1100 - lee pneumonias
TRANSCRIPT
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Top causes of death (2011)
United States Chile (& the World)
1. Ischemic heart
2. Cancer
3. Stroke
…
8. Pneumonia
1. Ischemic heart
2. Stroke
3. Pneumonia
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United States
Incidence
2-3 million cases/y
500,000 admissions
Mortality >60,000 deaths/y
Outpatient <1%
Ward 10-14%
ICU 30-40%
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Where can we impact ?
Diagnosis
Treatment
Death
Diagnostic aids
Prediction algorithms
Triage tools
Predicting the bugs
Timely antibiotics
Things that we do to
patients
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Some pathogens by risks
Alcoholism S. pneumoniae, anaerobes,
Klebsiella, (TB)
COPD, smoking S. pneumonia, H. influenzae,
M. catarrhalis, Legionella
Nursing home S. pneumoniae, GNB, H.
influenzae, S. aureus, C. pneumoniae, (TB)
Poor dental hygiene Anaerobes
Hotel, cruise Legionella
Birds, soil, caves Histoplasma, C. psittaci
Rabbits Francisella tularensis
Farm animals, cats Coxiella (Q-fever)
SW USA Hantavirus, coccidioides
Structural lung disease Pseudomonas, S. aureus,
Burkoholderia cepaci, (NTM)
SE and East Asia Pseumolmallei, SARS,
Bartlett, Clin Infect Dis 2003
ATS/IDSA 2007
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Adult CAP in Chile (N=365)
Bacteria (42.7% of cases) % of cases
Streptococcus pneumoniae 21.1%
Mycoplasma pneumoniae 9.0%
Chlamydia pneumoniae 7.9%
Legionella 5.07%
Staphylococcus aureus 2.2%
Moraxella catarrhalis 1.7%
Gram-negative bacillus 1.4%
Haemophilus influenzae 0.8%
Luchsinger, Avendano, Thorax 2013
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Barcelona, 1042 CAP/Ward patients
Leading Ward Pathogens
43% S. pneumoniae
13% Mixed
12% Viral
8% Legionella
5% H. influenzae
4% Pseudomonas
3% Mycoplasma pneumoniae
3% Chlamydia pneumoniae
2% each of S. aureus, GNEB, Coxiella burnetti
Cilloniz, Thorax 2011
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Barcelona, 260 CAP/ICU patients
Leading ICU Pathogens
42% S. pneumoniae
22% Mixed
8% Legionella
5% Pseudomonas
4% Viral
3% H. influenzae
3% Chlamydia pneumoniae
2% Mycoplasma pneumoniae
2% S. aureus
1% each GNEB, Coxiella burnetti
Cilloniz, Thorax 2011
7% mortality
(highest total deaths)
16% mortality
24% mortality
30% mortality
11% mortality
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Septic shock & Pneumococcus
1041 prospective cohort (Spain)
10.9% will develop septic shock
41% bacteremic, 37% MV
25% mortality
Independent risk factors for septic shock
Serotype 3 (Also more necrotizing pneumonia)
Chronic steroid use
Active smoking
Garcia-Vidal, Thorax 2010
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Indications for testing (ATS/IDSA)
ICU
Failure of therapy
Cavitary
Leukopenia
Active alcohol abuse
Chronic liver disease
Chronic lung disease
Asplenia
Recent travel
Pleural effusion
Clinical
Judgment
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Other considerations
Outpatient Optional
Seasonal variations Influenza +/- RSV
Urinary antigen testing: Specificity > Sens. Legionella, serogroup 1
Streptococcus
Intubated Tracheal aspirate in most is fine
?Bronchoscopy: opportunistic organisms, alternative diagnoses, immunocompromised
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PSI / PORT
Low risk class (I) or not (II-V)
Age
Physiologic parameters
Comorbidities
High risk class (II-V)
Age
Physiologic parameters
Comorbidities
Labs & Imaging
Fine, NEJM 1997
30-day Mortality
(I) 0.1%
(II) 0.6%
(III)0.9%
(IV)9.3%
(V) 27%
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PSI / PORT, Risk Class I
Age >50
Altered mental status
HR ≥ 125
RR >30
SBP <90
Temp <35 or ≥40 C
History of:
Cancer, CHF, stroke, kidney disease, liver disease
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CURB-65
Confusion
Urea >7 mmol/L (19 mg/dL)
Respiratory rate ≥30
BP, systolic <90
Age ≥65
Score
Mortality
0, 1 1.5%
Home?
2 9.2%
Inpatient?
3+ 22%
ICU?
Lim, Thorax 2003
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Independent predictors of death
CAPNETZ (German cohort, N=660,594)
Bedridden functional status OR 2.93
Nursing home residents OR 1.27
Age, decades OR 1.38
CRB OR 1.73
CRB-50
CRB-65
CRB-80
Ewig, Thorax 2013
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Other biomarkers of poor prognosis
Hypoglycemia (Gamble, Am J Med 2010)
Short & long-term
~20% mortality, with HR 2.96
Platelets (Mirsaeidi, Chest 2010)
Both low and high
Better predictor than WBC
Hyper > Hypo-capnea (Laserna, Chest 2012)
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NT-proBNP in Pneumonia Nowak, Chest 2012
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Procalcitonin Meta-analysis 14 RCT’s of 4211 patients
Schuetz, JAMA 2013 (Cochrane review)
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RCT in 302 with suspected CAP Christ-Crain, AJRCCM 2006
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Reduction of antibiotics Schuetz, JAMA 2013 (Cochrane review)
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Shorten antibiotics?: 401 VAP RCBT Chastre, JAMA 2003
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Procalcitonin
Increased in infection
Quantity correlates with severity
Evolving role:
Stopping antibiotics
(Initiating antibiotics)
Caveats:
Increased in trauma, burns, neuroendocrine tumors, ?viral infections, unclear role in fungus, PCP, HIV, TB, immunocompromised, etc.
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Schuetz, Chest 2012
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Schuetz, Chest 2012
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Timing is key
18209 Medicare patients >65yo, admitted
Houck, Arch Int Med 2004
Antibiotics
≤4hours
Antibiotics
>4hours
Adjusted
OR
P-value
Mortality,
30day
11.6% 12.7% 0.85 0.005
Mortality,
hospital
6.8% 7.4% 0.85 0.03
LOS >5days 42.1% 45.1% 0.90 0.003
Re-admit,
30-day
13.1% 13.9% 0.90 0.34
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Antibiotic choice: Considerations
Likely pathogen
Season
Clinical, epidemiologic features
Local microbiology in your practice
Local resistance patterns
Exposure to prior antibiotics
Healthcare contact or institutionalization
Severity of illness
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2007 ATS/IDSA guidelines
Outpatient
Macrolide alone
Doxycycline alone
Adjustments pending comorbidities, community
prevalence of resistant S. pneum.
Inpatient
Advanced macrolide + Beta-lactam
Respiratory fluoroquinolones alone
Adjust based on prior exposure, etc.
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ICU (ATS/IDSA 2007)
Always two drugs:
+ Beta-lactam
Cefotaxime, ceftriaxone, amp./sulbactam
+ Azithromycin or a respiratory
fluoroquinolone
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ICU with risk for pseudomonas
Expanding coverage for Pseudomonas:
+ Anti-pseudomonal Beta-lactam
Pip./tazobactam, cefipime, meropenem
+ Either of the two: Anti-pseudomonal fluoroquinolone
Aminoglycoside + azithromycin
If PCN allergy
Aztreonam, fluoroquinolone, aminoglycoside
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ICU: Penicillin Allergy
Aztreonam + Respiratory fluoroquinolone
If pseudomonas risk:
Aztreonam
Respiratory fluoroquinolone
Aminoglycoside
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Adherence to guidelines
780 prospective cohort of CAP (exclude NH)
Independent associations of Mortality:
Dambrava, ERJ 2008
Variable OR
Obtundation 7.04 (p=0.001)
Shock 5.89 (p=0.011)
Acute renal failure 3.28 (NS: p=0.075)
Arterial saturation <90% 2.86 (NS: p=0.056)
Aspiration 2.69 (p=0.046)
Adherence to ATS guideline 0.69 (NS)
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51% at risk for MDR bacteria
Comorbidities
Prior antibiotics within 90 days
Wound care
Home infusion therapy
Nursing home or extended care facility
Hospitalization for >1day within 90 days
Chronic renal failure
Aliberti, Clin Infect Dis 2012
Schorr, Arch Int Med 2008
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“Late onset” HAP/HCAP/VAP
S. pneumoniae
H. influenzae
S. aureus
GNEB
MDR
Pseudomonas
ESBL+ Klebsiella
Acinetobacter
MRSA
Legionella
Antibiotics (3 drugs)
Anti-pseudomonal cephalosporins
Anti-pseudomonal carbepenems
B-lactam/BL-inhibitor
Anti-pseudomonal fluoroquinolone
Aminoglycoside
Linezolid
Vancomycin
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Prevention ? Case study: VAP
Education, Hand-washing, Environmental decontamination
Early removal enteral feed
Reduce patient transport
Oral care (chlorhexidine)
Sedation vacation, extubation readiness
Semi-recumbent position
Minimize intubation
Oral intubation
ETT
Subglottic aspiration from ETT
Silver coated
Tracheal cuff pressure
(Reduce unnecessary ulcer prophylaxis)
Morrow, ERJ 2011
O’Grady, JAMA 2012
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What you do matter… Boudama, Clin Infect Dis 2010
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Summary
Be aware of your local bugs and issues
Risk prognosticate to help you decide on appropriate resource usage (clinical, biomarkers)
Consider MDR risks, and start appropriate empiric antibiotics (guidelines can be helpful)
Give it as quickly as you diagnose pneumonia
Biomarkers might help you limit antibiotic over-usage without harm
How you handle patients once in the hospital makes a difference (for worse, and for better)
Look for upcoming updates in guidelines