Strep Pneumoniae

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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

    1. 1. National Naval Medical Center Case Conference<br />Temujin T. Chavez, M.D.<br />LCDR MC USN<br />Infectious Diseases Fellow<br />
    2. 2. First 24 Hours<br />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<br />ROS: exposure to cousin with uri symptoms 10 days prior while traveling to Indiana. Denies hospitalized contacts or contacts evaluated in ED. (-) Influenzae vaccination<br />Dewitt ER: 7.39/43.8/49/26.4. Nasally intubated and transferred to WRAMC.<br />WRAMC: Piperacillin-Tazobactam 3.375 gm iv <4hrs, Vancomycin 1 gram <8hrs, Ceftriaxone 1 gram @ 9 hrs<br />
    3. 3. First 24 Hours<br />PMHx:<br />Anorexia Nervosa<br />Ovarian Ca s/p TAH<br />HTN<br />HLD<br />SurgHx:<br />TAHBSO 1986<br />Breast Bx Feb 2008<br />SocHx:<br />(-) Tobacco/etoh<br />FHx:<br />Sister (+) breast ca<br />
    4. 4. First 24 hours<br />T=97.7, BP=81/52, P=111, I/O (3 hrs) 1224 LR/300 UO<br />SIMV PS. Rate 12. PS 10cmH20. PEEP 5cmH2o. FIO2 100%<br />Gen: sedated. GCS 10T(E3, M6,VT)<br />APACHE IV score=76<br />APS Score=71<br />ABG 7.332/35.7/92/18.9/97%<br />SvO2=48.9<br />WBC=1.9, HCT=31<br />Na=125, BUN=24, Cr=1.4, Glc=115<br />Alb=2.2, Bili 0.6<br />Blood culture<br />4 of 4 bottles Streptococcus pneumoniae<br />Penicillin (0.5mcg/ml), Vanc (0.5mcg/ml), Ceftriaxone (0.016 mcg/ml), Levofloxacin (1.0 mcg/ml)<br />Resp culture<br />2+ PMN, 1+ EPI, Mixed flora<br />Streptococcus pneumoniae<br />
    5. 5. First 24 Hours<br />
    6. 6. Hospital Day 3<br />Consult Question<br />Optimal antibiotic therapy in pt with PCN sensitive bacteremic pneumococcal pneumonia on Piperacillin-Tazobactam/Ceftriaxone/Vancomycin?<br />
    7. 7. CAPEmpiric Antibiotic Therapy<br />CID 2007;44:S27-72<br />
    8. 8. Combination Antibiotic Therapy<br /><ul><li>Prospective observational study
    9. 9. Dec 1998 – Dec 2000
    10. 10. 844 w/ bacteremia 2nd to Streptococcus pneumoniae
    11. 11. Pts monitored for 14 days post bacteremia or longer if hospitalized
    12. 12. Monotherapy
    13. 13. Same single abx w/in 1st 2 days of + BCx
    14. 14. Combination therapy
    15. 15. Same 2 abx w/in 1st 2 days of +BCx
    16. 16. Figure A
    17. 17. Survival plot for pts not critically ill
    18. 18. Figure B
    19. 19. Survial plot for pts critically ill</li></ul>AM J Resp Crit Care 2004;170:440-44<br />
    20. 20. Combination Antibiotic Therapyin Critically Ill<br />Monotherapy<br />B-lactam (43)<br />Azithromycin (2)<br />Ciprofloxacin (1)<br />Clindamycin (1)<br />Combination Therapy<br />B-lactam/macrolide (14)<br />B-lactam/Vancomycin (12)<br />B-lactam/ Aminoglycoside (7)<br />Vancomycin/other (4)<br />Vancomycin/fq (4)<br />Dbl B-lactam(2)<br />
    21. 21. Combination Antibiotic Therapy<br />Am J Resp Crit Care 2004;170:440-44<br />
    22. 22. Empiric TherapyChoosing The Right Combination<br /><ul><li>Retrospective observational study
    23. 23. Jan 1999 – Dec 2002
    24. 24. 172 subjects having rad and ICD-9 diagnosis of CAP
    25. 25. Abx administered 1st 48hrs of admission
    26. 26. 33% w/in 4 hrs of presentation
    27. 27. Multivariate logistic regression model to assess 30 day mortality between B-lactam and FQ VS. other guideline therapy
    28. 28. B-lactam + FQ (30%)
    29. 29. B-lactam + Macrolide (17.2%)
    30. 30. Other regimens (11.4%)</li></ul>Crit Care 2006;10:1186-94<br />
    31. 31. Empiric TherapyChoosing The Right Combination<br />Crit Care 2006;10:1186-94<br />
    32. 32. Addition of macrolide to B-Lactam-Based Empiric Treatment<br /><ul><li>Retrospective observational study
    33. 33. 1991-2000
    34. 34. 409 pts w/ S. pneumoniae bacteremic pneumonia
    35. 35. B-lactam +/- other antibiotic
    36. 36. Pts observed from time of dx of bacteremia until death or d/c
    37. 37. 238 (58%) received B-lactam + macrolide
    38. 38. 171 (42%) received B-lactam +/- other abx</li></ul>CID 2003;36:389-95<br />
    39. 39. Addition of macrolide to B-Lactam-Based Empiric Treatment<br /><ul><li>Pts who did not receive a macrolide
    40. 40. HIV
    41. 41. Hematologic malignancies
    42. 42. Neutropenia
    43. 43. Nosocomial infection
    44. 44. Pts who received a macrolide
    45. 45. Shock at time of presentation
    46. 46. Admitted to ICU
    47. 47. Univariate analysis in hospital mortality
    48. 48. Shock (p<.0001)
    49. 49. Abx other than macrolide (p<.001)
    50. 50. Infxns R to PCN&Erythro (p=.02)
    51. 51. ICU admission (p<0.0001)</li></ul>CID 2003;36:389-95<br />
    52. 52. Addition of macrolide to B-Lactam-Based Empiric Treatment<br /><ul><li>Association btwn initial macrolide therapy and a lower in-hospital mortality rate remained sig after exclusion of pts who died </= 48 hrs p admission
    53. 53. Macrolide and PCN resistance
    54. 54. More virulent strains
    55. 55. Resistance to macrolide negates the beneficial effect of macrolides
    56. 56. Pts infected w/ resistant strains had a more serious disease</li></ul>CID 2003;36:389-95<br />
    57. 57. References<br />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.<br /> 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.<br />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.<br />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.<br />

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