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Community Acquired Pneumonia. Dr Vincent Ioos Medical Intensive Care Unit Pakistan Institute of Medical Sciences. Definition. Infection of the lung parenchyma that has been acquired in the community Before hospital admission or within 48 hours

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community acquired pneumonia

Community Acquired Pneumonia

Dr Vincent Ioos

Medical Intensive Care Unit

Pakistan Institute of Medical Sciences

definition
Definition
  • Infection of the lung parenchyma that has been acquired in the community
  • Before hospital admission or within 48 hours
  • ≠ hospital acquired pneumonia, health care associated pneumonia
  • ≠ acute bronchitis and exacerbation of COPD
  • ≠ obstructive pneumonia, TB
diagnosis
Diagnosis
  • Lack of sensitivity of clinical signs and symptoms
    • But good Positive Predictive value of the presence of crakles
    • Good Negative Predictive Value of RR>30/mn, HR>100/mn, T°>37,9°C
  • Fever frequently absent in older patients
  • CXR
  • Leucopenia : poor prognosis
  • Microbiological diagnosis : better treatment when pathogen oriented but contreversies on the value of tests
should we get a cxr
Should we get a CXR ?
  • Patient with severe infection : presence of pneumonia allows proper empiric antibiotic therapy
  • If patient is not severely ill : helps in deferentiating CAP from acute bronchitis or exacerbation of COPD, and assess if antibiotics are necessary or not
epidemiology
Epidemiology
  • Varies from one country to another
  • 2 questions :
    • Pathogens most likely to be responsible for CAP
    • Pattern of resistance, especially for Streptoccus Pn.
  • Epidemiological studies difficult : previous use of antibiotics, cost of C/S and serological studies, invasive procedures.
  • Sentinel surveillance systems for specific pathogens : data from microbiology departments, from disease oriented register.
in pakistan
In Pakistan
  • Lack of datas
  • Neighbooring countries
  • World surveillance networks
  • Peadiatric studies
shimia himachal pradesh india
Shimia, Himachal Pradesh, India
  • 70 patients with CAP, blood, sputum and pleural fluid c/s, Mycoplasma Pn. Ab
  • 75,6 % proven etiology
    • Streptococcus Pn 35,8%
    • Klebsiella Pn 22%
    • Staphylococcus Aureus 17%
    • Mycoplasma Pn 15%
    • E. Coli 11%
    • Beta hemolytic Streptococci 7,5%
    • GNB 5,9%

Bansal S, Indian J Chest Dis Allied Sci. 2004, Jan-March ; 46(1) : 17-22

new delhi
New Delhi
  • All India Institute of Medical Sciences, April 1997 – December 1998
  • 60 patients : blood C/S + Elisa Ab against L. Pneumophila (serogroups 1-7)
  • 13% “conventional bacterial etiology”
  • 15% serological evidence of recent infection with L. Pneumophila

Chaudhry R, Trop Doct. 2000 Oct ; 30(4):197-200.

shangai
Shangai
  • 389 patients with CAP between 2001-2003
  • Bacterial culture, PCR, specific immunological assays
  • Specific pathogen found in 39,8% :
    • Haemophilus Inflenzae 51%, among them 88,3% amoxicilline S
    • Mycoplasma Pn. 27%
    • Chlamydia Pn. 11%
    • Klebsiella spp. 10%
    • Streptococcus Pn. 8% among them 75% Peni S, 25%Peni I
    • Staphylococcus Aureus 4%
    • Legionella Pn. 1,3%
    • Moraxella Catharallis 0,6%

Huang HH, Eur J Clin Microbiol Infect Dis. 2006 Jun ; 25(6):369-74

iran afghanistan
Iran, Afghanistan
  • PubMed : country name + “pneumonia”,
  • Iran : 33 articles, no epidemiological data on CAP
  • Afghanistan : 12 articles, one on epidemiology datas on CAP… in Russian Soldiers
slide15

66 Laboratories in 1997, 81 in 1998 (17 in Asia-Pacific)

  • Pneumococal isolates from bloodstream and respiratory tract infections
  • 8252 respiratory tract isolates

Hoban DJ, Clin Infect Dis. 2001 May 15;32 Suppl 2:S81-93.

slide17
Network of microbiology departments in 26 countries
  • 1998-2000
  • Streptococcus Pneumonia (8882 isolates), Haemophilus Influenzae (8523), Moraxella Catharralis (874)
slide18

Streptococcus Pn. :

  • 95% Amoxicilline S
  • Quinolone resistance 1,1%
  • Haemophilus : Beta Lactamase production 16,9%
ari in children pakistan
ARI in children, Pakistan
  • 87 strains of Streptococcus pneumoniae from blood culture
  • 97% resistant to at least one drug
  • 31% R to Cotrimoxazole,
  • 39% R to Chloramphenicol
  • All isolates were susceptible to erythromycin, cefaclor, cephalothin, ceftriaxone, cefuroxime, rifampicin, vancomycin, and clindamycin

Mastro TD, Lancet 1991 Jan 19 ; 337(8734):156-9.

critical microbes
Critical microbes
  • Legionella Pneumophila
  • Influenza A +B
  • Avian Influenza
  • SARS
  • CA-MRSA

 Epidemiological challenges or treatment different from standart regimen

blood cultures pros
Blood cultures (pros)
  • Pretreatment blood cultures positive for a pathogen in 7 to 16 percent of hospitalized patients.
  • Streptococcus pneumoniae : 2/3 of the positive blood cultures
  • When positive, the microbial diagnosis is established.
  • Only diagnostic test done, in most cases : major source of microbiologic data (resistance patterns of S. pneumoniae)
blood cultures cons
Blood cultures (cons)
  • The blood culture positivity rate is relatively low.
  • High rate of false positive blood cultures (up to 10 percent). Eg Staphylococcus.
  • Positive cultures rarely lead to modification or narrowing of antibiotic therapy
sputum standard quality criterias
Sputum : standard quality criterias
  • Deep cough specimen obtained prior to antibiotics,
  • To be sampled only if macroscopically purulent sputum,
  • Cultures performed rapidly after collection, preferably within two hours
  • « Good" sputum sample : > 25 PMNs / LPF but < 10 SECs/LPF on Gram Stain
  • Interpretation : Quantitation of growth (heavy, moderate or light, quantitative threshold 107 CFU), clinical correlation, correlation with the Gram's stain
invasive sampling
Invasive sampling
  • Protected brush specimen
  • Bronchalveolar Lavage
  • In case of failure of the initial treatment
  • If epidemiology or clinical presentation suggest a specific pathogens that is not covered by usual treatment strategy
  • If patient is intubated (ICU)
pleural tap
Pleural Tap
  • Rarely positive
  • Evidences empyema
urinary antigens pros
Urinary antigens (pros)
  • Urine specimens avalable when patients cannot supply expectorated sputum.
  • Results of urine antigen testing immediately available.
  • Retains validity even after the initiation of antibiotic therapy.
  • High sensitivity compared to blood cultures and sputum studies.
urinary antigens cons
Urinary antigens (cons)
  • The sensitivity and specificity may be less in patients without bacteremia.
  • No microbial pathogen available for antibiotic sensitivity testing.
urinary antigen lp
Urinary Antigen LP
  • Legionella Pneumophila
    • Only for serotype 1 (the most frequent 80%)
    • Sensitivity 86%, specificity 93%
    • Positive 1 to 3 days after the onset of disease
urinary antigen sp
Urinary antigen (SP)
  • Sensitivity 77-89% if CAP with blood culture +, Sensitivity 44-64% if blood culture –
  • False positive test rare
  • Rapid diagnosis, still positive after 7 days of antibiotics, persists several weeks.
diagnostic yield of microbiological tests
Diagnostic yield of microbiological tests
  • Prospective study : 262 hospitalized patients with CAP.
  • Sputum for Gram staining, culture, and detection of pneumococcal antigen; blood for culture and serologic tests; urine for legionella and pneumococcal antigens; and specimens obtained by bronchoscopy.
  • A pathogen was identified in 158 (60 percent) patients
  • Adequate sputum samples obtained in only 44 patients : Gram's stain + positive sputum culture in 36/44 patients (82%).

Van der Eerden MM, Eur J Clin Microbiol Infect Dis 2005 Apr;24(4):241-9.

diagnostic yield of microbiological tests1
Diagnostic yield of microbiological tests
  • S. pneumoniae most commonly identified (97 of 158).
  • Urinary pneumococcal antigen test positive in 52/97 (54%) patients with pneumococcal pneumonia.
  • Blood cultures were positive in 40 of 254 (16%) patients.
  • Bronchoscopy : additive diagnostic value in 18/37 patients (49%) who did not expectorate sputum and in 14 of 27 patients (52 percent) who failed treatment within 72 hours after admission.

Van der Eerden MM, Eur J Clin Microbiol Infect Dis 2005 Apr;24(4):241-9.

slide35
PCR
  • Multiplex Real-time PCR
  • Respiratory viruses and atypical bacteria(eg, M. pneumoniae, L. pneumophila, Legionella spp, C. pneumoniae, influenza A and B virus, respiratory syncytial virus, parainfluenza viruses, human rhinovirus, metapneumovirus, adenovirus, and human coronaviruses)
  • 105 adults : etiology determined
    • 50% with conventional techniques
    • 80% with PCR
  • But increased cost. ? Less antibiotic use.

Templeton KE, Clin Infect Dis 2005 Aug 1;41(3):345-51.

minimal approach
Minimal approach
  • 2 blood cultures and Tracheal Aspirate culture if patient is intubated …

… before antibiotics are given

  • Urinary Legionella Pn. Antigen
where should the patient be managed
Where should the patient be managed ?
  • At home
  • In the ward
  • In the ICU
  • « saving lifes and saving money »
  • Identify low risk patient to « save money » (and hospital beds !)
  • Identify high risk patient to « save life »
slide39
Saving money, avoid unnecessary hospitalisation
  • Large cohorts for validation (38,039 adults retrospectively, 2,287 adults for prospective validation)
fine scoring system
Fine scoring system

Class Points

II  70

III 71 - 90

IV 91 - 130

V > 130

Fine et al. N Engl J Med 1997; 336: 243-50

decision
Decision
  • IV, V : admit the patient
  • I : no admission
  • II, III : no admission if score results from the age + 1 other criteria.
  • Admit systematically if :
    • Hypoxemia SaO2<90% / PaO2<60%
    • Vomitting prohibiting oral treatment,
    • immunosupression
  • Do not forget clinical judgement !

25 years old pt + hypotension + tachycardia = class II !

curb index
Curb Index

CURB  2 : hospital admission is recomended

Derivated indexes : CURB-65, CRB-65

risk factors for penicillin resistant s pneumoniae
Risk factors for penicillin-resistant S. pneumoniae
  • Age <2 years or >65 years
  • Beta-lactam or macrolide therapy within the past six months
  • Recent hospital stay < 3 months
  • Medical comorbidities
  • Immunosuppressive illness or therapy
  • Exposure to a child in a day care center
early antibiotics for severe pneumonia
Early antibiotics for severe pneumonia
  • Prognosis impaired when antibiotic administration is delayed
  • Recommandations :
    • < 2 hours for non ICU patients
    • < 1 hour for ICU patients
  • Several studies showed that in the real life this goals are difficult to achieve (recent Chest study)
anti pneumococcal quinolones
Anti-pneumococcal quinolones
  • Consequences on community microbiological ecology unknown
  • High incidence of TB in Pakistan : false negative AFB, difficulty in proper microbiological diagnosis of TB
  • To be given as an alternative to standard therapy
emerging pathogens
Emerging pathogens
  • SARS
  • H5N1
  • SA-MRSA
challenges in pakistan
Challenges in Pakistan
  • Epidemiologic datas desperately needed
  • Costs associated with CAP (Antibiotics)
  • Rational use of antibiotics
  • Importance of institution-based recommendations
  • National consensus statement : epidemiologist, microbiologist, pulmonologists, infectious disease specialists, Intensivists.
consensus statements
Consensus Statements
  • American Thoracic Society,
  • 2001British Thoracic Society, 2004
  • Infectious Diseases Society of America, 2003
  • European Respiratory Society, 2005
  • Panel of French Scientific Societies under the leadership of “Societe de pathologie infectieuse de langue francaise, SPILF”, March 2006