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

1. National Naval Medical Center Case Conference Temujin T. Chavez, M.D. LCDR MC USN Infectious Diseases Fellow

2. 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

3. 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

4. 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

5. First 24 Hours

6. Hospital Day 3 Consult Question Optimal antibiotic therapy in pt with PCN sensitive bacteremic pneumococcal pneumonia on Piperacillin-Tazobactam/Ceftriaxone/Vancomycin?

7. CAPEmpiric Antibiotic Therapy CID 2007;44:S27-72

9. Dec 1998 – Dec 2000

10. 844 w/ bacteremia 2nd to Streptococcus pneumoniae

11. Pts monitored for 14 days post bacteremia or longer if hospitalized

12. Monotherapy

13. Same single abx w/in 1st 2 days of + BCx

14. Combination therapy

15. Same 2 abx w/in 1st 2 days of +BCx

16. Figure A

17. Survival plot for pts not critically ill

18. Figure B

19. Survial plot for pts critically illAM J Resp Crit Care 2004;170:440-44

20. 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)

21. Combination Antibiotic Therapy Am J Resp Crit Care 2004;170:440-44

23. Jan 1999 – Dec 2002

24. 172 subjects having rad and ICD-9 diagnosis of CAP

25. Abx administered 1st 48hrs of admission

26. 33% w/in 4 hrs of presentation

27. Multivariate logistic regression model to assess 30 day mortality between B-lactam and FQ VS. other guideline therapy

28. B-lactam + FQ (30%)

29. B-lactam + Macrolide (17.2%)

30. Other regimens (11.4%)Crit Care 2006;10:1186-94

31. Empiric TherapyChoosing The Right Combination Crit Care 2006;10:1186-94

33. 1991-2000

34. 409 pts w/ S. pneumoniae bacteremic pneumonia

35. B-lactam +/- other antibiotic

36. Pts observed from time of dx of bacteremia until death or d/c

37. 238 (58%) received B-lactam + macrolide

38. 171 (42%) received B-lactam +/- other abxCID 2003;36:389-95

40. HIV

41. Hematologic malignancies

42. Neutropenia

43. Nosocomial infection

44. Pts who received a macrolide

45. Shock at time of presentation

46. Admitted to ICU

47. Univariate analysis in hospital mortality

48. Shock (p<.0001)

49. Abx other than macrolide (p<.001)

50. Infxns R to PCN&Erythro (p=.02)

51. ICU admission (p<0.0001)CID 2003;36:389-95

53. Macrolide and PCN resistance

54. More virulent strains

55. Resistance to macrolide negates the beneficial effect of macrolides

56. Pts infected w/ resistant strains had a more serious diseaseCID 2003;36:389-95

57. 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.