Pulmonary Infections

VUMC ASP CAP Algorithm

Background 

• Presentation: cough, purulent sputum, SOB, pleuritic chest pain, dyspnea, hypoxia, PLUS CXR/CT infiltrate. Nonspecific: leukocytosis, fever, elevated ESR/CRP, malaise 
• Consider viral etiology if multifocal consolidations or pt has known contact with viral pathology.

Evaluation 

• PA and lateral CXR or CT chest w/o contrast. QR: VUMC ASP CAP Algorithm 
  • Lobar consolid ation suggests bacterial , bilateral or patchy interstiti al infiltrate suggest viral vs atypical, cavitatio ns suggest fungal vs necrotiz ing bacterial vs mycoba cterial infectio n. (DDx also includes maligna ncy) 
• Sputum Cx (induced if needed), +/- BCx, nares MRSA PCR, procalcitonin, RPP, ABG vs VBG if impaired oxygenation or signs of respiratory distress, +/- Urine Legionella Ag, consider HIV and atypical fungal wu if not improving with abx or risk factors for fungal PNA 
• Use MDCalc to calculate CURB65 or Pulmonary Severity Index 
• VUMC definition for severe PNA 
  • 1 Major criterion: septic shock requiring pressors, respiratory failure requiring ventilation 
• 3 Minor criteria: respiratory rate 30+, PaO2/FIO2 <250, multilobar infiltrates, confusion/disorientation, uremia, leukopenia (<4k), thrombocytopenia (<100k), hypothermia (>36C), hypotension requiring significant fluids 
• MRSA Risk Factors: past (+) Resp Cx or nasal MRSA PCR w/in 12M, post-influenza PNA, cavitary or necrotizing PNA 
• PsA Risk Factors: past (+) Resp Cx w/in 6-12M, structural lung disease like bronchiectasis 
• MRSA and PsA Risk Factors: hospitalization and IV abx within previous 90 days, SOT, HSCT, rejection treatment, chronic GVHD, neutropenia, immunosuppressants (ie ritux, TNFa inhibitors, steroids, etc.)

Outpatient Management

Duration 5 days (with return precautions) 

• Low Risk: Amoxicillin 
• High Risk (chronic lung, heart, liver, or renal disease; DM, immunocompromised, smoking, alcohol dependence): Amox-clav OR cefuroxime AND azithro OR doxy 
  • Levofloxacin 750 mg daily if confirmed allergy to above regimens

Empiric Inpatient Regimens

• **For severe/ICU CAP: Add steroids per ICU protocol 
• For high-risk PCN AND cephalosporin allergy: Levofloxacin 
• DC atypical coverage if RPP - for Myco and Chlamydophila and urine legionella negative 
  • If RPP is + for Myco or C. pneumoniae, doxycycline 100mg PO BID is preferred. If high suspicion for Legionella or + urine ag, azithro or levofloxacin are preferred over doxy. 
• If Hx of ESBL organism, consider meropenem with ID approval 
• Avoid anaerobic coverage unless specific indication (empyema or lung abscess). If present, consider pip-tazo, metro, or clinda. Note, amp-sulbactam + CTX cover oral anaerobes 
• Transition to PO abx as soon as pt improving and can tolerate oral therapy. 
• Duration: 5 days total if improving 
• MRSA nasal swab has high NPV, if negative discontinue MRSA agent 
• Low sensitivity of S. pneumo to azithro and doxy, so these should not be used as monotherapy 
• Check for drug interactions with linezolid (e.g., SSRI, methadone, methamphetamine use)

VUMC ASP HAP/VAP Algorithm

Background 

• HAP: Pneumonia that develops ≥48 hours after admission. 
• VAP: Pneumonia that develops ≥48 hours after endotracheal intubation. 
• Presentation: new fever, cough, dyspnea, purulent secretions, leukocytosis, increased O2 requirement AND radiographic evidence of new or progressive infiltrate. 
• DDx: pulmonary edema, pulmonary embolism, aspiration pneumonitis, etc.

Evaluation 

• BCx, resp Cxs (ideally bronch vs sputum/aspirate), procalcitonin, MRSA nares PCR QR: VUMC ASP HAP/VAP Algorithm
• If c/f respiratory viruses: Covid/flu/RSV. RPP for immunocompromis ed, ICU pts, or underlying lung disease.

Management 

• Start empiric PsA coverage (Pip-tazo OR Cefepime). Consider if MRSA coverage (Vanc OR Linezolid) is needed 
• If pt has undergone nasal decolonization, unlikely to have MRSA VAP 
• Look at prior and current Cx results. If ESBL in previous 90d and unstable, start meropenem. 
  • Follow Cx results daily and tailor antimicrobials. Deescalate abx if no MRSA/PsA isolated and pt improving. 
  • Consider ID consult if no clinical improvement and/or MDR pathogen isolated. 
• Duration: 7D for uncomplicated cases. Longer in gram positive bacteremia, empyema, abscess, infected pleural effusion, necrotizing PNA, severe immunocompromise, etc. 
  • May be able to shorten duration if down-trending procalcitonin on day 4-5

Testing 

• Flu-like symptoms, +/- loss of taste/smell
• May need asymptomatic COVID-19 testing for admission to certain floors (check with charge RN if unsure) 
• Avoid retesting those with confirmed COVID-19 within the last 30d 
• Basic admission workup: CBC with diff, CMP, D-dimer, PT/INR, PTT, procalcitonin, CXR, contact+airborne precautions. +/- CTA PE if sudden or rapid worsening of hypoxia

Management 

• Anticoagulation/DVT prophylaxis: DVT ppx for all pts, treatment dose AC if develop DVT/PE 
• For pharmacologics VUMC requires Redcap, VA PADR requirements variable 
• Nirmatrelvir/ritonavir (Paxlovid) 
  • Within 5d sx onset with high risk for progression to severe disease W/O significant DDIs 
  • CIs: prohibitive DDIs (eval ALL meds for interaction), severe renal/hepatic impairment, uncontrolled HIV-1 infection (risk of resistance) 
  • eGFR >60: nirmatrelvir 300 mg + ritonavir 100 mg BID x 5 days 
  • eGFR 30 to <60 mL/min: nirmatrelvir 150 mg + ritonavir 100 mg BID x 5 days 
  • eGFR <30 mL/min: not recommended 
• Remdesivir 
  • Within 7d of sx onset with high risk for progression to severe disease 
  • CIs: ALT > 10x ULN, mechanical ventilation or ECMO 
  • Mild to moderate: 200mg x1 then 100mg q24h x 2d 
  • Severe: loading dose 200mg x1 then 100mg q24h x 4d 
  • Do not need to remain in the hospital to complete course of Remdesivir if sxs improve 
• Dexamethasone 
  • Requiring respiratory support (NC, non-invasive ventilation, mech ventilation, or ECMO) 
  • 6mg PO/IV x 10 days 
• Baricitinib (JAK inhibitor) 
  • Eligibility determined by ID and/or Pulm/Crit, generally in those requiring >6L or >40% FiO2, <7d since admission to hospital, or worsening despite steroids and supportive care 
  • CIs: treatment with tocilizumab, dialysis, ESRD, or anuric AKI, ALT >10x ULN, active TB or systemic fungal infection, or pregnancy 
  • Discuss with pharmacist if patient taking an OAT3 inhibitor, otherwise dosing based on eGFR: >60: 4 mg po qd; 30-59: 2 mg po qd; eGFR 15-29: 1 mg po qd 
  • 14d or until discharge o AEs: thrombosis, elevated LFTs, severe infection 2/2 lymphopenia and neutropenia 
• Tocilizumab (IL-6 inhibitor) 
  • Eligibility determined by ID and/or Pulm/Crit, usually for those on dexamethasone who are not eligible with baricitinib 
  • CIs: increased risk of GI perf (ie diverticulitis), demyelinating disorders, ALT>10x ULN, ANC <500, Plt <50k, active bacterial, fungal, or viral infection other with COVID-19 
  • Tx: 8mg/kg, up to max of 800mg IV, once 
  • Adverse events: Bowel perforation, elevated lipids, elevated LFTs, serious infections 
• Abx: Consider CAP coverage if evidence of PNA on imaging or lack of improvement despite supportive care

Multisystem Inflammatory Syndrome in Adults (MIS-A) 

• Consider in those with fever with unclear etiology, history of previous COVID-19 diagnosis 2-8 weeks prior, and laboratory evidence of organ dysfunction 
• See VUMC COVID-19 Guidance for MIS-A for full diagnostic criteria 
• Treatment: IVIG, steroids, and DVT ppx