1 / 78

Community Acquired Pneumonia (CAP)

CAP. Community Acquired Pneumonia (CAP). CAP. Improving Outcomes Through Education. The New Treatment Paradigm – Selecting Appropriate Empiric Antibiotics. www.drsarma.in. CAP. Prof. Dr. Sarma VSN Rachakonda M.D., M.Sc., (Canada), FCGP, FIMSA, FICP, FRCP (G), FCCP (USA ), FACP(USA)

tocho
Télécharger la présentation

Community Acquired Pneumonia (CAP)

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CAP Community Acquired Pneumonia (CAP)

  2. CAP Improving OutcomesThrough Education The New Treatment Paradigm – Selecting Appropriate Empiric Antibiotics

  3. www.drsarma.in CAP Prof. Dr. Sarma VSN Rachakonda M.D., M.Sc., (Canada), FCGP, FIMSA, FICP, FRCP (G), FCCP (USA), FACP(USA) Senior Consultant Physician & Cardio-metabolic & Chest Specialist Adjunct Professor, The Tamilnadu Dr. MGR Medical University Honorary National Professor of Medicine, IMA-CGP

  4. Pneumonias – Classification Nosocomial Pneumonias

  5. Community Acquired Pneumonia (CAP) • 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. Bartlett. Clin Infect Dis 2000;31:347-82.

  6. Guidelines for CAP • American Thoracic Society (ATS) • Guidelines - Management of Adults with CAP (2001) • Infectious Diseases Society of America (IDSA) • Update of Practice Guidelines Management of CAP in Immuno-competentadults (2003) • ATS and IDSA joint effort (we will follow this) • IDSA/ATS Consensus Guidelines on the Management of CAP in Adults (March 2007) • CAP – Consensus Statement on Indian Scenario

  7. Why Guidelines? • Evidence-based practice • Best outcome for patients • Best use of resource • Restricts idiosyncratic behaviour • Legal protection • Identify research needs • A tool for education • Gain public confidence

  8. CAP – The Two Presentations Classical Gradual & insidious onset Low grade fever Dry cough, No blood tinge Good GC – Walking CAP Low mortality 1-2%; except in cases of Legionellosis Mycoplasma, Chlamydiae, Legionella, Ricketessiae, Viruses are causative Atypical • Sudden onset of CAP • High fever, shaking chills • Pleuritic chest pain, SOB • Productive cough • Rusty sputum, blood tinge • Poor general condition • High mortality up to 20% in patients with bacteremia • S.pneumoniae causative

  9. CAP – Pathogenesis

  10. CAP – Risk Factors for Pneumonia • Age • Obesity; Exercise is protective • Smoking, PVD • Asthma, COPD • Immuno-suppression, HIV • Institutionalization, Old age homes etc • Dementia ID Clinics 1998;12:723. Am J Med 1994;96:313

  11. Community Acquired Pneumonia (CAP) Epidemiology • 4-5 million cases annually • ~500,000 hospitalizations – 20% require admission • ~45,000 deaths • Fewest cases in 18-24 yr group • Probably highest incidence in <5 and >65 yrs • Mortality disproportionately high in >65 yrs • Over all mortality is 2-30% • <1% for those not requiring hospitalization Bartlett. CID 1998;26:811-38.

  12. CAP – The Pathogens Involved 40-60% - No causative agent identified 2-5% - Two are more agents identified

  13. Streptococcus pneumonia (Pneumococcus) • Most common cause of CAP • About 2/3 of CAP are due to S.pneumoniae • These are gram positive diplococci • Typical symptoms (e.g. malaise, shaking chills fever, rusty sputum, pleuritic chest pain, cough) • Lobar infiltrate on CXR • May be Immuno suppressed host* • 25% will have bacteremia – serious effects *Anorexia, ETOH, HIV, Sickle cell disease, Splenectomy, Hematologic diseases

  14. CAP – Age wise Incidence

  15. CAP – Age wise Mortality

  16. CAP – Risk Factors for Hospitalization • Older, Unemployed, Unmarried • Recurrent common cold • Asthma, COPD; Steroid or bronchodilator use • Chronic diseases, Diabetes, CHF, Neoplasia • Amount of smoking • Alcohol is NOT related to increased risk for hospitalization ID Clinics 1998;12:723. Am J Med 1994;96:313

  17. CAP – Risk Factors for Mortality • Age > 65 • Bacteremia (for S. pneumoniae) • S. aureus, MRSA , Pseudomonas • Extent of radiographic changes • Degree of immuno-suppression • Amount of alcohol consumption ID Clinics 1998;12:723. Am J Med 1994;96:313

  18. CAP – Bacteriology in Hospitalized Pts

  19. CAP – Evaluation of a Patient

  20. CAP – Management Guidelines • Rational use of microbiology laboratory • Pathogen directed antimicrobial therapy whenever possible • Prompt initiation of Antibiotic therapy • Decision to hospitalize based on prognostic criteria - PORT or CURB 65

  21. PORT Scoring – PSI Pneumonia Patient Outcomes Research Team (PORT)

  22. Classification of Severity - PORT

  23. CAP – Management based on PSI Score

  24. CURB 65 Rule – Management of CAP

  25. Algorithmic Approach Step 4 Step 3 Step 2 Step 1

  26. How Should be Hospitalized? Class I and II Usually do not require hospitalization Class III May require brief hospitalization Class IV and V Usually do require hospitalization Severity of CAP with poor prognosis RR > 30; PaO2/FiO2 < 250, or PO2 < 60 on room air Need for mechanical ventilation; Multi lobar involvement Hypotension; Need for vasopressors Oliguria; Altered mental status

  27. CAP – Criteria for ICU Admission Major criteria • Invasive mechanical ventilation required • Septic shock with the need of vasopressors Minor criteria (least 3) • Confusion/disorientation • Blood urea nitrogen ≥ 20 mg% • Respiratory rate ≥ 30 / min; Core temperature < 36ºC • Severe hypotension; PaO2/FiO2 ratio ≤ 250 • Multi-lobar infiltrates • WBC < 4000 cells; Platelets <100,000

  28. Limitation of Common Investigations • Quality of Sputum issues • Positivity rate of sputum smear/culture is 50% • Culture and smear correlation • Blood cultures very insensitive – poor positive rates • Serology needs raising titers – costly, time issues • Viral isolations not feasible

  29. Scoring Systems • Pneumonia Severity Index (PSI) - PORT • CURB 65 • CRB 65 • ATS/IDSA Criteria • SMART-COP Rule (Systolic blood pressure, Multi-lobar chest radiography involvement, Albumin level, Respiratory rate, Tachycardia, Confusion, Oxygenation, and arterial pH) • SCAP Rule

  30. PSI v/s CURB 65: Limitations • While the PSI is indicated for identifying low-risk patients, the CURB65 is ideal for identifying high mortality risk patients with severe illness. • The downside of PSI is it cannot predict need for ICU care. • A recent meta-analysis by Chalmers et al. did not find any significant differences in overall test performance between PSI, CURB65 and CRB65 for predicting mortality of CAP. Both PSI and the CURB 65 have several limitations. These scoring systems are designed primarily to predict mortality. So, they are influenced by age and presence of co-morbid conditions. They are not very effective for predicting ICU admission

  31. Why SCAP for CAP in Indian Context? • The SCAP score needs only two additional parameters, compared to CURB65 components - CXR and ABG • SCAP score cannot be as accurate in the absence of ABG. • Results of both these tests are available within an hour • CURB-65/CRB-65 is recommended over the PSI in the Indian context. • Admission criteria should be based on CURB-65/CRB-65 • After the decision of hospital admission has been made , SCAP score (CURB-65 + CXR+ ABG) should be used to decide ward or ICU admission • In patients admitted in ICU, in addition to SCAP, Procalcitonin levels may be used as prognostic marker for patients at intermediate risk.

  32. CAP – Laboratory Tests • CXR – PA & lateral • CBC with Differential • BUN and Creatinine • FBG, PPBG • Liver enzymes • Serum electrolytes • Gram stain of sputum • Culture of sputum • Pre Rx. blood cultures • Oxygen saturation

  33. CAP – Value of Chest Radiograph • Usually needed to establish diagnosis • It is a prognostic indicator • To rule out other disorders • May help in etiological diagnosis J Chr Dis 1984;37:215-25

  34. Infiltrate Patterns and Pathogens

  35. CAP – Gram’s Stain of Sputum Good sputum samples is obtained only from 39% 83% show only one predominant organism

  36. Pathogens Retrieved from Blood Culture

  37. Mortality of CAP – Based on Pathogen • P. aeruginosa - 61.0 % • K. pneumoniae - 35.7 % • S. aureus - 31.8 % • Legionella - 14.7 % • S. pneumoniae - 12.0 % • C. pneumoniae - 9.8 % • H. influenza - 7.4 % Mandel LA et al. Clin Infect Dis. 2007; 44(suppl. 2) 827- 872

  38. Traditional Treatment Paradigm Conservative start with ‘workhorse’ antibiotics Reserve more potent drugs for non-responders

  39. New Treatment Paradigm Hit hard and early with appropriate antibiotic(s) Short Rx. Duration; De-escalate where possible

  40. The Therapy Conundrum Avoid emergence of multidrugresistantmicroorganisms ImmediateRx. of patients withserioussepsis Objective 1 Objective 2

  41. The Effect of the Traditional Approach 45 Inappropriate therapy (%) 50 40 34 30 17 20 10 0 CAP HAP HAP on CAP Kollef, et al. Chest 1999;115:462–474

  42. New data – Don’t Wait for Results ! Mortality (%) n=75 p<0.001 Switching after susceptibility results Adequate treatment within ‘a few hours’ Tumbarello, et al. Antimicrob Agents Chemother 2007;51:1987–1994

  43. CAP Treatment Consensus • Risk assessment approach • Early Antibiotic selection • Change treatment driven by local surveillance • Hit hard and hit early • As short a duration as possible • De-escalate when and where possible

  44. OPAT – OP Parenteral Antimicrobial Therapy

  45. Antibiotics of choice for CAP

  46. Empiric Treatment – Outpatient Healthy and no risk factors for DR S.pneumoniae 1. Macrolide or Doxycycline Presence of co-morbidities, use of antimicrobials within the previous 3 months, and regions with a high rate (>25%) of infection with Macrolide resistant S. pneumoniae 1. Respiratory FQ – Moxiflox, Gemiflox or Levoflox 2. Beta-lactam (High dose Amoxicillin, Amoxicillin- Clavulanate is preferred; Ceftriaxone, Cefpodoxime, Cefuroxime) plus a Macrolideor Doxycycline

  47. Empiric Treatment – Inpatient – Non ICU 1. A Respiratory Fluoroquinolone (FQ) or 2. A Beta-lactam plus a Macrolide (or Doxycycline) (Here Beta-lactam agents are 3 Generation Cefotaxime, Ceftriaxone, Amoxiclav) 3. If Penicillin-allergic Respiratory FQ or Ertapenem is another option

  48. Empiric Treatment: Inpatient in ICU 1. A Beta-lactam (Cefotaxime, Ceftriaxone, or Ampicillin-Sulbactam) plus eitherAzithromycinor Fluoroquinolone 2. For penicillin-allergic patients, a respiratory Fluoroquinolone and Aztreonam

  49. Empiric – Suspected Pseudomonas 1. Piperacillin-Tazobactam, Cefepime, Carbapenums (Imipenem, or Meropenem) plus either Cipro or Levo 2. Above Beta-lactam+Aminoglycoside+Azithromycin 3. Above Beta-lactam+ Aminoglycoside+ an antipseudomonal and antipneumococcal FQ 4. If Penicillin allergic - Aztreonam for the Beta-lactam

  50. Empiric – CA MRSA For Community Acquired Methicillin-Resistant Staphylococcus aureus (CA-MRSA) • Vancomycin or Linezolid Neither is an optimal drug for MSSA • For Methicillin Sensitive S. aureus(MSSA) B-lactam and sometimes a respiratory Fluoroquinolone, (until susceptibility results). • Specific therapy with a penicillinase-resistant semisynthetic penicillin or 1 gen cephalosporin

More Related