Outpatient management of community acquired pneumonia

Outpatient management of community acquired pneumonia Wei Shen Lim Consultant Respiratory Physician Honorary Professor of Medicine (University of Nottingham) Nottingham University Hospitals NHS Trust

What is your specialty? 1. Acute Medicine 2. Health care of the Elderly 3. Infectious Diseases 4. Respiratory Medicine 5. Other specialty 12 5 1 24 15 1 2 3 4 5

Clinical case 69 year old man Unwell a few days only. Fever, cough, green sputum. Very tried. Loss of appetite. Hypertension. Fit and well. Retired fibre glass factory Afebrile Pulse 90 BP 110/65 RR 24/min Hb 120 Urea 4.0 WCC 12 Creat 63 Platelets 628 CRP 95

Which antibiotic treatment is most appropriate? 1) IV Tazocin with early switch to PO. 2) IV Co-amoxiclav + Clarithromycin with early switch to PO. 3) PO Co-amoxiclav + Clarithromycin for 7 days. 4) PO Amoxicillin for 5 days. 1 23 19 13 1 2 3 4

Would you discharge this patient from hospital? 1) Yes 18 24 2) No 11 3) C. Unsure insufficient information provided 1 2 3

At the time of discharge, what follow up would you arrange? 1) GP follow up 2) Clinic follow up in 4 6 weeks 3) CXR follow up in 4 6 weeks, and write to patient 4) Advise no follow up (GP nor clinic), unless slow recovery 3 15 39 0 1 2 3 4

Outpatient management of CAP : a secondary care perspective ED Home Early discharge Follow up Post-discharge Primary Care ED AMU Hospital Care Patient at home

Low-severity CAP 40% British Thoracic Society national CAP audit 50 45 40 35 30 25 20 Low Moderate High 15 10 5 0 2009 2011 2014 2009 2011 2014 Priya D Thorax 2016

Outpatient treatment from ED Barcelona (Spain) 17% Utah (US) 42% Edmonton (Canada) 56% UK?? Cilloniz ERJ 2012, Jones BMC Pul Med 2014, Eurich AJRCCM 2015

Patients with CAP discharged from ED Barcelona. Single site. (ED physicians with interest in RTIs) 3,223 adults in ED 568 (17.6%) treated as OP. 301 (53.0%) males, mean age 47.2 yrs (19% aged >65 yrs) Low-mortality risk (PSI I-III, 97.0%; CURB65 0-1, 94.7%) 30-day mortality: n=3 (0.5%). Readmitted within 30-days: n=13 (2.3%). 69% comorbidities. Pleural effusion: n=30 (5.3%). 5 had empyema readmitted Cilloniz ERJ 2012

CAP discharged from ED - Canada Canada. 2000 2002. 7 EDs (n=3874) Treated as CAP. CXR abnormal n=16833 Mean age 51 years. Age >65 yrs (27%) PSI I III 83% 30-day mortality: n=27 (2%) Readmitted 30 days: n=141 (8%)

Microbiology: out-patient CAP Bacteraemia: n=21 (3.7%) None readmitted or died. Cilloniz ERJ 2012

NICE Pneumonia Guideline 2014 Low severity community acquired pneumonia: Offer a five day course of a single antibiotic to patients [Based on moderate to very low quality evidence from randomised controlled trials, a cost analysis with limitations, and the experience and opinion of the GDG]

Non-inferiority trial 580 adults hospitalised with CAP Beta-lactam + macrolide Beta-lactam alone Outcome: Clinical stability at Day 7 Garin, JAMA Int Med 2014

Patients not reaching clinical stability Absolute diff 7.6% (upper limit 90% CI 13%, higher than predefined boundary of 8%) Garin, JAMA Int Med 2014

Non-inferiority cluster cross-over trial. 656 Beta-lactam (BL) only 739 BL + macrolide 888 FQ only Outcome: 90-day mortality Postma, NEJM 2015

Postma, NEJM 2015

312 adults with CAP 5 days antibiotics if temp <37.8 and <2 signs of instability Usual care (duration of antibiotics) Outcome: CAP symptom score (D5,10); Clinical success days (D10,30) Uranga, JAMA Int Med 2016

Adequately powered? 80% had quinolones Open study Uranga, JAMA Int Med 2016

NICE Pneumonia Guideline 2014 Low severity community acquired pneumonia: Offer a five day course of a single antibiotic to patients [Based on moderate to very low quality evidence from randomised controlled trials, a cost analysis with limitations, and the experience and opinion of the GDG]

Interventions to increase outpatient care 6 studies Highly varied. Practice guideline implementation. Mortality assessment tool PSI Chalmers ERJ 2011

Reasons for hospitalisation of low-risk patients 12 US EDs No (%) low-risk patients (n=249) Unstable Comorbid illness 178 (71%) Abnormal symptoms/signs/tests 73 (29%) Pneumonia more severe than PSI 30 (12%) Primary care requested hospitalisation 40 (19%) Patient/family request 24 (10%) Psychosocial issues 16 (6%) Problems with outpatient therapy 28 (11%) Required hospital services 12 (5%) Aujewsky Clin Inf Dis 2009

Outpatient management of CAP : a secondary care perspective ED Home Early discharge Follow up Post-discharge Primary Care ED AMU Hospital Care Patient at home

Early discharge after admission: role of specialists Nottingham. Short stay unit nurse triage. Resp Med Non-specialist CAP n=123 n=174 LOS d (median) 1.7 3.0 (p<0.01) Discharged <24h 43% 32% Readmission 30d 4% 4% Cellulitis n=229 n=428 LOS d (median) 2.8 2.6 Discharged <24h 25% 31% Readmission 30d 3.5% 3.5% Bewick, Thorax 2009

Biomarker enhanced triage in LRTI Feasibility study (n=315). Multi-faceted triage 2 arms. a) Medical stability (CURB65 +/- proadm) b) Functional (Self-care index (SPI)) c) Biopsychosocial (post-acute care discharge score (PACD)) Non-sig trend to shorter LOS in proadm greoup - 0.5 days. Albrich ERJ 2013

Early supported discharge trial - feasibility Support = home visit, information, 24h telephone contact 200 patients screened (4 months) 42 eligible Reasons for ineligibility (n=158) n % Confusion 37 20 More input needed (PT,OT) 35 19 COPD discharge services 20 11 Unstable comorbidities 18 10 Deterioration/ mental health 17 10 Patient declined 13 7 (multiple reasons may apply per patient) 18 declined. Total recruited = 14 Collins BMC Pul Med 2014

Outpatient management of CAP : a secondary care perspective ED Home Early discharge Follow up Post-discharge Primary Care ED AMU Hospital Care Patient at home

Healthcare contact post-discharge 3 hospitals East Midlands, n=126. Working age adults. Mean age 50 yrs. 89% CURB65 0 1. Re-consultation 6 weeks n=71 (66%), 90% with GP Of 64 pts seen by GP, 37% received antibiotics. Readmission n=5 (4.5%) - (3 had seen GP). Daniel P, manuscript in preparation

CXR 2 3 months post-pneumonia Cohort Abnormality Cancer US (n=618) Outpatients 3.7% 1.5% Canada (n=3398) Hospital 50% 1.1% NZ (n=302) Hospital 2% US (n=40,744) Hosp, >65yr 2.4%* *9.2% had cancer in 5 yr period, median time 297 days. Factors associated with cancer: chronic pulmonary disease, any prior malignancy, smoking Little BP AJR Am J Roent 2014, Mortensen EM Am J Med 2010, Tang K: Arch Int Med 2011, MacDonald C Intern Med 2015

Summary: Outpatient management of CAP At ED/ AMU Guideline concordant practice: safe Role for Respiratory Medicine Amoxicillin 5 days From ward Role for Respiratory Medicine Hospital at home? Organisational hurdles After discharge Optimum follow up not determined

Thank you

Mycoplasma 4-yearly peaks in the UK Brown, Front Microbiol 2016

US CDC study of adult CAP: 5 hospitals Jain, NEJM 2015

CAPITAL study 19 hospitals critical pathway, n=9 SF-36 Bed-days Marrie, T et al. JAMA. 2000;283(6):749-755

CAPITAL study 18% less admission, low-risk patients 1.7 fewer bed-days/pt Marrie, T et al. JAMA. 2000;283(6):749-755