Community-Acquired, Health Care Associated, and Hospital Acquired Pneumonia Management of the Hospitalized Patient Update 2008 Scott A. Flanders, M.D. Associate Professor Director, Hospitalist Program University of Michigan Overview Community Acquired Pneumonia (CAP) • Pneumonia developing outside the hospital • But not HCAP Healthcare Associated Pneumonia (HCAP) • Pneumonia developing outside the hospital • But the patient has been “touched” by the healthcare system Hospital Acquired Pneumonia (HAP) • Pneumonia that develops > 48 hrs after admission • Ventilator Associated Pneumonia (VAP) is a subset of HAP CAP: Overview COMMON • 5-6 million cases / year • 1 million hospitalizations / year MORBIDITY / MORTALITY • 64 million days of restricted activity • High 30 day mortality: 10-35% • Leading cause of infectious death COSTLY • Costs: $12-20 Billion / Year • Inpatients: Mean $10k / episode Community-Acquired Pneumonia Care of the Hospitalized Patient • Admission Decision • Etiologic Testing • Antibiotic Therapy • Discharge Decision • Prevention Community-Acquired Pneumonia Care of the Hospitalized Patient • Admission Decision (Predicting ICU Care) • Etiologic Testing • Antibiotic Therapy • Discharge Decision • Prevention Admission Decision Predicting the Need for ICU Level Care SMART COP: Sens=92%, Spec=62% S e AUC n s i SMART COP 0.87 t i v i PSI IV&V 0.69 t y CURB-65 0.67 1-Specificity CID 2008 Community-Acquired Pneumonia Care of the Hospitalized Patient • Admission Decision • Etiologic Testing • Antibiotic Therapy • Discharge Decision • Prevention Etiologies / Diagnosis MRSA Pneumonia: The New Nightmare • CDC surveillance of 2003-2004 influenza season • 17 cases identified • 15/17 (88%) were MRSA; 85% PVL gene+ • Median age 21, 75% with no MRSA risk factors • 82% with +sputum, 50% +bld culture • 80% in ICU, 30% fatal • 100% erythromycin resistant, 50% fluoro resistant EID, 2006