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

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

  1. 1. Francesco Blasi Department of Physiopathology and Transplantation University of Milan Managing CAP and HAP
  2. 2. 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.
  3. 3. Torres A, et al. Thorax 2013;68:1057–65.
  4. 4. Estimated cost of median length of stay for patients with CAP in European hospitals
  5. 5. 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.
  6. 6. Risk Factors Analysis: MDR pathogens Aliberti A, et al CID 2012;54(4):470-8. MDR multi drug resustant HCAP health care associated pneumonia
  7. 7. Aliberti A, et al CID 2012;54(4):470-8. MDR multi drug resistant COPD chronic obstructive pulmonary disease
  8. 8. Aliberti S et al. Thorax 2013;68:997-9
  9. 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
  10. 10. CASE REPORT n. 1
  11. 11. 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
  12. 12. 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
  13. 13. PNEUMONIA LIVER Diaphragm
  14. 14. PNEUMONIA B LINES
  15. 15. TREATMENT?
  16. 16. • 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
  17. 17. ?
  18. 18. STRATIFYING RISK FACTORS
  19. 19. Aliberti A, et al CID 2012;54(4):470-8. MDR multi drug resistant COPD chronic obstructive pulmonary disease
  20. 20. 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 +++
  21. 21. In VII giornataOn day 3 Pleural effusion
  22. 22. Tracheal aspirate
  23. 23. WOULD YOU CHANGE?
  24. 24. Ceftriaxone 2gr 20.000 5.8 --- 18.000 14.6 15.000 --- 14.200 5.6 WBC CRP T Azithromycina 500 stop stop Imipenem 1g q8 EV Tracheal aspirate D1 D2 D3 D4 D5 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
  25. 25. Ceftriaxone 2gr 20.000 5.8 --- 18.000 14.6 15.000 --- 14.200 5.6 12.400 --- WBC CRP T Azithromycina 500 stop stop Imipenem 1g q8 EV D1 D2 D3 D4 D5 D6 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
  26. 26. Discharged on Day 20…
  27. 27. 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
  28. 28. TREATMENT OPTIONS FOR PATIENTS WITH SEVERE COMMUNITY-ACQUIRED PNEUMONIA [C4] (ICU OR INTERMEDIATE CARE) INSIDE HOSPITAL: CAP NO RISK FACTORS FOR P. aeruginosa Non-antipseudomonal cephalosporin III + macrolide * or moxifloxacin 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) PLUS Ciprofloxacin^ OR PLUS Macrolide* + aminoglycoside (gentamicin, tobramycin or amikacin)
  29. 29. WHAT EMPIRICAL ANTIBIOTIC TREATMENT IS RECOMMENDED FOR ASPIRATION PNEUMONIA? INSIDE HOSPITAL: CAP Hospital ward admitted from home Oral or iv-lactam/-lactamase inhibitor or Clindamycin or iv cephalosporin + oral metronidazole or moxifloxacin ICU or admitted from Nursing Home Clindamycin + cephalosporin or Cephalosporin + metronidazole
  30. 30. CASE REPORT n. 2
  31. 31. 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.
  32. 32. 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:
  33. 33. What kind of treatment?
  34. 34. 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 -Ceftriaxone 2 g iv + azithromycin 500 mg iv 18.600 7 12.500 12 10.420 6 WBC CRP T 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 0.30 0.25 0.10PCT
  35. 35. D1 D2 D3 -Ceftriaxone 2 g iv + azithromycin 500 mg iv 18.600 7 12.500 12 10.420 6 WBC CRP T 0.30 0.25 0.10PCT 9.000 3 0.08 D4
  36. 36. ….AND NOW?
  37. 37. DISCHARGED ON DAY 6
  38. 38. Pneumonia and Cardiovascular events PATHOPHYSIOLOGICAL MECHANISMS Corrales-Medina. Lancet 2012
  39. 39. Which patients in hospital are at risk? Lines and Medical devices Burns Renal dialysis Transplant recipients Cancer Post-surgery High dependency Elderly Neonates Hospital
  40. 40. 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 20.1 Pseudomonas aeruginosa 21.8 19.7 20.8 28.2 Klebsiella spp. 9.8 8.5 10.1 12.1 Escherichia coli 6.9 4.6 10.1 5.5 Acinetobacter spp. 6.8 4.8 5.6 13.3 Enterobacter spp. 6.3 6.5 6.2 6.2 Serratia spp. 3.5 4.1 3.2 2.4 Stenotroph. 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
  41. 41. MRSA trends, Europe EARS-NET
  42. 42. MDR Gram-negatives causing pneumonia Pseudomonas aeruginosa Acinetobacter Enterobacteriaceae Stenotrophomonas maltophilia
  43. 43. 0 5 10 15 20 25 30 35 40 2006 2007 2008 2009 2010 2011 EARS-NET Proportion% Year AMG FQ NEM PIP CAZ Pseudomonas aeruginosa resistance trends, Italy
  44. 44. 0 5 10 15 20 25 30 35 40 45 50 2005 2006 2007 2008 2009 2010 2011 Proportion% Year Klebsiella pneumoniae and resistance to 3rd gen. cephalosporins and fluoroquinolones, Italy EARS-NET R to 3GC R to FQ Increasing role of carbapenems
  45. 45. Giani et al – JCM 2009 Santoriello et al – unpublished Fontana et al – BMC Res Notes 2010 Marchese et al – J Chemother 2010 Ambretti et al – New Microb 2010 Gaibani et al – Eurosurv 2011 Mezzatesta et al – CMI 2011 Agodi et al – JCM 2011 Richter et al – JCM 2011 Di Carlo et al – BMC Gastroenterol 2011 Rossolini GM – unpublished late 2008 The first reported cases of KPC-Kp KPC-producing K. pneumoniae – the Italian epidemic early 2011 AMCLI – CoSA CRE network Frasson et al – JCM 2012 ARISS – CoSA survey 2012 late 2012
  46. 46. 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
  47. 47. 0 10 20 30 40 50 60 70 80 90 100 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 CRAB proportion by center – Italian surveillance Centers CRABproportion(%) AMCLI-CoSA – Italian national surveillance 2011 Mean, 43%
  48. 48. CASE 3
  49. 49. 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.
  50. 50. AFTER 4 DAYS 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
  51. 51. Your Diagnosis?
  52. 52. 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
  53. 53. WHICH TREATMENT?
  54. 54. 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 Ab anti-Legionella pneumophila: negative Swab: bacteria and fungi: neg Urinary antigens LP and SP: negative Tracheal aspirate: GRAM POSITIVE Blood culture: pending Ab anti-Mycoplasma: IgG negative and IgM negative Naso-pharyngeal swab DNA CP, MP, LP: negative 0.44 0.42 0.49PCT
  55. 55. WOULD YOU CHANGE?
  56. 56. Ceftriaxone 2gr 22.220 19 18.700 18 17.400 18 WBC CRP T Levofloxacin 500 q12 0.44 0.42 0.49 Vancomycin 500 mg in 50 cc F at 5 ml/h Stop D1 D2 D3 PCT
  57. 57. Ceftriaxone 2gr 22.220 19 18.700 18 17.400 20 WBC CRP T Levofloxacin 500 q12 0.44 0.42 --- Vancomycin 500 mg in 50 cc F at 5 ml/h 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
  58. 58. 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…
  59. 59. 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
  60. 60. Because of the CXR findings, patient underwent Thorax CT scan:
  61. 61. Because of the CXR findings, patient underwent Thorax CT scan:
  62. 62. Levofloxacin 500 q12 Vancomycin 500 mg in 50 cc F at 5 ml/h 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
  63. 63. EXITUS on DAY 10
  64. 64. 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
  65. 65. HAP, VAP Clinical Improvement at 48-72 hours? NO YES Cultures - Cultures + Cultures - Cultures + Search for other Pathogens, Complications, Other Diagnoses or Other Sites of infection Adjust antibiotic Therapy, search For other Pathogens, Complications Or other sies Of infection Consider Stopping antibiotics De-escalate Antibiotics, if Possible. Treat selected Patients for 7-8 days and reassess Am J Respir Crit Care Med 2005;171:388-416
  66. 66. 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 Spectrum Antipseudomonal cephalosporin (Ceftazidime 3x2g) or Antipseudomonal carbapenem (Imipenem/Cilastin 3x1g, Meropenem 3x1g) or -lactam/-lactamase inhibitor (Piperacillin/tazobactam 3x4.5g) Plus Antipseud fluoroquinolone (Ciprofloxacin 3x400mg, Levofloxacin 1x750mg) or Aminoglycoside (Amikacin 15mg/kg/d divided bid, max 1.5g/d) (MRSA – linezolid (2x600mg) or vancomycin (2x1g initial, control blood levels)) Am J Respir Crit Care Med 2005;171:388-416
  67. 67. • 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.
  68. 68. 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 Am J Respir Crit Care Med 2005;171:388-416

Editor's Notes

  • Proposed pathophysiological mechanisms contributing to cardiac complications in patients with acute pneumonia

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