Getting my own talk from yesterday up late.

Also presented at the Big Beasts session on Community-Acquired Pneumonia.

Focused at stewardship folks but something in here for everyone 👇

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First up, quick definition:
➡️ Since HCAP is now dead, CAP is basically all pneumonia acquired outside of a hospital.

Lots of stuff can cause CAP, but viruses cause a LOT. Any virus that can cause an upper respiratory infection can also cause pneumonia.

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Check out this CDC study: when a pathogen was found, #1 cause?

Rhinovirus.

Flu was #2.

Strep pneumo is #3, then 4 more viruses before you hit another bacteria.

(This study is well pre-COVID, but rest assured it would be well represented now).

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How do we do at getting a dx in the real world?

Not well at all. Can make de-escalation harder.

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Let's look at the diagnostics we have: Blood cultures - overdone for pneumonia, not positive much.

Strep pneumo Ur Ag - can be helpful if +, but recent paper from Erin McCreary Matt Davis suggests doesn't change practice much in the real world.

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Sputum cultures - underdone. Make efforts to get them and get them early. Think induced sputum in the ED with 7% hypertonic saline.

Neg cultures have value. If no MRSA/PsA grow, they're not there.

Viral options and multiplex PCR ($$$) highlighted below.

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Let's talk about procalcitonin.

It's a biomarker that, when negative, suggests safe to stop/not give abx.

Meta-analysis below of 26 RCTs: PCT-guided = less abx, less adverse effects, less mortality.

Guess how many RCTs the CAP guidelines cite?

0 🤔

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Negative trial in the US worth highlighting.

Some issues outlined here, but biggest is just educational intervention, no active ASP feedback in real time.

If you're going to use PCT, you need an ASP team reaching out to teams.

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Why do guidelines get PCT wrong?

They ask the wrong question. And cite sensitivity/specificity studies - can't get that with no gold standard.

Not really about bacterial vs viral. It's 'is it safe to hold abx if negative PCT?' RCTs say yes.

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Alright, how about treatment?

Amp-sulbactam first line for us.

Why not Ceftriaxone?

Need Ceftriaxone for intra-ab infxns - when narrower spectrum, less ESBL/VRE selecting, and less C diff causing Amp-sulbactam works just as well for PNA bugs, use that.

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