29-11-2013 1 Pneumonia in ER Pascal Van Bleyenbergh Department of Pneumology, UZ KULeuven Global mortality due to infection: major impact of pneumonia 0 0,5 1 1,5 2 2,5 3 3,5 Respiratory infec ons AIDS Gastroenteri s Tuberculosis Malaria Neonatal infec ons Deaths (millions) World Health Statistics, WHO 2010
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Pneumonia in ER - Medica · 29-11-2013 10 Streptococcus pneumoniae = most frequent pathogen = highest morbidity and mortality CAP: etiology Should always be covered when starting
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29-11-2013
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Pneumonia in ER
Pascal Van BleyenberghDepartment of Pneumology, UZ KULeuven
Global mortality due to infection:major impact of pneumonia
Even in developed countriesCAP mortality is not negligible…
1900 1950 2000
Mortality:- outpatients 1%- 5%- inpatients
- CAP III 6%-14%- CAP IV 36%-60%
- 18-44 year <1%- >65 year 12,5%
Feikin DR et al. Am J Public Health 2000; 90: 223-229National Center for Health Statistics 2000 (www.cdc.gov/nchs)
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Mixed patient populations in different settings and countries
*CAP=Community acquired pneumonia # average of 30-day and 90-day mortality in ICU vs ward patients, with average of 2 rates ~ 12%
Mortality for hospitalised patients with CAP has remained constant over time
Austrian R et al. Ann Intern Med 1964; 60: 759Fine MJ et al. JAMA 1996; 274: 134Feikin DR et al. Am J Pub Health 2000; 90: 223Restrepo MI et al. Chest 2008; 133: 610
CAP: assessment
History and clinical examination (vital signs!)
Routine laboratorium(PBC, electrolytes, liver and kidney function) severity
Oxygenation assessment (oximetry/ABG)
Chest X-ray- definate diagnosis of pneumonia (caveats!)- severity- underlying conditions or complicatins- no correlation with causal pathogen!!
• Coverage for Pseudomonas aeruginosaand MRSA only when specific risk factors are present
Pseudomonas risk factors
1. Recent hospitalisation
2. Frequent use of antibiotics/steroids (>4 in previous
year) or recent use of antibiotics/steroids (previous
3 months)
3. Very severe COPD (i.e. GOLD IV)
4. Isolation van P. aeruginosa during a previous AECOPD
of known kolonisation during stable periods
5. Presence of bronchiectasis
Eller et al. Chest 1998; 157: 1542Miravitlles et al. Chest 1999; 116: 40Woodhead et al. ERS Task force. Eur Resp J 2005; 26: 1138
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Risk factors for infection by multidrug resistant (MDR) pathogens
• Antibiotic therapy in previous 90 days• High frequency of resistance in community• Immunosuppression by disease or medication• Risk factors for HCAP
Hospitalisation for ≥2 days in previous 90 daysNursing home residenceHome intravenous therapyChronic dialysis within 30 daysChronic wound careClose contacts to MDR pathogens
Trouillet et al. AJRCCM 1998; 157: 531-539
CAP: treatment
• Pneumonia always antibiotics ASAP
• Which?→ criteria
- antibiotic spectrum- route of administration- bio-equivalence
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Antibiotics: which route to choose?
• Parenteral administration is widely andoften unnecessarily used
→ only 30-50% of patients admitted tohospital will initially require treatmentwith parenteral antibiotics
Parenteral therapyHigh severity pneumoniaImpaired consciousnessLoss of swallowing reflexFunctional or anatomical reasons for malabsorption
Chan R et al. BMJ 1995; 310: 1360-1362Macgregor RR et al. Clin Infect Dis 1997; 24: 457-467
IV vs. PO: bio-equivalent antibiotics
Levofloxacin
Moxifloxacin
Clarithromycin
Clindamycin
Linezolid
Metronidazole
Ornidazole
Fluconazole
SMX/TMP
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IV vs. PO: when to switch?
• No rigid recommendations
• Any decision should be individualised basedon assessing all factors
• Oral therapy should be considered in a patient who has shown clear evidence ofimprovement
• Ward pharmacists could play an important role…
Mandell LA et al. Can J Infect Dis 1995; 6: 306-315
IV vs. PO: when to switch?
Lim WS et al. Thorax 2009; 64(3); 1-55Halm EA, Fine MJ, Marrie TJ, et al. JAMA 1998; 279; 1452-1457
Liapikou A et al.Clin Infect Dis 2009; 48: 377-385
Severe CAP: IDSA/ATS criteria
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Biomarkers for identification of severe CAP
• Ideal marker has not yet been found• One marker panel of markers
CRP (c-reactive protein)
PCT (procalcitonine )
IL-6 (>>IL-8)
Pro-adrenomedullin
Pro-natriuretic peptide (proANP)
sTREM-1 (triggering receptor expressed on myeloid cells)
Pro-vasopressin (proAVP)
Christ-Crain M, Müller B. Eur Resp J 2007; 30: 556-573Menendez R et al. Thorax 2009; 64: 587-591Waterer GW et al. Am J Resp Crit Care Med 2011; 183: 157-164
Severe CAP & bacterial load
• PCR-based pneumococcal assay– sensitivity: 2x blood culture sensitivity– specificity ≈100%– load (copies/mL) strong predictor of the
risk of shock and risk of deathRello J et al. Chest 2009; 136: 832-840
Peters RP et al. J Clin Microbiol 2009; 47: 3308-3312Kee C et al. Chest 2010; 137: 243-244
Sepsis, shock, …death not only an exagerated host response
but also related to bacterial factors!
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Severe CAP & bacterial load
• PCR-based pneumococcal assay– sensitivity: 2x blood culture sensitivity– specificity ≈100%– load (copies/mL) strong predictor of the
risk of shock and risk of death
Therapy for severe CAP
• Combination therapy >> monotherapyMufson MA et al. Am J Med 1999; 107:34-43
Waterer GW et al. Arch Intern Med 2001; 161:1837-1842Baddour LM et. Am J Respir Crit Care Med 2004; 170:440–444
Nonsevere CAP Severe CAP
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Therapy for severe CAP
• Coverage for S. pneumoniae and Legionella species should be ensured
• Parenteral administration is recommended
• Coverage for Pseudomonas aeruginosaand MRSA when specific risk factors are present
Ruiz M et al. Am J Respir Crit Care Med 1999; 160:923–9
Adjunctive therapy for severe CAP
1. Corticosteroids
2. Macrolides
3. Activated Protein C
4. Tissue Factor Pathway Inhibitor
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• No improved survival or reversal of shock in patients with septic shock
Adjunctive therapy:corticosteroids
Sprung CL et al. N Engl J Med 2008;358:111-24
(hydrocortisone 50mg qid, 5d.)
• No evidence to support use of corticosteroidsin severe CAP without septic shock
Adjunctive therapy:corticosteroids
Snijders D et al. Am J Resp Crit Care Med 2010; 181: 975-982
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• Meta-analysis JAMA 2009:- overall no effect on 28-day mortality- moderate beneficial effect on mortality
“We believe that current evidence supports obligatorymacrolide therapy in all cases of CAP with physiologicalcompromise, especially those with or deemed at risk forseptic shock or mechanical ventilation”
Grant W. Waterer, Jordi Rello, andRichard G. WunderinkAm J Respir Crit Care Med 2011; 183: 157-164