically cover for these more resistant organisms. If the patient does have severe cap and is in our ICU, then we do need to empirically provide MRSA and Pseudomonas coverage, and then we will de escalate once we have our cultures back. Dr. Sean Kane 27:47 And I would say that for me, this is one of the bigger changes, moving away from that H cap diagnosis. You know, very frequently I would see patients that did not meet the criteria for severe cap, that their hemodialysis patient, or, you know, they've been in the hospital a couple times, and they empirically get vancomycin and Zosyn, regardless of their severity. I think that this is a big stewardship opportunity to not give them this incredibly broad spectrum agent that then they get C diff and then they get these other complications. So I think that this is probably a big win in terms of reserving these broader spectrum agents to really the patients that truly need them because of severity or because of true history of these organisms being present in Unknown Speaker 28:28 the past, definitely, I completely agree. Dr. Sean Kane 28:31 So those are some of the highlights, our highlights, if you will, from these guidelines. What are some other things that really stood out to you guys in terms of things in these 2019, CAP Guidelines. Dr. Khyati Patel 28:41 Let's talk about duration of these agents, right? So that's important. We kind of talked about some of the other agents, you know, five to seven days, but minimum treatment duration is still five days. So no change there. Obviously you're going to look at your patient in front of you. If they're not clinically feeling better or resolving, then you could treat it for longer. But minimum is five days. Speaker 1 29:02 One other point that I'm glad that they touched on is our coverage of aspiration pneumonia, because this comes up all the time in clinical practice, especially in the inpatient setting, where we have our patients that are elderly or have some type of neurologic condition, where they aspirate pretty frequently, and our providers are asking us, do we need extra anaerobic coverage? And really what the guidelines state is that you do not need additional anaerobic coverage unless the patient is presenting with a more severe infection, such as a lung abscess or an empyema. And the reason for this is that previous studies back in the day from the 70s and 80s really showed that anaerobes were a very prevalent pathogen in aspiration pneumonia. However, more recent studies have shown that that's really not the case, and just our usual CAP bugs (typical CAP pathogens) are likely culprits. Dr. Sean Kane 29:48 And I love this recommendation because we see tons of aspiration pneumonia in the hospital in general, but also it's a really good example of this is a practice that had been done despite really not having great data, even. Of those older articles, these were fairly small studies, and there were issues in how the studies were conducted, but we propagated this practice of, well, aspiration pneumonia, you need anaerobic coverage, because that's how it had always been done, and that's a great example of where evidence based medicine fits into clinical practices. That's not enough anymore to say, well, we always do it that way, having data and now guidelines that use that data to support a practice change is a big deal. This is going to be a big practice change in the hospital setting, for Speaker 1 30:30 sure, definitely. And it's a big win from a stewardship perspective as well, because something like clindamycin definitely increases a patient's risk for C. difficile infection. So if we don't need to use it and can avoid it, that benefits our patients. Dr. Sean Kane 30:44 mentioned this. Another big take home point for me was the death of H cap. So H cap is no longer a thing, and we do have kind of this substitute in terms of IV antibiotics within the past 90 days, plus hospitalization within the last 90 days. But even in those patients, we're only empirically covering for Pseudomonas and MRSA, if they're severe or they've had a history of those bugs in the past, again, big win in terms of stewardship with that. Dr. Khyati Patel 31:08 Another thing the guidelines are mentioning is, if they have influenza and pneumonia, you shouldn't think that it's a viral pneumonia. You should still treat this as a bacterial pneumonia, because secondary bacterial infections are very common in those who have influenza, along with Speaker 1 31:23 another point that the guidelines bring up is that they do not recommend the use of corticosteroids for the treatment of cap and there is some conflicting randomized control study data and some meta analyzes that do suggest potentially a mortality benefit, but this data has not been proven in other studies, and the guidelines really didn't feel that this data was robust enough. So unless our patient is in septic shock and requires steroids for other reasons, if the patient is just presenting with a cap, steroids are no longer recommended. So one other point that the guidelines brought up was their recommendation to use the psi or pneumonia Severity Index score instead of the curb 65 score in order to determine whether or not a patient should be admitted to the hospital. So if you recall, the psi score is a very long scoring tool with 19 different criteria versus the curb 65 which just is five different criteria that patients need to meet. But these are attempting to stratify patients based on their mortality determine whether or not they need to be admitted to the hospital. So this recommendation to now use psi may pose a problem for some of our providers, especially those in the outpatient setting that are trying to quickly make a decision don't may not necessarily have time to go through a 19 scoring criteria in order to determine whether or not to admit our patient. Dr. Sean Kane 32:43 Dr. Bertram, I know another thing that kind of caught your eye was the use of procalcitonin in terms of this laboratory diagnostic test that is typically an indicator bacterial infection of some kind, mostly with pneumonia. So hopefully they had something to say about that Speaker 1 32:58 As well. Yeah — the guidelines do bring up procalcitonin (they did not mention it in prior guidelines). They state it should not be used alone to determine initiation of antibiotics. However, you could consider getting repeat levels once the patient has been started on antibiotic therapy to potentially discontinue therapy sooner or de‑escalate therapy if the patient's procalcitonin is decreasing. Dr. Sean Kane 33:25 So what you're saying is that if it smells like pneumonia, walks like pneumonia — no matter what that procalcitonin says — you should give them antibiotics and then kind of figure it out a day or two later based on a trended procalcitonin. Speaker 1 33:36 exactly if the patient has radiographic evidence of a pneumonia, they're having all the symptoms of pneumonia, give them those antibiotics right away. Don't base it on just one single lab value. So I Dr. Sean Kane 33:46 did want to bring up one thing that I felt was almost missing from the guidelines, and that's the treatment of Legionella. And I know that these aren't Legionella guidelines, but I would have liked to have a mention of preferred therapies for Legionella. So if Legionella test is positive. Typically, we're looking at fluoroquinolone or macrolide, and that's basically a standard of care at this point. Sometimes doxycycline will be used if those first two agents aren't able to be given to a patient because of allergies or side effects, things like that. Most of that, again, with doxycycline, is more in vitro data as opposed to in vivo data. However, I would have liked them to comment in terms of, hey, we like both. We like one or the other. We like combo therapy. Some comment would have been nice in these guidelines, because I think that I see enough of that that I would like to have guidelines supporting a specific approach to those patients. Dr. Khyati Patel 34:33 Well, guess what? You're just gonna have to wait, what, 12 more years to get an update. Speaker 1 34:39 Something else that I think we may see in future guidelines is the role of rapid diagnostic testing, in particular these new multiplex PCR respiratory panels that are coming out that have multiple different targets for both viral and bacterial pathogens. So I think that this could potentially in the future, help us distinguish whether or not the patient has a viral versus a bacterial pneumonia, and. Alter therapy accordingly. Dr. Sean Kane 35:02 And I think that that's really exciting, because, you know, when we think of pneumonia, we always jump to bacterial pneumonia because we have drugs that treat that, and we think somewhat about influenza, because we have a drug that kind of sort of treats that. But lots of community acquire pneumonia is caused by viruses, and newer data is really supporting that. And I'm not saying that would necessarily do anything different, but it would be nice to kind of prove that in more patients, and have that data earlier on in terms of why the patient may not be improving. Maybe they don't have bacterial pneumonia, right? Speaker 1 35:32 Yeah — something else we may see is where newer agents fit into therapy (e.g., omadacycline and lefamulin, both recently FDA‑approved for community‑acquired pneumonia). We don't really know where they fit yet. Dr. Sean Kane 35:50 So to kind of wrap things up, in terms of some key concepts from these 2019 CAP Guidelines, one key concept is that in patients with community acquired pneumonia, respiratory and blood cultures should only be collected if you're in the hospital with severe community acquired pneumonia. And again, severe cap is a specific thing. You have to meet certain criteria to have severe community acquired pneumonia. We would also obtain respiratory and blood cultures in those that we're covering for MRSA or Pseudomonas because of risk factors that these patients have, mostly to de escalate. If their respiratory panel comes back not having these agents, we can get rid of that broader spectrum coverage. Dr. Khyati Patel 36:29 The preferred outpatient cap therapy in patients who don't have comorbidities is either amoxicillin or doxycycline. And those patients who have comorbidities, you're going to go with either beta lactam plus atypical coverage, or a respiratory fluoroquinolones. Speaker 1 36:45 Our third key point is that hospitalized CAP patients should have MRSA and Pseudomonas coverage only if it's warranted. So again, those situations would be if locally validated risk factors indicate that, or if the patient has a history of respiratory cultures that are growing one of these organisms, or if they were hospitalized within the previous 90 days and received IV antibiotic therapy. And again, we don't have to cover all of our patients, just those specific patients with anti MRSA and anti pseudomonal coverage, and then we can get cultures and de escalate as able. Our last key point is that patients with aspiration pneumonia do not need anaerobic coverage unless a lung abscess or empyema suspected. So our traditional cap therapy should more than cover what is needed. So I Dr. Sean Kane 37:30 think that wraps up episode 106 quite nicely. If you'd like to see a link to the 2019 CAP Guidelines, we have it at our website, HelixTalk.com click on episode 106 we are also on Twitter at HelixTalk. You can see old clinical pearls from basically the last year's worth of HelixTalk episodes. So you can follow us on twitter if you'd like to see those. And then finally, for the holidays, we would ask that you consider a five star review in iTunes for HelixTalk. It helps us kind of climb the iTunes rankings, so that other healthcare providers are more likely to see our content and benefit in terms of improving patient care through our episodes on things like community acquired pneumonia. So with that, I'm Dr. Kane, Dr. Khyati Patel 38:10 I'm Dr. Patel, and today we had Dr. Bertram with us. Thank you so much for joining us. Speaker 2 38:15 Yes, thank you so much for having me. And with that, we'll say, party hard. Enjoy the holidays. Narrator - Dr. Abel 38:21 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 38:32 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.