Community Acquired Pneumonia - CAP/FLU/COVID-19

• Identify the risk factors associated with an increased mortality with CAP. 

• List the pathogens associated with CAP.

• Develop a treatment plan for a patient with CAP based on potential pathogen, disease severity, and administration ease

• Identify the signs and symptoms of influenza and COVID.

• List the potential complications from influenza and COVID.

• Compare and contrast the available treatment options for influenza and COVID.

Learning Objectives

• Upper airway reflexes/tract

• Mucociliary transport

• Immune mediators

Pneumonia Anatomy - Host defenses

• Infectious Disease of the Lower Respiratory Tract

• Lower Respiratory Tract is considered a sterile site

• Results due to an imbalance between the pathogen and host factors

• Can be caused by bacteria, viruses, and fungi

Pneumonia Anatomy - points about pneumonia

• Strep Pneumo

• H. Flu

• Moraxella catarralis (M. Catarrhalis)

• Mycoplasma Pneumoniae

• Legionella

• Chlamydia

“Surely He Must Make Legion Climb”

Pathogens that can cause CAP!!!! - KNOW THIS!!!

Pseudomonas aeruginosa, Acinetobacter species, MRSA, Enterobacteriaceae family

Pathogens that can cause HAP/VAP (More in the other lecture)

Enterobacteriaceae family, Anaeorobic organisms

Pathogens that can cause Aspiration Pneumonia

Influenza virus, Respiratory syncytial virus (RSV), Rhinovirus, Parainfluenza viruses, Coronavirus, Adenovirus

Pathogens that can cause Viral Pneumonia

Pneumocystis jiroveci (PJP), Histoplasma capsulatum, Cryptococcus, Aspergillus

Pathogens that can cause Fungal Pneumonia

• Age

• Alcoholism

• Disease states

  • CHF, DM, malignancy

• History of previous PNA

• Post-obstructive or aspiration PNA

• Infections due to GNR or Staphylococcus aureus

• Delay in initiating antibiotics by 8 hours

Risk factors for increase pNeumonia mortality

Pathogen

• Typical CAP organisms

• ORAL ANEROBES

• Klebsiella penumoniae

Risk Factor

• HIV/AIDS

Pathogen:

• M. tuberculosis

• Pneumocystis jirovecii

• Cryptococcus

• Histoplasmosis

• Aspergillus

• Atypical mycobacteria

• Pseudomonas aeruginosa

• Haemophilus influenzae

Alcoholism Risk factor points and what pathogens for pneumonia

Pathogen

• Typical CAP organisms

• H. FLU

• Pseudomonas aeruginosa

Risk Factor

• INFLUENZA

Pathogen:

• Staph Aureus

• Flu virus

• Haemophilus influenzae

COPD Risk factor points and what pathogens for pneumonia

Pathogen

• Community Acquired MRSA

• Oral Anaerobes

• Fungal Pneumonia

• M. Tuberculosis

• Atypical Mycobacteria

Risk Factor

• Whooping Cough > 2 weeks

Pathogen:

• Bordetella pertusis

Lung abscess Risk factor points and what pathogens for pneumonia

• Chest radiograph

  • Typically see patchy infiltrates

  • Single vs multi-lobar disease

• Sputum culture/gram stain AND Blood cultures IF: 

  • Being treated as Severe CAP OR

  • Being covered or has a h/o for Pseudomonas or MRSA OR

  • Hospitalized and received antibiotics during the last 90 days

• Serologies

  • C. pneumoniae, M. pneumoniae

• Legionella urinary antigen

• Other laboratory findings

  • CBC, BMP, Arterial blood gas

Diagnosis of Pneumonia - How?

• Severity of illness assessments

  • Pneumonia Severity Index (PSI)

    • More data, better validation, more complex

    • Recommended by the Guidelines

  • CURB-65

    • Simpler, easier to assess patient quickly

• Neither of these should be used to determine level of care

  • ICU admission IF:

    • Patient is hypotensive and requires vasopressor support OR

    • Patient has respiratory distress requiring mechanical ventilation

Severity Of Illness for Pneumonia - HOW?

 

Points	Class	Mortality (%)
None	I	0.1
≤ 70	II	0.6
71-90	III	0.9
91-130	IV	9.3
> 130	V	27

PSI Evaluation Table

Confusion

Urea (BUN >20)

Respiratory Rate (>30)

Blood Pressure (<90 SBP or <65 DBP)

Age (>65)

0-1points = low risk/severity of pneumonia (outpatient)

2 points = moderate risk (consider inpatient)

3 points = High risk (inpatient, consider ICU)

Curb-65 score components

Risk factors for MRSA and/or Pseudomonas

• Prior infection with MRSA and/or Pseudomonas

• Prior hospitalization and treatment with IV antibiotics in the last 90 days

Comorbidities

• Chronic heart , lung, liver or renal disease; diabetes, alcoholism, malignancy or aslepenia

Risk/factors and comorbidities for CAP

• Amoxicillin 

• Doxycycline

• Macrolide (if local pneumococcal resistance is <25%)

Outpatient EMPIRIC treatment of CAP with NO COMORBIDITIES

• Amoxicillin/clavulanate OR 3rd generation Cephalosporin

  • PLUS add either macrolide or doxycycline

OR

• Respiratory Fluoroquinolone

  • Moxifloxacin, Levofloxacin or Gemifloxacin

Outpatient EMPIRIC treatment of CAP with COMORBIDITIES

Beta-lactam

• Ampicillin/Sulbactam

• Ceftriaxone

• Ceftaroline
  

PLUS

Macrolide/Tetracycline

• Azithromycin

• Clarithromycin

• Doxycycline

• Omadacycline

“ACC + ACDO” for GEN-MED/NON-SEVERE (Or LMD)

---

OR

Respiratory Fluoroquinolones (LMD)

• Levofloxacin

• Moxifloxacin

• Delafloxacin

CAN ADD VANCOMYCIN or LINEZOLID IF:

• They have a hx of MRSA infection

inpatient EMPIRIC treatment of CAP - GENERAL MEDICINE Floor, NON SEVERE

Beta-lactam

• Pip/Tazo

• Cefepime

• Ceftazadime

• Meropenem

• Aztreonam

PLUS

Macrolide/Tetracycline

• Azithromycin

• Clarithromycin

• Doxycycline

• Omadacycline

“PCCMA + ACDO” for GEN-MED/NON-SEVERE with PSEUDO (Or LMD)

---

OR

Respiratory Fluoroquinolones (LMD)

• Levofloxacin

• Moxifloxacin

• Delafloxacin

inpatient EMPIRIC treatment of CAP - GENERAL MEDICINE Floor, NON SEVERE, H/O PSEUDOMONAS

“ACC + ACDO/LMD” for ICU/SEVERE

• Ampicillin/Sulbatam

• Ceftriaxone

• Ceftaroline

PLUS

• Azithromycin

• clarithromycin

• Doxycycline

• Omadacycline

• Levofloxacin

• Moxifloxacin

• Delafloxacin

inpatient EMPIRIC treatment of CAP - ICU/(SEVERE CAP)

“ACC + ACDO/LMD” PLUS Vanco/Line for ICU/SEVERE + H/O MRSA

• De-escalate IF MRSA Swab/Culture is negative!!

inpatient EMPIRIC treatment of CAP - ICU/(SEVERE CAP) + H/O MRSA

“PCCMA + ACDO/LD” for ICU/SEVERE + H/O PSEUDO

inpatient EMPIRIC treatment of CAP - ICU/(SEVERE CAP) + H/O PSEUDOMONAS

Do NOT CHANGE therapy from guidelines UNLESS:

• Evidence of Lung Abscess

• Empyema (pus in pleural walls)

What should you do in patients with aspiration pneumonia?

• Patient MUST have signs of Clinical Stability:

  • Improved vital signs

  • Ability to eat

  • Normal mental status

• Minimum length of treatment: 5 days

CAP treatment duration

Give:

• in those with decompensated respiratory failure OR requiring mechanical ventilation

  • Give over 4-7 days, then taper off over 4-7 days

DO'N’T GIVE:

• if CAP is due to: fungal, tuberculosis or influenza

When should Steroids be given and NOT be given in patients who have CAP?

2 days (flu)

5 days (COVID)

incubation periods for FLu and COVID

• Non-productive cough

• Rhinitis

• Sore Throat

• Malaise

• High fever/ chills

• Headache

• Muscle aches/ arthralgias

Symptoms for BOTH flu and COVID

• Shortness of breath

• N/V/D

• Smell/Taste abnormalities

• Reddish/purple nodules on distal digits

Symptoms Unique to ONLY COVID

LFTs

LDH

CRP

Ferritin

PT

D-Dimer

Troponin

CPK

These lab values go UP when someone has COVID

WBC’s

Platelets

CrCL

These lab values go DOWN when someone has COVID

• Pneumonia

  • Viral pneumonia

  • Flu: Secondary bacterial pneumonia (Staph aureus)

• Myositis/ rhabdomyolysis

• CNS involvement

  • Encephalitis

  • Guillain-Barre Syndrome

• Worsening of underlying conditions 

  • CHF, Asthma, COPD

• Thromboembolism/Strokes/MI- COVID-19

• Renal Failure/Liver Failure

• Multisystem Inflammatory Syndrome (MIS)- COVID-19  

• Toxic shock syndrome

• Reye’s syndrome

• Myocarditis/pericarditis

Complications of FLU/COVID

• - Immunosuppressed

• - Health care personnel

• - Chronic lung disease, CAD, renal, hepatic, hematologic, metabolic (including DM), neurologic, neuromuscular disease

• - Neurodevelopmental diagnosis of epilepsy, CVA, intellectual disability, muscular dystrophy, or spinal cord injury

• - Pregnant or post-partum women

• - Children < 18 years old on long-term ASA therapy

• - Adults ≥ 65 YO

• - Native American or Alaskan Natives

• - Morbid obesity (BMI > 40)

• - Residents of LTCF

What patients are at high risk for FLU complications?

• Age 50 or older; significantly increase >/= 65 YO

• Unvaccinated or not being up to date with COVID-19 vaccinations

• Comorbid disease states: Immunocompromised states, asthma, Cancer (hematologic malignancies), chronic lung disease, CVD/CAD, DM, obesity, CKD, Chronic liver disease, CF, Mental health conditions, pregnancy, smoking, solid organ transplant

What patients are at high risk for COVID complications?

• Viral cultures

  • Nasal/ throat swabs or sputum cultures

  • May take 3-5 days to get final results

• Rapid test

  • Most look for viral antigens in sputum cultures

  • Different test for Influenza A and B

  • Sensitivities = 40-80%

    • Less sensitive in adults vs. children

  • Often can obtain results within an hour

  • Now available OTC and combined with COVID testing! 

• Diagnosis is often based on symptoms and history of exposure

Just really know the bold

What do we use to diagnose Flu?

1. NAAT/PCR

   1. GOLD STANDARD

   2. Detects Viral Nucleic Acids

   3. Can detect NA up to 5 days post-exposure

   4. If had COVID-19, not recommended to have a repeat NAAT in 90 days

2. Antigen testing

   1. Detects viral antigens

   2. Less sensitive than NAAT

   3. More sensitive in symptomatic patients

   4. Rapid turnaround

   5. Can have false positives

   6. Recommends 2 negative test for those with symptoms OR 3 negative test without symptoms (performed 48 hours apart)

What do we use to diagnose COVID?

• Analgesia

• Fluids

• Rest

• +/- Cough suppressants

Supportive care treatments for FLU/COVID

Confirmed or highly suspected influenza AND

• Presents within 48 hours of symptom onset

• Requires hospitalization

  • If > 48 hours, may still benefit from treatment

• OR in close contact with a “high risk” individual

WHEN do we Treat FLU?

1. Oseltamivir

2. Peramivir

3. Baloxavir

3 treatment options for the FLU

• Oseltamivir

  • Generic (cheaper)

  • Studied in Kids and pregnancy

  • Studied in IMMUNOCOMPROMISED and Pregnant individuals

  • 5 day tx

  • ppx 7 days

  • Neuropsych side effects

  • NO DDI’s!!!

• Baloxavir

  • Brand only ($$$)

  • only for >12 YO

  • Not Studied in immunocopromised or pregnant

  • only 1 dose

  • CANNOT CO-ADMINISTER with Di-valent or tri-valent anions

Oseltamivir vs Baloxavir

• High risk individuals during the 2 week post-vaccination

  • 6 weeks for children not previously vaccinated

• Adults and children ≥ 3 MO who are at high risk of developing complications AND the vaccination is contraindicated, unavailable, or expected to have low effectiveness

• Unvaccinated adults, including health care workers and children ≥ 3MO who are in close contact with persons at high risk of developing flu complications

• All residents in institutions such as LTCF

If 1 member of the family becomes ill with the flu and another family member is considered a high risk group

Who should receive chemoprophylaxis for the flu?

• Symptomatic management

• Those at high risk of severe disease:

  • Paxlovid (ritonavir-nirmatrelvir)

  • Remdesivir

  • Molnupiravir

how do we treat NON-HOSPITALIZED COVID patients who DO NOT need Oxygen/hospital?

• Dexamethasone 6mg PO daily for duration of oxygen supplementation (not to > 10 days)

• Consider remdesivir

how do we treat NON-HOSPITALIZED COVID patients who D/C from ED with New or increased Oxygen need?

MOA:

• inhibitor of SARS-CoV-2 main protease which inhibits viral replication

• Ritonavir inhibits the metabolism of Nirmatrelvir

Side effects:

• HTN

• Diarrhea

• Myalgias

CI/DDI:

• Sensitivity to nirmatrelvir or ritonavir

• Inhibitor of CYP3A4; NUMEROUS DDIs

• Not recommended in severe liver disease or GFR< 30 ml/min

MUST START treatment within 5 days of SYMPTOMS

Paxlovid MOA, Side effects, and CI/DDI’s

Hold:

• Rivaroxaban

• Erythromycin

• Ranolazine

• Sirolimus

• Tacrolimus

• Statins

• Colchicine

Stop:

• Anticonvulsants: Carbamazepine, phenobarbital, phenytoin, primidone

• Rifampin/rifapentine

• Amiodarone

• Clopidogrel

• Flecainide 

• Clozapine, Lursaidone

• Sildenafil/tadalafil

• St. John’s wort 

Paxlovid DDI’s

MOA:

• Nucleoside analog and inhibits the RNA-dependent RNA polymerase (RdRp) of coronaviruses ;is incorporated by the RdRp into the growing RNA product and allows for addition of three more nucleotides before RNA synthesis stalls.

Side effects:

• Nausea

• Increase LFTs

• Allergic reactions

• Increase in Prothrombin time

CI/DDI:

• Not to be used in those with an eGFR< 30 ml/min

• Substrate of cytochrome P450 (CYP) 3A4; inhibitor of CYP3A4, OATP1B1, OATP1B3, and MATE1

Remdesivir MOA, Side effects, and CI/DDI’s

MOA:

• Nucleoside analogue that incorporates into the cell and causes errors in viral genome and inhibition of replication 

Side effects:

• Diarrhea

• Skin Rash

CI/DDI:

• Cannot be used in those < 18 YO because of bone/cartilage effects

• Do not break or open capsule

• NOT recommended in pregnancy

• Women: Recommended to use contraception during therapy and 4 days thereafter

• Men: Use effective contraception x 3 months

ONLY USED IF Paxlovid NOT an OPTION

Lagevrio MOA, Side effects, and CI/DDI’s

They are at a high risk of progression

• Treat with Remdesivir

How do we treat hospitalized COVID patients who are W/O Oxygen?

Use either:

1. Remdesivir

2. Remdesivir + Dexamethasone

3. Dexamethasone

How do we treat hospitalized COVID patients who are ON Oxygen?

Use Dexamethasone

• Add barcitinib or IV tocilizumab IF increasing O2 demand

How do we treat hospitalized COVID patients who are ON HIGH-FLOW Oxygen?

Use Dexamethasone

• add IV tocilizumab if in ICU for 24 hours

How do we treat hospitalized COVID patients who are ON Ventilation or ECMO?