Join ASHP for a discussion concerning the updates from the 2019 IDSA/ATS Community Acquired Pneumonia Guidelines published in October of 2019. These guidelines are an update to the previous 2007 guidelines with new information on outpatient and inpatient management, as well as topics the previous guidelines did not address, such as aspiration pneumonia and the use of corticosteroids.
Kadyn McLean, PharmD is a PGY-1 Pharmacy Practice Resident at DCH Regional Medical Center in Tuscaloosa, AL. She received her Doctor of Pharmacy degree from Harding University College of Pharmacy in Searcy, AR in May 2019. While in school, she served as Vice President of her local SSHP chapter and was also an active member of APhA-ASP and the Rho Chi Society. She is currently an active member of ASHP and ACCP. Her current areas of interest include infectious disease, cardiology, and ambulatory care.
Katelin M. Lisenby, Pharm.D., BCPS is an Assistant Clinical Professor with the Department of Pharmacy Practice at Auburn University Harrison School of Pharmacy and an adjunct Assistant Clinical Professor with the University of Alabama College of Community Health Sciences Department of Family, Internal, and Rural Medicine.
Dr. Lisenby earned her Doctor of Pharmacy degree from Auburn University Harrison School of Pharmacy in 2013. She then went on to complete an ASHP Accredited residency in Pharmacy Practice at DCH Regional Medical Center in 2014. Following this completion, she joined the Auburn faculty beginning in the fall of 2014.
Dr. Lisenby's clinical practice is in ambulatory care at The Good Samaritan Clinic, which is a free primary care clinic in rural West Alabama that provides care to the uninsured in the seven surrounding counties. She collaborates with physicians and Family Medicine medical residents using an interdisciplinary shared visit model for patient encounters. Her areas of interest are in educational and interdisciplinary research and rural ambulatory care, which specifically include various cardiovascular diseases, diabetes, women’s health, and medication affordability. She is an active member of the American Society of Health-System Pharmacists (ASHP), Alabama Society of Health-System Pharmacists (ALSHP), American Association of Colleges of Pharmacy (AACP) and Society of Teachers of Family Medicine (STFM).
TIME-STAMPED SHOW NOTES
In today’s episode of ASHPOfficial, host Katelin Lisenby interviews Kadyn McLean, a PGY1 pharmacy practice resident at DCH Regional Medical Center in Tuscaloosa, Alabama. The two discuss the updates from the new 2019 IDSA/ATS Community Acquired Pneumonia Guidelines, published in October 2019. These guidelines update the 2007 guidelines on hospitalization, intensive care unit determination, inpatient and outpatient management, and HCAP, as well as addressing the new topics of aspiration pneumonia and corticosteroids.
(0:50) The two women begin the conversation by discussing how to determine whether or not patients should be hospitalized under the new guidelines. Previously, IDSA/ATS recommended using an objective scoring system paired with clinical judgement to determine if patients need to be hospitalized or just treated outpatient. The 2007 guidelines recommended using the CURB-65 criteria and the PSI (Pneumonia Severity Index) equally. However, the new guidelines recommend using PSI over the other because it increases the number of patients that they can safely treat in outpatient care. Kadyn explains that sometimes, however, the PSI is not as helpful because it can underestimate illness severity in younger patients. The reason for this is that a big part of the PSI score is a patient’s age. This is why they gave CURB-65 a conditional recommendation. Kadyn also dives into the topic of when patients should be admitted to an intensive care unit and how that need is assessed. CURB-65 and the PSI are useful in determining hospitalization needs, but not for determining if a patient needs more intensive care. Similarly to previous guidelines, the 2019 guidelines state that patients should be directly admitted to the ICU if they have hypotension requiring vasopressors or respiratory failure requiring mechanical ventilation. For the patients that don't meet these criteria, they suggest using the validated IDSA/ATS severity criteria, which are a long list of lab values, vital signs and physical exam findings that were published in the 2007 guidelines. The previous guidelines stated that if a patient met three or more of the minor criteria, then the guidelines recommend direct admission to the ICU. These new guidelines have made that a conditional recommendation and they recommend using it along with clinical judgment.
(3:57) Next, Kadyn discusses the new recommendations for outpatient management. The biggest change had to do with otherwise healthy patients without comorbidities. Macrolide monotherapy is no longer a strong recommendation because of increased resistance with strep pneumo, which is now widespread across the US. Now they are recommending using high dose amoxicillin monotherapy. This is a strong recommendation and requires a dosage of one gram three times a day. Another alternative treatment is doxycycline, but amoxicillin monotherapy is more strongly recommended. Macrolide monotherapy is acceptable only if local pneumococcal resistance rates are less than 25%, which Kadyn says is uncommon. Moving to inpatient management changes, Kadyn explains that therapy is now based on whether or not the pneumonia is considered severe or non-severe instead of using the terms ICU vs non-ICU. The new guidelines recommend using the validated IDSA/ATS severity criteria, and they base their recommendations on whether or not it’s severe. Another change is that there is now stronger evidence in favor of the beta-lactam plus macrolide combination over the beta-lactam plus fluoroquinolone combination when it comes to treating more severe cases of pneumonia. Both combinations are still recommended, but the 2019 guidelines present stronger evidence for beta-lactam plus macrolide.
(7:23) Previous guidelines referred to Healthcare Associated Pneumonia or HCAP, and in the 2019 guidelines, they said that this category is officially abandoned. Studies have shown that the factors used to define HCAP, like residents in a nursing home, chronic dialysis, home infusion, and wound care, don’t predict a high prevalence of antibiotic resistant pathogens in most settings. They’ve seen an increased use of broad-spectrum antibiotics without really an improvement in patient outcomes, so HCAP is no longer a category. Next, Kadyn explains how to know when to cover for MRSA, Pseudomonas, or other MDR pathogens. They now recommend they be based on locally validated risk factors, not any validated scoring systems to identify patients with these pathogens, and also suggest getting local data on MRSA and Pseudomonas prevalence and what their risk factors are at your local institution. Kadyn says that this is a process that involves documenting patients that do have those one of those two organisms and comparing that number with the total number of patients with CAP. She says that they do have a nasal screen for MRSA and that you should utilize that along with getting cultures. It has an excellent negative predictive value that you can trust, but, unfortunately, the positive predictive value is not as high.
(11:24) Kadyn goes over the instances in which cultures should be drawn. In the new guidelines they’re recommending getting blood and sputum cultures only in patients with severe CAP, patients that are being empirically treated for MRSA or Pseudomonas, or patients that have risk factors such as being previously infected or recently hospitalized and receiving IV antibiotics. The 2019 guidelines added the recommendations concerning MRSA and Pseudomonas for stewardship purposes and to aid clinicians in determining local risk factors and prevalence. Kadyn explains that you don’t want to get cultures from everybody, because the overall yield of blood cultures in pneumonia is very low, especially in non-severe patients, so they’re not helpful most of the time. As far as sputum cultures, it can be hard for patients to produce a good sputum culture. For this reason, you shouldn’t make every patient do that either. However, the guidelines do say that patients with severe CAP, if they're intubated, should have a lower respiratory tract sample sent for culture quickly after intubation. Those metrics are more likely to have an MDR pathogen and those lower respiratory endotracheal aspirates typically have a better yield than general sputum cultures.
(13:12) The 2019 guidelines also address two topics not previously addressed in the 2007 guidelines: aspiration pneumonia and the use of corticosteroids. They suggest not routinely adding anaerobic coverage for a suspected aspiration pneumonia unless a lung abscess for empyema is suspected. They also mention that the need for anaerobic coverage in CAP is genuinely overestimated. Kadyn shares that the new recommendation comes from more recent studies that have been done of acute aspiration events in hospitalized patients, and they actually suggest the anaerobic bacteria don't really play a major role. However, these are smaller studies and there haven't really been any large clinical trials comparing treatment with or without anaerobic coverage. Therefore, this is a conditional recommendation and they do suggest more research is needed in this area. Referring to the use of corticosteroids, the guidelines recommended not routinely using corticosteroids in non-severe CAP and suggest not routinely using them in severe CAP. Kadyn also mentions an update with flu season in full swing: if the flu is clinically suspected, a clinician should test for the flu and, if it comes back positive, co-treat with the antibiotic and oseltamivir. Throughout the episode, Kadyn shares a thorough overview of the 2019 Community Acquired Pneumonia Guidelines that will help doctors be more prepared for treating pneumonia.
Outbound Links & Resources Mentioned
- Subscribe to the podcast so you don’t miss an episode.
- Check out the ASHP website:https://www.ashp.org/
- Follow ASHPOfficial on Twitter: @ASHPOfficial
- Follow ASHPOfficial on Instagram: @ashpofficial
Takeaways in Today’s Episode
- The new 2019 Community Acquired Pneumonia Guidelines have updated their recommendations in multiple areas.
- To determine whether or not pneumonia patients should be hospitalized, the guidelines now recommend using both PSI and CURB-65, but strongly advise PSI over the other.
- Similarly to previous guidelines, if patients have hypotension requiring vasopressors or respiratory failure requiring mechanical ventilation, they should be directly admitted to the ICU.
- The biggest change as far as outpatient management involves otherwise healthy patients without comorbidities; the guidelines no longer recommend macrolide monotherapy.
- The new recommendation is to use high dose amoxicillin monotherapy, one gram three times a day.
- When it comes to inpatient management changes, therapy is now based on whether or not the pneumonia is considered severe or non-severe, instead of using terms like ICU versus non-ICU.
- HCAP (Healthcare Associated Pneumonia) is no longer a recognized category.
- The new guidelines recommend only getting blood and sputum cultures in patients with severe CAP, patients that are being empirically treated for MRSA or Pseudomonas, and patients that have other risk factors.
- In regards to aspiration pneumonia, the guidelines suggest not routinely adding anaerobic coverage for a suspected case unless a lung abscess for empyema is suspected.
- The new guidelines also mentioned the use of corticosteroids, recommending not routinely using corticosteroids in non-severe CAP and suggesting not routinely using them in severe CAP.
- If the flu is clinically suspected, test for it and co-treat if necessary.