COMMUNITY ACQUIRED PNEUMONIACOMMUNITY ACQUIRED PNEUMONIA - -OLD ENEMY & RECENT FOEOLD ENEMY & RECENT FOE

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

Parapneumonic effusionParapneumonic effusion

PneumothoraxPneumothorax

Lung abscess/Metastasis abscessLung abscess/Metastasis abscess

Septicemia /ARDSSepticemia /ARDS

Hepatitis, pericarditis, Myocarditis, Hepatitis, pericarditis, Myocarditis, meningoencephalitis.meningoencephalitis.

Co morbid illnessCo morbid illness

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

Risk class

Class Predictor level Mortality rate

I Absence of predictor 0.1- 0.4

II ≤ 70 0.6-0.7

III 71- 90 0.9-2.8

IV 91- 130 8.2-9.3

V > 130 29-31

CMD: 2005

Lo

wM

od

hig

hh

igh

CURB-65 score (Updated 2004.)

CConfusion* onfusion*

UUrea > 7 mmol/l rea > 7 mmol/l

RRespiratory rate ≥ 30/min espiratory rate ≥ 30/min

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)

DIAGNOSTIC TOOLSDIAGNOSTIC TOOLS

HISTORYHISTORY

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

IMAGING- CXR, CTIMAGING- CXR, CT

LABORATORYLABORATORY

CAP EARLY

Diagnosis

Does this patient have CAP?

CAP after 12 hours

CAP AFTER 12 HOURS

X-ray Swine fluX-ray Swine flu

LAB EvaluationLAB Evaluation

SPUTUM CULTURESPUTUM CULTURE BLOOD CULTUREBLOOD CULTURE ANTIGEN DETECTIONANTIGEN DETECTION ACUTE PHASE SEROLOGYACUTE PHASE SEROLOGY PCRPCR

LAB EvaluationLAB Evaluation

Bacteriological

60%

40% Dx Estb

Not Estb

60%

40% Dx Estb

Not Estb

CID 2003: 37(1 December)

PNEUMONIA IN ER

Sign & clinical symptoms suggestive of pneumonia

Obtain CXR

Infiltration suggestive pneumonia ?

Out of guideline

Risk stratification

OPD Inpatient

No

Yes Low Mod/High

Empirical Rx of CAP-

OPD

ATS- Guideline

Evidence Level- I Alternative

Young & otherwise healthy Macrolide Doxycycline

(Evidence level-Ⅲ)

Comorbid illness or risk factor 2nd Ceph +

Macrolide

Res FLQ.

(Evidence level-II)

CID

CID 2007:44 (1supl 2) ;s27

Empirical Rx of CAP-Empirical Rx of CAP-

Hospitalized patient

ATS GuidelineATS Guideline

Evidence level- IEvidence level- I AlternativeAlternative

Ordinary casesOrdinary cases 22ndnd/ / Ceph +MacrolideCeph +Macrolide B-lactam + DoxyB-lactam + Doxy(Evidence level- III)(Evidence level- III)

Suspected aspirationSuspected aspiration 3rd/ cepha+clinda3rd/ cepha+clinda Clinda +macrolideClinda +macrolide

(Evidence level –III)(Evidence level –III)

With bronchiactesisWith bronchiactesis Anti-PseudomonalAnti-Pseudomonal

33rdrd/4/4th th cephceph +macrolide +macrolideRFQ + macrolideRFQ + macrolide (Evidence level- II)(Evidence level- II)

CID 2003:37 (1 December)

Empirical Rx of CAP-Empirical Rx of CAP-

Severe Pneumonia (ICU)

Therapeutic GuidelineTherapeutic Guideline

First line Alternative

No pseudomonas risk

3rdCeph+macrolide Carbipenem+

Macrolide

Pseudomonas risk Antipseudomonas 3rdceph+aminogly+macrolide

AntiPseudomonal pencilline+ aminogly+macrolid

CID 2003:37 (1 December)

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

Duration of treatmentDuration of treatment

ABx ChoiceABx Choice

Drug categoryDrug category

Advanced macrolideAdvanced macrolide ClarithromycineClarithromycine AzithromycineAzithromycine RoxithromycineRoxithromycine

Respiratory quinolonesRespiratory quinolones

MoxifloxacineMoxifloxacine GatifloxacineGatifloxacine GemifloxacinGemifloxacin LevoloxacinLevoloxacin

AntiPseudomonal drugs

Antipseudomonal CephAntipseudomonal Ceph Ceftazidime- 3rd generationCeftazidime- 3rd generation Cefipime- 4th generationCefipime- 4th generation

Antipseudomonal penicillinAntipseudomonal penicillin

PiperacillinePiperacilline TazocineTazocine Ticarcilline-Clavulonic acidTicarcilline-Clavulonic acid

CarbapenemCarbapenem ImipenemImipenem MeropenemMeropenem

Pseudomonas Risk Factor

Severe structural lung disease (bronchiactesis)

Recent antibiotic therapy Stay in hospital (ICU)

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)

Hospital Acquired Pneumonia (HAP)Hospital Acquired Pneumonia (HAP)

Hospitalized community Acquired Pneumonia (HCAP)Hospitalized community Acquired Pneumonia (HCAP)

Ventilator Associated Pneumonia (VAP)Ventilator Associated Pneumonia (VAP)

Pneumonia in immunocompromized patientPneumonia in immunocompromized patient

PNEUMONIA TYPESPNEUMONIA TYPES

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

Parapneumonic effusionParapneumonic effusion

PneumothoraxPneumothorax

Lung abscess/Metastasis abscessLung abscess/Metastasis abscess

Septicemia /ARDSSepticemia /ARDS

Hepatitis, pericarditis, Myocarditis, Hepatitis, pericarditis, Myocarditis, meningoencephalitis.meningoencephalitis.

Co morbid illnessCo morbid illness

COPDCOPD Congestive heart failureCongestive heart failure MalignancyMalignancy Diabetes MellitusDiabetes Mellitus Hepatic or renal diseaseHepatic or renal disease

Risk factorsRisk factors

Risk factors for DSRPRisk factors for DSRP Age>65years Recent antibiotics within 3 months (DRSP) Immunosupressive therapy within 3 months HIV/ 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

FINE,S PSI SCORINGFINE,S 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

Risk class

Class Predictor level Mortality rate

I Absence of predictor 0.1- 0.4

II ≤ 70 0.6-0.7

III 71- 90 0.9-2.8

IV 91- 130 8.2-9.3

V > 130 29-31

CMD: 2005

Lo

wM

od

hig

hh

igh

CURB-65 score (Updated 2004.)

CConfusion* onfusion*

UUrea > 7 mmol/l rea > 7 mmol/l

RRespiratory rate ≥ 30/min espiratory rate ≥ 30/min

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

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

DIAGNOSTIC TOOLSDIAGNOSTIC TOOLS

HISTORYHISTORY

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

IMAZING- CXR, CTIMAZING- CXR, CT

LABORATORYLABORATORY

CAP EARLY

CAP AFTER 12 HOURS

X-ray Swine fluX-ray Swine flu

LAB evaluationLAB evaluation

SPUTUM CULTURESPUTUM CULTURE BLOOD CULTUREBLOOD CULTURE ANTIGEN DETECTIONANTIGEN DETECTION ACUTE PHASE SEROLOGYACUTE PHASE SEROLOGY PCRPCR

LAB evaluationLAB evaluation

Bacteriological

60%

40% Dx Estb

Not Estb

60%

40% Dx Estb

Not Estb

CID 2003: 37(1 December)

PNEUMONIA IN ER

Sign & clinical symptoms suggestive of pneumonia

Obtain CXR

Infiltration suggestive pneumonia ?

Out of guideline

Risk stratification

OPD Inpatient

No

Yes Low Mod/High

ABx ChoiceABx Choice

Antibiotic treatmentAntibiotic treatment

Antibiotic should be given as soon as clinical diagnosis of pneumonia is made.

If possible culture specimen should be sent prior to starting antibiotic.

Treatment shouldn’t be delayed if – a sputum sample is not readily available

Empirical Rx of CAP-

OPD

ATS- Guideline

Evidence Level- I Alternative

Young & otherwise healthy Macrolide Doxycycline

(Evidence level-Ⅲ)

Comorbid illness or risk factor 2nd Ceph +

Macrolide

Res FLQ.

(Evidence level-II)

CID

CID 2007:44 (1supl 2) ;s27

Empirical Rx of CAP-Empirical Rx of CAP-

Hospitalized patient

ATS GuidelineATS Guideline

Evidence level- IEvidence level- I AlternativeAlternative

Ordinary casesOrdinary cases 22ndnd/ / Ceph +MacrolideCeph +Macrolide B-lactam + DoxyB-lactam + Doxy(Evidence level- III)(Evidence level- III)

Suspected aspirationSuspected aspiration 3rd/ cepha+clinda3rd/ cepha+clinda Clinda +macrolideClinda +macrolide

(Evidence level –III)(Evidence level –III)

With bronchiactesisWith bronchiactesis Anti-PseudomonalAnti-Pseudomonal

33rdrd/4/4th th cephceph +macrolide +macrolideRFQ + macrolideRFQ + macrolide (Evidence level- II)(Evidence level- II)

CID 2003:37 (1 December)

Empirical Rx of CAP-Empirical Rx of CAP-

Severe Pneumonia (ICU)

Therapeutic GuidelineTherapeutic Guideline

First line Alternative

No pseudomonas risk

3rdCeph+macrolide Carbipenem+

Macrolide

Pseudomonas risk Antipseudomonas 3rdceph+aminogly+macrolide

AntiPseudomonal pencilline+ aminogly+macrolid

CID 2003:37 (1 December)

Drug categoryDrug category

Advanced macrolideAdvanced macrolideClarithromycineClarithromycine

AzithromycineAzithromycine

RoxithromycineRoxithromycine

Respiratory quinolonesRespiratory quinolones

MoxifloxacineMoxifloxacine GatifloxacineGatifloxacine GemifloxacinGemifloxacin LevoloxacinLevoloxacin

AntiPseudomonal drugs

Antipseudomonal CephAntipseudomonal Ceph Ceftazidime- 3Ceftazidime- 3rdrd generation generation

Cefipime- 4Cefipime- 4thth generation generation

Antipseudomonal penicillinAntipseudomonal penicillin

PiperacillinePiperacilline TazocineTazocine Ticarcilline-Clavulonic acidTicarcilline-Clavulonic acid

CarbapenemCarbapenem ImipenemImipenem MeropenemMeropenem

Pseudomonas Risk Factor

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,

gastrostomy tube, tracheostomies.

Hospital Acquired Pneumonia

Occur at least 2 days after admission in hospital

Usually developed in patients with

Chronic lung disease

General disability

Receiving assisted ventilation Endotracheal Intubation / tracheostomy

Infected ventilator

nebulisers

bronchoscops Dental or sinus injections Intra venous cannula injection

Organism involved Commonly gram negative organism Escherichia . Pseudomonas. Klebsiella Gram positive organism Staph. aureus commonly multidrug resistant variety. Anaerobic organism are more common than cap.

Management Adequate Gram-negative coverage obtained• third generation cephalosporin – cefotaxime

plus aminoglycoside- gentamycin• Imipenem or• Aztreomam plus flucloxacillin. Aspiration pneumonia.• Amoxiclav 1.2g 8-hrly plus metronidazol

500mg 8hrly

Suppurative & Aspirational Pneumonia (including pulmonary abscess Organism involved If healthy lung tissue

Staph. aureus

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,

gastrostomy tube, tracheostomies.

Hospital Acquired Pneumonia

Occur at least 2 days after admission in hospital

Usually developed in patients with

Chronic lung disease

General disability

Receiving assisted ventilation Endotracheal Intubation / tracheostomy

Infected ventilator

nebulisers

bronchoscops Dental or sinus injections Intra venous cannula injection

Organism involved Commonly gram negative organism Escherichia . Pseudomonas. Klebsiella Gram positive organism Staph. aureus commonly multidrug resistant variety. Anaerobic organism are more common than cap.

Management Adequate Gram-negative coverage obtained• third generation cephalosporin – cefotaxime

plus aminoglycoside- gentamycin• Imipenem or• Aztreomam plus flucloxacillin. Aspiration pneumonia.• Amoxiclav 1.2g 8-hrly plus metronidazol

500mg 8hrly

Suppurative & Aspirational Pneumonia (including pulmonary abscess Organism involved If healthy lung tissue

Staph. aureus

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