Transcript CAP

Management of Community Acquired Pneumonia
ATS/IDSA Guidelines 2006
Mazen Kherallah, MD, FCCP
Consultant, Infectious Disease and Critical Care Medicine
King Faisal Specialist Hospital & Research Center
www.icumedicus.com
CAP Guidelines
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BTS, Canadian, ATS (1993)
IDSA, ERS (1998)
DRSPTWG (2000)
IDSA (2000), Canadian (2000), JRS (2000)
ATS (2001), BTS (2001)
IDSA (2003) Mandell et al; CID (2003)
ATS/IDSA (2006)
Site of Care
Site of Care
 Significant impact on:
 Extent of laboratory evaluation
 Antimicrobial therapy
 Advantage of outpatient therapy:
 Cost
 Patient preference
 Faster convalescence and avoidance of nosocomial
complications
 Decisions:
 Hospital vs outpatients
 Intensive care vs general wards
Pneumonia Severity Index
Class
Points
Mortality*
Site of Care
I
<51
0.1%
OutPatient
II
51-70
0.6%
OutPatient
III
71-90
2.8%
In or OutPatient
IV
91-130
9.5%
Inpatient
V
>130
26.7%
Inpatient
CURB-65 Score:
1
1
1
1
1
Confusion (new disorientation in person, time or place)
Score
% Mortality
Site of Care
0 Elevation of blood 0.7
Outpt (BUN)
Urea, or blood urea nitrogen
(BUN)
1 level above 7 mmol/L
1-3.2(urea) or 20 mg% Outpt
30 breaths/min Hospital
2 Respiratory rate >=2-9
3
17
ICU
Low Blood pressure, < 90 mm Hg systolic OR =<60
4 mm Hg diastolic 41.5
ICU
5 Age >= 65 years 57
ICU
Lim et al. Thorax 2003;58:377
Clinical Indications for more Extensive Diagnostic
Testing.
Minor criteria
Major criteria
Respiratory rate 30 breaths/min
Invasive mechanical ventilation
PaO2/FiO2 ratio 250
Septic shock with the need for vasopressors
Multi-lobar infiltrates
Confusion/disorientation
Uremia (BUN level, 20 mg/dL)
Leukopenia (WBC count, >4000 cells/mm3)
Thrombocytopenia (platelet count, !100,000
cells/mm3)
Hypothermia (core temperature, <36°C)
Hypotension requiring aggressive fluid
resuscitation
Recommended ICU admission if either major or at least three minor criteria
Diagnostic Testing
Clinical Diagnosis
 Cough, fever,
sputum production,
and pleuritic chest
pain)
 Supported by
imaging of the lung,
usually by chest
radiography.
Clinical Indications for more Extensive Diagnostic
Testing.
Recommended Diagnostic Tests for Etiology
Pathogen
Rapid Test
Standard Test
Other
S. Pneumoniae
Gram stain
Urine antigen
Blood and
respiratory
cultures
H. Influenzae
Gram stain
Blood culture
M. Pneumoniae
PCR*
Ab-ELISA1
Culture
C. Pneumoniae
PCR*
Ab-MIF2
Culture
L. pneumophilia
Urine antigena
PCR*
DFA3
Respiratory
culture
Ab-IFA
Culture
(media)
•Not FDA approved
a sensitivity 60-80%; specificity >90%
1 IgM (1-50 weeks),, 2 Primary infection-IgM (4-6 weeks) IgG (often >6 weeks); 3 False positives with sputum.
Urinary Antigen for S. pneumoniae (UrSp)
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Immunochromatographic test
Sensitivity 50-80% (80-90% for bacteremia)
Specificity ~ 90%
In prospective study, of 269 patients with CAP and no
pathogen identified, UrSp detected in 69 (27.5%)
[Gutierrez et al. CID, 2003]
 False positive in children (oropharyngeal
colonization); Streptococcus spp. Bacteremia
 Recommended as ancillary test (not as substitute for
culture)
Mandell L et al. Clin Inf Dis, 2003
Blood Cultures
 Blood cultures for all inpatients probably has some benefits, but
limited and associated with increased cost and inappropriate
antibiotic
 False positive > true pathogen in less ill patients
 Strategy which targets higher risk patients seems reasonable
 Limit number of blood cultures by
 Targeting the patients at highest risk of bacteremia (Mastesky, Am J Resp
Crit Care Med, 2004)
 Targeting patients with highest risk of mortality (Fine, NEJM 1997)
 New CMS/JCAHO
 All patients with severe CAP (ICU)
 Optional for general ward patients (but not discouraged)
 If drawn in ER, before administration of antibiotics
Antibiotic Treatment
Most common etiologies of community-acquired
pneumonia
Ambulatory Patients
Hospitalized (Non-ICU)2
Severe (ICU)2
S. pneumoniae
S. pneumoniae
S. pneumoniae
M. pneumoniae
M. pneumoniae
Legionella spp.
H. Influenzae
C. pneumoniae
H. Influenzae
C. pneumoniae
H. Influenzae
Gram-negative bacilli
Respiratory viruses3
Legionella spp.
S. aureus
Aspiration
Respiratory viruses3
1Based
on collective data from recent studies
Pneumocystis spp.
3Influenza A and B, adenovirus, respiratory syncytial virus, and parainfluenza.
2Excluding
Adapted from File T. Lancet 2003
Risk factors for infection with b-lactam–resistant
S. pneumoniae
 Age <2 years or >65 years
 Previous b-lactam therapy within the previous 3
months
 Alcoholism
 Medical comorbidities
 Immunosuppressive illness or therapy
 Exposure to a child in a day care center
Treatment of Respiratory Tract Infections
 Empiric
 Historically ß-lactams have been the agent of choice
 Publication of treatment guidelines for CAP in the
1990s recommend macrolides for first-line use*
 Increase in macrolide use worldwide
 Also an increase in macrolide resistance
 Macrolide resistance is now more common in some areas
than ß-lactam resistance
*Niederman MS et al. Am Rev Resp Dis 1993;148:1418-1426
Antibiotic Choice: Outpatient
PSI <91 (Class I, II, III) or CURB-65 score 0-1
Previously healthy and no risk factors for
drug-resistant S. pneumoniae (DRSP)
infection:
A. A macrolide (azithromycin,
clarithromycin, or erythromycin) (strong
recommendation; level I evidence)
B. Doxycycline (weak recommendation; level
III evidence)
•Presence of comorbidities, such as
chronic heart, lung, liver, or renal disease;
diabetes mellitus; alcoholism; malignancies;
asplenia; immunosuppressing conditions or
use of immunosuppressing drugs;
•Use of antimicrobials within the previous
3 months:
A. A respiratory fluoroquinolone
(moxifloxacin, gemifloxacin, or levofloxacin)
(strong recommendation; level I evidence)
B. A b-lactam plus a macrolide (strong
recommendation; level I evidence): High
dose amoxicillin, amoxicillin-clavulanate
ceftriaxone, cefpodoxime, and cefuroxime.
Doxycycline [level II evidence] is an
alternative to the macrolide.
In regions with a high rate (>25%) of
infection with high-level (MIC >16 mg/mL)
macrolide-resistant S. pneumoniae,
Consider the use of alternative agents listed
above for any patient, including
those without comorbidities. (Moderate
recommendation; level III evidence.)
Antibiotic Choice: Inpatient
PSI >90 (Class IV) or CURB-65 score 2-5
Inpatient:
Non-ICU
Treatment
• Respiratory fluoroquinolone (strong recommendation; level I evidence)
• B-lactam plus a macrolide (strong recommendation; level I evidence) (cefotaxime,
ceftriaxone, and ampicillin; ertapenem for selected patients)
Inpatient,
ICU
Treatment
• B-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin (level
II evidence) or a fluoroquinolone (level I evidence) (strong recommendation)
• For Pseudomonas infection, use an antipneumococcal, antipseudomonal b lactam
(piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or
levofloxacin
or
the above b-lactam plus an aminoglycoside and azithromycin
or
the above b-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone
(Moderate recommendation; level III evidence.)
• For community-acquired methicillin resistant Staphylococcus aureus infection, add
vancomycin or linezolid. (Moderate recommendation; level III evidence.)
IDSA:2006
Atypicals et al
S. Pneumonia
H. Flu
Viral
Others
Penicillin I or R 47%
PSI <91 (Class I, II, III) or CURB-65 score 0-1
Previously well, no prior ATB
Macrolide, (azithromycin, clarithromycin, or erythromycin)
Doxycycline
Medical morbidity or use of antimicrobials
within the previous 3 months
Respiratory fluroquinolone* (levofloxacin, gatifloxacin, moxifloxacin, gemifloxacin)
High dose β-lactam + macrolide
Risk of aspiration
Am-CL; Clindamycin
PSI >90 (Class I, II, III) or CURB-65 score 2-5
General Word
Respiratory fluroquinolones
β-lactam* + macrolide
ICU
No risk for pseudomonas
β-lactam* + macrolide or
respiratory quinolone
*Amox-CL, Cefotaxime, Ceftriaxone or Ertapenem
**Pipercillin, imipenem, meropenem, cefepime
***Moxifloxacin, gemifloxacin, levofloxacin
Risk for psudomonas: brinchiectasis, recent ATB, prior ICU hospitalization
Antipseudomonas β-lactam** + ciprofloxacin
Time to First Antibiotic Dose
Timing of Antibiotic Administration
 IDSA 2000: within 8 hours (Meehan et al. JAMA, 1997)
 IDSA 2003: “Goal” within 4 hours (ouck et al: Arch
Intern Med 2004; 164:637-44)
 A problem of internal consistency is also present,
because, in both studies, patients who received
antibiotics in the first 2 h after presentation actually did
worse than those who received antibiotics 2–4 h after
presentation.
 The first antibiotic dose should be administered while
still in the ED. (Moderate recommendation; level III
evidence.)
Switch from Intravenous to Oral Therapy
Switch from Intravenous to Oral Therapy
 Patients should be switched from intravenous to oral
therapy when they are:
 Hemodynamically stable
 Improving clinically
 Are able to ingest medications
 Have a normally functioning gastrointestinal tract.
(Strong recommendation; level II evidence.)
 Patients should be discharged as soon as they are:
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clinically stable
Have no other active medical problems
Have a safe environment for continued care.
Inpatientobservation while receiving oral therapy is not
necessary.
(Moderate recommendation; level II evidence.)
Criteria for clinical stability.
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Temperature 37.8C
Heart rate 100 beats/min
Respiratory rate 24 breaths/min
Systolic blood pressure 90 mm Hg
Arterial oxygen saturation 90% or pO2 60 mm Hg
on room air
 Ability to maintain oral intake
 Normal mental status
Criteria for clinical stability.
Halm EA, et al.. Arch Intern Med 2002; 162:1278–84.
Duration of Therapy
Community-Acquired MRSA
Case of Severe CAP
 30 year old female
presents to ER at 04:00
with acute fever, dough,
and dyspnea
 Recent ‘viral syndrome’
 Severe hypoxemia
 Requires immediate
intubation
 Treated with 3rd gen ceph
pluse fluroquinolone
Case of Severe CAP
 Gram stain of ET
aspirate reveals
GPC in clusters
 Vancomycin was
added
 Patient has multiorgan dysfunction
expires at 16:00
 CA-MRSA isolated
Case of Severe CAP
 Gram stain of ET
aspirate reveals
GPC in clusters
 Vancomycin was
added
Case of Severe CAP
 Patient has multiorgan dysfunction
expires at 16:00
 CA-MRSA isolated
CA-MRSA Pneumonia
 Newly recognized pathogen: communityonset MRSA
 Genotypically and phenotypically distinct
HA-MRSA
 Often associated with severe disease
 Panton
Valentine Leukocidin (PVL)
 Associated with preceding influenza
 Pending new data; vancomycin or linezolid
recommended for initial therapy for severe
disease
Framcis et al. Clin Inf Dis. 2004;40:100-7, Wago and Eiland Clin Infect Dis. 2005;40:1376
Response to Therapy
Thank You