Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the diagnosis of community acquired pneumonia
2. Describe the recommended treatment options for community acquired pneumonia

Estimated time to complete activity: 0.5 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from through , participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.5 contact hours.

Designated for 0.2 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Community-acquired pneumonia (CAP), by definition, is pneumonia acquired outside a hospital. A joint guideline (2019) from the American Thoracic Society/IDSA addresses diagnosis, management and follow-up. The focus of this document is on non-immunocompromised individuals (e.g., those without inherited or acquired immune deficiency or drug-induced neutropenia, those actively receiving cancer chemotherapy, HIV with suppressed CD4 counts or transplant recipients).

Diagnosis (CDC)

• History
  • Abrupt onset of fever, chills or rigors
    • Typically, a single rigor and repeated shaking chills are not commonly seen
    • Older individuals may not mount a fever
  • Pleuritic chest pain
  • Cough productive of mucopurulent, rusty sputum
• Clinical exam
  • Dyspnea
  • Tachypnea or tachycardia
  • Hypoxia
  • Malaise or weakness
  • Nausea, vomiting and headache may occur, but is less common
  • Auscultation
    • Crackles
    • Dullness to percussion, egophony (voiced sounds more audible than usual) may signal consolidation
• Lab
  • Elevated WBC
• Imaging
  • Guideline recommends radiographic confirmation with plain chest film (evidence of infiltrate) due to inaccuracy of clinical findings  

Decision to Treat as Outpatient vs Inpatient

• In addition to clinical judgment, the Pneumonia Severity Index (PSI) can be used to determine treatment setting (see ‘learn more’ for calculators)
  • PSI is considered superior to CURB-65 based on RCTs although CURB-65 has the benefit of simplicity and ease of use  
  • The score predicts probability of mortality  
• PSI is a points-based system that uses the following features
  • Age | Comorbidities | Abnormal physical findings (e.g., respiratory rate of ≥30 or a temperature of ≥40 degrees C) | Abnormal labs (e.g., pH <7.35, a BUN ≥30 mg per dL (11 mmol per liter) or a sodium concentration <130 mmol per liter

Tests at Time of Diagnosis if Managed in the Outpatient Setting

• Gram stain and culture of lower respiratory secretions: Not recommended
• Blood cultures: Not recommended
• Legionella and Pneumococcal Urinary Antigen Testing: Not recommended (unless epidemiologic reasons, i.e., recent outbreak)
• Influenza: Recommended during periods of high influenza activity | Consider during periods of low influenza activity  
  • Use rapid influenza molecular assay (i.e., influenza nucleic acid amplification test) vs rapid influenza diagnostic test (i.e., antigen test)
  • Patient tests positive: Treat with anti-influenza medication (e.g., oseltamivir) independent of length of time of illness before diagnosis
  • Treat with standard antibacterial treatment (see below) for patients with clinical and radiographic evidence of CAP
•   Serum Procalcitonin: Should not be used to determine whether to withhold antibiotics
  • Some studies have indicated that serum procalcitonin could discriminate between viral and bacterial infection (biomarker levels higher in bacterial disease)
  • No clinical threshold has been established, with sensitivities ranging from 38% to 91%

Note: The American Thoracic Society has published guidelines regarding nucleic acid-based testing for viral pathogens in the setting of CAP

• Outpatients with suspected CAP
  • Recommendation against testing for respiratory samples for viral pathogen other than influenza (conditional recommendation, very-low-quality evidence)
• Hospitalized patients with suspected CAP
  • Recommendation against routine testing other for influenza unless severe CAP or immunocompromised (conditional recommendation, very-low-quality evidence)

SYNOPSIS:

Approximately 400,000 hospitalizations from pneumococcal pneumonia occur annually in the US. Pneumococci are responsible for up to 30% of adult CAP, with an incubation period of approximately 1 to 3 days. According the CDC, “the case-fatality rate is 5–7% and may be much higher among elderly persons.” Other bacterial pathogens include Haemophilus influenzae, Mycoplasma pneumoniae, Staphylococcus aureus, Legionella species, Chlamydia pneumoniae, and Moraxella catarrhalis. According the guideline, “The newer multidrug-resistant pathogens, including methicillin-resistant S. aureus (MRSA) and Pseudomonas aeruginosa requires separate treatment options.”

KEY POINTS:

Treatment

No comorbidities or Risk Factors for MRSA or Pseudomonas aeruginosa

• Amoxicillin 1 g three times daily (strong recommendation) or
• Doxycycline 100 mg twice daily (conditional recommendation) or
• Macrolide (conditional recommendations and only in areas with pneumococcal resistance to macrolides <25%): Azithromycin 500 mg on first day then 250 mg daily or clarithromycin 500 mg twice daily or clarithromycin extended release 1,000 mg daily

Outpatient with Comorbidities (can be ‘combination therapy’ or ‘monotherapy’ with no order of preference)

Combination Therapy (Amoxicillin/clavulanate or cephalosporin combined with a macrolide or doxycycline)

• Amoxicillin/clavulanate 500 mg/125 mg three times daily or amoxicillin/clavulanate 875 mg/125 mg twice daily or 2,000 mg/125 mg twice daily or
• Cephalosporin: Cefpodoxime 200 mg twice daily or cefuroxime 500 mg twice daily

Plus

• A macrolide: Azithromycin 500 mg on first day then 250 mg daily or clarithromycin 500 mg twice daily or extended release 1,000 mg once daily or
• Doxycycline 100 mg twice daily

Monotherapy

• Respiratory fluoroquinolone: Levofloxacin 750 mg daily or
• moxifloxacin 400 mg daily or
• Gemifloxacin 320 mg daily

Note: Comorbidities include: Chronic heart | Lung, liver, or renal disease | Diabetes mellitus | Alcoholism | Malignancy | Asplenia

Duration of Antibiotic Treatment and Follow-Up

• Antibiotic treatment in patients who are improving “should be continued until the patient achieves stability and for no less than a total of 5 days (strong recommendation, moderate quality of evidence)”
• Evidence of clinical stability includes
  • Resolution and stabilization of vital signs
  • Ability to eat
  • Normal mentation
• Need for follow-up chest film
  • In patients who recover within 5 to 7 days, the guideline suggests that routine CXR follow up is not required
  • Based on the literature, patients with lung cancer would have been candidates for routine screening and were generally current or ex-smokers

Learn More – Primary Sources:

Guideline: The American Thoracic Society and Infectious Diseases Society of America provide recommendations for the diagnosis and treatment of adults with community-acquired pneumonia.

American Thoracic Society: Nucleic Acid–based Testing for Noninfluenza Viral Pathogens in Adults
with Suspected Community-acquired Pneumonia

Outpatient vs. Inpatient Treatment of Community-Acquired Pneumonia: PSI and CURB-65 Scoring Models

QXMD PSI Calculator

CDC: Pneumococcal Disease

Related ObG Topics:

CDC Guidelines on the Prevention and Control of Influenza in Pregnancy

CDC Adult Vaccination Schedule

How to Tell the Difference Between the Flu and a Cold?

New 2019 / 2020 CDC Flu Vaccine Guidance: Updated Recommendations