Thanks to Dr. Szabo and Dr. Pickens for a fantastic grand rounds covering the new updated recommendations to severe CAP! [https://link.springer.com/article/10.1007/s00134-023-07033-8]
1) Suggest adding multiplex PCR to lower respiratory sample (very low evidence)
ResPOC trial [https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(17)30120-0/fulltext] – 720 patients presenting to ED with resp symptoms ran multiplex PCR and given information to clinical team -> slightly less abx (one dose vs 48hrs) and shorter LOS and good identification of viruses -> results 48-72hrs earlier than cultures, can quickly de-escalate or target resistance
Sputum biofires more often positive than BAL biofire (72% vs 49% and more likely polymicrobial, and also common discrepancy with cultures)
2) Consider HFNC instead of regular oxygen
RCT of standard oxygen facemask, HFNC, NIV [Frat NEJM 2015 https://pubmed.ncbi.nlm.nih.gov/25981908/] -> mortality benefit in those who got HFNC [though NIV might’ve been confounded because they targeted high tidal volumes]
3) Steroids? Based on their own meta-analysis, recommended if shock is concurrently present.
Didn’t include CAPE COD study, and driven by Meduri VA study [?confounded by gender]
Interesting thoughts on environmental ecology – examining the microbe in its true environment interacting with other bugs rather than taking it out and isolating it on a plate!
First, identify all microbes present [Human Microbiome Project – https://hmpdacc.org/]; there’s been a lot of interest recently!
The upper respiratory tract is different from the lower respiratory tract when you’re sick. Some features like bacterial burden or composition/diversity are associated with different outcomes!
Thanks, Dr. Szabo and Dr. Pickens!