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Community Acquired Pneumonia (CAP) by

CAP. Community Acquired Pneumonia (CAP) by. Dr. R V S N Sarma., MD., MSc., (Canada) Consultant Physician & Chest Specialist v isit us at: www.drsarma.in. CAP. Improving Outcomes Through Education. The New Treatment Paradigm – Selecting Appropriate Empiric Antibiotics.

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Community Acquired Pneumonia (CAP) by

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  1. CAP Community Acquired Pneumonia (CAP) by Dr. R V S N Sarma., MD., MSc., (Canada) Consultant Physician & Chest Specialist visit us at: www.drsarma.in

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

  3. Pneumonias – Classification Nosocomial Pneumonias

  4. Community Acquired Pneumonia (CAP) • Definition … an acute infection of the pulmonary parenchyma that is associated with 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.

  5. 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)

  6. 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

  7. CAP – The Two Types of 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

  8. CAP – Pathogenesis

  9. 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

  10. 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%; Hospitalized Pt  mort • <1% for those not requiring hospitalization Bartlett. CID 1998;26:811-38.

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

  12. 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

  13. CAP – Special Features – Pathogen wise Typical – S.pneumoniae, H.influenza, M.catarrhalis – Lungs Blood tinged sputum - Pneumococcal, Klebsiella, Legionella H.influenzae CAP has associated of pleural effusion S.Pneumoniae – commonest – penicillin resistance problem S.aureus, K.pneumoniae, P.aeruginosa – not in typical host S.aureus causes CAP in post-viral influenza; Serious CAP K.pneumoniae primarily in patients of chronic alcoholism P.Aeruginosa causes CAP in pts with CSLD or CF, Nosocom Aspiration CAP only is caused by multiple pathogens Extra pulmonary manifestations only in Atypical CAP

  14. S. aereus CAP – Dangerous • This CAP is not common; Multi lobar Involvement • Post Influenza complication, Class IV or V • Compromised host, Co-morbidities, Elderly • CA MRSA – A Problem; CA MSSA also occurs • Empyema and Necrosis of lung with cavitations • Multiple Pyemic abscesses, Septic Arthritis • Hypoxemia, Hypoventilation, Hypotension common • Vancomycin, Linezolid are the drugs for MRSA

  15. CAP – Age wise Incidence

  16. CAP – Age wise Mortality

  17. 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

  18. 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

  19. CAP – Bacteriology in Hospitalized Pts

  20. CAP – Evaluation of a Patient

  21. 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

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

  23. Classification of Severity - PORT

  24. CAP – Management based on PSI Score

  25. CURB 65 Rule – Management of CAP

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

  27. Who 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

  28. 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

  29. 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

  30. 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

  31. Infiltrate Patterns and Pathogens

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

  33. Pathogens Retrieved from Blood Culture

  34. 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 %

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

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

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

  38. 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

  39. 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

  40. 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

  41. OPAT – OP Parenteral Antimicrobial Therapy

  42. Antibiotics of choice for CAP

  43. 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 – Levoflox, Gemiflox or Moxiflox 2. Beta-lactam (High dose Amoxicillin, Amoxicillin- Clavulanate is preferred; Ceftriaxone, Cefpodoxime, Cefuroxime) plus a Macrolideor Doxycycline

  44. Empiric Treatment – Inpatient – Non ICU 1. A Respiratory Fluoroquinolone (FQ) Levoor 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

  45. 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

  46. Empiric Rx. – 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

  47. Empiric Rx. – 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 Cephalosporin

  48. Duration of Therapy • Minimum of 5 days • Afebrile for at least 48 to 72 h • No > 1 CAP-associated sign of clinical instability • Longer duration of therapy If initial therapy was not active against the identified pathogen or complicated by extra pulmonary infection

  49. Survival (%) Each hour of delay carries 7.6% reduction in survival Delay in treatment (hours) from hypotension onset New data – The Speed of Delay ! (Class 4,5) Kumar, et al. Crit Care Med 2006;34:1589–1596

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