Community Acquired Pneumonia

Question 1

What are common bacterial respiratory diseases associated with HIV?

Answer 1

Sinusitis, bronchitis, otitis, pneumonia

These diseases occur with increased frequency at all CD4 counts.

Question 2

What is the focus of the chapter on community-acquired pneumonia (CAP) in people with HIV?

Answer 2

Diagnosis, prevention, and management of bacterial CAP

Viral pneumonias like influenza and SARS-CoV-2 are outside the scope of these guidelines.

Question 3

What is considered an AIDS-defining condition regarding pneumonia?

Answer 3

Recurrent pneumonia (two or more episodes within a 1-year period)

Bacterial pneumonia is a common cause of HIV-associated morbidity.

Question 4

How has the incidence of bacterial pneumonia in individuals with HIV changed with ART?

Answer 4

Decreased from 22.7 to 9.1 episodes per 100 person-years

This decline occurred after the introduction of ART.

Question 5

What are the main risk factors for bacterial pneumonia in individuals with HIV?

Answer 5

• CD4 count <100 cells/mm3
• Lack of ART
• Chronic viral hepatitis
• Tobacco and alcohol use
• Injection drug use
• Chronic obstructive pulmonary disease (COPD)
• Malignancy
• Renal insufficiency
• Congestive heart failure
• Obesity

These factors contribute to the higher risk of pneumonia despite ART.

Question 6

What are the most frequently identified bacterial causes of CAP in individuals with HIV?

Answer 6

• Streptococcus pneumoniae
• Haemophilus species
• Staphylococcus aureus

Atypical pathogens like Legionella pneumophila and Mycoplasma pneumoniae are less common.

Question 7

What should be considered when diagnosing pneumonia in individuals with HIV?

Answer 7

Tuberculosis (TB) diagnosis

High incidence areas should always consider TB as a potential diagnosis.

Question 8

What is the significance of Pseudomonas aeruginosa and Methicillin-Resistant Staphylococcus aureus (MRSA) in individuals with HIV?

Answer 8

Higher frequency as community-acquired pathogens

Risk factors include advanced HIV disease, corticosteroid use, and recent hospitalization.

Question 9

What clinical symptoms are characteristic of bacterial pneumonia in individuals with HIV?

Answer 9

• Fever
• Chills
• Chest pain
• Cough with purulent sputum
• Dyspnea

These symptoms typically have an acute onset over 3 to 5 days.

Question 10

What is the relationship between CD4 count and bacteremia in individuals with HIV?

Answer 10

Increased incidence of bacteremia with lower CD4 counts

Particularly significant with counts <100 cells/mm3.

Question 11

What factors are associated with increased mortality in individuals with HIV and pneumonia?

Answer 11

• CD4 count <100 cells/mm3
• Radiographic progression of disease
• Presence of shock

These factors are independent predictors of increased mortality.

Question 12

What is the recommended diagnostic evaluation for CAP in hospitalized patients with HIV?

Answer 12

• Gram stain of sputum
• Two blood cultures

Especially for those with severe pneumonia or low CD4 counts.

Question 13

True or False: The use of Procalcitonin (PCT) testing is recommended for guiding treatment decisions in HIV-associated bacterial pneumonia.

Answer 13

False

Specific PCT thresholds for HIV-associated pneumonia have not been established.

Question 14

Fill in the blank: The clinical diagnosis of bacterial pneumonia requires a demonstrable infiltrate by _______ or other imaging technique.

Answer 14

chest radiograph

This should be in conjunction with compatible clinical symptoms.

Question 15

What are the potential long-term outcomes associated with pneumonia in individuals with HIV?

Answer 15

• Greater long-term mortality
• Impaired lung function
• Increased risk of subsequent lung cancer

Hospitalization for pneumonia has been linked to increased mortality up to one year later.

Question 16

What is the recommendation for routine diagnostic tests in outpatients with HIV and CAP?

Answer 16

Optional, especially if microbiologic studies cannot be performed promptly.

Question 17

What diagnostic tests are recommended for hospitalized patients with HIV and severe CAP?

Answer 17

Gram stain of sputum and two blood cultures.

Question 18

When should specimens for diagnostic tests be ideally obtained in patients with HIV?

Answer 18

Before initiation of antibiotics or within 12 to 18 hours after initiation.

Question 19

What urinary antigen tests are recommended in hospitalized patients with severe CAP?

Answer 19

• L. pneumophila
• S. pneumoniae

Question 20

What additional testing should be performed for adults with severe CAP?

Answer 20

Culture for Legionella on selective media or nucleic acid amplification testing.

Question 21

When should rapid MRSA nasal testing be performed?

Answer 21

In patients with risk factors for MRSA or in a high prevalence setting.

Question 22

What is the yield of sputum cultures in patients with HIV?

Answer 22

Identifies bacterial etiology in up to 30-40% of good quality specimens.

Question 23

What should be done in patients with pleural effusion and concern for empyema?

Answer 23

Diagnostic thoracentesis should be performed.

Question 24

What is the importance of pneumococcal vaccination in people with HIV?

Answer 24

Prevents bacterial pneumonia and invasive pneumococcal disease.

Question 25

What is the recommendation for PPSV23 in patients with CD4 counts <200 cells/mm3?

Answer 25

Preferably deferred until CD4 count increases to >200 cells/mm3 while on ART.

Question 26

What should be administered to all people with HIV during influenza season?

Answer 26

Immunization against influenza with inactivated, standard dose or recombinant vaccine.

Question 27

What modifiable factors are associated with an increased risk of bacterial pneumonia?

Answer 27

* Smoking cigarettes * Using injection drugs * Consuming alcohol

Question 28

What is the general approach to antibiotic treatment of CAP in patients with HIV?

Answer 28

Same basic principles as for patients without HIV.

Question 29

What factors guide the decision for outpatient treatment versus hospitalization for CAP?

Answer 29

Severity of illness, ability to take oral medications, adherence, and confounding factors.

Question 30

What scoring systems can guide decisions regarding treatment location for CAP in people with HIV?

Answer 30

* Pneumonia Severity Index (PSI) * CURB-65 * ATS/IDSA severity criteria

Question 31

What should be considered when selecting empiric antibiotic therapy for patients with HIV?

Answer 31

Local resistance patterns, MRSA testing results, and individual patient risk factors.

Question 32

What are the preferred antibiotics for outpatient CAP treatment in individuals with HIV?

Answer 32

* Oral beta-lactam plus a macrolide * Respiratory fluoroquinolone

Question 33

What is the preferred beta-lactam for outpatient CAP treatment?

Answer 33

High-dose amoxicillin or amoxicillin-clavulanate.

Question 34

What is the role of TMP-SMX in preventing bacterial respiratory infections in HIV patients?

Answer 34

Should not be prescribed solely to prevent bacterial respiratory infection.

Question 35

What factors are associated with decreased risk of bacterial pneumonia in HIV patients?

Answer 35

* Use of ART * TMP-SMX for PCP prophylaxis

Question 36

What are the considerations for using respiratory fluoroquinolones in patients with suspected TB?

Answer 36

Use with caution as it may delay proper TB diagnosis and treatment.

Question 37

What clinical trial demonstrated the efficacy of PCV against vaccine-type IPD in adults with HIV?

Answer 37

A trial on 7-valent PCV (PCV7) in Malawi showed 74% efficacy.

Question 38

What is the significance of CD4 count in the management of patients with HIV and CAP?

Answer 38

CD4 count <200 cells/mm3 is associated with increased risk of death.

Question 39

What additional vaccines are recommended for people with HIV?

Answer 39

COVID-19 vaccination and H. influenzae type vaccine if indicated.

Question 40

What are the preferred beta-lactams for outpatient CAP?

Answer 40

High-dose amoxicillin or amoxicillin-clavulanate ## Footnote Alternatives include cefpodoxime or cefuroxime.

Question 41

What are the preferred macrolides for outpatient CAP?

Answer 41

Azithromycin or clarithromycin

Question 42

What should be used as an alternative to beta-lactam for patients allergic to penicillin?

Answer 42

A respiratory fluoroquinolone (moxifloxacin or levofloxacin)

Question 43

What should be given to patients with contraindications to a macrolide or fluoroquinolone?

Answer 43

Doxycycline in addition to a beta-lactam

Question 44

Why is empirical monotherapy with a macrolide not recommended for outpatient CAP in patients with HIV?

Answer 44

Due to increasing rates of pneumococcal resistance and potential treatment failure

Question 45

What is the recommendation for non-severe CAP inpatient treatment?

Answer 45

IV beta-lactam plus a macrolide or respiratory fluoroquinolone

Question 46

What has been found regarding beta-lactam monotherapy versus beta-lactam/macrolide combination therapy?

Answer 46

Beta-lactam monotherapy was not found to be non-inferior to combination therapy

Question 47

What are the preferred beta-lactams for inpatient treatment of non-severe CAP?

Answer 47

Ceftriaxone, cefotaxime, or ampicillin-sulbactam

Question 48

What should be used in patients who are allergic to penicillin?

Answer 48

A respiratory fluoroquinolone (moxifloxacin or levofloxacin)

Question 49

What is the treatment recommendation for severe CAP?

Answer 49

IV beta-lactam plus azithromycin or a respiratory fluoroquinolone

Question 50

What are the preferred beta-lactams for severe CAP treatment?

Answer 50

Ceftriaxone, cefotaxime, or ampicillin-sulbactam

Question 51

What should be added for patients with risk factors for Pseudomonas infection?

Answer 51

An antipneumococcal, antipseudomonal beta-lactam plus ciprofloxacin or levofloxacin

Question 52

What is the recommendation for empiric coverage for MRSA in patients with risk factors?

Answer 52

Vancomycin or linezolid should be added to the regimen

Question 53

What should be done when the etiology of pneumonia is identified?

Answer 53

Antimicrobial therapy should be modified and directed at the identified pathogen

Question 54

When should a switch to oral therapy be considered?

Answer 54

In patients with CAP on IV therapy who have improved clinically and can tolerate oral medications

Question 55

When should ART be initiated in patients with bacterial pneumonia not already on treatment?

Answer 55

Promptly within 2 weeks of initiating therapy for pneumonia

Question 56

What is a predictor for longer time to clinical stability in CAP patients with HIV?

Answer 56

Advanced HIV infection and CD4 count <100 cells/mm3

Question 57

What is the recommendation regarding pneumococcal and influenza vaccines for patients with HIV?

Answer 57

Patients should receive both vaccines as recommended

Question 58

What should be avoided to prevent recurrences of bacterial respiratory infections?

Answer 58

Antibiotic chemoprophylaxis

Question 59

What is the recommendation regarding smoking cessation for patients with pneumonia?

Answer 59

Patients should be encouraged to quit smoking

Question 60

What macrolide is recommended for use during pregnancy?

Answer 60

Azithromycin

Question 61

What is the recommendation for using quinolones during pregnancy?

Answer 61

Use only when a safer alternative is not available

Question 62

Why is doxycycline not recommended during pregnancy?

Answer 62

Due to increased hepatotoxicity and staining of fetal teeth and bones

Question 63

What is the risk of birth defects or musculoskeletal abnormalities associated with quinolone use in pregnant women?

Answer 63

No increased risk found ## Footnote Studies evaluating quinolone use in pregnant women did not find an increased risk of birth defects or musculoskeletal abnormalities.

Question 64

What antibiotic is not recommended for use during pregnancy due to hepatotoxicity and fetal teeth staining?

Answer 64

Doxycycline ## Footnote Doxycycline is associated with increased hepatotoxicity and staining of fetal teeth and bones.

Question 65

What are the beta-lactam antibiotics associated with in pregnancy?

Answer 65

No teratogenicity or increased toxicity ## Footnote Beta-lactam antibiotics have not been associated with teratogenicity or increased toxicity in pregnancy.

Question 66

What is the theoretical risk associated with aminoglycosides during pregnancy?

Answer 66

Fetal renal or eighth nerve damage ## Footnote A theoretical risk exists, but documented cases in humans are limited.

Question 67

What should be avoided during the first trimester of pregnancy if alternate agents are available?

Answer 67

Telavancin ## Footnote Use of telavancin should be avoided in the first trimester if alternate agents with more experience in use in pregnancy are available.

Question 68

What is a potential consequence of pneumonia during pregnancy?

Answer 68

Increased rates of preterm labor and delivery ## Footnote Pneumonia during pregnancy is associated with increased rates of preterm labor and delivery.

Question 69

When should pregnant women with pneumonia be monitored for evidence of contractions?

Answer 69

After 20 weeks’ gestation ## Footnote Pregnant women with pneumonia after 20 weeks’ gestation should be monitored for evidence of contractions.

Question 70

What pneumococcal vaccines were found to be safe and immunogenic in pregnant women with HIV?

Answer 70

PCV10 and PPSV23 ## Footnote A study found that PCV10 and PPSV23 were equally safe and immunogenic in pregnant women with HIV.

Question 71

What vaccine is recommended for all pregnant women during influenza season?

Answer 71

Inactivated influenza vaccine ## Footnote The inactivated influenza vaccine is recommended for all pregnant women during influenza season.

Question 72

What should be administered to pregnant women with HIV to minimize increases in plasma HIV RNA levels?

Answer 72

Vaccination after ART has been initiated ## Footnote Vaccination of pregnant women is recommended after ART has been initiated to minimize increases in plasma HIV RNA levels.

Question 73

What should be administered to all people with HIV regardless of CD4 count?

Answer 73

Pneumococcal vaccination ## Footnote All people with HIV regardless of CD4 count should receive pneumococcal vaccination.

Question 74

What should be administered at least 8 weeks after PCV15 for those without previous pneumococcal vaccination?

Answer 74

PPSV23 ## Footnote If PCV15 is used, a dose of PPSV23 should be administered at least 8 weeks later.

Question 75

What is the recommendation for adults age ≥65 regarding influenza vaccination?

Answer 75

High-dose IIV or adjuvanted IIV ## Footnote Adults age ≥65 years are recommended to receive high-dose IIV or adjuvanted IIV over standard-dose unadjuvanted vaccine.

Question 76

What is the preferred outpatient therapy for community-acquired pneumonia?

Answer 76

An oral beta-lactam + a macrolide ## Footnote Preferred therapy is an oral beta-lactam plus a macrolide (azithromycin or clarithromycin).

Question 77

What is the preferred therapy for hospitalized patients with non-severe community-acquired pneumonia?

Answer 77

An IV beta-lactam + a macrolide ## Footnote The preferred therapy is an IV beta-lactam plus a macrolide (azithromycin or clarithromycin).

Question 78

What is the duration of therapy for most patients with community-acquired pneumonia?

Answer 78

5–7 days ## Footnote The patient should be afebrile for 48–72 hours and clinically stable before discontinuation of therapy.

Question 79

What should be considered for patients who have improved and can tolerate oral medications?

Answer 79

Switch from IV to PO therapy ## Footnote A switch should be considered for patients who have improved clinically, can swallow and tolerate oral medications.

Question 80

What is the recommendation regarding empiric therapy with a macrolide alone?

Answer 80

Not routinely recommended ## Footnote Empiric therapy with a macrolide alone is not routinely recommended because of increasing pneumococcal resistance.