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Community Acquired Pneumonia

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Community Acquired Pneumonia Dr Vincent Ioos Medical Intensive Care Unit Pakistan Institute of Medical Sciences Definition Infection of the lung parenchyma that has ... – PowerPoint PPT presentation

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Title: Community Acquired Pneumonia


1
Community Acquired Pneumonia
  • Dr Vincent Ioos
  • Medical Intensive Care Unit
  • Pakistan Institute of Medical Sciences

2
Definition
  • Infection of the lung parenchyma that has been
    acquired in the community
  • Before hospital admission or within 48 hours
  • ? hospital acquired pneumonia, health care
    associated pneumonia
  • ? acute bronchitis and exacerbation of COPD
  • ? obstructive pneumonia, TB

3
Diagnosis
  • Lack of sensitivity of clinical signs and
    symptoms
  • But good Positive Predictive value of the
    presence of crakles
  • Good Negative Predictive Value of RRgt30/mn,
    HRgt100/mn, Tgt37,9C
  • Fever frequently absent in older patients
  • CXR
  • Leucopenia poor prognosis
  • Microbiological diagnosis better treatment when
    pathogen oriented but contreversies on the value
    of tests

4
Should we get a CXR ?
  • Patient with severe infection presence of
    pneumonia allows proper empiric antibiotic
    therapy
  • If patient is not severely ill helps in
    deferentiating CAP from acute bronchitis or
    exacerbation of COPD, and assess if antibiotics
    are necessary or not

5
Which pathogens ?
6
Epidemiology
  • Varies from one country to another
  • 2 questions
  • Pathogens most likely to be responsible for CAP
  • Pattern of resistance, especially for Streptoccus
    Pn.
  • Epidemiological studies difficult previous use
    of antibiotics, cost of C/S and serological
    studies, invasive procedures.
  • Sentinel surveillance systems for specific
    pathogens data from microbiology departments,
    from disease oriented register.

7
Etiology Outpatients
8
Etiology ward patients
9
Etiology ICU patients
10
In Pakistan
  • Lack of datas
  • Neighbooring countries
  • World surveillance networks
  • Peadiatric studies

11
Shimia, Himachal Pradesh, India
  • 70 patients with CAP, blood, sputum and pleural
    fluid c/s, Mycoplasma Pn. Ab
  • 75,6 proven etiology
  • Streptococcus Pn 35,8
  • Klebsiella Pn 22
  • Staphylococcus Aureus 17
  • Mycoplasma Pn 15
  • E. Coli 11
  • Beta hemolytic Streptococci 7,5
  • GNB 5,9

Bansal S, Indian J Chest Dis Allied Sci. 2004,
Jan-March 46(1) 17-22
12
New Delhi
  • All India Institute of Medical Sciences, April
    1997 December 1998
  • 60 patients blood C/S Elisa Ab against L.
    Pneumophila (serogroups 1-7)
  • 13 conventional bacterial etiology
  • 15 serological evidence of recent infection with
    L. Pneumophila

Chaudhry R, Trop Doct. 2000 Oct 30(4)197-200.
13
Shangai
  • 389 patients with CAP between 2001-2003
  • Bacterial culture, PCR, specific immunological
    assays
  • Specific pathogen found in 39,8
  • Haemophilus Inflenzae 51, among them 88,3
    amoxicilline S
  • Mycoplasma Pn. 27
  • Chlamydia Pn. 11
  • Klebsiella spp. 10
  • Streptococcus Pn. 8 among them 75 Peni S,
    25Peni I
  • Staphylococcus Aureus 4
  • Legionella Pn. 1,3
  • Moraxella Catharallis 0,6

Huang HH, Eur J Clin Microbiol Infect Dis. 2006
Jun 25(6)369-74
14
Iran, Afghanistan
  • PubMed country name pneumonia,
  • Iran 33 articles, no epidemiological data on
    CAP
  • Afghanistan 12 articles, one on epidemiology
    datas on CAP in Russian Soldiers

15
  • 66 Laboratories in 1997, 81 in 1998 (17 in
    Asia-Pacific)
  • Pneumococal isolates from bloodstream and
    respiratory tract infections
  • 8252 respiratory tract isolates

Hoban DJ, Clin Infect Dis. 2001 May 1532 Suppl
2S81-93.
16
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17
  • Network of microbiology departments in 26
    countries
  • 1998-2000
  • Streptococcus Pneumonia (8882 isolates),
    Haemophilus Influenzae (8523), Moraxella
    Catharralis (874)

18
  • Streptococcus Pn.
  • 95 Amoxicilline S
  • Quinolone resistance 1,1
  • Haemophilus Beta Lactamase production 16,9

19
ARI in children, Pakistan
  • 87 strains of Streptococcus pneumoniae from blood
    culture
  • 97 resistant to at least one drug
  • 31 R to Cotrimoxazole,
  • 39 R to Chloramphenicol
  • All isolates were susceptible to erythromycin,
    cefaclor, cephalothin, ceftriaxone, cefuroxime,
    rifampicin, vancomycin, and clindamycin

Mastro TD, Lancet 1991 Jan 19 337(8734)156-9.
20
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21
Critical microbes
  • Legionella Pneumophila
  • Influenza A B
  • Avian Influenza
  • SARS
  • CA-MRSA
  • ? Epidemiological challenges or treatment
    different from standart regimen

22
Which diagnostic methods ?
23
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24
Blood cultures (pros)
  • Pretreatment blood cultures positive for a
    pathogen in 7 to 16 percent of hospitalized
    patients.
  • Streptococcus pneumoniae 2/3 of the positive
    blood cultures
  • When positive, the microbial diagnosis is
    established.
  • Only diagnostic test done, in most cases major
    source of microbiologic data (resistance patterns
    of S. pneumoniae)

25
Blood cultures (cons)
  • The blood culture positivity rate is relatively
    low.
  • High rate of false positive blood cultures (up to
    10 percent). Eg Staphylococcus.
  • Positive cultures rarely lead to modification or
    narrowing of antibiotic therapy

26
Sputum standard quality criterias
  • Deep cough specimen obtained prior to
    antibiotics,
  • To be sampled only if macroscopically purulent
    sputum,
  • Cultures performed rapidly after collection,
    preferably within two hours
  •  Good" sputum sample gt 25 PMNs / LPF but lt 10
    SECs/LPF on Gram Stain
  • Interpretation Quantitation of growth (heavy,
    moderate or light, quantitative threshold 107
    CFU), clinical correlation, correlation with the
    Gram's stain

27
Invasive sampling
  • Protected brush specimen
  • Bronchalveolar Lavage
  • In case of failure of the initial treatment
  • If epidemiology or clinical presentation suggest
    a specific pathogens that is not covered by usual
    treatment strategy
  • If patient is intubated (ICU)

28
Pleural Tap
  • Rarely positive
  • Evidences empyema

29
Urinary antigens (pros)
  • Urine specimens avalable when patients cannot
    supply expectorated sputum.
  • Results of urine antigen testing immediately
    available.
  • Retains validity even after the initiation of
    antibiotic therapy.
  • High sensitivity compared to blood cultures and
    sputum studies.

30
Urinary antigens (cons)
  • The sensitivity and specificity may be less in
    patients without bacteremia.
  • No microbial pathogen available for antibiotic
    sensitivity testing.

31
Urinary Antigen LP
  • Legionella Pneumophila
  • Only for serotype 1 (the most frequent 80)
  • Sensitivity 86, specificity 93
  • Positive 1 to 3 days after the onset of disease

32
Urinary antigen (SP)
  • Sensitivity 77-89 if CAP with blood culture ,
    Sensitivity 44-64 if blood culture
  • False positive test rare
  • Rapid diagnosis, still positive after 7 days of
    antibiotics, persists several weeks.

33
Diagnostic yield of microbiological tests
  • Prospective study 262 hospitalized patients
    with CAP.
  • Sputum for Gram staining, culture, and detection
    of pneumococcal antigen blood for culture and
    serologic tests urine for legionella and
    pneumococcal antigens and specimens obtained by
    bronchoscopy.
  • A pathogen was identified in 158 (60 percent)
    patients
  • Adequate sputum samples obtained in only 44
    patients Gram's stain positive sputum culture
    in 36/44 patients (82).

Van der Eerden MM, Eur J Clin Microbiol Infect
Dis 2005 Apr24(4)241-9.
34
Diagnostic yield of microbiological tests
  • S. pneumoniae most commonly identified (97 of
    158).
  • Urinary pneumococcal antigen test positive in
    52/97 (54) patients with pneumococcal pneumonia.
  • Blood cultures were positive in 40 of 254 (16)
    patients.
  • Bronchoscopy additive diagnostic value in 18/37
    patients (49) who did not expectorate sputum and
    in 14 of 27 patients (52 percent) who failed
    treatment within 72 hours after admission.

Van der Eerden MM, Eur J Clin Microbiol Infect
Dis 2005 Apr24(4)241-9.
35
PCR
  • Multiplex Real-time PCR
  • Respiratory viruses and atypical bacteria (eg, M.
    pneumoniae, L. pneumophila, Legionella spp, C.
    pneumoniae, influenza A and B virus, respiratory
    syncytial virus, parainfluenza viruses, human
    rhinovirus, metapneumovirus, adenovirus, and
    human coronaviruses)
  • 105 adults etiology determined
  • 50 with conventional techniques
  • 80 with PCR
  • But increased cost. ? Less antibiotic use.

Templeton KE, Clin Infect Dis 2005 Aug
141(3)345-51.
36
Minimal approach
  • 2 blood cultures and Tracheal Aspirate culture if
    patient is intubated
  • before antibiotics are given
  • Urinary Legionella Pn. Antigen

37
Where should the patient be managed ?
  • At home
  • In the ward
  • In the ICU
  •  saving lifes and saving money 
  • Identify low risk patient to  save money  (and
    hospital beds !)
  • Identify high risk patient to  save life 

38
Saving lifes the high risk patient
39
  • Saving money, avoid unnecessary hospitalisation
  • Large cohorts for validation (38,039 adults
    retrospectively, 2,287 adults for prospective
    validation)

40
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41
Fine scoring system
  • Class Points
  • II ? 70
  • III 71 - 90
  • IV 91 - 130
  • V gt 130

Fine et al. N Engl J Med 1997 336 243-50
42
Fine et coll. NEJM 1997
43
Decision
  • IV, V admit the patient
  • I no admission
  • II, III no admission if score results from the
    age 1 other criteria.
  • Admit systematically if
  • Hypoxemia SaO2lt90 / PaO2lt60
  • Vomitting prohibiting oral treatment,
  • immunosupression
  • Do not forget clinical judgement !
  • 25 years old pt hypotension tachycardia
    class II !

44
Curb Index
CURB ? 2 hospital admission is recomended
Derivated indexes CURB-65, CRB-65
45
Which treatment ?
46
Risk factors for penicillin-resistant S.
pneumoniae
  • Age lt2 years or gt65 years
  • Beta-lactam or macrolide therapy within the past
    six months
  • Recent hospital stay lt 3 months
  • Medical comorbidities
  • Immunosuppressive illness or therapy
  • Exposure to a child in a day care center

47
Treatment options for moderate CAP admitted to
hospital
48
Treatment options for patients with severe CAP
49
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50
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51
Early antibiotics for severe pneumonia
  • Prognosis impaired when antibiotic administration
    is delayed
  • Recommandations
  • lt 2 hours for non ICU patients
  • lt 1 hour for ICU patients
  • Several studies showed that in the real life this
    goals are difficult to achieve (recent Chest
    study)

52
Anti-pneumococcal quinolones
  • Consequences on community microbiological ecology
    unknown
  • High incidence of TB in Pakistan false negative
    AFB, difficulty in proper microbiological
    diagnosis of TB
  • To be given as an alternative to standard therapy

53
Emerging pathogens
  • SARS
  • H5N1
  • SA-MRSA

54
Challenges in Pakistan
  • Epidemiologic datas desperately needed
  • Costs associated with CAP (Antibiotics)
  • Rational use of antibiotics
  • Importance of institution-based recommendations
  • National consensus statement epidemiologist,
    microbiologist, pulmonologists, infectious
    disease specialists, Intensivists.

55
Consensus Statements
  • American Thoracic Society,
  • 2001British Thoracic Society, 2004
  • Infectious Diseases Society of America, 2003
  • European Respiratory Society, 2005
  • Panel of French Scientific Societies under the
    leadership of Societe de pathologie infectieuse
    de langue francaise, SPILF, March 2006
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