Strep Pneumoniae
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Strep Pneumoniae

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Case presentation of Streptococcus pneumoniae community acquired pneumonia in intensive care unit (ICU)

Case presentation of Streptococcus pneumoniae community acquired pneumonia in intensive care unit (ICU)

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  • Guideline concordant therapy: 1) B-lactam + macrolide or fq. 2)FQ + Clindamycin/Vancomycin/Aminoglycoside.FQ: Levofloxacin,Gatifloxacin,Moxifloxacin.The use of B-lactam with FQ associated with increased mortality
  • Rate of 3rd gen ceph with good antipneumococcal activtiy increased during the study period from 35.2% to 86-95%During 1997-2000, 60-65% of pts treated with b-lactam also treated with macrolide as part of empiric tx
  • Failure to include a macrolide in the initial treatment of pts with bacteremic pneumococcal pneumonia was an independent risk factor of death

Strep Pneumoniae Strep Pneumoniae Presentation Transcript

  • National Naval Medical Center Case Conference
    Temujin T. Chavez, M.D.
    LCDR MC USN
    Infectious Diseases Fellow
  • First 24 Hours
    HPI: Pt is a 48 yo female with reported anorexia nervosa who presented to Dewitt c/o 1 wk nonprod cough, weakness and recent orthostasis. Int Med Clinic Dewitt eval s/f SaO2 84% RA to 87% 4 L NC. SBP 125 and Pulse 125
    ROS: exposure to cousin with uri symptoms 10 days prior while traveling to Indiana. Denies hospitalized contacts or contacts evaluated in ED. (-) Influenzae vaccination
    Dewitt ER: 7.39/43.8/49/26.4. Nasally intubated and transferred to WRAMC.
    WRAMC: Piperacillin-Tazobactam 3.375 gm iv <4hrs, Vancomycin 1 gram <8hrs, Ceftriaxone 1 gram @ 9 hrs
  • First 24 Hours
    PMHx:
    Anorexia Nervosa
    Ovarian Ca s/p TAH
    HTN
    HLD
    SurgHx:
    TAHBSO 1986
    Breast Bx Feb 2008
    SocHx:
    (-) Tobacco/etoh
    FHx:
    Sister (+) breast ca
  • First 24 hours
    T=97.7, BP=81/52, P=111, I/O (3 hrs) 1224 LR/300 UO
    SIMV PS. Rate 12. PS 10cmH20. PEEP 5cmH2o. FIO2 100%
    Gen: sedated. GCS 10T(E3, M6,VT)
    APACHE IV score=76
    APS Score=71
    ABG 7.332/35.7/92/18.9/97%
    SvO2=48.9
    WBC=1.9, HCT=31
    Na=125, BUN=24, Cr=1.4, Glc=115
    Alb=2.2, Bili 0.6
    Blood culture
    4 of 4 bottles Streptococcus pneumoniae
    Penicillin (0.5mcg/ml), Vanc (0.5mcg/ml), Ceftriaxone (0.016 mcg/ml), Levofloxacin (1.0 mcg/ml)
    Resp culture
    2+ PMN, 1+ EPI, Mixed flora
    Streptococcus pneumoniae
  • First 24 Hours
  • Hospital Day 3
    Consult Question
    Optimal antibiotic therapy in pt with PCN sensitive bacteremic pneumococcal pneumonia on Piperacillin-Tazobactam/Ceftriaxone/Vancomycin?
  • CAPEmpiric Antibiotic Therapy
    CID 2007;44:S27-72
  • Combination Antibiotic Therapy
    • Prospective observational study
    • Dec 1998 – Dec 2000
    • 844 w/ bacteremia 2nd to Streptococcus pneumoniae
    • Pts monitored for 14 days post bacteremia or longer if hospitalized
    • Monotherapy
    • Same single abx w/in 1st 2 days of + BCx
    • Combination therapy
    • Same 2 abx w/in 1st 2 days of +BCx
    • Figure A
    • Survival plot for pts not critically ill
    • Figure B
    • Survial plot for pts critically ill
    AM J Resp Crit Care 2004;170:440-44
  • Combination Antibiotic Therapyin Critically Ill
    Monotherapy
    B-lactam (43)
    Azithromycin (2)
    Ciprofloxacin (1)
    Clindamycin (1)
    Combination Therapy
    B-lactam/macrolide (14)
    B-lactam/Vancomycin (12)
    B-lactam/ Aminoglycoside (7)
    Vancomycin/other (4)
    Vancomycin/fq (4)
    Dbl B-lactam(2)
  • Combination Antibiotic Therapy
    Am J Resp Crit Care 2004;170:440-44
  • Empiric TherapyChoosing The Right Combination
    • Retrospective observational study
    • Jan 1999 – Dec 2002
    • 172 subjects having rad and ICD-9 diagnosis of CAP
    • Abx administered 1st 48hrs of admission
    • 33% w/in 4 hrs of presentation
    • Multivariate logistic regression model to assess 30 day mortality between B-lactam and FQ VS. other guideline therapy
    • B-lactam + FQ (30%)
    • B-lactam + Macrolide (17.2%)
    • Other regimens (11.4%)
    Crit Care 2006;10:1186-94
  • Empiric TherapyChoosing The Right Combination
    Crit Care 2006;10:1186-94
  • Addition of macrolide to B-Lactam-Based Empiric Treatment
    • Retrospective observational study
    • 1991-2000
    • 409 pts w/ S. pneumoniae bacteremic pneumonia
    • B-lactam +/- other antibiotic
    • Pts observed from time of dx of bacteremia until death or d/c
    • 238 (58%) received B-lactam + macrolide
    • 171 (42%) received B-lactam +/- other abx
    CID 2003;36:389-95
  • Addition of macrolide to B-Lactam-Based Empiric Treatment
    • Pts who did not receive a macrolide
    • HIV
    • Hematologic malignancies
    • Neutropenia
    • Nosocomial infection
    • Pts who received a macrolide
    • Shock at time of presentation
    • Admitted to ICU
    • Univariate analysis in hospital mortality
    • Shock (p<.0001)
    • Abx other than macrolide (p<.001)
    • Infxns R to PCN&Erythro (p=.02)
    • ICU admission (p<0.0001)
    CID 2003;36:389-95
  • Addition of macrolide to B-Lactam-Based Empiric Treatment
    • Association btwn initial macrolide therapy and a lower in-hospital mortality rate remained sig after exclusion of pts who died </= 48 hrs p admission
    • Macrolide and PCN resistance
    • More virulent strains
    • Resistance to macrolide negates the beneficial effect of macrolides
    • Pts infected w/ resistant strains had a more serious disease
    CID 2003;36:389-95
  • References
    Mandell LA, et al. Infectious Disease Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. CID 2007;44:s27-72.
    Mortensen EM, et al. The Impact of Empiric Antimicrobial Therapy With a B-Lactam and Fluoroquinolone on Mortality for Patients Hospitalized with Severe Pneumonia. Crit Care 2006;10:1186-94.
    Martinez JA, et al. Addition of a Macrolide to a B-Lactam-Based Empirical Antibiotic Regimen Is Associated with Lower In-Hospital Mortality for Patients with Bacteremic Pneumococcal Pneumonia. CID 2003;36:389-395.
    Baddour LM, et al. Combination Antibiotic Therapy Lowers Mortality among Severely Ill Patients with Pneumococcal Pneumonia. AM J Resp Crit Care Med 2004;170:440-44.