Podcast

CABP Presentations and Determining Site of Care

02/19/2023

In this podcast, Frank LoVecchio, MD, discusses typical and atypical presentations of community-acquired bacterial pneumonia (CABP), as well as important considerations for health care providers when determining the site of care for these patients. This podcast is part 1 of a 3-part series on unmet needs in treatment of CABP.

Additional Resources: 

For more information on community-acquired bacterial pneumonia, visit our CABP Resource Center.

Frank LoVecchio, MD, is the principal investigator for the Infectious Disease Network (IDNet) studies, and the medical director of clinical and community translational research at Arizona State University, in Phoenix, Arizona.

 

TRANSCRIPTION:

Leigh Precopio:  Hello everyone, and welcome to another installment of Podcasts360, your go‑to resource for medical news and clinical updates. I'm your moderator, Leigh Precopio, with Consultant360.

Community‑acquired bacterial pneumonia, or CABP, is a leading cause of death in the United States. Understanding presentation symptoms, and how these presentations impact the need for inpatient versus outpatient care is the first critical step in improving patient outcomes.

To learn more about treating patients with CABP, Consultant360 reached out to Frank LoVecchio, MD, who is the medical director of Clinical and Community Translational Research at Arizona State University, and the principal investigator for the Infectious Disease Network Studies.

Thank you for taking the time to speak with me today. To begin, could you briefly discuss some of the typical and atypical presentations of CABP?

Frank LoVecchio, MD:  I love that question. They used to be broken into pneumococcal pneumonia and others because pneumococcal pneumonia was considered typical pneumonia, and it was the big killer.

Interestingly enough, it's still the big killer today, although the strains, the presentations, and the variants have changed a lot because of normal antimicrobial lifespans but also because of vaccines, et cetera. Typical pneumonias are ones that usually give you shaking chills, lots of sputum.

Nowadays it's evolved into, on chest X ray, it looks like a lobar infiltrate. Whereas opposed to atypical, it might have slower progression. It might give you a hacking cough, a cough that's typically non‑productive, but any cough eventually will become productive right? If you cough hard enough, you're going to bring up some lung particle, et cetera, or some inflammatory tissue.

And then your chest X‑ray many times doesn't show the classic lobar pneumonia. I always say this, but then I'm always cautious and say, look, not everybody with Strep pneumo has the lobar infiltrate, and not everybody with atypical has these patchy infiltrates.

Leigh Precopio:  How do those clinical scenarios impact site of care decisions?

Dr LoVecchio:  The most important questions to ask is, who the patient is, how does the patient look. How the patient looks, it's pretty obvious. If they look like they're dying, they're septic. Their vital signs are abnormal. Their blood pressure is low. Their respirations are fast. Their oxygen is low. Those are things that, in front of you, are very important.

Sometimes they might look OK, but still be considered high‑risk because of their history. Some of the things you have to clue in on the history, it would be age, comorbidities, are they immunosuppressed? Do they have HIV? Have they received medications for malignancies? Chemotherapeutic agents put you more at risk to develop worst pneumonia, and unfortunately higher mortality. The things you should ask for, lots of us when we see these patients, we have little checklists sometimes for seeing how likely the patient is to decompensate, and how likely they are to do well if they were sent home.

It's become a little bit easier, although none of the checklists are absolutely 100%, but you can make a pretty good judgment just by viewing history and physical.

Leigh Precopio:  That leads me a bit into my next question. How do these presentations and courses of treatment differ in various patient populations, such as in older adults or patients who are immunocompromised?

Dr LoVecchio:  One of the things we use initially to evaluate patients is severity scores. Two popular ones are the Pneumonia Severity Index (PSI), and the other one is CURB‑65. These help us in the sense that they make a risk for the patient based upon prior studies.

There are unfortunately shortcomings of both of them. For example, if you look at the CURB‑65, it doesn't have hypoxia. So if you were 64 years old, and you didn't have uremia, and respirations were OK, your blood pressure was decent, the CURB-65 index would say you're safe to go home, but what if their oxygen was 90%?

A lot of people pre‑COVID would never send a patient like that home. Things are much different now with COVID. We do push the envelope a little bit in the sense that we send people home with hypoxia, if they have good follow‑up, especially if they have oxygen, especially if that's the only thing wrong with them.

I don't know if we're going to totally adapt that to bacterial pneumonia, but I see the writing on the wall for that. I think the push is to adapt that more for bacterial pneumonia, to send people home with oxygen.

On your initial evaluation, you should ask about age, comorbidities, and try to adapt one of these indexes. Personally, I use the Pneumonia Severity Index. I feel like it's a little longer, it tells me a little bit more about the patient. The negative with it for me is that it requires me to check some laboratory work, which I don't always do. I don't always do because it's not necessary based upon your clinical judgment, which also is held in very high regard in treating patients with pneumonia.

The other thing you should consider now is, do they have COVID or not? Other things such as you know, do they need influenza testing, et cetera. Sometimes, when the incidence is very high, it changes your management. If everybody had influenza during that time of year, you're checking the boxes here for Pneumonia Severity Index or CURB‑65, and you find out that a lot of those patterns fall into what would be present with pneumonia or COVID‑19, and because of that, maybe you don't pay much attention to it.

Severity scores are used for bacterial pneumonia, and they’re most commonly validated in patients who have atypical pneumonia or lobar pneumonia.

As you move along though, and as we get a little bit older and have more risk factors, PSI scores with 3 or 4, or CURB‑65 scores of 1 to 2. You usually push the patients towards the general floor admission bed, or maybe a med‑surg bed or maybe observation, for example.

We always bring up blood cultures pretty early on. We are very worrisome about getting looked at from CMS or other outside agencies. If this CMS is looking at us, the hospital is looking at what we order and do, and because of that, we're very aware of it.

I try to break it down into getting blood cultures this way. If you're very sick and going to the intensive care unit, you need to get blood cultures before you give antibiotics. If you're going home, you're not supposed to get blood cultures. But the middle one is hard. The middle one is going to be admitted to the floor, and you're going to get blood cultures, you have to get them before you give antibiotics. Like always, it's always a good practice.

For me in the emergency department sometimes, I'll get blood cultures. I know that it's really not going to change what I do, but many times I get blood cultures and hold them, or maybe hold the blood, and if the internist wants to get them, I’ll allow them, because it is more important for me to start the antibiotics.

There's a lot of cool other tests that came out that could particularly help you to figure out what kind of pneumonia they have. Not everybody has them. Some people use Gram stains and cultures. Now that's fine, but not always obtainable. But there are some streptococcal urine antigens. There is some Legionella testing.

I'm bringing up Legionella because the atypical pneumonia is one, if not the highest mortality. You don't want to miss that. It doesn't occur that often, thank God.

As you get sicker and sicker, yes, PSI scores of 4 or 5, you're going to be more likely to go to the intensive care unit, and you probably want to get all those laboratory data, try to figure out exactly what they have.

Eventually, you might be able to do a bronchoscopy. That's something we typically do in the emergency department, but sometimes it gives you more accuracy with regard to what the patient needs, what antibiotics, et cetera.

Many people, if you make it to the ICU with pneumonia – I know if you make it inpatient at our institution, we like to offer you HIV testing. For a while we were giving it to people for free or checking it for free, in cooperation with the Department of Public Health. It's a good idea to offer that to patients who have pneumonia.

Leigh Precopio:  How do symptom severity impact the presentations and treatment regimen?

Dr LoVecchio:  When we think about symptom severity, I put myself into who the patient is, but with regard to symptom, you say, "Look, are you coughing, yes, no? And are you bringing stuff up?"

If they're bringing stuff up, people argue, "This sputum culture is associated with this and that." I think it's been disproven. And what I mean by that is much of the sputum is usually coming from posterior of the pharynx, and because of that the colors can be different. I clue myself into whether it's bloody or not. I clue myself into if it's very frothy or not. If they have shaking chills. Shaking chill is classic for Strep pneumo.

Sometimes I see patients who have multiple shaking chills and they end up having pneumococcus or Strep pneumo, and the residents will ask, "Why? I thought they were supposed to have 1 shaking chill." The reply is always the patient didn't need antibiotics. So, people can present atypically. But severity as far as shortness of breath, comfort level, fever, are also important thing is to ask about. Respiration rates.

I also try to say it does it fit. Just because they have a cough and fever and shortness of breath, it doesn't mean they can't have other things. As an example, sometimes they have pulmonary embolism. I always remind people when I evaluate them that remember, it's a very, very common presentation. It looks very much like pneumonia.

One of the things that can help you is most patients with pulmonary embolism will have tachycardia, and usually we can't get their heart rate down despite treating their fever, despite treating their hypoxia, et cetera.

Obviously, there's many tests you should run for evaluation of pulmonary embolism if you suspect that. Maybe you could do D‑dimers, maybe you could do a CAT scan. If you're being admitted to the hospital you’re probably considered high‑risk, and sometimes a CAT scan is better than a blood test.

Leigh Precopio:  What are some clinical pearls you've found choosing between inpatient and outpatient care for individuals with CABP?

Dr LoVecchio:  For me, to try to figure out whether you need inpatient or not, the best thing to go with, for one, start with your clinical judgment. If the patient looks really bad, you're probably not going to send them home.

What do I mean by really bad? You look at things like the CURB‑65, which is pretty straight forward and easy to remember. If they have any one of these, you should admit them. If they have confusion, they'd be considered low‑risk, 2.7%, 30‑‑day mortality.

On those, if they're level 1, if they have 1 point, many people will try to or consider admission. Some others will say, "Hey, you know what, they can go home if they're alive, but all the other things are OK."

These are typically patients they look OK, but to have confusion that trumps everything. If they're confused, they won't remember to take their antibiotics, et cetera. CURB‑65 will tell you if they've confusion, that's only 1 point. If it's the only thing, they could consider outpatient antibiotic.

If you have 2 things, almost everyone will typically admit you. Even if you look at the CURB‑65 rules, they'll say, "Look, you have 2 points." For example, the mortality at 30 days is about 7%, 6.8% to be exact. That's a high percentage of people that are going to die at 30 days, and that's if you only have 2 things.

The other things that we looked at are confusion, BUN over 19 ‑‑ You could just say BUN 20 ‑‑ respiration 30, which helps me remember these things.

Blood pressure 90/60 so if it's lower than those, and then age over or equal to 65, hence the term CURB‑65. We get confusion, BUN, uremia, respiration for R, B for blood pressure.

I think most people, when they have 3 risk factors, their mortality rate shoots up to about 14%. That's pretty high. The problem I have sometimes is I see somebody and they're confused, their respiration rates are under 30, their blood pressure is OK, and maybe they're 65. Well, I might not check labs on them, partly because I don't think they're necessarily needed in this person, but I have to realize that there is a small chance, even though they look good, that their BUN is high, and that would put them in a higher risk category. If I'm not checking the lab, many times I'll often give them that 1 point.

A lot of it is, maybe it's not available to you because you're a primary care office, et cetera. You don't want to send them off to the lab. I always tell people, if you're not getting the lab, to err on the fact that they were positive. A more accurate PSI or PORT Score, in my opinion, you ask more things and you're less likely to miss some of the important things.

Of course, you'd ask about age, you'd ask about sex, and it turns out in this case that it's better to be female. Females have a lower risk of dying from pneumonia. If you're a nursing home resident, I think that's important. That's one of the things that CURB‑65 doesn't ask about.

If you're nursing home resident, you're more likely to have resistant organism. That would make you more likely to be 3, and more likely to have morbidity and mortality. If you have a history of cancer or neoplastic disease, liver disease, congestive heart failure. And especially with this, liver disease sometimes we take for granted, and realize that liver disease is very high, you're given 10 points for all of these things, the liver disease is 20 points, neoplastic is 30 points. Things that we would miss on the CURB‑65, become a little bit more important in this.

If you have a history of a stroke, if you have a history of a renal disease, if you have altered mental status or respirations over 30, those become very important in this also, much like the CURB-65.

There's a lot of overlap. Altered mental status compares to CURB‑65's confusion, respirations over 30, and systolic blood pressure under 90. You get lots of points with them for PSI, specifically 20 points for each of them.

Also, if you have extremes of temperature. It's good to take temperature into consideration. If your temperature is 40 and above or under 35 Celsius, you get points for that. Meaning, those are considered negative.

If your heart rate is elevated. The heart rate elevated is 125 in this. Most people would agree, if you saw somebody with community-acquired pneumonia, and they looked otherwise well but their heart rate was 120 despite not being hypoxic, being on fluids, and Tylenol, they're probably not going to go home.

The other good thing about this, is it does ask about oxygen, which CURB‑65 doesn't. It looks for partial pressure of oxygen less than 60. Lots of us just do oxygen and saturations. That corresponds to a saturation of, give or take of 90‑ish, depending on where you live.

The other thing you look for is laboratory data. We don't always do that on every patient, but if they're sick enough and they check some of the boxes above, we should consider lab. Particularly CBC, because if their hematocrit is low they're more likely to have higher mortality.

I don't think white count matters that much. It's not included in any of these risks, but the BUN is. The sodium is. If sodium is very low, then they’re higher risk. If their glucose is very high, they're higher‑risk. It incorporates them being at diabetic risk there.

Things have changed. I remember with COVID, a lot of these seemed to be positive, and then you could look at them and they could probably go home.

Leigh Precopio:  Is there anything else you would like to discuss about when you would utilize the Pneumonia Severity Index, the CURB‑65, or the Expanded CURB‑65 when evaluating these patients?

Dr LoVecchio:  In using those risk scores, we talk a little bit about them, CURB‑65 and PSI scores. One of the things that you should think about is clinical judgment.

There's some studies out there where clinical judgment is as good as these scores. Always remember that clinical judgment probably gets better with age or doesn't happen right away. You have to be out of residency and practicing for a little while or see multiple patients like this for a while.

In general, you get a little feel of what these patients look like and you're able to use your clinical judgment a little bit more. I think the other important things that happen as you move along in your career, you realize that there's a lot of social aspects you have to consider.

What I mean by that is, it's great, you've figured out the patient fits the criteria for outpatient antibiotics. When you do that, you establish, "OK I'm going to give you this antibiotic because it's best based upon these guidelines." Then, you come to realize the patient can't afford it or they are uninsured, for example. I think you have to be very specific about that, their social situation is always very important.

Leigh Precopio:  Great. Thank you again for answering my questions today.

Dr LoVecchio:  Thank you.