Pulmonary Infections - VASP¶

Acute Bronchitis¶

Background¶

1-3 wks productive cough, often preceded by URI, may have wheezing/rhonchi
Distinct from chronic bronchitis (>3 mos of consecutive cough x 2 consecutive yrs)
Distinct from PNA (parenchymal consolidation, fever >100.4F, hypoxia, tachypnea)
DDx: COVID-19, post-nasal drip, GERD, undertreated/new asthma, ACE-i induced bradykinin cough, undertreated CHF, acute PE, or new lung cancer
Typically a clinical dx; CXR/labs not necessary unless PNA suspected

Management¶

Supportive: lozenges, cough suppressants (guaifenesin or dextromethorphan), smoking cessation. Consider albuterol inhaler for wheezing
No indication for antibiotics

Community Acquired Pneumonia (CAP)¶

See CAP algorithm on VASP website

Background¶

All PNA that does not otherwise meet criteria for Hospital Acquired Pneumonia (PNA that develops ≥48 hours after hospital admission), Ventilator Associated Pneumonia (PNA that develops ≥48-72 hours after endotracheal intubation), or aspiration PNA
Healthcare-associated pneumonia is no longer a clinical entity per 2016 IDSA guidelines
MRSA Risk Factors:
- Recent history of MRSA
- Cavitary lesion or necrotizing pneumonia
- Post-influenza bacterial PNA
- Pts with IDU
- Severe hypoxemia requiring intubation
Pseudomonas Risk Factors:
- Recent history of Pseudomonas
- Bronchiectasis or structural lung disease
Both MRSA and Pseudomonas Risk Factors:
- Hospitalization AND IV antibiotics in previous 90 days
- Immunocompromising conditions
*Double coverage for Pseudomonas is not indicated in general population; LVQ has 82% sensitivity so not recommended unless isolate proven susceptible

Evaluation¶

Sputum cultures prior to abx, consider BCx in select groups (severe pna, ICU admission, cavitary disease, immunosuppression).
Rule out flu if the right season, COVID-19, consider RVP if it will change management
CURB-65 or PSI can aid in decision between outpt vs inpt therapy
- CURB-65: Confusion, Uremia (BUN >=19mg/dL), RR (>30/min), BP(<90/60), Age ≥ 65 If ≥ 2, hospitalization is recommended.
Consider urine pneumococcal Ag, urine Legionella Ag in severe CAP and in certain pts (e.g., neutropenia, asplenia, obstructive lung disease, hyponatremia, diarrhea, or heavy ETOH);
CRP, ESR, and pro-calc have not been shown to reliably improve outcomes; however, pro-calcitonin < 0.25 suggests against bacterial respiratory infection and antibiotic discontinuation is encouraged
PA/ lateral CXR. If immunocompromised, consider CT chest w/o contrast (does not improve outcomes)
- Lobar Consolidation - likely bacterial
- Interstitial Infiltrate - likely atypical vs. viral vs. non-infectious
- Cavitation - concerning for fungal vs. necrotizing vs. mycobacterial

Management¶

Antibiotic Duration: 5-7 days (at least 5 days and improvement with clinical stability)
Outpatient management
- Low Risk (no chronic heart, lung, liver, renal disease, DM, alcoholism, immunocompromise)
  - Amoxicillin 1g TID
- High Risk
  - Amox/clav 875/125 mg BID
  - Cefuroxime 500 mg BID
  - Levofloxacin 750 mg daily
Inpatient management

	Non-Severe/Non-ICU	Severe/ICU
No MRSA or Pseudomonas Risk Factors (see above) If cultures are positive, target antibiotics to the recovered pathogen.	Preferred: Ampicillin-sulbactam 3g IV q6h OR Ceftriaxone 2g IV daily High Risk Penicillin AND Cephalosporin Allergy: Levofloxacin 750mg PO (or IV) daily	Preferred: Ampicillin-sulbactam 3g IV q6h OR Ceftriaxone 2g IV daily + Azithromycin 500mg IV (or PO) daily OR Doxycycline 100mg IV (or PO) q12h High Risk Penicillin AND Cephalosporin Allergy: Levofloxacin 750mg IV (or PO) daily Addition of steroids per ICU protocol If RPP and Legionella urine antigen (if collected) negative, atypical coverage should be discontinued. If RPP is positive for M. pneumoniae or C. pneumoniae, doxycycline 100mg PO BID is preferred. If high suspicion for Legionella or positive urine antigen, azithromycin or levofloxacin are preferred over doxycycline.
MRSA or Pseudomonas Risk Factors (see above) *If MRSA or P. aeruginosa are not recovered on culture, change to routine CAP coverage. If cultures are positive, target antibiotics to the recovered pathogen.	MRSA Options: Vancomycin (pharmacy consult) OR Linezolid 600mg PO (or IV) BID P. aeruginosa Options: Cefepime 2g IV q8h or Piperacillin/tazobactam 3.375g IV q8h	MRSA: Vancomycin OR Linezolid (if no bacteremia) PLUS Pseudomonas: Cefepime 2g q8h or Pip/tazo PLUS Atypical: Azithromycin 500 mg IV (or PO) daily Addition of steroids per ICU protocol If RPP and Legionella urine antigen (if collected) negative, atypical coverage should be discontinued. If RPP is positive for M. pneumoniae or C. pneumoniae, doxycycline 100mg PO BID is preferred. If high suspicion for Legionella or positive urine antigen, azithromycin or levofloxacin are preferred over doxycycline.

Anaerobic Coverage: Do NOT start metronidazole or clindamycin for aspiration pneumonia. Anaerobic coverage should be considered if empyema or lung abscess detected.
Transition to PO as soon as patient able to tolerate PO medications and is clinically improving. If patient has concurrent bacteremia, transition after at least 3 days of IV antibiotics.

Additional Information¶

MRSA nasal swab has reported negative predictive value for MRSA pneumonia ranging 95% to >99%; consider sending and if negative, discontinue MRSA agent
CTX is generally adequate coverage for aspiration PNA without evidence of abscess, empyema, or cavitary lesion on imaging
Aspiration pneumonitis does not require abx. Rapid resolution of leukocytosis and stabilization of vitals suggest aspiration pneumonitis.
There is low sensitivity of S. pneumoniae to azithromycin (42%) and doxycycline (72%), so these should not be used as monotherapy
Check for drug interactions with linezolid (e.g., SSRI, methadone, methamphetamine use)

Hospital Acquired Pnuemonia (HAP) and Ventilator Associated Pnuemonia (VAP)¶

See HAP/VAP algorithm on VASP website

Background¶

HAP: Pneumonia that develops >48 hours after admission
VAP: Pneumonia that develops >48 hours after endotracheal intubation

Evaluation¶

Cultures of blood, sputum, endotracheal aspirate and/or bronchoscopy specimen
Consider MRSA nares to help with de-escalation
If there is concern for respiratory viruses: send SARS-CoV-2/influenza/RSV (RPP may be considered for immunocompromised patients)

Management¶

Initially cover for MRSA and Pseudomonas
Antibiotic Duration: 7 days in uncomplicated cases, although specific pathogens (e.g., Pseudomonas) may require longer duration and ID guidance
Consider ID consultation if the pt is not clinically improving on empiric therapy or if an MDR pathogen grows from culture
If no MRSA isolated and pt is improving, consider stopping vancomycin ASAP
There is concern for nephrotoxicity with combination Vancomycin and piperacillin-tazobactam, but data controversial

	MRSA Coverage	Pseudomonas Coverage
Empiric Antibiotics	Vancomycin (Pharmacy dosing) or linezolid	Cefepime 2g q8h OR Piperacillin-tazobactam 3.375 q8h extended infusion

Influenza¶

Background¶

Dx often clinical w/cough, sore throat, sputum/nasal discharge, HA, fever, myalgias, and malaise; ± N/V/D. Exam with increased flushing, rarely with lower respiratory symptoms.

Evaluation¶

During flu season: Obtain COVID/RPP or dedicated influenza PCR; testing is more accurate if obtained within 96 hour of symptom onset
CXR if concerned for bacterial superinfection

Management¶

Antivirals most effective when given <48 hours from symptom onset; however, recommended to be given if symptomatic despite duration and to all hospitalized pts
Oseltamivir 75mg BID x 5 days, peramivir 600mg IV x 1 (needs renal adjustment), or baloxavir (age ≥12) 40mg once (use 80 mg if >80kg)
Amantadine and rimantadine are no longer used due to emerging resistance