Pneumonia Symposia presented at Hôpital Sacré Coeur in Milot, Haiti, 2011.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
3. Types
of
Pneumonia
• Community-‐acquired
-‐
Present
on
admit
or
within
1st
48
hours
-‐
No
risk
for
nosocomial
pathogens
• Healthcare-‐associated
(HCAP)
-‐
pa;ents
with
extensive
exposure
to
healthcare
system
prior
to
admit
• Hospital-‐acquired
(HAP)
-‐
develops
≥
48
hours
post
admit
• Ven;lator-‐associated
(VAP)
-‐
Develops
≥
48
hours
post
intuba;on
4. Epidemiology
• 450
million
cases
worldwide
• 4
million
deaths
per
year
• Highest
risk
in
children
<
5
and
adults
over
75
• 1.4
million
children
under
5
died
in
2010
-‐
18%
of
deaths
-‐
More
than
TB,
HIV
&
malaria
combined
-‐
Most
of
those
deaths
in
developing
countries
-‐
Major
risks
are
malnutri;on
and
poverty
WHO and Ruuskanen, O, et al. Lancet, 2011.
5. Preven;on
• Vaccina;on
-‐
Hib,
pertussis,
measles,
pneumococcus
-‐
up
to
30%
reduc;on
in
incidence
• Nutri;on
• Breas^eeding
1st
six
months
-‐
up
to
15%
reduc;on
in
incidence
• Prompt
access
to
treatment
• Reduce
indoor
air
pollu;on
WHO, 2011.
6. Epidemiology
• Common
cause
of
sepsis
• 7th
leading
cause
of
death
• 5-‐6
million
pa;ents/year
• Mortality
not
significantly
improved
for
years
• ~
$10B
per
year
spent
• Over
1
million
cases
per
year
7. Microbiology
• S.
pneumo
remains
most
common
bacteria
• Influenza
most
common
virus
-‐
RSV,
metapneumo,
parainfluenza,
adeno
• Mycobacteria
• Fungi
8. Microbiology
-‐
Bacteria
• Typical
-‐
S.
pneumo
-‐
H.
influenza
-‐
Moraxella
-‐
Staph
a.
-‐
Aerobic
gram
nega;ve
10. • Table
6.
Most
common
e0ologies
of
community-‐acquired
pneumonia.
Pa;ent
type
E;ology
Outpa;ent
Streptococcus
pneumoniae
Mycoplasma
pneumoniae
Haemophilus
influenzae
Chlamydophila
pneumoniae
Respiratory
viruses
Inpa;ent
(non-‐ICU)
S.
pneumoniae
Respiratory
viruses
M.
pneumoniae
C.
pneumoniae
H.
influenzae
Legionella
species
Aspira;on
11. Table
6.
Most
common
e0ologies
of
community-‐
acquired
pneumonia.
Pa;ent
type
E;ology
Inpa;ent
(ICU)
S.
pneumoniae
Staphylococcus
aureus
Gram-‐nega;ve
bacilli
H.
influenzae
12. Specific
Bugs
• S.
pneumo
-‐
Lobar
consolida;on
-‐
Rust
colored
sputum
• H.
flu
-‐
elderly
or
underlying
lung
disease
22. • Table
4.
Criteria
for
severe
community-‐acquired
pneumonia.
• Minor
criteriaa
Respiratory
rateb
>=30
breaths/min
Pa02/Fi02
ra;ob
<=250
Mul;lobar
infiltrates
Confusion/disorienta;on
Uremia
(BUN
level,
>=20
mg/dL)
Leukopeniac
(WBC
count,
<4000
cells/mm3)
Thrombocytopenia
(platelet
count,
<100,000
cells/mm3)
Hypothermia
(core
temperature,
<36°C)
Hypotension
requiring
aggressive
fluid
resuscita;on
• Major
criteria
Invasive
mechanical
ven;la;on
Sep;c
shock
with
the
need
for
vasopressors
23. Micro
Tes;ng
• Up
to
70%
of
cases
never
have
iden;fied
bug
• Out-‐pa;ents
–
no
specific
tes;ng
needed
• Floor
Pa;ents
–
targeted
tes;ng
• ICU
Pa;ents:
-‐
Blood
Cultures
-‐
Sputum
Cultures
-‐
Urine
an;gen
tes;ng
(Legionella,
Pneumo)
-‐
Tes;ng
may
improve
mortality
in
this
group
24. Blood
Cultures
• Only
+
in
~
15%
of
pneumonia
pa;ents
• Majority
of
+
cultures
are
strep
pneumo
• ATS/IDSA
recommend
cultures
in:
-‐
ICU
pa;ents
-‐
Cavity
on
CXR
-‐
Leukopenia
-‐
Chronic
liver
disease
or
EtOH
abuse
-‐
Asplenia
-‐
Pleural
Effusion
25. Sputum
Cultures
• Rate
of
+
cultures
highly
variable
(10-‐80%)
• ATS/IDSA
guidelines:
-‐
ICU
Pa;ents
-‐
Failure
of
empiric
therapy
-‐
Cavity
on
CXR
-‐
Alcohol
abuse
or
immunocompromise
-‐
Severe
lung
disease
-‐
Pleural
effusion
26. Urinary
An;gen
Tes;ng
• Bejer
accuracy
vs.
sputum
&
blood
tes;ng
• Easier
to
obtain
vs.
sputum
• Fast
turn
around
• Not
affected
by
abx
treatment
up
to
3
days
• Cannot
do
sensi;vity
tes;ng
• Legionella
test
only
for
Group
1
(~
80%
of
dz)
• ?
Lower
accuracy
in
absence
of
bacteremia
27. Severity
Assessment
-‐
PSI
• Derived
from
14K
pa;ents
with
CAP
• Validated
in
40K
pa;ents
with
CAP
• Designed
to
predict
mortality
• Excluded
immunosuppression
• 20
variables
• 2
step
process
• Complexity
limits
use
Fine,
MJ,
et
al.
NEJM,
1997.
31. PSI
-‐
Mortality
• Class
I
–
0.1-‐0.4%
(no
predictors)
• Class
II
–
0.6-‐0.7%
(<
70
points)
• Class
III
–
0.9-‐2.8%
(70-‐90)
• Class
IV
–
4-‐10%
(90-‐130)
• Class
V
–
27%
(>130)
32. PSI
-‐
U;lity
• Performs
well
at
mortality
predic;on
• Unable
to
consistently
predict
need
for
ICU
• Mixed
success
at
guiding
out-‐pt
vs.
in-‐pa;ent
-‐
Class
I-‐III
poten;al
out-‐pa;ent
therapy
shown
in
some
ED
studies
-‐
In
studies
using
PSI,
up
to
30-‐60%
of
low
risk
pts
were
s;ll
admijed
Singanayagam,
A
,et
al.
Q
J
Med,
2009.
Niederman,
M,
Respirology,
2009.
33. CURB-‐65
(BTS)
• Confusion
• Uremia
(BUN
>
20)
• RR
≥
30
• BP
–
SBP
<
90
or
DBP
<
60
• 65
or
older
• CRB-‐65
excludes
BUN
Lim,
WS,
et
al.
Thorax,
2003.
34. CURB-‐65
• Get
1
point
for
each
of
5
items
• 0
–
0.7%
mortality
• 1
–
1.7%
mortality
• 2
–
8.3%
mortality
• 3
–
17%
mortality
• 4
–
41%
mortality
• 5
–
57%
mortality
35. CURB-‐65
• 0-‐1
–
treat
as
out-‐pa;ent
• 2
–
brief
observa;on
admit
• 3
or
more
–
admit,
assess
for
ICU
36. ATS/IDSA
• Table
4.
Criteria
for
severe
community-‐acquired
pneumonia.
• Minor
criteria
Respiratory
rate
>=30
breaths/min
Pa02/Fi02
ra;o
<=250
Mul;lobar
infiltrates
Confusion/disorienta;on
Uremia
(BUN
level,
>=20
mg/dL)
Leukopeniac
(WBC
count,
<4000
cells/mm3)
Thrombocytopenia
(platelet
count,
<100,000
cells/mm3)
Hypothermia
(core
temperature,
<36°C)
Hypotension
requiring
aggressive
fluid
resuscita;on
• Major
criteria
Invasive
mechanical
ven;la;on
Sep;c
shock
with
the
need
for
vasopressors
37. SMART-‐COP
• Tool
to
predict
need
for
vasopressors/MV
• Based
on
study
of
882
pa;ents
• SBP
<
90
• Mul;lobar
infiltrates
• Albumin
<3.5
• RR
>
25
or
30
(depending
upon
age)
• Tachycardia
>
125
• Confusion
• Oxygen
reduced
• pH
<
7.35
Charles,
PC,
et
al.,
Clin
Infect
Dis,
2008.
38. SMART-‐COP
• Hypotension,
hypoxia
&
low
pH
each
2
points
• All
others
1
point
each
• 92
%
of
pa;ents
requiring
ICU
care
had
≥
3
points
• Less
accurate
in
pa;ents
<
50
39. Biomarkers
–
Procalcitonin
(PCT)
• Levels
rise
during
infec;on
-‐
?
More
specific
to
bacterial
infec;on
-‐
?
More
specific
to
infec;on
that
CRP
• Low
PCT
high
NPPV
(98.9%)
for
mortality
from
CAP
-‐
even
in
pa;ents
with
high
CRB-‐65
• High
PCT,
and
failure
to
drop,
a/w
↑
mortality
• High
PCT
a/w
blood
culture
+
Kruger,
S,
et
al.,
Eur
Resp
J,
2008.
40. PCT
Guided
Abx
Therapy
• 302
CAP
pa;ents,
randomized,
open
trial
• Control
pa;ents
–
usual
prac;ce
• PCT
group
–
abx
use
encouraged
if
PCT
high,
discouraged
if
PCT
low
-‐
PCT
done
Day
1,
4,
6
and
8
• PCT
group
had
much
less
abx
use
-‐
mostly
via
shorter
courses
of
abx
in
PCT
pts
• Similar
need
for
ICU,
mortality,
etc
Christ-‐Crain,
M,
et
al.
AJRCCM,
2006.
41. Other
Biomarkers
of
Interest
• CRP
-‐
?
Par;cular
sugges;ve
of
pneumococcus
• Pro-‐atrial
natriure;c
pep;de
• Pro-‐vasopressin
42. ATS/IDSA
Summary
Site
of
Care
• Consider
CURB-‐65
or
PSI
to
guide
tx
loca;on
-‐
CURB-‐65
≥
2,
in-‐pa;ent
• ICU
if
≥
3
minor
criteria
of
ATS
criteria
Diagnos;c
Tes;ng
• Must
have
infiltrate
on
CXR
• Diagnos;c
tes;ng
op;onal
for
outpa;ents
43. ATS/IDSA
Summary
–
Outpt
Treatment
• No
significant
co-‐morbidi;es
-‐
Macrolide
(Level
1)
-‐
Doxycycline
(Level
3)
• Major
co-‐morbidi;es
-‐
Respiratory
quinolone
(Level
1)
-‐
β-‐lactam
+
macrolide
• Cochrane
Review
(2009)
–
current
evidence
insufficient
for
abx
choice
in
out-‐pt
CAP
44. ATS/IDSA
Summary
–
Inpt
Treatment
• Non-‐
ICU
-‐
Respiratory
quinolone
-‐
β-‐lactam
+
macrolide
• ICU
-‐
β-‐lactam
+
either
an
IV
macrolide
or
respiratory
quinolone
-‐
Assess
for
Pseudomonas
&
CA
MRSA
45. ATS/IDSA
Summary
–
Abx
Issues
• Time
to
1st
Dose
-‐
Did
not
specify
exact
;me,
but
-‐
1st
dose
should
be
given
in
ED
• Switch
IV
to
Oral
-‐
Hemodynamically
stable
-‐
Clinically
improving
-‐
Able
to
take
PO
with
normal
GI
func;on
46. ATS/IDSA
Summary
–
Abx
Dura;on
• At
least
5
days
of
effec;ve
therapy
• Afebrile
for
at
least
48
hours
• At
most
fail
1
criteria
of
clinical
stability
• Longer
dura;on
if:
-‐
Ini;al
abx
not
effec;ve
against
pathogen
-‐
Resistant
organism
-‐
Extrapulmonary
infec;on
-‐
Immunosuppressed
host
47. Table
10.
Criteria
for
clinical
stability
• Temperature
<=37.8°C
• Heart
rate
<=100
beats/min
• Respiratory
rate
<=24
breaths/min
• Systolic
blood
pressure
>=90
mm
Hg
• Arterial
oxygen
satura;on
>=90%
or
pO2
>=60
mm
Hg
on
room
air
• Ability
to
maintain
oral
intakea
• Normal
mental
statusa
48. Clinical
Stability
• Hospitalized
pa;ents
take
2-‐4
days
to
achieve
stability
• May
be
longer
with
lobar
or
necro;zing
pna
• Can
take
up
to
1
month
for
all
symptoms
to
resolve
• Can
take
up
to
3
months
for
CXR
to
clear
49. Treatment
Failure
• Lack
of
improvement
or
clinical
deteriora;on
• Occurs
in
up
to
15%
of
cases
• Early
–
worsening
in
first
72
hours
• Late
-‐
≥
72
hours
of
therapy
50. PaAerns
and
e0ologies
of
types
of
failure
to
respond
Deteriora;on
or
progression
Early
(<72
h
of
treatment)
Severity
of
illness
at
presenta;on
Resistant
microorganism
Uncovered
pathogen
Inappropriate
by
sensi;vity
Metasta;c
infec;on
Empyema/parapneumonic
Endocardi;s,
meningi;s,
arthri;s
Inaccurate
diagnosis
PE,
aspira;on,
ARDS,
Vasculi;s
(e.g.,
SLE)
Delayed
Nosocomial
superinfec;on
Nosocomial
pneumonia
Extrapulmonary
Exacerba;on
of
comorbid
illness
Intercurrent
noninfec;ous
disease
PE
Myocardial
infarc;on
Renal
failure
51. PaAerns
and
e0ologies
of
types
of
failure
to
respond.
• Failure
to
improve
-‐
Early
(<72
h
of
treatment)
Normal
response
-‐
Delayed
Resistant
microorganism
Uncovered
pathogen
Inappropriate
by
sensi;vity
Parapneumonic
effusion/empyema
Nosocomial
superinfec;on
Nosocomial
pneumonia
Extrapulmonary
Noninfec;ous
Complica;on
of
pneumonia
(e.g.,
BOOP)
Misdiagnosis:
PE.
CHF,
vasculi;s
Drug
fever
52. Risk
Factors
for
Lack
of
Response
• Mul;-‐lobar
pneumonia
• High
PSI
• Cavity
or
effusion
• Leukopenia
• Liver
disease
54. CAP
Mortality
in
US
• ~
1%
in
out-‐pa;ents
• ~
5-‐10%
in
ward
pa;ents
• Up
to
1/3
of
ICU
pa;ents
• Higher
mortality
in
non-‐responders
• Higher
mortality
in
pa;ents
with
concomitant
acute
cardiac
event
55. CAP
Mortality
• >
in
resistant
GNR
and
Staph
• Intermediate
in
Strep,
influenza
• Lowest
in
mycoplasma
56. CAP
Outcomes
• 1,555
pa;ents
in
study
of
pna
outcomes
• Both
in-‐pa;ents
and
out-‐pa;ents
included
• 8.7%
died
within
90
days
• 29%
died
within
1st
year,
19%
died
in
2nd
year
16%
died
in
year
3
• Outcome
compared
to
age
matched
controls
• Mortality
higher
in
pna
pts
across
all
age
groups
Mortensen,
EM,
et
al.,
Clin
Inf
Dis,
2003.
57. CAP
Outcomes
• 170
Pa;ents
with
pneumococcal
pneumonia
• Assessed
incidence
of
-‐
Acute
MI
-‐
Afib
or
VT
-‐
New
or
worsening
CHF
• 33
(19%)
had
≥
1
cardiac
event
-‐
12
MI
-‐
13
CHF
-‐
8
arrhythmia
Musher,
DM,
et
al.,
Clin
Inf
Dis,
2007.
58. CAP
&
Steroids
• 46
pa;ent
RCT
in
severe
CAP
• Hydrocor;sone
200
mg
bolus
then
10mg/hr
for
7
days
• 1⁰
end-‐point:
improvement
in
P/F,
MODS
and
development
of
sep;c
shock
by
Day
8
• 2⁰
end-‐point:
dura;on
MV,
LOS,
mortality
• All
1⁰
end-‐points
bejer
in
tx
group
• 2⁰
end-‐points
also
bejer
Confalonieri,
M,
et
al.
AJRCCM,
2005.
59. CAP
&
Steroids
• 213
pa;ents
hospitalized
with
CAP
• Randomized
to
prednisone
40
for
7
d
• 1⁰
outcome:
cure
at
7
d
• 2⁰
outcome:
cure
at
30d,
LOS,
;me
to
stability
defervesence,
CRP
• Results
–
No
difference,
even
in
subset
with
severe
pna
-‐More
late
failure
with
prednisone
60. Viral
Pneumonia
• More
common
in
children
• Likely
underdiagnosed
historically
• Diagnos;c
op;ons
are
improving
• O@en
co-‐exists
with
bacterial
pneumonia
• Limited
treatment
op;ons
• Seasonal
pajerns
• Can
have
epidemics
Ruuskanen, O, et al. Lancet, 2011.
61. Viral
Pneumonia
-‐
Diagnosis
• Nasal
swabs,
aspirates,
washes
• Throat
swab
• Expectorated
or
induced
sputum
• BAL
• PCR
techniques
have
increased
yield
62. Viral
Pneumonia
-‐
Diagnosis
• Signs
&
symptoms
overlap
with
those
of
bacterial
pneumonia
• Viral
may
have
more
insidious
onset
or
have
prodrome
• ?
More
likely
to
have
wheeze
• Consider
if
not
responding
to
an;bio;cs
63. Viruses
• RSV
• Influenza
• Parainfluenza
• Human
metapneumo
virus
• Coronavirus
(SARS)
• Avian
influenza
A
(H5N1)
-‐
60%
fatality
rate
• Pandemic
influenza
A
(H1N1)
64. An;-‐virals
• Neurominidase
inhibitors
–
Influenza
viruses
-‐
Oseltamivir,
peramivir,
zanamivir,
amantadine
and
rimantadine
• Ribavirin
–
RSV,
human
metapneumo,
para
65. Health
Care-‐Associated
Pneumonia
(HCAP)
• Nursing
home
residents
• Recent
hospitaliza;on
• Chronic
dialysis
• Home
infusion
therapy
• Home
wound
care
therapy
66. Hospital-‐Acquired
Pneumonia
(HAP)
• Develops
≥
48
hours
a@er
admit
• Highest
risk
of
HAP
is
in
intubated
pa;ents
• Es;mated
incidence
4-‐7/1000
admits
• Pa;ents
with
HAP
have
20-‐50%
mortality
67. Ven;lator-‐Associated
Pneumonia
(VAP)
• Develops
>
48
hours
a@er
intuba;on
• Not
present
at
;me
of
intuba;on
• 1-‐4%
daily
risk
while
intubated
68. MDR
Organisms
• Resistant
to
≥
2
an;bio;cs
usually
used
to
treat
the
organism
• Risk
Factors
for
MDR
infec;on:
-‐
Received
an;bio;cs
in
last
90-‐180
days
-‐
Hospitalized
≥
2
days
in
last
90
days
-‐
Current
hospitaliza;on
has
been
for
≥
5
days
-‐
High
local
incidence
of
MDR
organisms
-‐
Immunosuppressed
pa;ent
69. Treatment
• General
Principles
-‐
Start
empiric
an;bio;cs
promptly
based
on
local
an;-‐biogram
-‐
Blood
&
Sputum
culture
if
possible
-‐
Prompt
ini;a;on
of
appropriate
abx
crucial
-‐
Assess
for
risk
for
MDR
organism
-‐
Descalate
as
quickly
as
able
(within
72
hours)
70. Importance
of
Timing
of
Abx
• Observa;onal
study
of
107
consecu;ve
VAP
pa;ents
in
single
ICU
• Compared
pt
with
>
24
hour
delay
in
abx
• Mortality
in
delay
pa;ents
70%
vs.
28%
• Even
adjusted
for
severity
of
illness,
etc,
delay
abx
s;ll
led
to
increased
mortality
Iregui M, et al. Chest, 2002.
71. Importance
of
Appropriate
Abx
• Retrospec;ve
study
of
431
HCAP
pa;ents
• Single
center
• Mortality
in
pa;ents
with
appropriate
regimen
was
18%
vs.
30%
(p
0.013)
Zilberberg, et al. Chest, 2008.
72.
73. Treatment
Guidelines
• 303
pa;ents
in
4
ICU’s
• 129
had
guideline
recommended
an;bio;cs
• 174
pa;ents
did
not
get
recommended
abx
• 34%
of
adherent
pa;ents
died
vs.
20%
• Other
studies
have
suggested
opposite
results
• Emphasizes
the
importance
of
adjus;ng
therapy
to
local
pathogens
Kett, DH, et al. Lancet Infect Dis, 2011.
74. Dura;on
of
An;bio;cs
• Prospec;ve
RCT
of
401
pa;ent
with
VAP
• Excluded
immunosuppressed
pa;ents
• Compared
8
vs.
15
days
of
an;bio;cs
• Outcomes:
death,
recurrence
&
abx
free
days
• No
difference
in
Mortality
or
ICU
days
• Overall
recurrence
rate
not
different
• If
GNR,
8d
group
had
higher
recurrence,
but
no
mortality
difference
&
less
resistance
Chastre, et al. JAMA, 2003.