Göksel Kıter Pamukkale University, Medical Faculty Chest Department [email protected] What should we do to solve the problems in lower respiratory infections?
Apr 01, 2015
Göksel Kıter
Pamukkale University, Medical Faculty
Chest Department
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
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