Göksel Kıter Pamukkale University, Medical Faculty Chest Department gokselkiter@yahoo.com What should we do to solve the problems in lower respiratory.

Göksel Kıter

Pamukkale University, Medical Faculty

Chest Department

gokselkiter@yahoo.com

What should we do to solve the problems in lower respiratory

infections?

What should we do to solve the problems in pneumonia topic?

Göksel Kıter

Pamukkale University, Medical Faculty

Chest Department

gokselkiter@yahoo.com

The problem is not the inability to find the solution, it is the inability to

recognize the problem. G.K.Chesterton

In this presentation

• The problems will be defined by reviewing– Related publications (2000-2007)– Previous congress presentation (2000-2007)– Previous presentation by Prof Dr Tevfik Özlü

• The suggestions to solve those problems will be discussed

National publications

Turkish Thoracic Journal (in Turkish; 2000-2007)

• Key word: “pneumonia” 21 articles– 5 review articles– 4 diagnosis and treatment guidelines (2002)– 5 investigations– 5 case reports– 1 İİP review article

• Key word: “infection”– 1 investigation

National publications

Tuberculosis and Thoracic Journal (2000-2007)

• Key word: “pneumonia” 40 articles– 3 review articles– 12 investigations– 1 case report– 24 other (2 tb-2 empiyema)

• Key word: “infection”– 1 other

National publications

Respiratory Journal (2000-2007)

• Key words: “pneumonia” 19 articles– 7 investigations– 2 case reports– 10 other (1 empiyema review)

• Key word: “infection”– 16 other

TTS CongressesYEAR Total Pnm (%) OP PD PP

2000 379 29 (7.6) 6 11 12

2001 492 20 (4) 4 7 9

2002 659 26 (3.9) 4 7 15

2003 706 16 (2.2) 0 0 16

2004 860 15 (1.7) 5 0 10

2005 621 5 (0.8) 5 0 0

2006 428 57 5 0 52*

2007 356 13 (3.6) 5 8 0

www.pubmed.com

• 2005-2007 (.....1990)

• 19 articles

• 12 Infectious Diseases, 1 Infetion Control Consersium, 3 Pediatric Diseases, 1 Intensive Care Unit, 1 Internal Medicine

• Intensive Care Unit infections, Hospital aquired infections, infections over age 65

• The antibiotic resistances of Streptococcus

Suggestion 1

In CAP;The efficacy of prevention methodsEpidemiologic studiesImprovement in diagnostic toolsTreatment in outpatient clinics

Microbiologic studiesAntibiotic resistance ratesCombining the data from clinic and lab. studies

Sputum smearGram staining of sputum

HAP;Epidemiologic studiesPatogen definition in any unitThe efficacy of prevention methodsRisk factors for severe diseaseTreatment optionsBest timing for ending therapy

Pneumonia in ICUEpidemiologic studiesPatogen definition in any unitThe efficacy of prevention methodsRisk factors for severe diseaseTreatment optionsBest timing for ending therapy

Antibiotic Consumption in 26 Countries

Goossens.HA. Lancet 2005; 365:579-87

Christ Crain M et al., Lancet 2004; 363: 600-7

Randomizied controlled, open, Intervention Study in one Swiss Center

234 Patients admitted to an emergency department with suspected LRTI

•Standard-AB-Therapy (n=119) in according to Swiss guidelines

•PCT-guided AB-Therapy (n=123)

Results:

50 % lower Antibiotic prescription in the PCT guided group

No difference for all examined outcome parameters

Procalcitonin Guided Therapy

Christ-Crain M et al, AJRCCM 2006; 174(1):84-93

Randomization ProCT GroupStandard Group(without ProCT)

<0.1

0.1-0.25

>0.25

ProCT (ug/L)

AB treatment (prescription & duration according to evidence-

based guidelines

Follow-up ProCT Day 4 Day 6 Day 8

AB Therapy

NO!

No

Yes

CAP

STOP or continue, based on the same cutoffs

AB duration according to guidelines

>0.5 YES!

Follow-up after 4-6 wksincl. Rx

Clin

ical and

PC

T co

ntro

l after 6-12h

The ProCAP StudyThe ProCAP Study

The ProCAP Study – Antibiotic DurationThe ProCAP Study – Antibiotic Duration

p < 0.001

Standard group

PCT group

2

4

6

8

10

12

13

20

15

17

19

Standard group PCT group

0

10

20

30

40

50

60

70

80

90

100

AB started > 4d > 6d > 8d > 10d > 14d > 21d

An

tib

ioti

c P

resc

rip

toin

(%

)

Christ-Crain M et al, AJRCCM 2006; 174(1):84-93

p < 0.001

Standard group

PCT group

2

4

6

8

10

12

13

20

An

tibio

tic d

ura

tion

(d

ays

) 15

17

19

Suggestion 2

• Drug efficacy and safety studies• The reliable and pratical markes for the

decision to start/stop the therapy

National Guidelines

Ekim N, Köktürk O, Arseven O, Eraksoy H ve ark.Toplum Kökenli Pnömoni. Tanı ve Tedavi Rehberi.Toraks Bülteni 1998 ; 3:2-4.

Pnömoniler (Bir devin uyanışı). Uçan ES (ed), İzmir, 1995

The consistency with hospitalization and treatment criteria: Highest in 1999

Mortality was 5% (Highest in 1999-14%)

Table IV. Consistency with hospitalization criteria Table V. Consistency with treatment criteria

% %

Year: 2001  Volume: 49  Number: 3  297-311

The success rates in community-acquired pneumonia treated consistently or inconsistently with the Turkish Thoracic Society Pneumonia Guidelines

Münire Gökırmak1, H Canan Hasanoğlu1, Zeki Yıldırım1, Nurhan Köksal1, Zeynep Orhan1, Süleyman S Hacıevliyagil1

İnönü Üniv. Turgut Özal Tıp Merk. Göğüs Hastalıkları Ana BD., Malatya

•Typical CAP (14), Atypical CAP (2), unclassified CAP (5), •CAP in patients over age 60 or with accompanied disease (26), •Mild-moderate CAP that requires hospitalization (30),•Severe CAP that requires treatment in ICU (71)

•36 (24%) treatment consistent with national quidelines

success rate 92% (3 nonresponder treated with antistaph.)•112 treatment inconsistent with national quidelines

success rate 76%, with second line treatment regimen 96% (3 exitus)

The indication to treat in ICU was in 49 cases6 major: 1 with MV43 minor: MV requirement in 7; all in the clinic

Intermadiate / Intensive Care

In-Hospital Mortality for Community Acquired

Pneumonia and Evaluation According to National

Diagnosis and Treatment Guidelines

Original article Respiratory system infections

Fidan A et al. Toraks Dergisi, 2005;6(2):115-121

%13.9%6.1mortality

The consistency to treatment criteria according to year and group

CAP group

Consistently treated Overtreated Undertreated TotalYear

Suggestion 3

• Every solution brings new problems.

• Solving the problem changes the problem.

• There is one solution for every problem. What is difficult

is to find it.

• The complicated problems have simple and easily

understandable wrong answers.

• They are the componets of the problem who

don’t work on the solving process.

Murphy’s Rules