Transcript Community Acquired Pneumonia Prof. Adel Khattab , MD, FCCP
Community Acquired Pneumonia
Prof. Adel Khattab , MD, FCCP
Prof. & Head Of Pulmonary Medicine Dept. Ain Shams University Advisor of the MOH for Chest Diseases & Aviian Flu
ETIOLOGY OF CAP
Conventional diagnostic testing for CAP is imperfect e.g role of sputum isolates in diagnosing aetiology of LRTI is controversial (colonization)
No sufficiently rapid and accurate battery of diagnostic tests for CAP are available presently
Etiology remains unknown in up to 50% of cases
However, local knowledge of likely pathogen is imperative
Carroll KC. J Clin Micro 2002;40:3115-3120 Bartlett et al. NEJM 1995;333:1618-1624 Niederman et al. Am J Respir Crit Care Med 2001;163:1730-1754
Etiology of Community Acquired Pneumonia
Legionella 3% Chlamydia Mycoplasma 13% 3% H. influenzae 7% Other bacteria 7% S. pneumoniae 48% Viral 19% W S Lim,J T Macfarlane, et al. Thorax 2001;56:296-301
Aspiration Pneumonia
The bacteriology of aspiration pneumonia arising in the community setting has been confusing, and the exact role of anaerobes is uncertain.
Thus, the level of involvement of enteric Gram-negative pathogens in aspiration related illnesses is quite high and must be considered when selecting therapy.
The Disease Process
Definition: Signs/symptoms of acute infection plus acute infiltrate or auscultatory findings Signs and symptoms: chill and/or fever, pleuritic chest pain, productive cough, tachypnea, tachycardia, rales and/or consolidation Clinical sequelae: bacteremia, metastatic foci of infection, death No association between signs/symptoms and bacterial etiology Bartlett JG, et al
. Clin Infect Dis.
2000;31:347-82. Donowitz GR, Mandell GL.
Principles and Practice of Infectious Diseases
1995:619-37. Fang GD, et al
. Medicine (Baltimore).
1990;69:307-16.
IDSA / ATS Consensus Guidelines on the Management of CAP in Adults 2007
Advantages of Guidelines
Synthesize large amounts of information Define the strength of existing data (evidence grading) Discuss and define relevant management issues, providing an orderly approach Help guide accurate initial empiric therapy Provide a standard against which care can be evaluated Focus on cost-effective management Identify defects in knowledge base to direct future research Tool to improve patient outcomes 29
Concerns About Guidelines
Management without thought Deviations may be basis for discipline If experts cannot all agree, how can we have accurate guidelines?
What do we do if the existing knowledge base is of poor quality?
How strong should new data be before changing and updating guidelines?
30
Inpatient Community-Acquired Pneumonia Guideline Adherence Improves Mortality
1.00
Guideline-Concordant Antibiotics (n=323) 0.95
0.90
Nonguideline-Concordant Antibiotics (n=97) 0.85
0.80
0.75
0 10 20 Days from Presentation 30
Mortensen EM, et al.
Am J Med
. 2004;117:726-731.
Implementation of Guideline Recommendations
Locally adapted guidelines should be implemented to improve process of care variables and relevant clinical outcomes. (Strong recommendation; level I evidence.)
Management of CAP:
Site-of-Care Decisions Hospitalization ?
ICU admission?
Assess the ability to safely and reliably take oral medication & the availability of outpatient support resources
Recommended diagnostic tests for etiology
Pretreatment Gram stain and culture of expectorated sputum should be performed only if a good-quality specimen can be obtained and quality performance measures for collection, transport, and processing of samples can be met. (Moderate recommendation; level II evidence.)
Recommended diagnostic tests for etiology (cont.)
Patients with severe CAP, as defined above, should at least have blood samples drawn for culture, urinary antigen tests for
Legionella pneumophila
and
Streptococcus pneumoniae
performed, and expectorated sputum samples collected for culture. For intubated patients, an endotracheal aspirate sample should be obtained. (Moderate recommendation; level II evidence.)
Serum Markers To Predict CAP Outcomes
The two serum markers that have been most widely studied for this purpose are CRP and PCT . In general, both measures have been used to correlate with outcomes, but more data have recently been collected with PCT , and the most exciting finding has been that serial measures correlate not only with outcomes, but may also be useful for guiding the duration of therapy.
Reasons to Perform Diagnostic Testing
Confirm the presence of community-acquired pneumonia: chest radiograph, serum markers Establish an etiologic diagnosis Proper therapy: look for unusual or resistant pathogens Epidemiologic purposes: eg,
Legionella
spp and environmental source, design of future empiric treatment Focused and tailored therapy: proper duration, de-escalate, escalate Determine severity and prognosis: bacteremia, procalcitonin, C-reactive protein Define duration of therapy: procalcitonin 66
Reasons NOT to Perform Diagnostic Testing
Expensive Time consuming May delay therapy Low yield of true positives: role of prior antibiotics False positive may add to overuse of antibiotics False negatives may lead to undertreatment Mixed infection (atypicals) may not be detected, yet needs therapy No effect on outcome 67
Therapy
General & supportive
Therapy
Antibiotic
• Fluid / diet • Antipyretics • Cough syrup • O 2 therapy • TTT of complications & Coexisting illness
CAP:
When to start empiric therapy?
As soon as possible in ED
CAP: delay-to-AB> 4h after arrival
Increased mortality Increased LOS
IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:S27–72
Recommended empirical antibiotics for CAP:
Outpatient
1 Previously healthy and no risk factors for drug resistant S. pneumoniae (DRSP) infection:
a)
Macrolides
(Azithromycin, clarithromycin or erythromycin)
(strong recommendation; level I evidence)
b)
Doxycycline
(weak recommendation; level III evidence)
IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:S27–72
Recommended empirical antibiotics for CAP:
Outpatient
2. Presence of comorbidities
such as heart, lung, or renal disease, diabetes, alcoholism, malignancies, Asplenia, immunosuppressing conditions or drugs; Antibiotic Use in last 90 days, or other risks of DRSP infection a) Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) (strong recommendation; level I evidence) b) B-lactam plus a macrolide (strong recommendation; level I evidence)
IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:S27–72
Recommended empirical antibiotics for CAP:
Outpatient
Presence of comorbidities a) B-lactam plus a macrolide
High-dose amoxicillin [e.g. 1 g 3 times daily] or Amoxicillin-clavulanate [2 g 2 times daily]
Alternatives
: Ceftriaxone, Cefpodoxime & Cefuroxime, Doxycycline alternative to macrolide
IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:S27–72
Recommended empirical antibiotics for CAP:
Inpatient, Non-ICU ttt
a) Respiratory fluoroquinolone
(strong recommendation; level I evidence)
b) b-lactam plus a macrolide Cefotaxime, Ceftriaxone, Ampicillin, or Ertapenem
(strong recommendation; level I evidence) Doxycycline as an alternative to the macrolide.
(weak recommendation; level III evidence)
IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:S27–72
Recommended empirical antibiotics for CAP:
Inpatient, ICU ttt
A) b-lactam plus either azithromycin
(level II evidence)
or a respiratory fluoroquinolone
(strong recommendation; level I evidence)
(cefotaxime, ceftriaxone, or ampicillin-sulbactam) IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:S27–72
Recommended empirical antibiotics for CAP:
Inpatient, ICU ttt
•
If Pseudomonas is a consideration Antipseudomonal b-lactam
(piperacillin-tazobactam, cefepime, imipenem, or meropenem)
+ either ciprofloxacin or levofloxacin
(750 mg dose)
Or The above b-lactam + aminoglycoside & azithromycin Or The above b-lactam + aminoglycoside & an antipneumococcal fluoroquinolone IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:S27–72
Recommended empirical antibiotics for CAP:
Inpatient, ICU ttt
•
Community Acquired MRSA (CA-MRSA)
If CA-MRSA is a consideration
add vancomycin or linezolid
IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:S27–72
Switch from intravenous to oral therapy.
Patients should be switched from intravenous to oral therapy when they are hemodynamically stable and improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract.
(Strong recommendation; level II evidence.)
Approaches to Switching from IV to oral therapy 1. Step – down therapy: Conversion from one antibiotic given IV to another given orally.
2. Transitional – therapy: Conversion from same antibiotic given IV to oral but not at the same dosage or strength.
3. Sequential – therapy: Conversion from same antibiotic IV to oral at the same dosage and strength.
CAP: Duration of Therapy
“A minimum of 5 days… Afebrile for 48-72 h (level I evidence), … No more than1 CAP associated sign of Clinical instability “
IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:S27–72
Duration of antibiotic therapy
A longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extra-pulmonary infection, such as meningitis or endocarditis. (Weak recommendation; level III evidence.)
Considerations for patients worsening or failing to improve by day three
• Predisposing condition requiring >3 days for improvement (continue present Rx) e.g. elderly patient • Incorrect diagnosis or complicating condition • Common: Pulmonary embolism or infarction, carcinoma, pulmonary edema, bronchiectasis, etc.
• Uncommon: Pulmonary eosinophilia, alveolar hemorrhage, foreign body • Unexpected pathogens: eg, mycobacteria, MRSA etc.