COMMUNITY ACQUIRED PNEUMONIA COMMUNITY ACQUIRED PNEUMONIA - - OLD ENEMY & RECENT FOE OLD ENEMY & RECENT FOE Dr. Md. Sayedul Islam Dr. Md. Sayedul Islam Consultant Consultant pulmonologist & pulmonologist & intensivist intensivist King Saud Chest Hospital King Saud Chest Hospital
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COMMUNITY ACQUIRED PNEUMONIA - OLD ENEMY & RECENT FOE Dr. Md. Sayedul Islam Consultant Consultant pulmonologist & intensivist King Saud Chest Hospital.
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Dr. Md. Sayedul IslamDr. Md. Sayedul Islam Consultant Consultant pulmonologist & intensivistpulmonologist & intensivistKing Saud Chest HospitalKing Saud Chest Hospital
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.
EPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGY
Current CAP burdenCurrent CAP burden
6Th leading cause of death6Th leading cause of death.
60
45
35
15
0
10
20
30
40
50
60
Hospital
ICU
Mortality
DRSP
60
45
35
15
0
10
20
30
40
50
60
Hospital
ICU
Mortality
DRSP
CID 2007: 44 (supl 2), s27
ETIOLOGYETIOLOGY
Pneumococcal burdenPneumococcal burden
PATHOLOGYPATHOLOGY
PATHOLOGYPATHOLOGY
Pneumonia with complication Pneumonia with complication
Pneumonia with co morbid illnessPneumonia with co morbid illness
Pneumonia with risk factorsPneumonia with risk factors
Pneumonia with unstable vital signPneumonia with unstable vital sign
Assessment of pneumoniaAssessment of pneumonia
Complication of PneumoniaComplication of Pneumonia
COPDCOPD Congestive heart failureCongestive heart failure MalignancyMalignancy Diabetes MellitusDiabetes Mellitus Hepatic or renal diseaseHepatic or renal disease
Risk factorsRisk factors
Risk factors for DRSPRisk factors for DRSPAge>65years Recent antibiotics within 1 months (DRSP) Immunosupressive therapy within 3 monthsHIV/ Immunocompromized patient
Unstable Vital signUnstable Vital sign
Altered level of conciousness Heart rate >125 Respiratory rate >30/m Systolic BP<90 mmHg Temperature <35 or >400 C
Maximize the outcome of CAP
Site of care decisionSite of care decision
Time of first antibioticsTime of first antibiotics
Proper choice of antibioticsProper choice of antibiotics
SITE OF CARESITE OF CARE
PORT PEDICTION RULEPORT PEDICTION RULE
CURB- 65CURB- 65
FINEFINE””S PSI SCORINGS PSI SCORING
PORT Prediction RulePORT Prediction Rule
Items Score
Neoplastic disease 30
CLD 20
CCF 10
CVD 10
Renal 10
Altered mentation 20
Respiratory rate >30/m 20
Systolic BP <90mmHg 20
Temperature <35ºC 15
Patients outcome research team Patients outcome research team
PORT Prediction Rule-PORT Prediction Rule-contdcontd
Items Score
Na+ 10
PH <7.35 30
Urea ≥ 30mg/dl 20
Glucose >250 mg/dl 10
HCT < 30 10
Pao2 <60 mmHg 10
Pleural effusionPleural effusion 10
PORT Prediction Rule - PORT Prediction Rule - contdcontd
BBlood pressure (lood pressure (SBP < 90mmHg or DBP 60mmHg) SBP < 90mmHg or DBP 60mmHg)
Age ≥ Age ≥ 6565 years years
Score 1 point for each feature presentScore 1 point for each feature present
Pneumonia severity scoring index Pneumonia severity scoring index system (CURB-65 scoring) system (CURB-65 scoring)
Age Age Co morbidityCo morbidity Unstable vital signUnstable vital sign
Group-I = No to all, Low mortality risk, eligible for OPD management of CAPGroup-II = Yes to 1-2 of three questions, Intermediate mortality risk, close monitoring or hospitalization for up to 48 hours,Group III = Yes to all, Moderate to high mortality risk, proceed to hospitalization
Pneumonia severity scoring index Pneumonia severity scoring index system (Fine`s PSI scoring)system (Fine`s PSI scoring)
Head to head comparison of first line AbxHead to head comparison of first line Abx
MOXIRAPID study groupMOXIRAPID study group
85.20%
85.40%
85.60%
85.80%
86.00%
86.20%
86.40%
86.60%
Ctrx+Clar
MxF
Clin Infect Dis.2005 Dec 15; 41(12):1697-705
For adult hospitalized Patient with CAP, MxF therapy is clinicallyequivalent to high dose Ctrx +clari
PROBLEM OF CAP
DRSP
MDRSP
EPIDEMIC AND PANDEMIC FLU
De- Escalation is use of EITHER OR De- Escalation is use of EITHER OR BOTH-BOTH-
Fewer drugs, Fewer drugs,
Narrower spectrumNarrower spectrum
De Escalation reduced drug resistance De Escalation reduced drug resistance and decrease mortalityand decrease mortality
De-EscalationDe-Escalation
VACCINEVACCINE
INFLUENZA VACCINEINFLUENZA VACCINE
PNEUMOCOCCAL VACCINEPNEUMOCOCCAL VACCINE
S. pneumonae and H. influenzae are important pathogens S. pneumonae and H. influenzae are important pathogens in CAPin CAP
Resistant in S. pneumoae is increasing worldwide.Resistant in S. pneumoae is increasing worldwide. -Fatal pandemic H1N1 cases had bacterial coinfection,esp Spn-Fatal pandemic H1N1 cases had bacterial coinfection,esp Spn
Risk stratification by prediction scoring, appropriate ABx, Risk stratification by prediction scoring, appropriate ABx, De-excalation may reduce the resistance patternDe-excalation may reduce the resistance pattern
Moxifloxacin has excellent activity against typical RTI Moxifloxacin has excellent activity against typical RTI pathogene, including PRSP.pathogene, including PRSP.
ConclusionConclusion
Thanks for Your Attention!
The Abbreviated Mental Test (eachquestion scores 1 mark, total 10 marks)
+ Age+ Date of birth+ Time (to nearest hour)+ Year+ Hospital name+ Recognition of two persons (e.g. doctor,nurse)+ Recall address (e.g. 42 West Street)+ Date of First World War+ Name of monarch+ Count backwards 20 ® 1
Place/severity or pathogen Duration of treatment (days)
Home treated, not severe (microbiologically undefined) 7Hospital treated, not severe (microbiologically undefined) 7Hospital treated, severe (microbiologically undefined) 10Legionella infection 14–21“Atypical” pathogen 14Pneumococcal infection (uncomplicated) 7Staphylococcal infection 14–21Gram negative enteric bacilli 14–21
Importance of guideline of Importance of guideline of empirical therapyempirical therapy
Ideally the first dose of antibiotic should be administered within 6 hours of initial medical assessment to improve the outcome
CAP is the evolving process and patient may shift between risk groups. The physician must be responsive to these changes and can only do so when the patient is managed in appropriate setting.
Timely therapy can only be given when disease is recognized & severity is appropriately assessed.
EPIDEMIOLOGYEPIDEMIOLOGY
CAP PRODUCING ORGANISM
Deference between Typical & Deference between Typical & AtypicalAtypical
Features Typical AtypicalCough Present, productive May be absent, when
present dry, hacking
Main complain Fever, chest pain Fever, body ache
Physical finding Typical physical finding
Of consolidation
Feature out of proportion to physical finding
culture 60% culture positive Usually culture –ve/
serology diagnostic
TLC Usually very high May be normal
CxR Lober consolidation Variable
COMMUNITY ACQUIRED PNEUMONIACOMMUNITY ACQUIRED PNEUMONIA - Old enemy & recent foe- Old enemy & recent foe
Dr. Md. Sayedul IslamDr. Md. Sayedul Islam Consultant Consultant pulmonologist & intensivistpulmonologist & intensivistKing Saud Chest HospitalKing Saud Chest Hospital
Commonly defined as-
An acute infection of the lower respiratory An acute infection of the lower respiratory tract tract
In patient who has not resided in a In patient who has not resided in a hospital or health care facilities in the hospital or health care facilities in the previous 14 days.previous 14 days.
DEFINITIONDEFINITION
Infection is usually spread by droplet inhalation
Most patients affected are previously well.
-Smoker
-Alcoholic more susceptiblemore susceptible
-Steroid therapy
COMMUNITY ACQUIRED PNEUMONIACOMMUNITY ACQUIRED PNEUMONIA
EPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGY
EPIDEMIOLOGYEPIDEMIOLOGY
Current CAP burdenCurrent CAP burden
6Th leading cause of death6Th leading cause of death.
60
45
35
15
0
10
20
30
40
50
60
Hospital
ICU
Mortality
DRSP
60
45
35
15
0
10
20
30
40
50
60
Hospital
ICU
Mortality
DRSP
CID 2007: 44 (supl 2), s27
ETIOLOGYETIOLOGY
Pneumococcal burdenPneumococcal burden
AGE DISTRIBUIONAGE DISTRIBUION
PATHOLOGYPATHOLOGY
PATHOLOGYPATHOLOGY
Community Acquired Pneumonia (CAP)Community Acquired Pneumonia (CAP)
BBlood pressure (lood pressure (SBP < 90mmHg or DBP 60mmHg) SBP < 90mmHg or DBP 60mmHg)
Age ≥ Age ≥ 6565 years years
Score 1 point for each feature presentScore 1 point for each feature present
Pneumonia severity scoring index Pneumonia severity scoring index system (CURB-65 scoring) system (CURB-65 scoring)
Age Age Co morbidityCo morbidity Unstable vital signUnstable vital sign
Group-I = No to all, Low mortality risk, eligible for OPD management of CAPGroup-II = Yes to 1-2 of three questions, Intermittent mortality risk, close monitoring or hospitalization for up to 48 hours,Group III = Yes to all, Moderate to high mortality risk, proceed to hospitalization
Pneumonia severity scoring index Pneumonia severity scoring index system (Fine`s PSI scoring)system (Fine`s PSI scoring)
The Abbreviated Mental Test (eachquestion scores 1 mark, total 10 marks)
+ Age+ Date of birth+ Time (to nearest hour)+ Year+ Hospital name+ Recognition of two persons (e.g. doctor,nurse)+ Recall address (e.g. 42 West Street)+ Date of First World War+ Name of monarch+ Count backwards 20 ® 1
Place/severity or pathogen Duration of treatment (days)
Home treated, not severe (microbiologically undefined) 7Hospital treated, not severe (microbiologically undefined) 7Hospital treated, severe (microbiologically undefined) 10Legionella infection 14–21“Atypical” pathogen 14Pneumococcal infection (uncomplicated) 7Staphylococcal infection 14–21Gram negative enteric bacilli 14–21
Duration of treatmentDuration of treatment
CAP PRODUCING ORGANISM
Deference between Typical & AtypicalDeference between Typical & Atypical
Features Typical AtypicalCough Present, productive May be absent, when
Severe structural lung disease (bronchiactesis) Recent antibiotic therapy Stay in hospital (ICU)
Importance of guideline of empirical Importance of guideline of empirical therapytherapy
Ideally the first dose of antibiotic should be administered within 6 hours of initial medical assessment to improve the outcome
CAP is the evolving process and patient may shift between risk groups. The physician must be responsive to these changes and can only do so when the patient is managed in appropriate setting.
Timely therapy can only be given when disease is recognized & severity is appropriately assessed.
Head to head comparison of first line AbxHead to head comparison of first line Abx
MOXIRAPID study groupMOXIRAPID study group
85.20%
85.40%
85.60%
85.80%
86.00%
86.20%
86.40%
86.60%
Ctrx+Clar
MxF
Clin Infect Dis.2005 Dec 15; 41(12):1697-705
For adult hospitalized Patient with CAP, MxF therapy is clinicallyequivalent to high dose Ctrx +clari
00.5
11.5
22.5
33.5
44.5
5
Moxi
Cef+ Mac
Fever resolutionFever resolution
Day
sD
aysMoxi-Rapid trialMoxi-Rapid trial
ECCMID (European congress of clinical Microbiology and infectious Disease)
CAPRIE studyCAPRIE study
85
86
87
88
89
90
91
92
93
Moxi
Levo
Clinical cure Day 5-21 post therapyClinical cure Day 5-21 post therapy
Cu
re %
of
pat
ien
tsC
ure
%o
f p
atie
nts
Bacterial co-infection from fatal Bacterial co-infection from fatal pandemic H1N1 pandemic H1N1
During May - august 2009, 77 us patients with During May - august 2009, 77 us patients with fatal cases of confirmed H1N1fatal cases of confirmed H1N1
Of the 77 cases, > 30 cases had bacterial coinfection-- Of the 77 cases, > 30 cases had bacterial coinfection-- -10 cases with S. pneumoniae, -10 cases with S. pneumoniae, -6 with S. pyogenes, -6 with S. pyogenes, -7 cases with S. aureus, -7 cases with S. aureus, -2 with S. mitis, and -2 with S. mitis, and -1 with H influenzae, -1 with H influenzae, -rest of the cases were involved with -rest of the cases were involved with multiple pathogen.multiple pathogen. MMWR,Sep29,2009
DurationDuration of treatment of treatment
Uncomplicated pneumonia 7-10 days
Legionella, Staph, Klebsiella needs 14 days or more
Pneumonia with complication needs treatment for 4wks or longer
De- Escalation is EITHER OR BOTHDe- Escalation is EITHER OR BOTH
Fewer drugs, Fewer drugs,
Narrower spectrumNarrower spectrum
De Escalation reduced drug resistance De Escalation reduced drug resistance and decrease mortalityand decrease mortality
De-EscalationDe-Escalation
VACCINEVACCINE
S. pneumonae and H. influenzae are important pathogens S. pneumonae and H. influenzae are important pathogens in CAPin CAP
Resistant in S. pneumoae is increasing worldwideResistant in S. pneumoae is increasing worldwide --In Asia, macrolides resistance was higher than in other areasIn Asia, macrolides resistance was higher than in other areas -Penicilln and macrolides resistance were clinically significant-Penicilln and macrolides resistance were clinically significant -Fatal pandemic H1N1 cases had bacterialcoinfection,esp Spn-Fatal pandemic H1N1 cases had bacterialcoinfection,esp Spn
Prevalence of BLANR in H. influenza bring concern in Prevalence of BLANR in H. influenza bring concern in Japan.Japan.
Moxifloxacin has excellent activity against typical RTI Moxifloxacin has excellent activity against typical RTI pathogene, including PRSP.pathogene, including PRSP.
ConclusionConclusion
Pneumonia in ER
Atypical PneumoniaAtypical Pneumonia
MRSA -PneumoniaMRSA -Pneumonia
National Nosocomial Infection Surveys reportNational Nosocomial Infection Surveys report
1975 1975 : 2-3% of all : 2-3% of all S. aureusS. aureus isolation isolation
1997-19991997-1999 : Over 34% of all : Over 34% of all S. aureusS. aureus
1999 1999 : Incidence of MRSA, CAP is 25% of : Incidence of MRSA, CAP is 25% of
all S. aureusall S. aureus
MRSA- Risk Factors (CAP)MRSA- Risk Factors (CAP)
Intravenous drug useIntravenous drug use Chronic antimicrobial therapyChronic antimicrobial therapy HemodialysisHemodialysis The major route of MRSA spread is direct The major route of MRSA spread is direct
patient to patient contactpatient to patient contact Via the hand of medical personnel.Via the hand of medical personnel.
Sites of colonizationSites of colonization
Anterior nares Wound, burns or other areas of decrease
skin integrity. The perineal area Upper respiratory tract. Skin adjacent to- invasive device,
Klebsiella Pneumonia In pulmonary infarct or collapsed lobe.
Step pneumoniae
Staph. Aureaus
Strep pyogenes & H. inflenzae
Antibiotic treatmentAmoxycillin 500mg 6hrly orally plus
Metronidazole 400 mg 8 hrly
If anaerobic infection suspected
Antibiotic therapy modified according to CS
Removal or treatment of endobronchial obstruction if any.
Duration 4-6 weeks.
Pneumonia in immunocompromised patient
In AIDS disease
Disseminated infectiono Cytomegalovirus (CMV) infectiono Bacterial septicemiao Pneumococcal o salmonella
Atypical PneumoniaAtypical Pneumonia
MRSA -PneumoniaMRSA -Pneumonia
National Nosocomial Infection Surveys reportNational Nosocomial Infection Surveys report
1975 1975 : 2-3% of all : 2-3% of all S. aureusS. aureus isolation isolation
1997-19991997-1999 : Over 34% of all : Over 34% of all S. aureusS. aureus
1999 1999 : Incidence of MRSA, CAP is 25% of : Incidence of MRSA, CAP is 25% of
all S. aureusall S. aureus
MRSA- Risk Factors (CAP)MRSA- Risk Factors (CAP)
Intravenous drug useIntravenous drug use Chronic antimicrobial therapyChronic antimicrobial therapy HemodialysisHemodialysis The major route of MRSA spread is direct The major route of MRSA spread is direct
patient to patient contactpatient to patient contact Via the hand of medical personnel.Via the hand of medical personnel.
Sites of colonizationSites of colonization
Anterior nares Wound, burns or other areas of decrease
skin integrity. The perineal area Upper respiratory tract. Skin adjacent to- invasive device,