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Pulmonary Infections

Pulmonary Infections. Amar Safdar, MD, FACP Associate Professor of Medicine M. D. Anderson Cancer Center. BACKGROUND Community-Acquired Pneumonia. Incidence 2 to 12 cases per 1,000 population per year 600,000 admissions per year 4,200,000 inpatients days Annual cost > $8.4 billion

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Pulmonary Infections

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  1. Pulmonary Infections Amar Safdar, MD, FACP Associate Professor of Medicine M. D. Anderson Cancer Center

  2. BACKGROUNDCommunity-Acquired Pneumonia

  3. Incidence 2 to 12 cases per 1,000 population per year • 600,000 admissions per year • 4,200,000 inpatients days • Annual cost > $8.4 billion • Mostly associated with extended length of hospital stay [LOS] • Recently, guidelines and/or standardized order sets (SOSs) used by intensive clinical case management (ICCM) substantially reduced LOS while maintaining quality of care. Fishbane S, et al. Arch Intern Med 2007;167:1664–1669.

  4. Pneumonia Severity Index (PSI) • The mortality rate was higher in ICU vs. non-ICU patients (37% vs. 20%, respectively; p = 0,003). • A low level of consciousness (OR, 3.95; 95% CI, 2 to 5) • Shock (OR, 24.7; 95% CI, 14 to 44) were associated with a higher risk of death. The modified ATS severity rule had the best accuracy in predicting ICU admission and mortality. Valencia M, et al. Chest 2007;132:515–522.

  5. Etiology of Community-Acquired Pneumonia Among Patients who Require Hospitalization

  6. CAP Treatment Response

  7. Treatment of Community-Acquired Pneumonia • A pathogen directed treatment (PDT) approach compared with an empirical broad spectrum antibiotic treatment (EAT) strategy. • No significant differences were found between the two treatment groups in LOS, 30 day mortality, clinical failure, or resolution of fever. • Side effects, occurred more frequently in patients in the EAT group than in those in the PDT group (60% v 17%, 95% CI –0.5 to –0.3; p<0.00). Van der Eerden MM, et al. Thorax 2005;60:672–678.

  8. Long-Term Follow up of Patients with Community-Acquired Pneumonia

  9. In this case-control study of Medicare patients with CAP, with five control subjects matched for age, sex, and race with each case, the in-hospital and 1-year mortality rates for patients with CAP were significantly higher than those for control subjects. Kaplan, V, et al. Arch Intern Med 2003; 163,317-323

  10. Current CAP Core Measures for Admitted Patients • First dose of antibiotics within 4 h of arrival to hospital • Oxygenation assessment within 24 h of hospital admission • Correct antibiotic for admitted patients Non-ICU  • ICU – Includes no monotherapy • Blood cultures within 24 h for all patients admitted to ICU in first 24 h  • Blood for cultures drawn prior to antibiotics administration for those drawn in emergency department • Evaluation and offering of pneumococcal and influenza vaccination • Smoking cessation advice Niederman MS. Am J Med 2004;117:51S–57S.

  11. BACKGROUNDHealthcare-Associated Pneumonia

  12. Pieracci EM, et al. Am Surg 2007:73:419–432.

  13. Community–Acquired MRSA

  14. Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in the United States. MRSA rates are according to US Census Bureau Regions. Data are cumulative data from 1998 to March 2005. IP, inpatient; OP, outpatient. Adapted from Styers et al.

  15. SCCmec 4 Subtypes:[mecA gene located on a mobile cassette chromosome] • HA-MRSA – subtype I–III • CA-MRSA – subtype IV–V

  16. Kahl BC, Peters G. Science 2007;315:1082–1083.

  17. In a retrospective study conducted in the United States and taken from a large multi-institutional database examined rates of CAP, HCAP, ventilator-associated pneumonia, and HAP. Approximately 50% of patients had CAP and more than 20% had HCAP, with S aureus being a major causative pathogen. Kollef MH, et al. Chest. 2005;128;6:3854-3862.

  18. Results of nonbronchoscopic BAL fluid cultures collected within 4 h of ICU admission in 95 elderly nursing-home patients with aspiration pneumonia admitted to the ICU. The dominant organism group was enteric Gram-negative pathogens, and anaerobes were less common and often part of a mixed infection. El Solh, AA, et al. Am J Respir Crit Care Med 2003;167,1650-1654

  19. Stenotrophomonas maltophilia pneumonia • Patients at risk for developing Stenotrophomonas maltophilia pneumonia: • Critical Care Unit stays • Mechanical ventilation • Neutropenia • Non-neutropenic, non-ICU cancer patients (Cases) with S. maltophilia pneumonia, compared with neutropenic, non-ICU patients had [1997-2004]: • Higher exposure to carbapenem antibiotics (58 vs. 41%; p < 0.03) • More frequent hematologic malignancy (95 vs. 64%; p < 0.0003) • Presented with concurrent bacteremia more often (23 vs. 0%; p < 0.0005). Aisenberg G, et al. Eur J Clin Microbiol Infect Dis 2007;26:13-20.

  20. Hospital-acquired S. maltophilia pneumonia was more common among neutropenic or ICU patients than non-neutropenic, non-CCU cancer patients (98 vs. 61%; p < 0.000002). • Among the cases: 34% received outpatient oral antimicrobial therapy and 28% were admitted to the ICU. • The mean duration of ICU stay, even among these eight patients (19 +/- 40 days), was comparable to that of patients with neutropenia (23 +/- 26 days) and those who developed S. maltophilia pneumonia during their ICU stay (34 +/- 22 days; p = 0.46). • The overall infection-associated mortality in the 108 cancer patients with S. maltophilia pneumonia was 25%. • 20% of patients without traditional risk factors for S. maltophilia pneumonia died due to progressive infection. • In a multivariate logistic regression analysis, only admission to the ICU predicted death (odds ratio 33; 95% confidence interval, 4.51-241.2; p < 0.0006). The results of this study indicate S. maltophilia pneumonia is a serious infection even in non-neutropenic, non-ICU patients with cancer Aisenberg G, et al. Eur J Clin Microbiol Infect Dis 2007;26:13-20.

  21. Ventilator-Associated Pneumonia

  22. Pieracci EM, et al. Am Surg 2007:73:419–432.

  23. Pieracci EM, et al. Am Surg 2007:73:419–432.

  24. Clinical Pulmonary Infection Score (CPIS) Temperature Leukocyte count CXR infiltrates Volume of tracheal secretions PaO2:FIO2 Culture and GS of tracheal aspirate [0-2 points each yields 12 points; > 6 points indicates high probability of VAP] The National Nosocomial Infection Surveillance system diagnostic criteria for nosocomial pneumonia The negative predictive value of a GS showing no organisms in a clinically stable patient approaches 100%

  25. J Trauma 2007;62:1377–1383.

  26. J Trauma 2007;62:1377–1383.

  27. Pieracci EM, et al. Am Surg 2007:73:419–432.

  28. HAP/ VAP OUTBREAKSMULTIDRUG RESISTANT [MDR] ORGANISMS

  29. Large outbreak of infection due to clonal Multidrug-Resistant Acinetobacter baumannii caused significant morbidity and expense. Aerosolization of MDR A. baumannii during pulsatile lavage debridement of infected wounds and during the management of respiratory secretions from colonized and infected patients may promote widespread environmental contamination. Young LS, et al. Infect Control Hosp Epidemiol 2007

  30. Infection control measures included the following: • Limitations on the performance of pulsatile lavage wound debridement • The removal of items with upholstered surfaces • The implementation of contact isolation for patients with suspected MDR A. baumannii infection.

  31. CONTROL HAP OUTBREAKS Multifaceted infection control interventions decrease spread and colonization/infection due to MDR organisms among hospitalized patients.

  32. The current recommendations for empirical antibiotic treatment of hospital-acquired pneumonia (American Thoracic Society and Trouillet) showed a good ability to predict the involved pathogen. • The main reason was the failure to treat highly resistant strains. • The ATS and Trouillet antibiotic treatment recommendations were adequate in 79% and 80% of the patients, respectively. • The microorganisms implicated in the treatment inadequacy of the ATS guideline were Pseudomonas aeruginosa, Acinetobacter baumanii, Stenotrophomonas maltophilia and methicillin-resistant Staphylococcus aureus.

  33. Viral Pulmonary Infections

  34. Increasing Drug-Resistant H5N1 • Respiratory Viruses • Influenza virus • Parainfluenza virus • Respiratory syncytial virus • Adenovirus • Metapneumonvirus

  35. POSTVIRAL SUPERINFECTIONS • Streptococcus pneumoniae • Staphylococcus aureus • Pseudomonas spp. • Stenotrophomonas maltophilia • Fungal infections

  36. CONCLUSIONS • CAP and HAP leads to serious morbidity and substantially increases healthcare cost. • Inappropriate/discordant antimicrobial therapy increases risk of complications, prolongs hospital stay, treatment failure and death. • In most patients, inappropriate therapy is given for pulmonary infections due to MDR organisms. • Effective, multifaceted infection control surveillance and infection control measures are pivotal in reducing the risk of these life-threatening infections.

  37. Pieracci EM, et al. Am Surg 2007:73:419–432.

  38. MYCOBACTERIAL INFECTIONS

  39. Tuberculosis Background • 8 million new cases of M. tuberculosis are estimated to occur yearly adding to the existing burden of 1.7 billion cases worldwide [One-third of worlds population is now estimated to be infected with this potentially devastating infection] • In 1993, the World Health Organization declared tuberculosis as public health emergency, as 3 million patients were expected to die annually due to complications arising from tuberculosis, making it the most frequent cause of death due to an infectious organism. • Man is the only known reservoir of M. tuberculosis.

  40. Background • In the US, reported M. tuberculosis declined during the 20th century until 1985. • The unanticipated rise in the newly diagnosed cases between 1985 and 1992 was attributed to HIV-AIDS, illicit drug use, homelessness, and ineffective tuberculosis control programs in the large urban centers. • Since 1992, the decline in M. tuberculosis cases was attributed to re-implementation of effective public health surveillance `programs with emphasis on 1) early diagnosis (interrupt infection transmission in the community), and 2) DOT (ensured compliance of adequate anti-tuberculosis therapy). • These measures led to the lowest ever recorded new tuberculosis cases in 1997.

  41. Risk Factors In the developing world • Protein-calorie malnutrition. • Residents of overcrowded communities with inadequate sanitation, and poor-ventilation. • Silicosis. • HIV-AIDS, which has now replaced Mycobacterium tuberculosis as the most common cause of death due to a single infectious agent.

  42. Risk Factors In the developed world • HIV-AIDS. • Homelessness, stay in homeless shelters. • Illicit drug use. • Incarceration in correctional facilities. • Nursing home residents. • Silicosis. • Substantial rapid weight loss. • Previous gastrectomy. • Prolonged systemic corticosteroids (> 15 mg prednisone/day). • Chronic end-stage renal disease. • Tumor necrosis factor inhibitor therapy for rheumatoid arthritis such as Infliximab, Adalimumab, etc.

  43. Risk Factors • Cancer: Hodgkin’s Disease, gastric, head and neck malignancies. We have recently described patients with AML, CML, and NHL also at risk for developing tuberculosis. [0.2/1000 new cancer diagnosis, 1.3/1000 new leukemia diagnosis] • Organ-transplant recipients have higher rate of infection compared with patients undergoing HSCT. • Patients undergoing HSCT in high M. tuberculosis endemic areas have increased risk of infection. • In the US, M. tuberculosis reactivation remains a concern in foreign-born patients undergoing immunosuppressive antineoplastic therapy. De La Rosa et al. Eur J Clin Microbiol Infect Dis 2004;10:749-52.

  44. Diagnosis of Active Tuberculosis

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