Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today, we're addressing concerns regarding pneumonia anti-microbial treatment and anti-microbial resistance. We're talking today about antibiotic stewardship. Joining me in this panel is Dr. Elias Woldegabriel. He's an Attending Physician in Infectious Disease at the Carle Foundation Hospital and Dr. Matthew Pike. He's a Pharmacist and Clinical Coordinator for Inpatient Pharmacy at Carle Foundation Hospital.

Gentlemen, I'm so glad to have you with us today. And Dr. Woldegabriel, I'd like to start with you. The American Thoracic Society and Infectious Diseases Society of America updated their diagnosis and treatment of adults with community acquired pneumonia, official guidelines in 2019. What made you want to talk about these guidelines today?

Elias Woldegabriel, MD (Guest): Thank you for this opportunity to speak with you today. And we have a few reasons why we would like to address this topic at this time. Even if this guideline was released in 2019, we feel that it's not widely adopted as much as we would like. And there are a number of reasons why is this may be happening. Throughout our world, you know, the COVID-19 pandemic has been going on for over a year now.

And most of our providers' attention is focused in combating this pandemic that we are dealing with. And so the other important thing is community acquired pneumonia is one of the main reasons why providers subscribe antibiotics and by addressing proper use of antibiotics, focusing on community acquired pneumonia, we believe we can package a lot of misuse of antibiotics, which is associated with a lot of drugs resistance development. As we are aware development of drug resistance is a big issue. And most people are aware of the development of super bugs, which are challenging to treat. And it is associated with a lot of morbidities and mortalities. And because of that, we would like to address this topic as much as possible so that patient outcome can be improved by appropriate use of antibiotics.

Matthew Pike, Pharm.D. (Guest): I certainly agree with that. And also, with this guideline coming out in 2019, the last iteration before that of these guidelines was way back in 2007. And so there were a number of developments in the meantime, and I think a lot of items that we make sure were disseminated out to those on the frontlines who are prescribing antibiotics and anti-virals for pneumonia cases, to improve care and prevent that development of resistance.

Host: Well, thank you both for that. And Matthew, this has become a bigger concern in recent years. Many providers talk about it. I've done a ton of shows on it. Tell us a little bit about why you think this is happening and just any of the history that you can share about antibiotic resistance and the overuse of antibiotics in our society, really.

Dr. Pike: It's certainly a growing problem. We've seen the rise here at Carle Foundation as well. It may have taken longer to get here, with where we were in east central Illinois, versus maybe some metropolitan areas where they've been dealing with higher rates of resistance, more concerning bugs for a longer period of time.

But, it's either here or arriving here and so we want to be prepared for that. And hope that we can do about it by being good stewards of antibiotics, avoiding overuse, using narrow spectrum only the most necessary durations of antibiotics, all of these typical stewardship topics and endeavors that we take on, to hopefully combat that and, cut things off as much as we can and preserve the tools that we have for treating patients, to avoid these scenarios where something could come around and an infection that was previously treatable is now no longer so.

Host: So interesting how this has all evolved into this antibiotic stewardship really initiative. It's going on all over the country and Dr. Woldegabriel, I expect one of the first questions providers may have about these new guidelines is which antibiotics are recommended for treating community acquired pneumonia in adults. And can you tell us a little bit about that?

Dr. Woldegabriel: Absolutely. As you rightfully said, you know, most providers want to treat patients appropriately with the right antibiotics for the right amount of time. And that is the most important question we would like to address today. And before we suggest what antibiotic to use, the first question we need to address is what kind of patients are we treating?

If we are treating a patient without any co-morbidities in outpatient settings, the treatment recommendation includes different choices. The most common antibiotics recommended will be amoxicillin, 1 gram by mouth three times per day. And the second option will be to use the doxycycline 100 milligrams twice per day. There is a third antibiotics that we can use under the general drug category called macrolide antibiotics.

But this is not suggested to be used by itself if there is a significant resistance to macrolide antibiotics regarding treating pneumococcal pneumonia and the cutoff point we encouraged to take is, you know, if there is a 25% resistance to macrolides, we try to avoid using macrolides to treat pneumonia any more now by themselves. But if local resistance is lower than 25%, the providers have a choice to use either azithyromycin or clarithromycin to treat outpatient pneumonia.

Host: Well, doctor, can you expand on that a little bit? Is there a reason that comorbidities factor into this treatment? Are patients with comorbid conditions likely to experience anti-microbial resistance in their treatments?

Dr. Woldegabriel: Oh, absolutely. In patients by nature who have a lot of comorbidities tend to be in and out of hospital multiple times, which makes them susceptible to get pneumonia with multi-drug resistant organisms. And those are things people with comorbidities don't respond to treatments the way people without comorbidities respond to treatment, and generally outcome of the pneumonia treatment in people who have multiple comorbidities like chronic heart disease, chronic lung disease, diabetes, and people who have splenectomy, tends to be poorer especially if the initial antibiotic choice is not the right antibiotics. For that of reason, the antibiotic recommendation is different compared to people without any co-morbidities. So, in people who have a lot of the above mentioned comorbidities, we encourage people to use a combination of antibiotics, which includes a beta lactam antibiotic, like amoxicillin clavulanate, or cefuroxime. Cefuroxime which are cephalosporin drugs, plus macrolide antibiotics. If there is any contraindication to use beta lactam plus macrolides, the other option will be to use a beta lactam antibiotics plus doxycyclin as a second agent. And there is another option for people with comorbidities, monotherapy with fluoroquinolones, either, levofloxacin, moxifloxacin, and depending on the place where practitioners can have the option to use gatifloxacin as well.

Host: This is such an interesting topic we're discussing here today. So Matthew, we touched earlier on duration of treatment and Dr. Woldegabriel just gave us a little bit of reasoning for this. So in adults with CAP, how long is an appropriate course of this type of therapy of antibiotic therapy, and should this be modified if a patient improves quickly?

Dr. Pike: Well, of course there's always patient specific factors to take into account as far as how quickly they respond to treatment. One of the main things that the guidelines highlight though, is that it's a minimum duration of five days, so even if a patient responds quickly within a day or two, signs and symptoms are improving, you still want to treat for this minimum of five days.

But five days you can get by with that if a patient has had a sufficient response. And so I think that's a good take home point that not every patient will require seven to 10 days or more, that might have been durations that were used in the more distant past. So, five days could be sufficient longer though, depending on patient response.

Host: Dr. Woldegabriel, tell us the current recommendations regarding other tests that should be ordered or cultures or imaging that's conducted. Expand a little bit on that for us.

Dr. Woldegabriel: So as we tried to elude at the beginning of this discussion, there are a lot of new developments in terms of tests that we can order and new antibiotics regimen. And this makes it difficult for providers to follow a certain guideline. So the 2019 community acquired pneumonia guideline tried to address some of tests which are not important.

And some of the test results needs to be considered depending on the clinical scenarios. And some of the points I want to address are as follows. First one is, do providers need to test for pneumococcal or Legionella by doing a urine antigen test? So right now the recommendation is not to do these tests in most patients unless patients have signs and symptoms of severe community acquired pneumonia. And in particular, if there is an outbreak of Legionella in the community, it is reasonable to do Legionella antigen test. Otherwise we try to discourage testing for pneumococcal and Legionella antigen test because for one thing, the yield is very low.

And if providers follows the guidelines and treat with the recommended antibiotics, outcome is not different, whether we need, whether we do these tests or not. And the other important point I want to address is during influenza season, it is highly recommended to test for influenza. And even if, patients test positive for influenza, there is a high likelihood of having a double pneumonia with bacterial pneumonia. So we would like to recommend antibiotic use at least for the first few days depending on that patient's clinical situation.

And the other important point I want to address is the use of a sputum gram stain and culture. Again, for most people, especially in the outpatient setting, it's not important to do a sputum gram stain and culture. And just following the guideline and treating with antibiotics is sufficient. there are scenarios where doing a sputum gram stain and culture is important, especially in the inpatient setting. If patient is having increased risk factor for MRA, say pneumonia or pseudomonas pneumonia, it is reasonable to do a sputum gram stain and culture, since this will help us in deescalating antibiotics, as soon as possible. One of the new modalities we have since 2007 guideline was serum blood test called a procalcitonin, which provide us thought would gave us opportunity to differentiate between a viral pneumonia and bacterial pneumonia.

The decision, whether to use antibiotics based on procalcitonin is nowadays discouraged because people who have a viral pneumonia can have a positive procalcitonin and vice versa. People with bacterial pneumonia, may have a low procalcitonin. So we would like to discourage using procalcitonin as a guideline of whether to initiate antibiotics or not.

Host: So I'd like to give you each a chance for a final thought. Matthew, I'd like to start with you. Who is this guidelance intended for and tell us what the Carle Foundation Hospital has been doing to help ensure these recommendations are followed.

Dr. Pike: So, these guidelines are intended for a wide range of different providers and practitioners; essentially anybody who is treating inpatients or outpatients for community acquired pneumonia. The guidelines encompass both settings. Certainly providers can access these guidelines online via the Infectious Disease Society of America website.

They are posted there. Internally at Carle, we've done education to various inpatient and outpatient provider groups, to bring them up to date on these guidelines and those have been well-received and we've seen some good yield from that with changes in practice and good comments and questions that come from it. So, the word is getting out and I believe this podcast will only help further that.

Host: Well, we certainly hope so. And Dr. Woldegabriel, last word to you, where should physicians and advanced practice providers look, if they have questions about these guidelines and what do you want them to know? Where to look, if they're interested in learning more about antibiotic stewardship?

Dr. Woldegabriel: Thank you for giving me this opportunity again. And the first thing I want to emphasize is, you know, this is a guideline. By nature, guidelines are intended to be used in conjunction with clinical judgment. So, this doesn't replace individual clinical judgment, but when the guideline is adopted plus used with clinical judgment, we know it works better in terms of improving patient outcomes.

It also decreases admission to the hospital, hospital length of stay. So, the importance of, you know, using both clinical judgment and following that guideline is very, very important. Of course, in 15 minutes, we are unable to address the antibiotic recommendation for both inpatient and outpatient. So, our discussion has focused on the outpatient part and the inpatient of this podcast is to encourage people to review these guidelines at their own convenience. And as Matt mentioned, this guideline is available at different sites, other than the Infectious Disease Society or the Pulmonary Care and the American Thoracic Society website. People who want to know, they can directly go to American Journal of Respiratory and Critical Care Medicine, October, 2019 edition and they can download this guideline to use at their convenience.

Host: Thank you so much, gentlemen, for joining us today, what a fascinating topic. And such an educational and informative information today. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at carleconnect.com for more information, and to get connected with one of our providers.

I'm Melanie Cole. Thanks so much for listening.