Transcript Community aquired pneumonia File

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 CommunityAcquired Pneumonia
Chlamydia
13%
Legionella
3%
Mycoplasma
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 aspirationrelated 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
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Signs and symptoms:
chill and/or fever, pleuritic
chest pain, productive cough,
tachypnea, tachycardia, rales
and/or consolidation
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Clinical sequelae: bacteremia,
metastatic foci of infection,
death
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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
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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
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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?
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Inpatient Community-Acquired Pneumonia
Guideline Adherence Improves Mortality
1.00
Probability of Survival
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
Mortensen EM, et al. Am J Med. 2004;117:726-731.
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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
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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.)
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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
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Confirm the presence of community-acquired pneumonia:
chest radiograph, serum markers
Establish an etiologic diagnosis
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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
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Reasons NOT to Perform
Diagnostic Testing
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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
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Therapy
General & supportive
Therapy
Antibiotic
• Fluid / diet
• Antipyretics
• Cough syrup
• O2 therapy
• TTT of complications & Coexisting illness
CAP: When to start empiric therapy?
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As soon as possible in ED
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CAP: delay-to-AB> 4h after arrival
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Increased mortality
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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 drugresistant 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 (750mg 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.
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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:
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Conversion from one antibiotic given IV to
another given orally.
2. Transitional – therapy:
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Conversion from same antibiotic given IV to
oral but not at the same dosage or strength.
3. Sequential – therapy:
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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 CAPassociated 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
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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
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Common:
Pulmonary embolism or infarction, carcinoma, pulmonary
edema, bronchiectasis, etc.
•
Uncommon:
Pulmonary eosinophilia, alveolar hemorrhage, foreign
body
•
Unexpected pathogens: eg, mycobacteria, MRSA etc.
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