Community acquired pneumonia challenges in the new millenium
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Community Acquired Pneumonia Challenges in the New Millenium. Adeel A. Butt, MD Assistant Professor of Medicine University of Pittsburgh Director, VAPHS ID-HIV Clinics Center for Health Equity Research and Promotion. Community Acquired Pneumonia. Definition:

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Community Acquired Pneumonia Challenges in the New Millenium

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Community Acquired PneumoniaChallenges in the New Millenium

Adeel A. Butt, MD

Assistant Professor of Medicine

University of Pittsburgh

Director, VAPHS ID-HIV Clinics

Center for Health Equity Research and Promotion


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, MD

Bartlett. Clin Infect Dis 2000;31:347-82.


Community Acquired Pneumonia

  • Epidemiology:

    • 4-5 million cases annually

    • ~500,000 hospitalizations

    • ~45,000 deaths

    • Mortality 2-30%

      • <1% for those not requiring hospitalization

Bartlett. CID 1998;26:811-38.

Adeel A. Butt, MD


Community Acquired Pneumonia

  • Epidemiology: (contd)

    • fewest cases in 18-24 yr group

    • probably highest incidence in <5 and >65 yrs

    • mortality disproportionately high in >65 yrs

Adeel A. Butt, MD


Community Acquired Pneumonia

Incidence

# in 1000s

Adeel A. Butt, MD


Community Acquired Pneumonia

Mortality

# in 1000s

Adeel A. Butt, MD


Community Acquired Pneumonia

  • Risk Factors for pneumonia

    • age

    • alcoholism

    • smoking

    • asthma

    • immunosuppression

    • institutionalization

    • COPD

    • PVD

    • dementia

ID Clinics 1998;12:723. Am J Med 1994;96:313

Adeel A. Butt, MD


Community Acquired Pneumonia

  • 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

  • Adeel A. Butt, MD


    Community Acquired Pneumonia

    • 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

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    • Risk Factors for Mortality

      • age

      • bacteremia (for S. pneumoniae)

      • extent of radiographic changes

      • degree of immunosuppression

      • amount of alcohol

    Adeel A. Butt, MD


    S. pneumoniae: 20-60%

    H. influenzae: 3-10%

    Chlamydia pneumoniae: 4-6%

    Mycoplasma pneumonaie: 1-6%

    Legionella spp. 2-8%

    S. aureus: 3-5%

    Gram negative bacilli: 3-5%

    Viruses: 2-13%

    Community Acquired Pneumonia

    Microbiology

    40-60% - NO CAUSE IDENTIFIED

    2-5% - TWO OR MORE CAUSES

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    • Laboratory Tests:

      • CXR

      • CBC with differential

      • BUN/Cr

      • glucose

      • liver enzymes

      • electrolytes

      • Gram stain/culture of sputum

      • pre-treatment blood cultures

      • oxygen saturation

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    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

    J Chr Dis 1984;37:215-25


    Community Acquired Pneumonia

    Usefulness of Gram Stain

    • Good sputum samples obtained from 39%

    • 83% show one predominant morphotype

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    Who should be hospitalized?

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    • 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

  • Adeel A. Butt, MD

    Fine MJ. NEJM 1997;336:243-50


    Community Acquired Pneumonia

    • Class I & II:

      • usually do not require hospitalization

  • Class III:

    • may require brief hospitalization

  • Class IV & V:

    • usually do require hospitalization

  • Fine MJ. NEJM 1997;336:243-50

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    Adeel A. Butt, MD


    Adeel A. Butt, MD


    Community Acquired Pneumonia

    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

    Management

    • Rational use of microbiology laboratory

    • Pathogen directed antimicrobial therapy whenever possible

    • Prompt initiation of therapy

    • Decision to hospitalize based on prognostic criteria

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    Empiric Treatment

    • Outpatient:

      • macrolide

      • doxycycline

      • Fluoroquinolone

        NOT IN ANY SPECIFIC ORDER

    IDSA guidelines: Clin Infect Dis 2000;31:347-82

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    Empiric Treatment

    • Patients in General Medical Ward:

      • 3GC + macrolide

      • B/B-I + macrolide OR B/B-I + FQ

      • FQ alone

    IDSA guidelines: Clin Infect Dis 2000;31:347-82

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    Empiric Treatment

    • Patients in ICU:

      • 3GC + macrolide

      • 3GC + FQ

      • B/B-I + macrolide

      • B/B-I + FQ

    IDSA guidelines: Clin Infect Dis 2000;31:347-82

    Adeel A. Butt, MD


    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.


    Community Acquired Pneumonia

    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

    Adeel A. Butt, MD

    IDSA guidelines: Clin Infect Dis 2000;31:347-82


    Increased drug efflux

    coded by mefE

    susceptible to clindamycin

    most cases in US

    may be overcome by achievable levels of macrolides

    Ribosomal methylase

    coded by ermAM

    resistant to clindamycin

    mostly in Europe

    not overcome by standard doses

    Community Acquired Pneumonia

    Macrolide Resistance

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    (Newer)Fluoroquinolones

    • Active against 98% of resistant pneumococcus

    • Resistance has begun to increase

    Chen DK. NEJM 1999;341:233-9

    Ho PL. Antimicrob Agents Chemother 1999;43:1310-3.

    Wise R. Lancet 1996;348:1660

    Adeel A. Butt, MD


    FQ Resistance

    • 4 cases from Canada with pneumococcal pneumonia

    • 1 died

    • 2 developed resistance while on Rx

    • 2 had resistantbugs 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


    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.


    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.


    Community Acquired Pneumonia

    • 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.

    Gleason. Arch Int Med 1999;159:2562-72.

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    • 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)

    Stahl. Arch Int Med 1999;159:2576-80.

    Adeel A. Butt, MD


    Community Acquired Pneumonia

    • 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

    Adeel A. Butt, MD

    Vergis. Arch Int Med 2000;160:1294-1300.


    Community Acquired Pneumonia

    • 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

    Adeel A. Butt, MD


    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

    Cost-Effectiveness of IV-Oral Switch Therapy

    Paladino. Chest Oct 2002;122:1271-1279.


    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%


    Community Acquired Pneumonia

    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)

    Adeel A. Butt, MD


    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


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