community acquired pneumonia challenges in the new millenium dr. yousef noaimat md.fccp consultant...
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Community Acquired Pneumonia
Challenges in the New Millenium
DR. Yousef Noaimat MD.FCCPConsultant in pulmonary and internal
medicine.
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Community Acquired Pneumonia
Definition: … an acute infection of the pulmonary
parenchyma that is associated with at least some symptoms of acute infection, accompanied by the presence of an acute infiltrate on a chest radiograph, or auscultatory findings consistent with pneumonia, in a patient not hospitalized or residing in a long term care facility for > 14 days before onset of symptoms.
Adeel A. Butt, MDBartlett. Clin Infect Dis 2000;31:347-82.
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Community Acquired Pneumonia
Epidemiology: 4-5 million cases annually ~500,000 hospitalizations ~45,000 deaths Mortality 2-30%
<1% for those not requiring hospitalization
Adeel A. Butt, MDBartlett. CID 1998;26:811-38.
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Epidemiology: (contd) fewest cases in 18-24 yr group probably highest incidence in <5
and >65 yrs mortality disproportionately high
in >65 yrs
Community Acquired Pneumonia
Adeel A. Butt, MD
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Community Acquired Pneumonia
Adeel A. Butt, MD
898
1071
83
1171 1207
684
0
200
400
600
800
1000
1200
1400
<5 5 to17
18-24 25-44 45-64 >65
# of cases
# in 1000s
Incidence
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Community Acquired Pneumonia
Adeel A. Butt, MD
25.7
74.9
0
10
20
30
40
50
60
70
80
<4 5 to 14 15-24 25-44 45-64 >65
# of deaths# in 1000s
Mortality
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Risk Factors for pneumonia age alcoholism smoking asthma immunosuppression institutionalization COPD PVD dementia
Community Acquired Pneumonia
Adeel A. Butt, MDID Clinics 1998;12:723. Am J Med 1994;96:313
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Risk Factors (contd.) Men: age and smoking, weight gain
RR 1.5 for age 50-54, 4.17 for > 70 Smoking, current: RR 1.5; heavy: 2.54; Quit <10
yrs: 1.5 Weight gain >40 lbs since age 21
Women: smoking, BMI, weight gain BMI 25-26.9, RR 1.53: BMI >30, RR 2.22 Exercise protective: RR 0.66 for most active
Alcohol consumption NOT associated with increased risk in men or women
Community Acquired Pneumonia
Adeel A. Butt, MD
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Risk Factors in Patients Requiring Hospitalization older, unemployed, unmarried common cold in the previous year asthma, COPD; steroid or
bronchodilator use Chronic disease amount of smoking alcohol NOT related to increased risk
Community Acquired Pneumonia
Adeel A. Butt, MD
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Risk Factors for Mortality age bacteremia (for S. pneumoniae) extent of radiographic changes degree of immunosuppression amount of alcohol
Community Acquired Pneumonia
Adeel A. Butt, MD
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S. pneumoniae: 20-60% H. influenzae: 3-10% Chlamydia pneumoniae:
4-6% Mycoplasma
pneumonaie: 1-6%
Adeel A. Butt, MD
Community Acquired Pneumonia
Legionella spp. 2-8%
S. aureus: 3-5% Gram negative
bacilli: 3-5% Viruses: 2-13%
40-60% - NO CAUSE IDENTIFIED
2-5% - TWO OR MORE CAUSES
Microbiology
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Community Acquired Pneumonia
Adeel A. Butt, MD
Evaluation for CAP
History, PE, CXR
No infiltratemanage/evaluate for alternate diagnosis Infiltrate + clinical evidence of pneumonia
evaluate for admission
outpatient:empiric treatment with macrolide, doxycycline, FQ
hospitalizelabs
medical ward:abx < 8 hrs ICU: abx < 8 hrs
no pathogen identifiedB-lactam + macrolide
FQ
no pathogen identified B-lactam + macrolide
B-lactam + FQ
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Laboratory Tests: CXR CBC with differential BUN/Cr glucose liver enzymes electrolytes Gram stain/culture of sputum pre-treatment blood cultures oxygen saturation
Community Acquired Pneumonia
Adeel A. Butt, MD
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Diagnostic Evaluation CXR
usually needed to establish diagnosis prognostic indicator rule out other disorders may help in etiological diagnosis
Only 3% of outpatients and 28% of ER patients with suggestive signs and symptoms actually have pneumonia
Adeel A. Butt, MD
Community Acquired Pneumonia
J Chr Dis 1984;37:215-25
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Usefulness of Gram Stain Good sputum samples obtained from 39% 83% show one predominant morphotype
Community Acquired Pneumonia
Adeel A. Butt, MD
Pneumococcus H. flu.
Sensitivity 57 82
Specificity 97 99
Pos Pred Value 95 93
Neg Pred Value 71 96
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Community Acquired Pneumonia
Adeel A. Butt, MD
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PORT Publications: Class I:
age < 50; 0/5 co-morbid conditions; normal or mildly deranged VS; normal mental status
Class II-V: points assigned based on above, 5
co-morbid conditions, 5 PE findings, 7 lab or X-ray findings
Community Acquired Pneumonia
Adeel A. Butt, MDFine MJ. NEJM 1997;336:243-50
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Class I & II: usually do not require
hospitalization
Class III: may require brief hospitalization
Class IV & V: usually do require hospitalization
Community Acquired Pneumonia
Adeel A. Butt, MDFine MJ. NEJM 1997;336:243-50
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Adeel A. Butt, MD
Age: Male FemaleNursing home resident
Number of yearsNumber – 1010
Co-morbid illness Neoplastic disease Liver disease CHF Cerebrovascular disease Renal disease
3020101010
Physical Exam Altered mental status RR > 30 Systolic bp < 90 Temp <35oC or >40oC Pulse >125
2020201510
Lab/X-ray findings Arterial pH <7.35 BUN > 30 Sodium < 130 Hematocrit <30% Glucose > 250 PaO2 <60 Pleural effusion
30202010101010
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Adeel A. Butt, MD
Risk Class Points Mortality
I Absence ofpredictors
0.1%
II < 70 0.6%
III 71-90 2.8%
IV 91-130 8.2%
V > 130 29.2%
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Severity of CAP RR > 30 PaO2/FiO2 < 250, or PO2 < 60 on room air Need for mechanical ventilation Mulitlobar involvement Hypotension Need for vasopressors Oliguria Altered mental status
Adeel A. Butt, MD
Community Acquired Pneumonia
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Management Rational use of microbiology
laboratory Pathogen directed antimicrobial
therapy whenever possible Prompt initiation of therapy Decision to hospitalize based on
prognostic criteriaAdeel A. Butt, MD
Community Acquired Pneumonia
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Outpatient: macrolide doxycycline Fluoroquinolone
NOT IN ANY SPECIFIC ORDER
Adeel A. Butt, MD
Community Acquired Pneumonia
Empiric Treatment
IDSA guidelines: Clin Infect Dis 2000;31:347-82
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Patients in General Medical Ward: 3GC + macrolide B/B-I + macrolide OR B/B-I + FQ FQ alone
Adeel A. Butt, MD
Community Acquired Pneumonia
Empiric Treatment
IDSA guidelines: Clin Infect Dis 2000;31:347-82
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Patients in ICU: 3GC + macrolide 3GC + FQ B/B-I + macrolide B/B-I + FQ
Adeel A. Butt, MD
Community Acquired PneumoniaEmpiric Treatment
IDSA guidelines: Clin Infect Dis 2000;31:347-82
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Deviation From Guidelines
Not many Studies done to assess this Prospective study in a tertiary care hospital Adherence to ATS guidelines was 88% No significant difference in mortality or LOS Mortality in Class V patients higher in
nonadherent treatments Adherence to ATS associated with
decreased mortality Mortality in Class I, II & III was ZERO.
Menendez. Chest 2002;122:612-617.
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Concerns about multiply resistant pneumococcus:
25-40% overall penicillin resistance intermediate resistance of
questionable significance high level resistance associated with in
vitro macrolide and 3GC resistance clinical failures not really documented
Community Acquired Pneumonia
Adeel A. Butt, MDIDSA guidelines: Clin Infect Dis 2000;31:347-82
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Increased drug efflux
coded by mefE susceptible to
clindamycin most cases in US may be overcome by
achievable levels of macrolides
Community Acquired Pneumonia
Adeel A. Butt, MD
Ribosomal methylase coded by ermAM resistant to
clindamycin mostly in Europe not overcome by
standard doses
Macrolide Resistance
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Active against 98% of resistant pneumococcus
Resistance has begun to increase
Community Acquired Pneumonia
Adeel A. Butt, MD
(Newer)Fluoroquinolones
Chen DK. NEJM 1999;341:233-9
Ho PL. Antimicrob Agents Chemother 1999;43:1310-3.
Wise R. Lancet 1996;348:1660
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FQ Resistance 4 cases from Canada with
pneumococcal pneumonia 1 died 2 developed resistance while on Rx 2 had resistant bugs to begin with Authors suggested that recent FQ
use should be a contra-indication to using a FQ for empiric treatment of CAP
Davidson. NEJM 2002;346:747-750
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FQ Resistance In a case control study,
colonization or infection by FQ resistant pneumococci was independently associated with: COPD Nosocomial origin of bacteremia Residence in a nursing home Prior exposure to FQ
Ho. Clin Infect Dis 2001;32:701-707.
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Other Concerns
Delay in diagnosis and treatment of TB Johns Hopkins study 33 patients with TB 16 received FQ for empiric Rx of CAP TB treatment initiation time:
21 days in the FQ group 5 days in the non-FQ group
Dooley. Clin Infect Dis 2002;34:1607-1612.
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Choice of Initial Antimicrobial Regimen Second generation generation
cephalosporin plus a macrolide, non-pseudomonal third generation cephalosporin plus a macrolide, or a fluoroquinolone alone were all associated with a lower 30 day mortality in patients with CAP.
Adeel A. Butt, MD
Community Acquired Pneumonia
Gleason. Arch Int Med 1999;159:2562-72.
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Macrolide Use and LOS: Patients who received macrolides
within first 24 hours of admission had a shorter LOS (2.8 days vs. 5.3 days)
Adeel A. Butt, MD
Community Acquired Pneumonia
Stahl. Arch Int Med 1999;159:2576-80.
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Azithromycin vs. Cefuroxime + Erythromycin prospective, randomized trial 145 patients Clinical cure 91% in each group. 4 S. pneumoniae strains with MIC
0.064-2 ug/ml: 1/1 in azithromycin group cured, 2/3 in cef/erythro group cured
Community Acquired Pneumonia
Adeel A. Butt, MDVergis. Arch Int Med 2000;160:1294-1300.
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IV followed by Oral Azithromycin 615 patients: Azithromycin given to 414 202 in a comparison trial with ATS
recommended cefuroxime + erythromycin
77% vs 74% clinical cure or improvement
Microbiological cure rates similar or better in azithromycin group
Community Acquired Pneumonia
Adeel A. Butt, MD
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Cost-Effectiveness of IV-Oral Switch Therapy
Azithromycin
Mean cost - $4,104
CE Ratio per expected cure - $5,265
Cefuroxime + Erythro
Mean cost - $4,578
CE Ratio per expected cure - $ 6,145
Paladino. Chest Oct 2002;122:1271-1279.
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Clarithromycin ER
Head-to-head comparison with FQ Vs. Levofloxacin1
252 patients Clinical cure 88% in Clarithro; 86% levo Radiographic success 95% vs. 88%
Vs. Trovafloxacin2
Clinical cure 87% vs. 95% Radiographic success 95% vs. 95%
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Report from the DRSP Therapeutic Working Group
Use a macrolide or doxycycline for outpatients Beta-lactam for inpatient Reserve FQ for:
if above fails if allergic to any of the above documented high level resistance (pen MIC >4)
Community Acquired Pneumonia
Adeel A. Butt, MD
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Summary
We have some really good drugs available Use antibiotics judiciously Do consider local and national resistance
patterns For Class I, II and possibly III, first line
recommendations are a macrolide or doxycycline
Revise therapy based on clinical and microbiological response
Consider prior exposure when choosing an Abx