New GLA pneumonia guidelines!

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Based on recent guidelines from the Infectious Diseases Society of America, the Antimicrobial Stewardship Program and Infectious Diseases Section at GLA have revised our local guidelines for management of pneumonia and updated our order sets (both for Inpatient Antibiotic Protocols and Outpatient Antibiotic Protocols).  

The full guidelines are attached and also available at http://www.vaglaid.org/gla-guidelines.

Main takeaway points:

  • The Pneumonia Severity Index can be used in making a decision as to whether a patient with pneumonia is best served in an inpatient vs. outpatient setting: https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap (link provided in order sets)

  • Once a patient is admitted, the following criteria can be used to determine pneumonia severity (which has an impact on antimicrobial selection). Severe inpatient pneumonia can be defined by meeting either one major or three or more minor criteria:

    • Major criteria

      • Septic shock requiring vasopressors

      • Respiratory failure requiring mechanical ventilation

    • Minor criteria

      • Respiratory rate ≥ 30 breaths/min

      • PaO2/FiO2 ratio ≤ 250

      • Multilobar infiltrates

      • Confusion/disorientation

      • Azotemia (BUN > 20mg/dL)

      • Leukopenia (WBC < 4000 cells/µL)

      • Thrombocytopenia (platelets < 100,000/ µL)

      • Hypothermia (core temperature < 36°C)

      • Hypotension requiring aggressive fluid resuscitation

  • “Healthcare-associated pneumonia” (aka “HCAP”) is no longer a recognized distinct clinical entity. Risk factors for MRSA and resistant-Gram negative bacteria as pathogens in community-acquired pneumonia and ward-onset hospital acquired pneumonia should be assessed on an individual basis.

    • Risk factors for which MRSA coverage should be considered in CAP and ward-onset HAP:

      • Isolation of MRSA from respiratory culture/nares within the past year

      • Severe disease per criteria above

    • Risk factors for which broadened Gram-negative coverage should be considered in CAP and ward-onset HAP:

      • Isolation of ceftriaxone-resistant Gram-negative rods from respiratory cultures within the past year

      • Receipt of broad-spectrum Gram-negative therapy in the past 90 days

      • Residence in skilled nursing facility (relative indication)

  • Most community-acquired pneumonia can be treated with 5 total days of therapy, and most hospital-acquired pneumonia can be treated with 7 total days of therapy.

New PCR-based GI panel for stool diagnostics and C. difficile testing update

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The GLA microbiology lab is now performing a new PCR-based method for testing for gastrointestinal pathogenic microorganisms. This replaces routine stool bacterial cultures and also detects C. difficile, norovirus, and common parasites, including Entamoeba histolytica, Giardia lamblia, and Cryptosporidium.

A full list of the pathogens targeted with this test is available at:

https://www.biofiredx.com/products/the-filmarray-panels/filmarraygi/

This test is orderable as “GI Panel” in CPRS and is available from the Microbiology Test Order Screen that can be reached from many inpatient and outpatient order sets. Stool O&Ps and specific testing for Microsporidia now require ID approval.

Please note that for patients with new-onset diarrhea who are on or have recently received antibiotics, C. difficile PCR testing should be ordered, not the full GI Panel. C. difficile testing has also recently been updated, as all positive PCR tests (either from the GI Panel or the specific C. difficile PCR) will be reflexed for toxin immunoassay testing. Samples that are PCR positive and toxin negative are likely to represent colonization with C. difficile and not active infection.

Also remember that stool microbiology testing should be done on frankly liquid bowel movements (Bristol stool chart 7). Also do not test in the setting of recent laxatives, stool softener, or tube feed initiation.

Please contact the Infectious Diseases service (fellow pager UCLA 89321; antibiotic approval pager VA 73022) with any questions.