pneumonia

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Slide 1 : CAP community-acquired pneumonia
Slide 2 : Community-acquired pneumonia (CAP) is a common and potentially serious illness. It is associated with considerable morbidity and mortality, particularly in elderly patients and those with significant comorbidities
Slide 3 : EPIDEMIOLOGY  The overall rate of CAP ranges from 8 to 15 per 1000 persons per year the highest rates are at the extremes of age
Slide 4 : Community-acquired pneumonia (CAP) affects 5.6 million adults annually in the United States and causes 1.7 million hospitalizations per year
Slide 5 : Combined mortality rates for pneumonia and influenza indicate that this is the sixth-leading cause of death in the United States
Slide 6 : It is the cause of 46% of all deaths from infectious disease
Slide 7 : There is seasonal variation, with more cases occurring during the winter months.
Slide 8 : CLINICAL EVALUATION clinical evaluation chest radiograph gas exchange (oximetry or arterial blood gas) routine blood chemistry and blood counts collection of two sets of blood cultures with or without microbiologic testing.
Slide 9 : Common clinical features cough, fever, pleuritic chest pain, dyspnea and sputum production. Mucopurulent sputum production bacterial pneumonia scant or watery sputum production atypical pathogen
Slide 10 : Other common features gastrointestinal symptoms (nausea, vomiting, diarrhea) mental status changes Chest pain 30% chills 40 to 50 % rigors 15 %.
Slide 11 : physical examination Febrile 80% frequently absent in older patients. A respiratory rate >24 breaths/minute 45 to 70 % may be the most sensitive sign in elderly patients tachycardia
Slide 12 : leukocytosis (typically between 15,000 and 30,000 per mm3) with a leftward shift. Leukopenia can occur, and generally con notes a poor prognosis.
Slide 13 : The radiographic appearance lobar consolidation "typical" bacteria interstitial infiltrates Pneumocystis jirovecii (formerly P. carinii) viruses cavitation
Slide 14 : false negative If the clinical syndrome favors pneumonia but the radiograph is negative, the radiograph may represent a false negative result. In some cases this can be clarified by computerized tomography (CT) scan, which has higher sensitivity and accuracy than chest radiographs for detecting CAP .
Slide 15 :
Slide 16 :
Slide 17 : Blood cultures  The risk of bacteremia is increased among patients with underlying liver disease demonstrating hypotension (systolic BP <90 mm Hg) tachycardia (pulse rate > 125 beats/min) extremes of temperature (< 35 C or > 40 C), Exhibiting certain abnormal laboratory features (BUN> 30 mg/dL, sodium < 130 mmol/L, WBC count < 5,000 L or > 20,000 L)
Slide 18 : The risk of bacteremia is significantly decreased among patients who have received antibiotics previously.
Slide 19 :
Slide 20 : 88% of bacteremia would be detected
Slide 21 : sputum culture and Gram stain not required for all out patient recommended for hospitalized patients with any of the following criteria: 1- drug-resistant pathogen or an organism not covered by usual empiric therapy is suspected 2- Intensive care unit admission 3- Failure of antibiotic therapy (either outpatients or hospitalized patients) 4- Cavitary lesions 5- Active alcohol abuse 6- Severe obstructive or structural lung disease 7-Positive urine antigen test for pneumococcus 8-Positive urine antigen test for Legionella (special culture needed) 9-Pleural effusion
Slide 22 : severe CAP aggressive efforts at establishing an etiologic diagnosis should be made, including the collection of bronchoscopic samples of lower respiratory secretions in selected patients, although the benefit of such efforts has not been proven
Slide 23 : Routine serologic testing is not recommended for any population with CAP. For patients with severe CAP, Legionella and pneumococcal urinary antigen should be measured
Slide 24 : causative pathogens identified in < 50% Of Cases
Slide 25 : typical organisms 1-Streptococcus Pneumoniae(most common pathogen) 2-Haemophilus influenzae 3-Staphylococcus aureus 4-Group A streptococci 5-aerobic gram-negative bacteria (residence in a nursing home probable aspiration, previous hospital admission, previous antimicrobial treatment, and the presence of pulmonary comorbidity ) 6-Moraxella 7-catarrhalis
Slide 26 : Atypical organisms Mycoplasma pneumoniae Chlamydia pneumoniae, Legionella ssp C. psittac more subacute, with nonproductive cough and a chest radiograph that appears characteristically worse than the patient’s clinical appearance
Slide 27 : latest Infectious Diseases Society of America/American Thoracic Society (ATS) CAP guideline patients with CAP are classified into one of two groups, each with a list of likely pathogens.
Slide 28 : Stratification is based on an assessment of 1- the need for a specific site of therapy (outpatient, inpatient ward, or ICU), 2- the presence of comorbidities, and the likelihood for drug-resistant S pneumoniae (DRSP), enteric Gram-negative organisms, and Pseudomonas aeruginosa
Slide 29 : Organisms Associated with Community-Acquired Pneumonia Outpatiet S pneumoniae M pneumoniae H influenzae C pneumoniae Respiratory viruses
Slide 30 :
Slide 31 : Inpatient (non-ICU) S pneumoniae M pneumoniae C pneumoniae H influenzae Legionella spp Aspiration Respiratory viruses
Slide 32 :
Slide 33 : Inpatient (ICU) S pneumoniae S aureus Legionella spp Gram-negative bacilli H influenzae
Slide 34 :
Slide 35 : Although the incidence of DRSP is increasing, available data show that the rate of mortality in patients with CAP is adversely affected by drug-resistant pneumococci only when minimum inhibitory concentration values to penicillin are = 4 mg/L
Slide 36 :
Slide 37 : Site of treatment The admission decision can be difficult hospitalization multiple risk factors for a complicated course social factors
Slide 38 : Admission to the ICU for patients with severe CAP modified ATS criteria The major criteria septic shock requiring vasopressor support requirement for mechanical ventilation The minor criteria systolic BP< 90 mm Hg, multilobar disease Pao2/fraction of inspired oxygen ratio < 250
Slide 39 : severe CAP defined as the presence of either one of two major criteria or the presence of two or three minor criteria
Slide 40 : The modified ATS rule achieved predicting admission to the ICU a sensitivity of 69% specificity of 97% predicting mortality a sensitivity of 94% specificity of 93%
Slide 41 : modified BTS criteria CURB Age >65 years respiratory rate > 30 breaths/min Blood pressure (systolic <90 mmHg or diastolic <60 mmHg BUN > 7.0 mmol/L ( 19.1 mg/dL) confusion (based upon a specific mental test or disorientation to person, place, or time)
Slide 42 :
Slide 43 :
Slide 44 :
Slide 45 :  Antibiotic therapy is typically begun on an empiric basis Patients should initially be treated empirically based on the likely pathogens for each of the sites of care, although when culture results become available, organism-specific therapy may be possible for some patient
Slide 46 : Outpatient treatment Previously healthy and no use of antimicrobials within the previous 3 months Macrolide OR Doxycyline
Slide 47 : * Presence of comorbidities chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; *immunosuppressing conditions immunosuppressing drugs; * antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected) A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR A beta-lactam PLUS a macrolide
Slide 48 : In regions with a high rate (>25 percent) of infection with high-level (MIC =16 µg/mL) macrolide-resistant Streptococcus pneumoniae consider use of alternative agents listed in (2) above
Slide 49 : Inpatients, non-ICU treatment A respiratory fluoroquinolone OR A beta-lactam PLUS a macrolide
Slide 50 : Which better ?????? Although both regimens appear therapeutically equivalent, particularly among inpatients, in the outpatient treatment of the more complicated patient, an antipneumococcal fluoroquinolone may be more convenient than a B -lactam/macrolide combination.
Slide 51 : Inpatients, ICU treatment A beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS azithromycin OR A beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS a respiratory fluoroquinolone OR For penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam
Slide 52 : Special concerns If Pseudomonas is a consideration: An anti pneumococcal, anti pseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) PLUS either ciprofloxacin or levofloxacin (750 mg) OR The above beta-lactam PLUS an aminoglycoside and azithromycin OR The above beta-lactam PLUS an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for above beta-lactam)
Slide 53 : If CA-MRSA is a consideration Add vancomycin or linezolid
Slide 54 : In the ICU-admitted patient current data do not support the use of an antipneumococcal fluoroquinolone alone, and therapy should be with a B-lactam plus either a macrolide or fluoroquinolone using a regimen with two antipseudomonal agents in appropriate, at-risk patient
Slide 55 : the use of antibiotics in the previous 3 months is a significant predictor of antibiotic resistance to that class. Accordingly, the guidelines recommend use of an alternative class of therapy if an agent has been used within the past 3 months
Slide 56 : combination antibiotic therapy (usually a B-lactam plus a macrolide) is superior to single-agent therapy (usually a B -lactam alone) among severely ill patients with bacteremic pneumococcal pneumonia
Slide 57 : Clinical response to therapy  some improvement in the patient's clinical course is usually seen within 48 to 72 hours Patients who do not demonstrate some clinical improvement within 72 hours are considered nonresponders
Slide 58 :
Slide 59 : Radiographic response Radiographic improvement typically lags behind the clinical response
Slide 60 : The chest x-ray usually cleared within four weeks in patients younger than 50 years of age without underlying pulmonary disease. In contrast, resolution could be delayed for 12 weeks or more in older individuals and in those with underlying lung disease
Slide 61 : Switch to oral therapy   Patients requiring hospitalization for CAP are generally begun on intravenous therapy
Slide 62 : Patients met the following criteria prior to switching: resolution of fever a febrile (< 37.8 C) on two occasions 8 h apart improvement in respiratory function improvement in cough and dyspnea decrease in white blood cell (WBC) count normal gastrointestinal tract absorption
Slide 63 : Even if the patient is febrile, a switch in therapy can occur if other clinical features are favorable. If the patient has met criteria for a switch, oral therapy can be started and the patient discharged on the same day if other medical and social factors permit
Slide 64 : Outcomes are identical to patients staying in hospital longer to complete their course of therapy
Slide 65 : Length of stay has been shown to be related to three quality-of-care measures 1- initial administration of antibiotics in the emergency department, 2- appropriate antibiotic selection, 3- Shortened door to needle time
Slide 66 : Initiation of antibiotic therapy in the emergency department led to shorter hospital stays for CAP by approximately 2 days
Slide 67 : The following have been listed as quality indicators in the assessment of care of the CAP patient: • Antibiotics administered in a timely way, within either 4 h or 8 h of hospital admission; • Oxygen assessment or therapy within 8 to 24 h of hospital arrival; • Blood specimen for culture drawn before the administration of antibiotics in the hospitalized patient; • Administration of antibiotics with activity against all likely causative pathogens, prefer- ably the least-expensive efficacious regimen
Slide 68 : • Counseling patients regarding smoking cessa- tion; • Switching from IV to oral antibiotics if the patient is clinically improving and hemody- namically stable, with discharge within 24 h of switching to oral therapy; • Chest radiography within 24 h of hospital admission; and • Use of methods to increase vaccination rates against influenza and pneumococcus; and No discharge home for patients who are unstable on the day of discharge.
Slide 69 : Duration of therapy  recommendation of the IDSA/ATS guidelines patients with CAP should be treated for a minimum of five days No differences were found in clinical or microbiological outcomes between short (3 to 7 days) and long (7 to 10 days) regimens.
Slide 70 : Longer durations of therapy are needed in the following settings: 1- If the initial therapy was not active against the subsequently identified pathogen   2- If extrapulmonary infection is identified (eg, meningitis or endocarditis)   3- If the patient has documented P. aeruginosa or S. aureus pneumonia, or pneumonia caused by some unusual and less common pathogens (eg, Burkholderia pseudomallei, fungus)
Slide 71 : mortality associated with CAP
Slide 72 :
Slide 73 : Clinical failure ******occurred in 13-15%. related to CAP severe sepsis(33%) the first 72 h of hospitalization acute myocardial infarction (28%), and progressive pneumonia (19%)
Slide 74 : unrelated to CAP was the development of hospital-acquired pneumonia (45%)
Slide 75 : Treatment failure Risk factors  liver disease pneumonia risk class leukopenia multilobar CAP Pleural effusion radiographic signs of cavitation
Slide 76 : factors associated with a lower risk of treatment failure influenza vaccination initial treatment with fluoroquinolones A concurrent diagnosis of COPD
Slide 77 : Failure of empiric therapy increases the rate of mortality in patients with CAP 11-fold after adjustment for risk class
Slide 78 : Community-Acquired Methicillin-Resistant S aureus community- acquired MRSA is not common typically characterized by a short duration of illness and focal necrotizing infiltrates The disease may be rapidly progressive
Slide 79 : susceptible in vitro vancomycin, linezolid, trimethoprim- sulfamethoxazole, doxycycline, and fluoroquinolones, clindamycin The initial choice in most published series has been IV vancomycin
Slide 80 : although linezolid appears to be at least equivalent to vancomycin in the treatment of nosocomial MRSA pneumonia The efficacy of treatment with trimethoprim-sulfa- methoxazole in systemic infections caused by MRSA was comparable with vancomycin, and it has been effective alone and in combination with rifampin in patients with soft-tissue infections caused by community-acquired MRSA.
Slide 81 : Newer Studies
Slide 82 : **the use of macrolide was associated with a decreased rate of mortality at 30 days (20.3%)and at 90 days(24.5%) in patients with severe sepsis and in patients with macrolide-resistant pathogens.
Slide 83 : unadjusted rate of mortality **Patients treated with monotherapy ( B-lactam alone) 22% **patients treated with combination therapy ( B-lactam, macrolide) 7%
Slide 84 : benefits of atypical coverage were associated with the use of macrolides but not the use of fluoroquinolones or tetracyclines
Slide 85 : Patients treated with atypical coverage decreased time to clinical stability, decreased length of stay, decreased rate of total mortality, Decreased CAP-related mortality
Slide 86 : Why???? All patients with CAP could potentially be infected with C pneumoniae, M pneumoniae, and Legionella sp (the “atypical” pathogens), either alone or as part of a mixed infection thus, all patients should receive therapy to account for this possibility.
Slide 87 : CRP levels A decrease of < 60% in CRP levels in 3 days and a decrease of < 90% in CRP levels in 7 days were both associated with an increased risk of having received inappropriate empiric antibiotic treatment
Slide 88 : Consecutive CRP measurements may be useful in the first week in follow-up of antibiotic treatment for severe CAP, and delayed normalization of CRP levels is associated with a greater risk of having received inappropriate antibiotic treatment
Slide 89 : role of statins and angiotensin-converting enzyme (ACE) inhibitors After adjusting for potential confounders, current statin use and ACE inhibitor use were significantly associated with decreased 30-day mortality development of complicated pneumonia
Slide 90 : statin use was independently protective against a CRP that failed to decrease by = 50% at day 4
Slide 91 : ****** groups with radiographic progression plus bacteremia or radiographic progression( first 48 h ) alone had a greater risk for shock an increased risk of ICU death than patients without either finding, whereas bacteremic patients had no increased risk
Slide 92 : Influenza vaccination was associated with a 51% reduction of mortality outside influenza season. Adjustment for age, sex, and comorbidities did not alter these findings. functional and socioeconomic status markedly attenuated these benefits
Slide 93 : Patients with CAP should be appropriately vaccinated for influenza and pneumococcal infection
Slide 94 : SMOKING CESSATION   Smoking cessation should be a goal for hospitalized patients with CAP who smoke
Slide 95 : Thank you

 


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