Managing Community-acquired Pneumonia and Hospital-acquired Pneumonia - Professor Francesco Blasi

Francesco BlasiDepartment of Physiopathology and Transplantation

University of Milan

Managing CAP and HAP

GLOSSARY

CAP- is defined as a pulmonary infection developing in the community or <48 hours of hospital admission.These patients may be managed in ER, the general ward or admitted directly to the ICU.

HAP is defined as a pulmonary infection developing during hospitalisation, 48 hours or more after admission, and not present or incubating at the time of admission.

VAP is defined as a pneumonia that arises more than 48–72 hours after endotracheal intubation.

Torres A, et al. Thorax 2013;68:1057–65.

Estimated cost of median length of stay for patients with CAP in European hospitals

This was an observational, prospective study of consecutive patients coming from the community who were admitted to the Policlinico Hospital, Milan, Italy, with a diagnosis of pneumonia between April 2008 and April 2010. A total of 935 consecutive patients with pneumonia were enrolled during the study period

Aliberti A, et al CID 2012;54(4):470-8.

Risk Factors Analysis: MDR pathogens

Aliberti A, et al CID 2012;54(4):470-8.MDR multi drug resustantHCAP health care associated pneumonia

Aliberti A, et al CID 2012;54(4):470-8.MDR multi drug resistantCOPD chronic obstructive pulmonary disease

Aliberti S et al. Thorax 2013;68:997-9

New approach: Stratify risk factors

New findings: • Different risk factors have different importance for MDR prediction

•Chronic renal failure is an independent risk factor for MDR (A window of patient’s functional status)

•Patient’s targeted approach for empiric antibiotic therapy is possible

Aliberti A, et al CID 2012;54(4):470-8MDR multi drug resistant

CASE REPORT n. 1

Male, 74 y/o

Active smoker. Former parachutist.

Past medical history:

10-year history of COPD (dystrophic bullae) in LTOT since 1 year (2 L/m- 1.5 L/m). Chronic heart failure, pleural effusions since 4 years. Benign prostatic hyperplasia, depression, peptic ulcer.

Discharged 2 months before from the Internal Medicine Dpt with a diagnosis of UTI treated with ciprofloxacin.

FEV1: 64%

DLCO 47%

BGA (O2:1 L/m): pH: 7.49 PaCO2: 36 PaO2:64 HCO3: 22

Since the day before: fever (38 °C) and dyspnea.

BP: 150/60 mmHg HR: 80 bpm RR: 20 bpm T: 39 °C

Chest examination: not wheezing

K: 3.25 Na: 133 CRP: 5.8 WBC: 20.000

PNEUMONIA

LIVER

Diaphragm

PNEUMONIA

B LINES

TREATMENT?

• Ceftriaxone 2gr ev

• Azithromycin 500 mg ev

Since the day before: fever (38 °C) and SOB.

BP: 150/ 60 mmHg HR: 80 bpm RR: 20 bpm T: 39 °C

Chest examination: non wheezing

K: 3.25 Na: 133 CRP: 5.8 WBC: 20.000

STRATIFYING RISK FACTORS

Aliberti A, et al CID 2012;54(4):470-8.MDR multi drug resistantCOPD chronic obstructive pulmonary disease

D1

Ceftriaxone 2gr

20.000

5.8 ---

18.000

14.6

WBC

CRP

T

Azithromycina 500

D2 D3

Ab anti-Legionella pneumophila: negative

Swab: bacteria and fungi: neg

Urinary antigens LP and SP: negative

Blood culture: negative

Ab anti-Mycoplasma: IgG negative and IgM negative

Naso-pharyngeal swab DNA CP, MP, LP: negative

Tracheal aspirate : Gram negative +++

In VII giornata

On day 3

Pleural effusion

Tracheal aspirate

WOULD YOU CHANGE?

Ceftriaxone 2gr

20.000

5.8 ---

18.000

14.6

15.000

---

14.200

5.6

WBC

CRP

T

Azithromycina 500 stopstop

Imipenem 1g q8 EVTracheal aspirate

D1 D2 D3 D4 D5







Ceftriaxone 2gr

20.000

5.8 ---

18.000

14.6

15.000

---

14.200

5.6

12.400

---

WBC

CRP

T

Azithromycina 500 stopstop

Imipenem 1g q8 EV

D1 D2 D3 D4 D5 D6







Tracheal aspirate

Discharged on Day 20…

TREATMENT OPTIONS FOR HOSPITALIZED PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA (no need for intensive care treatment) (in alphabetical order) [C4]

INSIDE HOSPITAL: CAP

Aminopenicillin macrolide *#

Aminopenicillin / ß-lactamaseinhibitor # macrolide *

Non-antipseudomonal cephalosporin cefotaxime or ceftriaxone ±macrolide *

Levofloxacin #

Moxifloxacin #§

Penicillin G macrolide

TREATMENT OPTIONS FOR PATIENTS WITH SEVERE COMMUNITY-ACQUIRED PNEUMONIA [C4] (ICU OR INTERMEDIATE CARE)


NO RISK FACTORS FOR P. aeruginosa Non-antipseudomonal cephalosporin III + macrolide *ormoxifloxacin or levofloxacin ± non-antipseudomonal cephalosporin III

RISK FACTORS FOR P. aeruginosa Antipseudomonal cephalosporin ** or acylureidopenicillin / ß-lactamaseinhibitor or carbapenem (meropenem preferred, up to 6 g possible, 3x2 in 3hours infusion)PLUSCiprofloxacin^ OR PLUSMacrolide* + aminoglycoside (gentamicin, tobramycin or amikacin)

WHAT EMPIRICAL ANTIBIOTIC TREATMENT IS RECOMMENDED FOR ASPIRATION PNEUMONIA?


Hospital ward admitted from homeOral or iv-lactam/-lactamase inhibitoror Clindamycinor iv cephalosporin + oral metronidazoleor moxifloxacin

ICU or admitted from Nursing HomeClindamycin + cephalosporinorCephalosporin + metronidazole

CASE REPORT n. 2

Male, 56 y/o

He was referred to our ER because of new cough with sputum production, fever off and on (Tmax: 38°C) and mild dyspnea since 72 hours.

He also reported a 6-day history of malaise, sore throat and chills during the previous 15 days. Symptoms persisted in spite of NSAID

Past medical history:

-COPD (GOLD III)

- Hepatitis C, not on treatment

Allergy Hx: denied; Food exposure: denied; recent travel: denied; Family Hx: non-contributory

He was on aspirin

Tobacco 1-2 packs per day x 25 years, but no cigarettes in the prior 8 days due to feeling poorly. Trader.

He was hospitalized for 16 days during the past 2 months for surgery (bowel obstruction) and treated with different antibiotics.

VentiMask (FiO2: 31%)Vital sign

BP: 120/70 mmHg

HR: 125 r

RR: 28 bpm

T: 38 °C

SpO2: 83% on RA

PSI RC: IV

Physical examination revealed decreased breathing sound on right

chest with fine moist rales on the lower lobe

In the ER:

http://images.google.it/imgres?imgurl=http://www.health-res.com/EX/08-03-16/pneumonia-Community_acquired.jpg&imgrefurl=http://www.health-res.com/acquired-pneumonia-in-the-elderly/&usg=__xvFm-p7_17255t4QsYz6NcRf214=&h=1144&w=1079&sz=219&hl=it&start=9&um=1&itbs=1&tbnid=6No9KWZynCguqM:&tbnh=150&tbnw=141&prev=/images?q=pneumonia&um=1&hl=it&sa=G&imgsz=qsvga&as_st=y&tbs=isch:1

What kind of treatment?

In the ward:

- Ceftriaxone 2 g iv + azithromycin 500 mg iv

Pneumonia screening: sputum/BAL; blood culture, urinary antigens, serology for atypical pathogens

D1 D2 D3


18.600

7

12.500

12

10.420

6

WBC

CRP

T







0.30 0.25 0.10PCT

D1 D2 D3


18.600

7

12.500

12

10.420

6

WBC

CRP

T

0.30 0.25 0.10PCT

9.000

3

0.08

D4

….AND NOW?

DISCHARGED ON DAY 6

Pneumonia and Cardiovascular events PATHOPHYSIOLOGICAL MECHANISMS

Corrales-Medina. Lancet 2012

Which patients in hospital are at risk?

Lines andMedical devices

Burns

Renal dialysis

Transplantrecipients

Cancer

Post-surgery

High dependency

Elderly

Neonates

Hospital

HAP(SENTRY surveillance system - n=31,436)

Jones et al – CID 2010

Incidence, %

Pathogen All regions United States Europe Latin

America

Staphylococcus aureus 28.0 36.3 23.0 20.1Pseudomonas aeruginosa 21.8 19.7 20.8 28.2Klebsiella spp. 9.8 8.5 10.1 12.1Escherichia coli 6.9 4.6 10.1 5.5Acinetobacter spp. 6.8 4.8 5.6 13.3Enterobacter spp. 6.3 6.5 6.2 6.2Serratia spp. 3.5 4.1 3.2 2.4Stenotroph. maltophilia 3.1 3.3 3.2 2.3

Streptococcus pneumoniae 2.9 2.5 3.6 2.4

Haemophilus influenzae 2.7 2.5 3.7 1.3

MRSA trends, Europe

EARS-NET

MDR Gram-negatives causing pneumonia

Pseudomonas aeruginosa

Acinetobacter

Enterobacteriaceae

Stenotrophomonas maltophilia

2006 2007 2008 2009 2010 20110

5

10

15

20

25

30

35

40

EARS-NET

Pro

port

ion

%

Year

AMG

FQ

NEM

PIP

CAZ

Pseudomonas aeruginosa resistance trends, Italy

2005 2006 2007 2008 2009 2010 201105

101520253035404550

Pro

port

ion

%

Year

Klebsiella pneumoniae and resistance to 3rd gen. cephalosporins and fluoroquinolones, Italy

EARS-NET

R to 3GC

R to FQ

Increasing role of carbapenems

Giani et al – JCM 2009Santoriello et al – unpublished

Fontana et al – BMC Res Notes 2010Marchese et al – J Chemother 2010Ambretti et al – New Microb 2010Gaibani et al – Eurosurv 2011Mezzatesta et al – CMI 2011Agodi et al – JCM 2011Richter et al – JCM 2011Di Carlo et al – BMC Gastroenterol 2011Rossolini GM – unpublished

late 2008

The first reported cases of KPC-Kp

KPC-producing K. pneumoniae – the Italian epidemic

early 2011

AMCLI – CoSA CRE networkFrasson et al – JCM 2012ARISS – CoSA survey 2012

late 2012

AMCLI-CoSA – Italian national surveillance 2011

CRAB detected in ALL CENTERS

Nationwide cross-sectional survey, 2011(6 weeks / 25 centers / N=585 isolates)

Carbapenem-R Acinetobacter, Italy

C-02

C-19

C-01

C-25

C-09

C-13

C-16

C-23

C-21

C-08

C-20

C-17

C-11

C-14

C-12

C-05

C-03

C-15

C-07

C-06

C-04

C-24

C-18

C-22

C-10

0

10

20

30

40

50

60

70

80

90

100

CRAB proportion by center – Italian surveillance

Centers

CR

AB

pro

port

ion

(%

)

AMCLI-CoSA – Italian national surveillance 2011

Mean, 43%

CASE 3

Female, 86 y/o

She was referred to our ER because of a 7-day history of dyspnea. She also reported a history of recurrent urinary infections

Her past history was remarkable for:

- NIDDM associated with retinopathy

- Chronic vascular encephalopathy

- Essential hypertension

- Left knee joint prosthesis (25 years back)

She was on: aspirin, ibesartan, nifedipine, metformin, furosemide

She was a former worker. Non-smoker. Non-allergic.

She was admitted to the internal medicine department with a diagnosis of decompensated chronic heart failure.

AFTER 4 DAYSBP: 190/90 mmHg

HR: 115 bpm

RR: 26 bpm

T: 39 °C

SpO2: 88% in RA

Glucose: 369

Abnormal chest sounds (rales and rhonchi) were detected bilaterally in the lower lobes

EKG: sinusal rhythm; HR 115, PQ: 0.20, no modifications of ventricular reporalization

Your Diagnosis?

VentiMask (FiO2: 50%)

BP: 190/90 mmHg

HR: 115 bpm

RR: 26 bpm

T: 39 °C

SpO2: 88% in RA

Glucose: 369

Abnormal chest sounds (rales and rhonchi) were detected bilaterally in the lower lobes

EKG: sinusal rhythm; HR 115, PQ: 0.20, no modifications of ventricular reporalization

WHICH TREATMENT?

In the ward (Internal Medicine):

- Ceftriaxone 2 gr

- Levofloxacin 500 mg x 2 EV

Pneumonia screening: sputum/BAL; blood culture, urinary antigens, serology for atypical pathogens

D1 D2 D3

Ceftriaxone 2gr

22.220

19

18.700

18

17.400

18

WBC

CRP

T

Levofloxacin 500 q12




Tracheal aspirate: GRAM POSITIVE

Blood culture: pending



0.44 0.42 0.49PCT

WOULD YOU CHANGE?

Ceftriaxone 2gr

22.220

19

18.700

18

17.400

18

WBC

CRP

T


0.44 0.42 0.49

Vancomycin 500 mg in 50 cc F at 5 ml/h

Stop

D1 D2 D3

PCT

Ceftriaxone 2gr

22.220

19

18.700

18

17.400

20

WBC

CRP

T


0.44 0.42 ---


12.800

14

0.28

11.000

11

0.21

11.550

12

0.20

11.400

13

0.20

D1 D2 D3 D4 D5 D6 D7

PCT

DAY 8:

Episode of ACPE with sudden dyspnea and hypoxemia. Good response with furosemide, nitroderivates and helmet CPAP.

On Day 8, once the episode of ACPE was treated, patient was on CPAP…

After 2 hours from that CXR, patient was still on CPAP:

Sudden hypoxemia with a SpO2 of 88% on CPAP - 10 cmH2O and FiO2: 40%-

BP: 160/90

HR: 110 R

RR: 24 bpm

Active urinary output

CPAP

10 cmH2O

FiO2: 80%

SpO2: 80%

BP: 160/90

HR: 110 RS

RR: 24 bpm

Active urinary output

Hypoxemia was unresponsive to high pressures and FiO2

Echocardiograpy: Normal RA and RV

Normal LV function

Because of the CXR findings, patient underwent Thorax CT scan:



12.800

14

0.28

11.000

11

0.21

11.550

12

0.20

11.400

13

0.20

Blood was found during a bronchoscopy with a SpO2 75% 98%.

Patient was put on Ventimask 35%

Stop

Stop

Linezolid 600 mg q12 EV

Tobramycin EV

Imipenem 1 g q8 EV

D5 D6 D7 D8

WBC

CRP

T

PCT

EXITUS on DAY 10

HAP or VAP

Obtain lower respiratory tract sample for culture(quantitative or semiquantitative) & microscopy

Begin empiric antimicrobial therapy using algorithm and local microbiologic data (unless low clinical suspicion and

Negative microscopy of LRT sample)

Days 2 & 3: Check cultures & assess clinical response:(Temperature, WBC, CXR, Oxygenation, sputum purulence,

Haemodynamic changes and organ function)

Clinical Improvement at 48-72 hours?

Am J Respir Crit Care Med 2005;171:388-416

HAP, VAP

Clinical Improvement at 48-72 hours?

NO YES

Cultures - Cultures + Cultures - Cultures +

Search for otherPathogens,

Complications, Other Diagnosesor Other Sites of

infection

Adjust antibioticTherapy, search

For otherPathogens,

Complications Or other siesOf infection

ConsiderStoppingantibiotics

De-escalateAntibiotics, if

Possible.Treat selected

Patients for7-8 days and

reassess


HAP, VAP

Late onset (5days) or risk factors for multidrug resistant pathogens

NO YES

Limited Spectrum

Ceftriaxone (1 x 2g) or Fluoroquinolone (Levofloxacin 1x750mg or Moxifloxacin 1x400mg) or

Ampicillin / sulbactam (3x3g) or

Ertapenem (1x1g)

Broad SpectrumAntipseudomonal cephalosporin (Ceftazidime 3x2g)orAntipseudomonal carbapenem (Imipenem/Cilastin 3x1g, Meropenem 3x1g)or-lactam/-lactamase inhibitor (Piperacillin/tazobactam 3x4.5g)

Plus

Antipseud fluoroquinolone (Ciprofloxacin 3x400mg, Levofloxacin 1x750mg) orAminoglycoside (Amikacin 15mg/kg/d divided bid, max 1.5g/d) (MRSA – linezolid (2x600mg) or vancomycin (2x1g initial, control blood levels))


• The lack of initial improvement in PaO2/FiO2, along with an increase in the SOFA score, was the two clinical evolutionary findings that predicted mortality in a multivariate model.

• These feasible and low-cost variables should be evaluated in future trials to test interventions in patients with ICUAP.

Four Major Principles

1. Avoid inadequate treatment

2. Variable bacteriology between hospital sites

and over time

3. Avoid antibiotic overuse – accurate diagnosis and

pathogen directed therapy

4. Prevention strategies for modifiable risk factors


Managing Community-acquired Pneumonia and Hospital-acquired Pneumonia - Professor Francesco Blasi

Health & Medicine

Transcript of Managing Community-acquired Pneumonia and Hospital-acquired Pneumonia - Professor Francesco Blasi