Transcript Appropriate Antibiotics Use in CAP and HCAP at Sisters

Appropriate Antibiotics use in
CAP and HCAP at Sisters
Hospital in 2008.
Syed Faraz Masood, MBBS
Nashat H. Rabadi, MD, FCCP
Community Acquired Pneumonia
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Common : 5 to 6 million cases/year
20% are hospitalized ( 10% in ICU)
No. 1 cause of death from infectious disease
No. 6 cause of death in adults
Mortality rates :
– Outpatients = 1-5%
– Inpatients = 12% ( higher in ICU- 50%)
• Costs : 9.7 billion
: inpatient – $7,517 vs. outpatient - $264
CAP
Definition
• CXR – infiltrate
• Auscultatory findings
• Signs of RTI
– Cough +/- sputum
– Fever or hypothermia
– WBC
CAP - Pathogenesis
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Aspiration
Inhalation
Hematogenous
Direct extension
Reactivation
RESPIRATORY PATHOGENS IN CAP
Respiratory Pathogens in CAP
Risk Factors.
• Age.
• Smoking.
• Co-morbid Conditions.
• Poor Prognosis.
– Pleural Effusion.
– Bacteremia.
Cultures.
• Sputum Cx
– Not needed as outpatient.
– May or may not be needed inpatient.
• Blood Cx
• Urinary Antigens.
CURB - 65
C – Confusion
U – Urea. BUN > 20
R – Respiratory rate > 30 / min
B – Blood pressure . SBP < 90 or DBP < 60
65 – Age > 65
Number of factors
0
1
2
3
4
5
Mortality Rate
0.7%
2.1%
9.2%
14.5%
40%
57%
Management.
• Site of Care:
– Inpatient vs. outpatient.
– Floor vs. ICU.
• PSI
• CURB 65
Empirical Treatment
• Hospitalized Patients:
– 2nd or 3rd generation Cephalosporins plus a
Macrolide.
– Floroquinolones.
• For all critically ill patients,
– 2nd or 3rd generation Cephalosporin + Macrolide or
Floroquinolones – necessary to provide coverage for
Legionella Pneumophilia.
– Change antibiotics – based on culture and sensitivity.
Nosocomial Pneumonia
• Hospital Acquired Pneumonia:
– > 48 hours of admission to hospital.
• Ventilator associated Pneumonia.
– > 48 hours of intubation.
Health-care Associated
Pneumonia.
• Antimicrobial therapy in preceding 90
days.
• Hospitalization for 2 or more days in the
preceding 90 days.
• Residence in a NH or an extended care
facility.
• Home infusion therapy.
• Chronic Dialysis within 30 days.
• Immunosuppressive state and/or therapy.
Health-care Associated
Pneumonia.
• Epidemiology extrapolated from HAP/VAP
• Second most common Nosocomial
Infection.
• High morbidity / mortality.
• Increase hospital stay by 7-9 days.
• Excess cost of $ 40,000 per patient.
• Early VAP/HAP (<5 days)
– Similarly as CAP
– No MDR pathogens.
• Late VAP/HAP (>5 days) treated similarly
as HCAP:
– MDR pathogens.
Microbiology
• Polymicrobial.
– Methicillin-resistant Staphylococcus Aureus.
– Pseudomonas Aeruginosa.
– Acinetobacter
– E.Coli
– Klebsiella Pneumoniae (ESBL).
Increased crude and attributable mortality
associated with MDR pathogens.
Pathogenesis of HCAP
• Colonization: Lower Respiratory Tract.
• Aspiration; inhalation.
• Host-related: severity of illness, prior
surgery.
• Environment-related: antibiotic exposure,
medications, invasive devices.
• Host’s mechanical, humoral and cellular
defenses.
Diagnosis
• Lower Respiratory Tract Cultures:
– Sputum Cultures.
– Endotracheal aspirates.
– Bronchoscopy
• Broncho-alveolar Lavage (BAL).
• Protected Brushed Specimen (PBS).
Empirical Treatment
• Anti-pseudomonal cephalosporins
or
• Anti-pseudomonal cabrapenems
or
• Beta-lactam/beta-lactamase inhibitors
And
• Anti-pseudomonal floroquinolones.
PLUS
• Vancomycin or Linezolid.
HAP,VAP or HCAP Suspected
Obtain Blood & Lower Respiratory Tract
Cultures
Early, Appropriate, Adequate Antibiotics
Assess Clinical Response
Check Microbiology
Clinical Improvement (24-48 hrs)
NO
Search for Complications:
Abscess or Empyema
Untreated Pathogen
Non-Infectious Cause
ATS Consensus Statement. AJRCCM 171: 2005
YES
• Streamline Antibiotics.
• Treat Uncomplicated
patients for 7 days.
• Reassess & Follow up.
Mortality in Nosocomial
Pneumonia.
• Presence of MDR pathogens.
• Initial Inappropriate antibiotics.
• Co-morbidities.
Initial Inadequate Therapy Increases
Mortality
Alvarez-Lerma,1996
Initial adequate
therapy
Rello, 1997
Initial inadequate
therapy
Kollef, 1999
Kollef, 1998
Ibrahim, 2000
Luna, 1997
0
20
40
60
80
100
% Mortality
Alvarez-Lerma F, et al. Intensive Care Med. 1996;22:387-394.
Ibrahim EH, et al. Chest. 2000;118L146-155.
Kollef MH, et al. Chest. 1999; 115:462-474.
Kollef MH, et al. Chest. 1998;113:412-420.
Luna CM, et al. Chest. 1997;111:676-685.
Rello J, et al. Am J Respir Crit Care Med. 1997;156:196-200.
Adequate Therapy Reduces Mortality Only If
Selected Prior to Identification of the Pathogen
100
P<.001
90
80
P=NS
No Antibiotic
Adequate Antibiotic
Inadequate Antibiotic
% Mortality
70
P=NS
60
50
40
30
20
10
0
Pre-BAL
BAL=bronchoalveolar lavage. NS=Not significant.
Luna CM, et al. Chest. 1997;111:676-685.
Post-BAL
Post-result
Research Question
• Appropriateness of CAP treatment at
Sister’s Hospital.
• Appropriateness of HCAP treatment at
Sister’s Hospital.
• Mortality.
• Length of Stay.
Method
• IRB approval.
• HIPAA Compliance.
• 248 charts reviewed with diagnosis of
pneumonia.
• Retrospective analysis.
• Single institution (Community Hospital setting).
• 1 Calendar year. (Jan 1st – Dec 31st 2008)
Classification
150
100
Patients
50
0
CAP HCAP HAP
Patients
143
90
10
VAP
No
PNA
2
3
Community Acquired Pneumonia
58%
60%
50%
42%
40%
< 65 years
> 65 years
30%
20%
10%
0%
< 65 years
> 65 years
Gender
56%
54.5%
54%
52%
50%
48%
45.5%
46%
44%
42%
40%
females
males
females
males
Annual Frequency.
25
20
15
Frequency
10
5
0
J
F
M
A
M
J
J
A
S
O
N
D
• Antibiotics administered in ER: 100%
• Appropriate antibiotics:
93.2%
• Cultures performed:
95.7%
• Positive Cultures:
8.1%
Coverage
120
100
101
80
60
42
40
20
0
NonHousestaff
Housestaff
NonHousestaff
Housestaff
Cultures
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Blood Cx
Sputum Cx
No Cultures
Blood Cx
Sputum Cx
No Cultures
Urinary Antigens for
S.pneumo/Legionella
45%
55%
U-Ag done
U-Ag not done
Positive Cultures
140
120
100
80
60
40
20
0
Sputum
Blood
U-antigens
Others
Positive Cultures
11
4
2
1
Total Cultures
67
131
82
Microbiology of CAP
Influenza (2)
Strep. Pneumo
(4)
MRSA (1)
Stenotrophom
onas (1)
MSSA (1)
H. Influenzae
(2)
P.Aerugino (2)
M.Cat (1)
Choice of Initial Antibiotics
Others
5%
Levaquin
19%
Rocephin/Zithromax
Levaquin
Others
Rocephin
Zithromax
76%
Mortality
– Number of Deaths:
6/143
– Mortality Rate:
4.2%
– Average Length of Stay:
5.8 days.
Health-care Associated
Pneumonia.
67%
70%
60%
50%
40%
33%
< 65 years
> 65 years
30%
20%
10%
0%
< 65 years
> 65 years
Gender
80%
71%
70%
60%
50%
40%
29%
30%
20%
10%
0%
females
males
females
males
Annual Frequency
14
12
10
8
6
4
2
0
J
F
M
A
M
J
J
Months.
A
S
O
N
D
Multi-Drug Resistant Risk Factors
50
40
30
20
MDR risk factors
10
0
MDR risk
factors
LTCF
IS
PH
HD
47
24
31
9
Initial Antibiotic Coverage in ER
80
60
Appropriate
40
'Partially'
Appropriate
Inappropriate
20
0
Appropriate
Antibiotic
4
'Partially'
Inappropriate
Appropriate
15
71
Initial Antibiotics Choice
Vanco/
Zosyn(1)
Ceftriaxone
(4)
Zyvox/
Premaxin (1)
Vanco/
Zosyn/
Levaquin (1)
Vanco/
Imipenem (1)
Levaquin
(14)
antibiotics
Rocephin/
Zithromax
(50)
Other Combinations used…
• Vanco/Zithro
• Levaquin/Genta/Aztre
onam.
• Levaquin/Aztreonam
• Levaquin/Aztreonam/
Clindamycin.
• Levaquin/Ceftazidime
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Aztreonam/Zithro
Levaquin/Zithro
Clindamycin
Primaxin/Zithromax
Levaquin/Clindamycin
Zosyn/Zithromax
Zosyn/Levaquin.
Coverage.
80
60
NonHousestaff
Coverage
Housestaff
Coverage
40
20
0
Coverage
NonHousestaff
Coverage
Housestaff
Coverage
65
25
Appropriately changed within 24
hours of admission
70
60
50
40
30
Antibiotics
Total Patients
20
10
0
Non-housestaff
Housestaff
Antibiotics
6
8
Total Patients
65
25
9.2%
32%
Appropriate Change in Subgroups
in Covered Patients.
10
8
6
4
Appropriate
Total
2
0
LTCF
IS
PH
HD
Appropriate
5
2
1
0
Total
10
10
2
3
100%
90%
80%
70%
60%
Blood Cx
Sputum Cx
No cultures
50%
40%
30%
20%
10%
0%
Cultures.
Blood Cx
Sputum Cx
No cultures
95.50%
45.50%
2.22%
Urinary Antigens for
S.pneumo/Legionella
49%
51%
U-Ag done
U-Ag not done
Positive Cultures
100
80
60
Positive Cultures
Total Cultures
40
20
0
Sputum
Blood
U.Antigens
Other
Positive Cultures
11
4
5
1
Total Cultures
41
86
46
Microbiology
Stenotropho
Actinobacter monas (1)
CMV (1)
(1)
MSSA (1)
S.Pneumo
(8)
P.Aerugino
(3)
MRSA (6)
• Appropriate antibiotics in ER:
4.4%
• Partially appropriate in ER:
15.5%
• Inappropriate antibiotics in ER:
78.8%
• Appropriate change in 24 hours:
16.27%
• Cultures performed:
97.7%
• Positive cultures:
18.1%
• Average Length of Stay:
9.5 days
• Average age:
71.2 years
Mortality
• Total Number of Deaths:
11/90
• Mortality Rate:
12.2%
• Deaths on Inappropriate Antibiotics: 9/11
Comparison
Variables
HCAP
CAP
Age
Females
Sputum Cx yield
71.2 years
71.5%
26.8%
69 years
54.5%
16.2%
Blood Cx yield
Urinary Ag yield
Mortality
4.6%
10.8%
12.4%
3.2%
2.4%
4.2%
LOS
Housestaff
covered
9.5 days
27.7%
5.8 days
29.3%
Where’s the problem?
Pneumonia
CAP
RECOGNIZE
THE
DIFFERENCE
HCAP
HAP,VAP or HCAP Suspected
Obtain Blood & Lower Respiratory Tract
Cultures
Early, Appropriate, Adequate Antibiotics
Assess Clinical Response
Check Microbiology
Clinical Improvement (24-48 hrs)
NO
Search for Complications:
Abscess or Empyema
Untreated Pathogen
Non-Infectious Cause
ATS Consensus Statement. AJRCCM 171: 2005
YES
• Streamline Antibiotics.
• Treat Uncomplicated
patients for 7 days.
• Reassess & Follow up.
Strategies to Improve HCAP
Outcomes
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Education.
Order Sheets.
De-escalation.
Consultation.
Re-evaluation.
References
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National Center for Health Statistics. Health, United States, 2006, with chart book on trends in
the health of Americans. Available at: http://www.cdc.gov/nchs/data/hus/hus06.pdf. Accessed
17 January 2007.
American Thoracic Society; Infectious Diseases Society of America. (2005). "Guidelines for the
management of adults with hospital-acquired, ventilator-associated, and healthcare-associated
pneumonia". Am. J. Respir. Crit. Care Med. 171 (4): 388–416.
Alvarez-Lerma F, et al. Modification of empiric antibiotic treatment in patients with pneumonia
acquired in the intensive care unit. Intensive Care Med. 1996;22:387-394
Ibrahim EH, et al. The Influence of Inadequate Antimicrobial Treatment of Bloodstream
Infections on Patient Outcomes in the ICU Setting*. Chest. 2000;118L146-155.
Kollef MH, et al. Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital
Mortality Among Critically III Patients. Chest. 1999; 115:462-474.
Kollef MH, et al. The Influence of Mini-BAL Cultures on Patient Outcomes*: Implications for
the Antibiotic Management of Ventilator-Associated Pneumonia Chest. 1998;113:412-420.
Luna CM, et al. Impact of BAL Data on the Therapy and Outcome of Ventilator-Associated
Pneumonia*. Chest. 1997;111:676-685.
Rello J, et al. The Value of Routine Microbial Investigation in Ventilator-Associated Pneumonia
Am J Respir Crit Care Med. 1997;156:196-200.
Acknowledgement
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Dr. Nashat Rabadi.
Cliff Gadra and the Medical Records team.
Dr. Varuna Nargunan.
Danielle Casucci.
Dr. Sateesh Satchidanand
IRB team.
Thank You!