06/25/98
BACTERIAL BACTERIAL PNEUMONIAPNEUMONIA
Developing AntimicrobialDeveloping Antimicrobial
Drugs For TreatmentDrugs For Treatment
Alma C. Davidson, M.D.Alma C. Davidson, M.D.
Division of Anti-Infective Drug ProductsDivision of Anti-Infective Drug Products
ODE IVODE IV
July 30, 1998July 30, 1998
2July 1998
Separation of CAP from NPSeparation of CAP from NP More stringent criteria for NPMore stringent criteria for NP Need for NP patients to have both Need for NP patients to have both
fever and leukocytosis plus at least fever and leukocytosis plus at least one of the other signs and symptoms one of the other signs and symptoms
ISSUES in ACM - March ISSUES in ACM - March 19971997
3July 1998
ISSUES in ACM - cont’dISSUES in ACM - cont’d
Diagnostic criteria for ventilator-Diagnostic criteria for ventilator-associated pneumonia (VAP)associated pneumonia (VAP)
Subsetting patients with VAPSubsetting patients with VAP How to handle patients who have How to handle patients who have
evidenceevidence
of multiple pathogens in sputumof multiple pathogens in sputum Gram stain should correlate with Gram stain should correlate with
culture results.culture results.
4July 1998
Questions and Comments Questions and Comments fromfromIndustry - cont’dIndustry - cont’d
Are blood cultures necessary for Are blood cultures necessary for outpatients with pneumonia?outpatients with pneumonia?
NoNo
5July 1998
Questions and Comments Questions and Comments fromfromIndustry - cont’d Industry - cont’d
Eliminate blood cultures as inclusion criteria since these Eliminate blood cultures as inclusion criteria since these are pending for two days after enrollment.are pending for two days after enrollment.
Recommend eliminating fever as inclusion criteria Recommend eliminating fever as inclusion criteria since fever is absent from one-third of pneumonia since fever is absent from one-third of pneumonia cases, especially in the elderlycases, especially in the elderly
Recommend eliminating WBC count since labs often Recommend eliminating WBC count since labs often pending for several hours at time of prestudy visit or pending for several hours at time of prestudy visit or are being sent to central labare being sent to central lab
6July 1998
Questions and Comments Questions and Comments fromfromIndustry - cont’d Industry - cont’d
For atypical pathogens, are sputum screen and For atypical pathogens, are sputum screen and culture required for inclusion ? culture required for inclusion ?
We prefer culture where applicable;We prefer culture where applicable;
sputum screen not needed.sputum screen not needed.
7July 1998
Changes in New Changes in New DocumentDocument
Separation of CAP and NPSeparation of CAP and NP Disease definition and additional text inDisease definition and additional text in
inclusion and exclusion criteria of CAPinclusion and exclusion criteria of CAP Clarification of evaluation visits Clarification of evaluation visits Dichotomous clinical outcome responsesDichotomous clinical outcome responses Nosocomial pneumonia - inclusion andNosocomial pneumonia - inclusion and
exclusion criteriaexclusion criteria
9July 1998
Disease DefinitionDisease Definition
new coughnew cough auscultatory findingsauscultatory findings new infiltrate or progressive infiltrate(s) onnew infiltrate or progressive infiltrate(s) on
chest radiograph, accompanied by:chest radiograph, accompanied by: fever or hypothermia, leukocytosis, sputumfever or hypothermia, leukocytosis, sputum
productionproduction Etiology: polymicrobialEtiology: polymicrobial
10July 1998
Disease Definition - cont’dDisease Definition - cont’d
Acquired by a patient in the following Acquired by a patient in the following settings:settings: in a hospital or long-term-care facility after in a hospital or long-term-care facility after
being admitted for >48 hours or being admitted for >48 hours or <7 days after a patient is discharged from <7 days after a patient is discharged from
hospital ( patient’s initial hospitalization should hospital ( patient’s initial hospitalization should be be 3 days duration )3 days duration )
11July 1998
Risk FactorsRisk Factors
Host factors ( e.g. extremes of age, severe Host factors ( e.g. extremes of age, severe underlying disease ) underlying disease )
Colonization by gram-negative microorganismsColonization by gram-negative microorganisms Aspiration or refluxAspiration or reflux Prolonged mechanical ventilation Prolonged mechanical ventilation Factors that impede adequate pulmonary toiletFactors that impede adequate pulmonary toilet
12July 1998
Problems in Diagnosis of Problems in Diagnosis of NPNP
Clinical criteria lack specificityClinical criteria lack specificity No “gold standards” for diagnostic procedures (e.g. invasive No “gold standards” for diagnostic procedures (e.g. invasive
procedures)procedures) High potential for more than one ongoing infectious process High potential for more than one ongoing infectious process Use of antimicrobials in ICU empirically or use for infections Use of antimicrobials in ICU empirically or use for infections
of other sites or organs.of other sites or organs.
13July 1998
Nosocomial Bacterial Nosocomial Bacterial Pneumonia - EtiologyPneumonia - Etiology
Gram-negative enteric bacilli (predominant)Gram-negative enteric bacilli (predominant) Gram-positive cocci, including: Gram-positive cocci, including:
Staphylococcus aureus Staphylococcus aureus ( e.g.,( e.g., MRSA MRSA ), ), Streptococcus pneumoniaeStreptococcus pneumoniae
AnaerobesAnaerobes OthersOthers
14July 1998
Inclusion Criteria Inclusion Criteria (Clinical)(Clinical)
The following clinical findings should beThe following clinical findings should be
present:present: Fever or hypothermia Fever or hypothermia Leukocytosis or leukopenia Leukocytosis or leukopenia
15July 1998
Inclusion Criteria Inclusion Criteria (Clinical)(Clinical)
AndAnd at least two of the following : at least two of the following : new coughnew cough new onset of purulent sputum or significant changes new onset of purulent sputum or significant changes
in character of sputumin character of sputum auscultatory findings auscultatory findings dyspneadyspnea tachypneatachypnea
16July 1998
Inclusion CriteriaInclusion Criteria (Clinical )(Clinical )
Hypoxemia by pulse oximetry or by Hypoxemia by pulse oximetry or by arterial blood gas arterial blood gas
Respiratory failure requiring mechanical Respiratory failure requiring mechanical ventilation ventilation
Intubated patients requiring increased Intubated patients requiring increased oxygenationoxygenation
17July 1998
Inclusion CriteriaInclusion Criteria (Radiographic)(Radiographic)
New or evolving infiltrate (s) on New or evolving infiltrate (s) on chest radiograph which is not chest radiograph which is not related to another disease process. related to another disease process. Caveat: State of hydrationCaveat: State of hydration
18July 1998
Inclusion CriteriaInclusion Criteria (Microbiologic)(Microbiologic)
Gram stain and culture of respiratory Gram stain and culture of respiratory tract specimentract specimen
Antimicrobial susceptibility testing shouldAntimicrobial susceptibility testing should
be performed on pathogenic isolatesbe performed on pathogenic isolates Alternate diagnostic tests ( Alternate diagnostic tests ( Legionella Legionella ))
19July 1998
Inclusion CriteriaInclusion Criteria (Microbiologic)(Microbiologic)
Blood cultures, two sets ( aerobic Blood cultures, two sets ( aerobic and anaerobic from two different and anaerobic from two different sites ) - up to 48 hours prior to sites ) - up to 48 hours prior to initiation of therapyinitiation of therapy
20July 1998
Inclusion Criteria Inclusion Criteria (Microbiologic)(Microbiologic)
Blood culture isolates should be Blood culture isolates should be utilized toutilized to
corroborate with the sputum corroborate with the sputum culture results in cases where culture results in cases where multiple pathogens are isolated.multiple pathogens are isolated.
21July 1998
Caveat:Caveat:
No consensus on criteria for No consensus on criteria for interpretation of culture results of interpretation of culture results of specimens obtained from specimens obtained from mechanically ventilated patientsmechanically ventilated patients
22July 1998
PEDIATRIC PATIENTSPEDIATRIC PATIENTS
Same clinical and radiographic criteriaSame clinical and radiographic criteria
( definitions of fever and WBC ( definitions of fever and WBC different from adults )different from adults )
Blood cultures could be substituted Blood cultures could be substituted when sputum is lackingwhen sputum is lacking
23July 1998
Exclusion CriteriaExclusion Criteria
Patients excluded in CAP and in generalPatients excluded in CAP and in general
considerations ( COPD not excluded )considerations ( COPD not excluded ) Patients with sustained shockPatients with sustained shock APACHE II score <8 or >25APACHE II score <8 or >25 Known or suspected concomitant bacterialKnown or suspected concomitant bacterial
infection requiring additional systemic infection requiring additional systemic
treatmenttreatment
24July 1998
Exclusion Criteria- Exclusion Criteria- cont’dcont’d
Chronic immunosuppressive therapyChronic immunosuppressive therapy Neutropenia Neutropenia Epilepsy or seizureEpilepsy or seizure Recent alcohol or drug abuse orRecent alcohol or drug abuse or
dependencedependence
25July 1998
Drug and Drug Dosing Drug and Drug Dosing RegimensRegimens
The proposed duration of study The proposed duration of study drug and comparator may vary drug and comparator may vary depending ondepending on
specific antimicrobial agent andspecific antimicrobial agent and
respiratory pathogen isolated.respiratory pathogen isolated.
26July 1998
EVALUATION VISITSEVALUATION VISITS Pre-therapy Pre-therapy On- therapy On- therapy End-of-therapy ( Optional )End-of-therapy ( Optional ) Early Post-therapy ( Optional )Early Post-therapy ( Optional ) Test-of- Cure Test-of- Cure
27July 1998
Pre-Therapy VisitPre-Therapy Visit
Documentation of history ( including riskDocumentation of history ( including risk
factors ), P.E. , chest x-ray, lab tests ( Gram factors ), P.E. , chest x-ray, lab tests ( Gram stain, culture and susceptibility testing, blood stain, culture and susceptibility testing, blood cultures ), and baseline Ocultures ), and baseline O saturation by pulse saturation by pulse oximetry or arterial blood gas;oximetry or arterial blood gas;
Apache II Score ( if available ) in ICU patientsApache II Score ( if available ) in ICU patients
28July 1998
On-Therapy VisitOn-Therapy Visit
Daily clinical assessments should be Daily clinical assessments should be recorded in the case report form recorded in the case report form
Laboratory assessments to be made Laboratory assessments to be made during the course of the study should during the course of the study should be tailored to the antimicrobial agent.be tailored to the antimicrobial agent.
29July 1998
On-TherapyOn-Therapy VisitVisit - - cont’dcont’d
General principles during this visit:General principles during this visit: Culture of respiratory tract secretions Culture of respiratory tract secretions
obtained by semi-invasive obtained by semi-invasive technique(s) and susceptibility technique(s) and susceptibility testing, should be obtained at 72 testing, should be obtained at 72 hours after initiation of therapy in hours after initiation of therapy in patients who are clinically failing.patients who are clinically failing.
30July 1998
On Therapy Visit - cont’dOn Therapy Visit - cont’d
Blood cultures and Blood cultures and susceptibility testing susceptibility testing should be repeated at 72 should be repeated at 72 hours if (+) at entry or if hours if (+) at entry or if patient is clinically failing.patient is clinically failing.
31July 1998
Test-of-Cure VisitTest-of-Cure Visit
7 - 14 days after completion of 7 - 14 days after completion of therapy therapy
Repeat culture and susceptibility Repeat culture and susceptibility testing should be done in patients testing should be done in patients with continuing significant with continuing significant respiratory secretions.respiratory secretions.
32July 1998
OUTCOMEOUTCOME
Clinical OutcomeClinical Outcome - primary efficacy - primary efficacy variablevariable
Clinical responses Clinical responses
1. Clinical cure1. Clinical cure
2. Clinical failure2. Clinical failure
33July 1998
Microbiologic OutcomeMicrobiologic Outcome
Eradication ( Documented eradication )Eradication ( Documented eradication ) Presumed eradication Presumed eradication Persistence ( Documented persistence )Persistence ( Documented persistence ) Presumed persistencePresumed persistence
35July 1998
QUESTIONS to ACM :QUESTIONS to ACM :
1. How should we set the diagnostic1. How should we set the diagnostic
criteria for ventilator-associatedcriteria for ventilator-associated
pneumonia ? pneumonia ?
2. Should we screen BALs in a similar 2. Should we screen BALs in a similar
manner as sputum (in terms of manner as sputum (in terms of
cytological screening) to determine cytological screening) to determine
adequacy of specimen ?adequacy of specimen ?
36July 1998
ACKNOWLEDGMENTACKNOWLEDGMENT
Thanks to the following colleagues :Thanks to the following colleagues : Renata Albrecht, M.D.Renata Albrecht, M.D. Mercedes Albuerne, M.D.Mercedes Albuerne, M.D. John Alexander, M.D.John Alexander, M.D. Sousan Altaie, Ph.D.Sousan Altaie, Ph.D. Lillian Gavrilovich, M.D.Lillian Gavrilovich, M.D. Holli Hamilton, M.D., MPHHolli Hamilton, M.D., MPH Mamodikoe Makhene, M.D., MPHMamodikoe Makhene, M.D., MPH Alexander Rakowsky, M.D.Alexander Rakowsky, M.D.