MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA … of CAP in Asia Pacific region.pdf · Chong-Kin LIAM...

ChongChong--Kin LIAM Kin LIAM Department of MedicineDepartment of Medicine

Faculty of MedicineFaculty of MedicineUniversity of MalayaUniversity of Malaya

Kuala LumpurKuala [email protected]@ummc.edu.my

MANAGEMENT OF MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA COMMUNITY ACQUIRED PNEUMONIA

IN THE ASIA PACIFIC REGIONIN THE ASIA PACIFIC REGION

COMMUNITY ACQUIRED PNEUMONIACOMMUNITY ACQUIRED PNEUMONIA

A common disorder

Annual incidence in USA - 12 per 1000 adults- 25-44 per 1000 in those aged >65 years

Marfarlane J. Semin Respir Infect 1994; 9:153-65

COMMUNITY ACQUIRED PNEUMONIACOMMUNITY ACQUIRED PNEUMONIA

In JapanAnnual incidence: 15 per 1000 adults and childrenAnnual incidence requiring hospitalisation:

3.4 per 1000 adults and children

6th leading cause of death worldwide

JRS guidelines (2005). Respirology 2006; 11:S79-S133

Bartlett JG, et al. Clin Infect Dis. 1998;26:811-838; Marrie TJ. Infect Dis Clin North Am. 1998;12:723-740; Reimer LG, Carroll KC. Clin Infect Dis.1998;26:742-748.

CAP: Key Bacterial Pathogens

20%

40%

S. pneumoniaeH. influenzae

• In most studies, Streptococcus pneumoniaeis the most commonly identified pathogen followed by Haemophilus influenzae



6%

10%

7% 20%

40%

S. pneumoniaeH. influenzae Legionella spp.M. pneumoniae C. pneumoniae Atypical

pathogens:23%

.. and atypical pathogens: Mycoplasma pneumoniaeChlamydophila pneumoniaeand Legionella spp.



16%

6%

1%

10%

7% 20%

40%

S. pneumoniaeH. influenzae Legionella spp.M. pneumoniae C. pneumoniae M. catarrhalis Others

Atypicalpathogens:

23%

Other bacteria include Moraxella catarrhalis, Staphylococcus aureus, Klebsiella spp., and other gram-negative bacilli

HospitalisedHospitalised patientspatients(non(non--ICU)ICU)Ambulatory patientsAmbulatory patients SevereSevere

(ICU)(ICU)

CAP patients are generally categorised into 3 groups

• outpatients

• inpatients

• intensive care patients

Clinical Practice GuidelinesClinical Practice Guidelines

Most common microbial Most common microbial aetiologiesaetiologies of CAP of CAP (in the West)(in the West)

InpatientInpatient(non(non--ICU)ICU)OutpatientOutpatient

S. S. pneumoniaepneumoniaeM. M. pneumoniaepneumoniaeH. H. influenzaeinfluenzaeC. C. pneumoniaepneumoniaeRespiratory viruses*Respiratory viruses*

S. S. pneumoniaepneumoniaeM. M. pneumoniaepneumoniaeC. C. pneumoniaepneumoniaeH. H. influenzaeinfluenzaeLegionellaLegionella speciesspeciesAspirationAspirationRespiratory viruses*Respiratory viruses*

S. S. pneumoniaepneumoniaeStaphStaph. . aureusaureusLegionellaLegionella sppspp..EnterobacteriaceaeEnterobacteriaceae sppspp..Pseudomonas Pseudomonas sppspp..H. H. InfluenzaeInfluenzae

InpatientInpatient(ICU)(ICU)

IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72

Ref: File TM. Community-acquired pneumonia. Lancet 2003; 362:1991-2001[Based on collective data from recent studies]

Influenza A and B, adenovirus, Influenza A and B, adenovirus, RSV & RSV & parainfluenzaparainfluenza

• For all 3 categories of patients, the number one pathogen is pneumococcus

Most common microbial Most common microbial aetiologiesaetiologies of CAP of CAP (in the West)(in the West)


S. S. pneumoniaepneumoniaeM. M. pneumoniaepneumoniaeH. H. influenzaeinfluenzaeC. C. pneumoniaepneumoniaeRespiratory viruses*Respiratory viruses*

S. S. pneumoniaepneumoniaeM. M. pneumoniaepneumoniaeC. C. pneumoniaepneumoniaeH. H. influenzaeinfluenzaeLegionellaLegionella speciesspeciesAspirationAspirationRespiratory viruses*Respiratory viruses*

S. S. pneumoniaepneumoniaeStaphStaph. . aureusaureusLegionellaLegionella sppspp..GramGram--negative bacillinegative bacilliH. H. InfluenzaeInfluenzae


• For all 3 categories of patients, the number one pathogen is pneumococcus

• Atypical pathogens are also prominently represented

• Legionella - an important pathogen in patients with severe CAP


Influenza A and B, adenovirus, Influenza A and B, adenovirus, RSV & RSV & parainfluenzaparainfluenza

LocationLocation No. of No. of patientspatients

Rank order / FrequencyRank order / Frequency of microbial cause of microbial cause (%)(%)2211 33 44 55 UnknownUnknown

• The aetiology of CAP in Japan is quite similar to that of Western countries • High incidence of infection by Gram –ve bacilli• Infection due to M tuberculosis may commonly present as CAP in countries with a high prevalence of TB

OkayamaOkayama11Ishida T, Ishida T, et al.et al.Chest Chest 1998;114:15881998;114:1588--9393

326326S S pneumoniaepneumoniae

2323

H H influenzaeinfluenzae

77

M M pneumoniaepneumoniae

55

K K pneumoniaepneumoniae

44

S S millerimilleri

44 3939OkayamaOkayama223 hospitals3 hospitalsMiyashita N, Miyashita N, et al.et al.Chest Chest 2000;119:12952000;119:1295--66


2121


1111


1010

C C pneumoniaepneumoniae

88

S S aureusaureus

55 4242

KoreaKorea33Woo JH, Woo JH, et al.et al.Korean J Infect Korean J Infect DisDis2001, 33:12001, 33:1--77

562562(588 cases)(588 cases)

S S pneumoniaepneumoniae

2222


1515

Ps Ps aeruginosaaeruginosa

1010

S S aureusaureus

1010

S S viridansviridans

66 6262

Hong KongHong Kong44CHS Chan, CHS Chan, et alet al..

ChestChest1992;101:4421992;101:442--66

9090M tuberculosisM tuberculosis

1212


1212

Chlamydia Chlamydia sppspp

66

ViralViral

66


44 5959

AetiologiesAetiologies of CAP Requiring Hospitalization in Asia of CAP Requiring Hospitalization in Asia 1



BangkokBangkok5a5a3 hospitals3 hospitalsWattanathumWattanathum, , et alet al..Chest Chest 2003;123:15122003;123:1512--99


2222

Gram Gram --veve bacillibacilli

1818((K. K. pneumpneum 10)10)

C. C. pneumoniaepneumoniae

1616


77

PenangPenang88Hooi LN, Hooi LN, et al.et al.Med J MalaysiaMed J Malaysia2001;56:2752001;56:275--8383


1515


77


66


33

K. LumpurK. Lumpur77Liam CK, Liam CK, et al.et al.Respirology Respirology 2001;6:2592001;6:259--6464


1010


66


66


44


44127127

SingaporeSingapore66Hui KP, Hui KP, et alet al..Singapore Med JSingapore Med J1992;101:4421992;101:442--66


2121


1212

Gram Gram --vevebacillibacilli

1010


55


55

S S aureusaureus

55

L L pneumophilapneumophila

55 2929

5858

4242

5757• Studies in Singapore and Malaysia (countries with a high prevalence of TB) also show pulmonary TB commonly presents as CAP



1111

B B pseudomalleipseudomallei

11111.4% in Bangkok1.4% in Bangkok5a5a


99


44


1010 4343

KhonKhon KaenKaen55ReechaipichitkulReechaipichitkul W, W, et al. Southeast et al. Southeast Asian J Trop Med Asian J Trop Med Public Health Public Health 2005; 36:1562005; 36:156--6161



BangkokBangkok5a5a3 hospitals3 hospitalsWattanathumWattanathum, , et alet al..Chest Chest 2003;123:15122003;123:1512--99


2222

Gram Gram --veve bacillibacilli

1818((K. K. pneumpneum 10)10)

C. C. pneumoniaepneumoniae

1616


77

K. LumpurK. Lumpur99Liam CK, Liam CK, et al.et al.Respirology Respirology

2006;11:7862006;11:786--9292

346346K K pneumoniaepneumoniae

1111


99


66


44

K. LumpurK. Lumpur77Liam CK, Liam CK, et al.et al.Respirology Respirology 2001;6:2592001;6:259--6464


1010


66


66


44


44127127

SingaporeSingapore66Hui KP, Hui KP, et alet al..Singapore Med JSingapore Med J1992;101:4421992;101:442--66


2121


1212

Gram Gram --vevebacillibacilli

1010


55


55

M tuberculosisM tuberculosis

55


55 2929

5858

4242

5353• Studies in Singapore and Malaysia (countries with a high prevalence of TB) also show pulmonary TB commonly presents as CAP



1111


11111.4% in Bangkok1.4% in Bangkok5a5a


99


44


1010 4343

KhonKhon KaenKaen55ReechaipichitkulReechaipichitkul W, W, et al. Southeast et al. Southeast Asian J Trop Med Asian J Trop Med Public Health Public Health 2005; 36:1562005; 36:156--6161



United United KingdomKingdom(4 studies)(4 studies)


2222

LegionellaLegionella sppspp

1818

VirusesViruses

1010

S S aureusaureus

99

Influenza A Influenza A & B& B

55 3232

AetiologiesAetiologies of Severe CAP Requiring ICU Admissionof Severe CAP Requiring ICU Admission

Other parts Other parts of Europeof Europe(10 studies)(10 studies)


2222

Gram Gram ––veveenteric bacillienteric bacilli

99

S S aureusaureus

77


77


66 4343SingaporeSingaporeNUH NUH Lee KH, Lee KH, et al.et al.Singapore Med J Singapore Med J 1996;37:3741996;37:374--7777

5959 K K pneumoniaepneumoniae

1515


88

S S aureusaureus

77


77


55 3232SingaporeSingaporeSGH SGH Tan YK, Tan YK, et al.et al.EurEur RespirRespir J J 1998;12:1131998;12:113--1515

5757B B pseudomalleipseudomallei

1818


1616

KlebsiellaKlebsiella sppspp

99

S S aureusaureus

99


77 2828

KhonKhon KaenKaenReechaipichitkulReechaipichitkul W, W, et al.Southeast Asian et al.Southeast Asian J Trop Med Public J Trop Med Public Health Health 2004;35:4302004;35:430--33


2929


2121


1919


1212

S S aureusaureus

66 4141

Patients who met ATS criteria for severe CAP

91.4% of patients had co-morbidity, most common was diabetes mellitus; Mortality: 21%



United United KingdomKingdom(4 studies)(4 studies)


2222


1818

VirusesViruses

1010

S S aureusaureus

99

Influenza A Influenza A & B& B

55 3232

AetiologiesAetiologies of Severe CAP Requiring ICU Admissionof Severe CAP Requiring ICU Admission

Other parts Other parts of Europeof Europe(10 studies)(10 studies)


2222

Gram Gram ––veveenteric bacillienteric bacilli

99

S S aureusaureus

77


77


66 4343SingaporeSingaporeNUH NUH Lee KH, Lee KH, et al.et al.Singapore Med J Singapore Med J 1996;37:3741996;37:374--7777

5959 K K pneumoniaepneumoniae

1515


88

S S aureusaureus

77


77


55 3232SingaporeSingaporeSGH SGH Tan YK, Tan YK, et al.et al.EurEur RespirRespir J J 1998;12:1131998;12:113--1515


1818


1616

KlebsiellaKlebsiella sppspp

99

S S aureusaureus

99


77 2828

KhonKhon KaenKaenReechaipichitkulReechaipichitkul W, W, et al.Southeast Asian et al.Southeast Asian J Trop Med Public J Trop Med Public Health Health 2004;35:4302004;35:430--33


2929


2121


1919


1212

S S aureusaureus

66 4141

Burkholderia pseudomallei should be considered a causative organism in patients with severe CAP

in Southeast Asia particularly if the patient has diabetes mellitus



Nova ScotiaNova Scotia11

MarrieMarrie TJ, TJ, et al.et al.Am J MedAm J Med1996;101:5081996;101:508--1515

149149M M pneumoniaepneumoniae

2323


1111

M M pneumoniaepneumoniae&&

C C pneumoniaepneumoniae33

Influenza AInfluenza A

33

C C burnetiiburnetii

33 4848

ArgentinaArgentinaErardErard PH, PH, et alet al..Am Soc Am Soc MicrobiolMicrobiol1991;108:56A1991;108:56A


1313


77


44


44

Cryptococcus Cryptococcus sppspp44 6565

LausanneLausanneBochudBochud PY, PY, et alet al..Medicine Medicine 2001;80:7522001;80:752--8787


2323


1414

Influenza virusInfluenza virus

1212


55


22 4646

AetiologiesAetiologies of CAP treated on an ambulatory basisof CAP treated on an ambulatory basis

FinlandFinlandJokinenJokinen C, C, et alet al..ClinClin Infect Infect DisDis2001;15:11412001;15:1141--5454


3737


1414

ChlamydiaeChlamydiae

99

VirusesViruses

88


44 4545



Nova ScotiaNova Scotia11

MarrieMarrie TJ, TJ, et al.et al.Am J MedAm J Med1996;101:5081996;101:508--1515


2323


1111

M M pneumoniaepneumoniae&&

C C pneumoniaepneumoniae33


33


33 4848

ArgentinaArgentinaErardErard PH, PH, et alet al..Am Soc Am Soc MicrobiolMicrobiol1991;108:56A1991;108:56A


1313


77


44


44

Cryptococcus Cryptococcus sppspp44 6565

LausanneLausanneBochudBochud PY, PY, et alet al..Medicine Medicine 2001;80:7522001;80:752--8787


2323


1414

Influenza virusInfluenza virus

1212


55


22 4646

FinlandFinlandJokinenJokinen C, C, et alet al..ClinClin Infect Infect DisDis2001;15:11412001;15:1141--5454


3737


1414

ChlamydiaeChlamydiae

99

VirusesViruses

88


44 4545

BangkokBangkok3 hospitals3 hospitalsWattanathumWattanathum, , et alet al..Chest Chest 2003;123:15122003;123:1512--99

9898C C pneumoniaepneumoniae

3737


3030


1313


88

Mixed infectionMixed infection

1313 2525

JapanJapan3 hospitals (Okayama)3 hospitals (Okayama)Miyashita N, Miyashita N, et alet al..J Med J Med MicrobiolMicrobiol2005; 54:3952005; 54:395--400400


2727


1212


1111


55 4747

Viruses 2Viruses 2M M catarrhaliscatarrhalis22

AetiologiesAetiologies of CAP treated on an ambulatory basisof CAP treated on an ambulatory basis

AsiAAsiA--CAP StudyCAP StudyResults from 1374 patients with paired sera showed infection rates for

Mycoplasma pneumoniae 12.2%

Chlamydophila pneumoniae 4.7%

Legionella pneumophila 6.6%

Overall infection rate by atypicalrespiratory pathogens = 23.5%

Ngeow YF, et al. Int J Infect Dis 2005 May;9:144-53

Severity Assessment

The key to deciding initial site of care

Outpatient

Medical ward

Critical care ward / ICU

Severity assessment is made on the basis of prognostic criteria: • patients’ age• comorbidities• physical, laboratory and radiographic findings

Severity of illness score (e.g., CURB-65)

Prognostic models (e.g., PSI)

can be used to identify patients who may be treated as outpatients (Strong recommendation; level I evidence)

Severity assessment & Prognostication


Severity Assessment

Fine MJ, et al. A prediction rule to identify low-risk patients with CAP. N Engl J Med 1997;336:243-50

Pneumonia Severity Index (PSI)Pneumonia Severity Index (PSI)

Requires computation of a score based on 20 variables

Severity Assessment



stratifies patients into 5 mortality risk classes:Risk Risk class Score 30-day mortalityLow I No predictors 0.1%

Low II < 70 0.6%

Low III 71 – 90 0.9%

Moderate IV 91 – 130 9.3%

High V > 130 27.0%

Severity Assessment



On the basis of associated mortality rates, patients inRisk class 30-day mortality

I 0.1%

II 0.6%

III 0.9%

IV 9.3%

V 27.0%

Treat as outpatientsTreat as outpatients

Treat in an observation unit Treat in an observation unit oror short short hospitalisationhospitalisation

Treat as inpatientsTreat as inpatients

Severity Assessment

CURBCURB--65 score 65 score (6-point) – adopted by BTS

Score 1 point for each feature presentConfusionUrea > 7 mmol/LRespiratory rate > 30/minBlood pressure (SBP < 90 mmHg or DBP < 60 mmHg)Age > 65 yrs

Lim WS, et al. Thorax 2003;58:377-382

CURB-65 score Risk of mortality

Score 0 0.7%Score 1 3.2%

Score 2 13%

Score 3 17%Score 4 41.5% Score 5 57%

Patients who have a CURB-65 score of 3 or more are at high riskof death and should be managed as severe pneumonia

At increased risk of death - should be considered for short stay inpatienttreatment or hospital supervised outpatient treatment (use clinical judgement)

Patients who have a CURB-65 score of 0 or 1 are at low risk of death - can be treated as having non-severe pneumonia and may be suitable for home treatment

Recommendations

Lim WS, et al. Thorax 2003;58:377-382

There is growing evidence that CURB, CURB-65 and CRB-65 all allow for similar predictions of death from CAP as compared to the PSI

A prospective observational study of 1016 consecutive inpatients with CAPin an Emergency Department mean (SD) age: 72 (+ 17) yrs The ability of the three rules to predict 30 day mortality was compared

Yan Man S, et al. Prospective comparison of 3 predictive rules (PSI, CURB-65, CRB-65) for assessing severity of CAP (and to predict 30-day mortality) in Hong Kong. Thorax 2007; 62: 348-53

PSI class 30-day mortality (%)I 0II 0.8III 5IV 9.3V 22.1

CURB-650 0.91 3.62 7.33 16.44 26.65 37.5

CRB-650 2.31 5.12 11.23 23.24 40 Yan Man S, et al. Prospective comparison of 3 predictive rules for

assessing severity of CAP in Hong Kong. Thorax 2007; 62: 348-53

All 3 predictive rules showed the same trend of increasing mortality with worsening risk groups (p <0.001)

Sensitivity, specificity, positive and negative predictive Sensitivity, specificity, positive and negative predictive values of values of 30 day mortality30 day mortality of the different predictive rulesof the different predictive rules

All 3 clinical decision rules had high negative predictive values but low positive predictive values at all cut-off points and are therefore more useful in ruling out serious illness

Yan Man S, et al. Prospective comparison of 3 predictive rules for assessing severity of CAP in Hong Kong. Thorax 2007; 62: 348-53

Sensitivity, specificity, positive and negative predictive Sensitivity, specificity, positive and negative predictive values of values of 30 day mortality30 day mortality of the different predictive rulesof the different predictive rules

All 3 clinical decision rules had high negative predictive values but low positive predictive values at all cut-off points and are therefore more useful in ruling out serious illness


PSI : complicated computation of a score may not be PSI : complicated computation of a score may not be practical for routine application in busy hospital emergency practical for routine application in busy hospital emergency departments or primary care settingsdepartments or primary care settingsCURBCURB--65 : simpler to apply 65 : simpler to apply CRBCRB--65 : is also easily applicable in primary care settings65 : is also easily applicable in primary care settings

ICU admission rates also increased with the risk levels of each rule, but were only statistically significant in CURB-65 and CRB-65


Sensitivity and specificity for highSensitivity and specificity for high--risk group of risk group of the 3 predictive rules in identifying ICU admissionthe 3 predictive rules in identifying ICU admission

Sensitivity (%) Specificity (%)

PSI 29.3 82.7

CURB-65 41.5 75.0

CRB-65 24.4 90.3

Modified ATS 90.2 59.1rule†


† Ewig S, et al. Severe CAP: assessment of severity criteria. Am J Respir Crit Care Med 1998;158:1102–8.

Because of their low sensitivities, none of the 3 rules appears to be useful for identifying patients requiring ICU care

Sensitivity and specificity for highSensitivity and specificity for high--risk group of risk group of the 3 predictive rules in identifying ICU admissionthe 3 predictive rules in identifying ICU admission

Sensitivity (%) Specificity (%)

PSI 29.3 82.7

CURB-65 41.5 75.0

CRB-65 24.4 90.3

Modified ATS 90.2 59.1rule†


† Ewig S, et al. Severe CAP: assessment of severity criteria. Am J Respir Crit Care Med 1998;158:1102–8.

Because of their low sensitivities, none of the 3 rules appears to be useful for identifying patients requiring ICU care

Although far from being perfect, the modified American Although far from being perfect, the modified American Thoracic Society score is currently the best tool in identifyingThoracic Society score is currently the best tool in identifying

patients for ICU admissionpatients for ICU admission

Site-of-care decisions 1Prediction rules give an indication of disease severityPrediction rules give an indication of disease severityPrediction rules have not been found to be useful in Prediction rules have not been found to be useful in predicting ICU admission predicting ICU admission Generally, patients of higher risk classes have higher rates Generally, patients of higher risk classes have higher rates of ICU admissionof ICU admissionUnlike 30 day mortality, the association is not strong enough Unlike 30 day mortality, the association is not strong enough to allow for individual predictions and decisions to allow for individual predictions and decisions Criteria for ICU admission vary from country to country and Criteria for ICU admission vary from country to country and from hospital to hospitalfrom hospital to hospitalCriteria for ICU admission: disease severity is not the only Criteria for ICU admission: disease severity is not the only factor to consider; other factors to consider: disease factor to consider; other factors to consider: disease prognosis, preprognosis, pre--morbid status, age of patient, and the morbid status, age of patient, and the availability of ICU resourcesavailability of ICU resources

Site-of-care decisions 2

All predictive rules serve only as a guide to clinical All predictive rules serve only as a guide to clinical managementmanagement

Severity of illness is not the only factor to be Severity of illness is not the only factor to be considered when deciding on admissionconsidered when deciding on admission

Social and home circumstances must be Social and home circumstances must be considered as wellconsidered as well

Physicians should always exercise clinical Physicians should always exercise clinical judgment and common sense in making these judgment and common sense in making these decisionsdecisions

Criteria for severe CAPCriteria for severe CAPMajor criteria

Need for mechanical ventilation Septic shock requiring vasopressors

2007 IDSA / ATS Consensus Guidelines

Criteria for severe CAPCriteria for severe CAPMajor criteria

Need for mechanical ventilation Septic shock requiring vasopressors

Minor criteriaRespiratory rate >30 breaths/minPaO2/FiO2 ratio <250Multilobar infiltratesConfusion/disorientationUraemia (BUN level, >20 mg/dL)Leukopenia (WBC count, <4 x 109/L)Thrombocytopenia (platelet count, <100 x 109/L)Hypothermia (core temperature, <36ºC)Hypotension requiring aggressive fluid resuscitation


ICU admission decisionICU admission decisionDirect admission to an ICU is required for patients with

septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation

(Strong recommendation; level II evidence)

Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP

(Moderate recommendation; level II evidence)

Mandell LA, et al. IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72

ICU admission decisionICU admission decisionDirect admission to an ICU is required for patients with

septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation

(Strong recommendation; level II evidence)

Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP

(Moderate recommendation; level II evidence)


This recommendation requires prospective validation

EffectsEffects ofof antibioticantibiotic administrationadministration withinwithin 4 4 hrshrs ofof arrivalarrivalatat thethe hospital hospital onon inin--hospital & 30hospital & 30--day mortality day mortality **

0

2

4

6

8

10

12

14

16

18

Hosp Fine II-III Hospital IV-V 30 days Fine II-III

30 days FineIV-V

< 4h> 4 h

OR:0.62

OR:0.87

OR:0.86

*In Medicare patients older than 65 yrs who had not received pre-hospital antibiotic therapy (n = 13,771)

Houck PM, et al. A retrospective study on Medicare patients.Arch Intern Med 2004;164:637–44

EffectsEffects ofof antibioticantibiotic administrationadministration withinwithin 4 4 hrshrs ofof arrivalarrivalatat thethe hospital hospital onon inin--hospital & 30hospital & 30--day mortality day mortality **

0

2

4

6

8

10

12

14

16

18

Hosp Fine II-III Hospital IV-V 30 days Fine II-III

30 days FineIV-V

< 4h> 4 h

OR:0.62

OR:0.87

OR:0.86

*In Medicare patients older than 65 yrs who had not received pre-hospital antibiotic therapy (n = 13,771)

15% reduction in both in-hospital and 30-day mortality

Houck PM, et al. A retrospective study on Medicare patients.Arch Intern Med 2004;164:637–44

Treat earlyInitiation of antimicrobial therapy

within 4 hrs of arrival at the hospital was associated with a 0.4 day shorter mean LOS

Houck PM, et al. A retrospective study on Medicare patients.Arch Intern Med 2004; 164:637-44

Treat earlyInitiation of antimicrobial therapy

within 4 hrs of arrival at the hospital was associated with a 0.4 day shorter mean LOS

Houck PM, et al. A retrospective study on Medicare patients.Arch Intern Med 2004; 164:637-44

In the 2003 IDSA guidelines (also JRS guidelines 2005), initiating antibiotic therapy within 4 hrs after registration for hospitalised patients was a performance indicator

Guidelines for managing CAPGuidelines for managing CAPPrinciples of empirical therapy

2007 2007 IDSA / ATS Consensus Guidelines: IDSA / ATS Consensus Guidelines: Rather than designating a Rather than designating a specific window in which to initiate treatment,specific window in which to initiate treatment, hospitalized patients with hospitalized patients with

CAP should receive the first antibiotic dose in the EDCAP should receive the first antibiotic dose in the ED

Treat earlyCannot reliably differentiate aetiology based on clinical and radiological findings


Treat earlyCannot reliably differentiate aetiology based on clinical and radiological findingsTreat the most likely pathogens– S. pneumoniae (?DRSP*); H. influenzae– Atypicals– Others (co-morbidity and local epidemiology)


Treat earlyCannot reliably differentiate aetiology based on clinical and radiological findingsTreat the most likely pathogens– S. pneumoniae (?DRSP*); H. influenzae– Atypicals– Others (co-morbidity and local epidemiology)

Likely antibiotic sensitivity of presumed pathogens


Antibiotic Resistance IssuesResistance to commonly used antibiotics for CAP is major consideration in choosing empirical therapy

Resistance patterns vary by geography

Therefore, antibiotic recommendations must be modified based on local susceptibility patterns

Risk factors for infection with β-lactam-resistant Streptococcus pneumoniae•Age <2 yrs or >65 yrs•β-lactam therapy within the previous 3 months•Alcoholism•Medical comorbidities•Immunosuppressive illness or therapy•Exposure to a child in a day care centre

Probably related to greater exposure to antibiotics among these categories ofindividuals and increased selection of antibiotic-resistant strains

Mandell LA, et al. IDSA / ATS Consensus Guidelines. Clin Infect Dis 2007; 44:S27-72American Thoracic Society Guidelines Am J Respir Crit Care Med 2001; 163:1730-54

Mandell LA, et al. IDSA / ATS Consensus Guidelines. Clin Infect Dis 2007; 44:S27-72American Thoracic Society Guidelines Am J Respir Crit Care Med 2001; 163:1730-54


Risk factors for infection with β-lactam-resistant Streptococcus pneumoniae•Age <2 yrs or >65 yrs•β-lactam therapy within the previous 3 months•Alcoholism•Medical comorbidities•Immunosuppressive illness or therapy•Exposure to a child in a day care centre


Recent treatment with antimicrobials Recent treatment with antimicrobials -- the mostthe mostsignificant:significant:

Recent therapy or repeated courses of therapy with Recent therapy or repeated courses of therapy with ββ--lactamslactams, , macrolidesmacrolides, or , or fluoroquinolonesfluoroquinolones are risk are risk factors for factors for pneumococcalpneumococcal resistance to the same resistance to the same class of antibioticclass of antibiotic

PenicillinPenicillin--intermediate (MIC 0.12intermediate (MIC 0.12––1 mg/L)1 mg/L)PenicillinPenicillin--resistant (MIC resistant (MIC ≥≥22 mg/L)mg/L)

Song JH, et al. ANSORP. Antimicrob Agents Chemother June 2004; 48:2101-7

South KoreaSouth Korea24.3% → 9.7%55.4% → 54.8%

ChinaChina (Beijing, Shanghai)(Beijing, Shanghai)9.8% 9.8% →→ 19.819.8%%

0% 0% →→ 23.4% 23.4%

ThailandThailand35.7% 35.7% →→ 26.9%26.9%22.2% 22.2% →→ 26.9%26.9%

TaiwanTaiwan9.3% → 24.6%

29.4% → 38.6%

SingaporeSingapore4.9% → 28.6 %

18.2 % → 17.1% MalaysiaMalaysia

6.0% → 9.1%3.0% → 29.5%

VietnamVietnam28.2% 28.2% →→ 20.6%20.6%32.6% 32.6% →→ 71.4%71.4%

PhilippinesPhilippinesNA → 27.3%NA → 0%

Hong KongHong KongNA → 24.1%NA → 43.8%

Saudi ArabiaSaudi ArabiaNA NA →→ 20.5%20.5%NA NA →→ 10.3%10.3% IndiaIndia

3.8% 3.8% →→ 7.8%7.8%0% 0% →→ 0%0%

Prevalence of penicillinPrevalence of penicillin--resistant resistant S. S. pneumoniaepneumoniae**in 12 Asian countries in 12 Asian countries (1996(1996--1997 and 20001997 and 2000--2001)2001)

Asian Network for Surveillance of Resistant Pathogens (ANSORP)Asian Network for Surveillance of Resistant Pathogens (ANSORP) * Clinical isolates

PenicillinPenicillin--intermediate (MIC 0.12intermediate (MIC 0.12––1 mg/L)1 mg/L)PenicillinPenicillin--resistant (MIC resistant (MIC ≥≥22 mg/L)mg/L)


South KoreaSouth Korea24.3% → 9.7%55.4% → 54.8%

ChinaChina (Beijing, Shanghai)(Beijing, Shanghai)9.8% 9.8% →→ 19.819.8%%

0% 0% →→ 23.4% 23.4%

ThailandThailand35.7% 35.7% →→ 26.9%26.9%22.2% 22.2% →→ 26.9%26.9%

TaiwanTaiwan9.3% → 24.6%

29.4% → 38.6%

SingaporeSingapore4.9% → 28.6 %

18.2 % → 17.1% MalaysiaMalaysia

6.0% → 9.1%3.0% → 29.5%

PhilippinesPhilippinesNA → 27.3%NA → 0%

Hong KongHong KongNA → 24.1%NA → 43.8%

Saudi ArabiaSaudi ArabiaNA NA →→ 20.5%20.5%NA NA →→ 10.3%10.3% IndiaIndia

3.8% 3.8% →→ 7.8%7.8%0% 0% →→ 0%0%

Prevalence of penicillinPrevalence of penicillin--resistant resistant S. S. pneumoniaepneumoniae**in 12 Asian countries in 12 Asian countries (1996(1996--1997 and 20001997 and 2000--2001)2001)

Asian Network for Surveillance of Resistant Pathogens (ANSORP)Asian Network for Surveillance of Resistant Pathogens (ANSORP) * Clinical isolates

Overall, 23% of S pneumoniae isolates were penicillin-intermediate and 29.4% were penicillin-resistant

VietnamVietnam28.2% 28.2% →→ 20.6%20.6%32.6% 32.6% →→ 71.4%71.4%

IDSA / ATS Consensus Guidelines on the management of CAP in adults. CID 2007; 44:S27-72

The available data suggest that the clinically relevant level ofpenicillin resistance is a MIC of at least 4 mg/L

Feikin DR,, et al. Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995–1997. Am J Public Health 2000; 90:223–9.

Intermediate Intermediate ResistantResistant

Prevalence of resistance of Prevalence of resistance of S. S. pneumoniaepneumoniae to other to other ββ--lactamslactams and erythromycinand erythromycin in Asia in Asia Jan 2000 Jan 2000 –– Jun 2001 Jun 2001 ANSORPANSORP


South KoreaSouth KoreaCoCo--amoxiclavamoxiclav 6.5%, 6.5%, 9.7%9.7%CefuroximeCefuroxime 3.2%, 3.2%, 61.361.3%%CeftriaxoneCeftriaxone 3.2%, 3.2%, 3.2% 3.2% ErythromycinErythromycin 0.00.0%, %, 80.680.6%%

China China (Beijing, Shanghai)(Beijing, Shanghai)CoCo--amoxiclavamoxiclav 2.7%, 2.7%, 7.3%7.3%CefuroximeCefuroxime 4.5%, 4.5%, 19.8%19.8%CeftriaxoneCeftriaxone 0.0%, 0.0%, 1.1% 1.1% ErythromycinErythromycin 0.90.9%, %, 73.973.9%%

TaiwanTaiwanCo-amoxiclav 3.5%, 1.8%Cefuroxime 8.8%, 40.4%Ceftriaxone 1.8%, 0.0% Erythromycin 1.8%, 86.0%

VietnamVietnamCoCo--amoxiclavamoxiclav 14.3%, 14.3%, 22.2%22.2%CefuroximeCefuroxime 4.8%, 4.8%, 74.2%74.2%CeftriaxoneCeftriaxone 9.5%, 9.5%, 3.2% 3.2% ErythromycinErythromycin 1.61.6%, %, 92.192.1%%

Hong KongHong KongCoCo--amoxiclavamoxiclav 0.9%, 0.9%, 3.6%3.6%CefuroximeCefuroxime 10.0%, 10.0%, 50.050.0%%CeftriaxoneCeftriaxone 3.7%, 3.7%, 0.0% 0.0% ErythromycinErythromycin 0.00.0%, %, 76.876.8%%


Prevalence of resistance of Prevalence of resistance of S. S. pneumoniaepneumoniae to other to other ββ--lactamslactams and erythromycinand erythromycin in Asia in Asia Jan 2000 Jan 2000 –– Jun 2001 Jun 2001 ANSORPANSORP


ThailandThailandCoCo--amoxiclavamoxiclav 0.0%, 0.0%, 0.0%0.0%CefuroximeCefuroxime 1.9%, 1.9%, 36.5%36.5%CeftriaxoneCeftriaxone 1.9%, 1.9%, 0.0% 0.0% ErythromycinErythromycin 5.85.8%, %, 36.5%36.5%

SingaporeSingaporeCoCo--amoxiclavamoxiclav 0.0%, 0.0%, 0.0%0.0%CefuroximeCefuroxime 5.7%, 5.7%, 28.6%28.6%CeftriaxoneCeftriaxone 0.0%, 0.0%, 0.0% 0.0% ErythromycinErythromycin 2.92.9%, %, 40.0%40.0%

MalaysiaMalaysiaCo-amoxiclav 2.3%, 0.0%Cefuroxime 2.3%, 29.5%Ceftriaxone 0.0%, 2.3% Erythromycin 6.8%, 34.1%

PhilippinesPhilippinesCo-amoxiclav 0.0%, 0.0%Cefuroxime 0.0%, 0.0%Ceftriaxone 0.0%, 0.0% Erythromycin 4.5%, 18.2%

Saudi ArabiaSaudi ArabiaCoCo--amoxiclavamoxiclav 0.0%, 0.0%, 0.0%0.0%CefuroximeCefuroxime 2.6%, 2.6%, 12.8%12.8%CeftriaxoneCeftriaxone 0.0%, 0.0%, 0.0% 0.0% ErythromycinErythromycin 0.00.0%, %, 10.3%10.3%

IndiaIndiaCoCo--amoxiclavamoxiclav 0.0%, 0.0%, 0.0%0.0%CefuroximeCefuroxime 0.0%, 0.0%, 1.3%1.3%CeftriaxoneCeftriaxone 0.0%, 0.0%, 0.0% 0.0% ErythromycinErythromycin 0.00.0%, %, 1.3%1.3%


Susceptibilities of Susceptibilities of S. S. pneumoniaepneumoniae isolates to isolates to fluoroquinolonesfluoroquinolones in 11 Asian countries in 11 Asian countries Jan 2000 Jan 2000 –– Jun 2001Jun 2001


South KoreaSouth KoreaLevofloxacinLevofloxacin 0.0%, 0.0%, 0.0%0.0%GatifloxacinGatifloxacin 0.0%, 0.0%, 0.0%0.0%MoxifloxacinMoxifloxacin 0.0%, 0.0%, 0.0%0.0%CiprofloxacinCiprofloxacin 6.5%6.5%

China China (Beijing, Shanghai)(Beijing, Shanghai)LevofloxacinLevofloxacin 0.0%, 0.0%, 0.0%0.0%GatifloxacinGatifloxacin 0.0%, 0.0%, 0.0%0.0%MoxifloxacinMoxifloxacin 0.0%, 0.0%, 0.0%0.0%CiprofloxacinCiprofloxacin 3.6%3.6%

ThailandThailandLevofloxacinLevofloxacin 0.0%, 0.0%, 0.0%0.0%GatifloxacinGatifloxacin 0.0%, 0.0%, 0.0%0.0%MoxifloxacinMoxifloxacin 0.0%, 0.0%, 0.0%0.0%CiprofloxacinCiprofloxacin 3.8%3.8%

TaiwanTaiwanLevofloxacinLevofloxacin 0.0%, 0.0%, 1.8%1.8%GatifloxacinGatifloxacin 1.8%, 1.8%, 1.8%1.8%MoxifloxacinMoxifloxacin 1.8%, 1.8%, 0.0%0.0%CiprofloxacinCiprofloxacin 7.0%7.0%

SingaporeSingaporeLevofloxacinLevofloxacin 2.9%, 2.9%, 0.0%0.0%GatifloxacinGatifloxacin 0.0%, 0.0%, 0.0%0.0%MoxifloxacinMoxifloxacin 0.0%, 0.0%, 0.0%0.0%CiprofloxacinCiprofloxacin 5.9%5.9%

MalaysiaMalaysiaLevofloxacinLevofloxacin 0.0%, 0.0%, 0.0%0.0%GatifloxacinGatifloxacin 0.0%, 0.0%, 0.0%0.0%MoxifloxacinMoxifloxacin 0.0%, 0.0%, 0.0%0.0%CiprofloxacinCiprofloxacin 4.6%4.6%

VietnamVietnamLevofloxacinLevofloxacin 0.0%, 0.0%, 0.0%0.0%GatifloxacinGatifloxacin 0.0%, 0.0%, 0.0%0.0%MoxifloxacinMoxifloxacin 0.0%, 0.0%, 0.0%0.0%CiprofloxacinCiprofloxacin 4.8%4.8%

PhilippinesPhilippinesLevofloxacinLevofloxacin 0.0%, 0.0%, 0.0%0.0%GatifloxacinGatifloxacin 0.0%, 0.0%, 0.0%0.0%MoxifloxacinMoxifloxacin 0.0%, 0.0%, 0.0%0.0%CiprofloxacinCiprofloxacin 9.1%9.1%

Hong KongHong KongLevofloxacinLevofloxacin 0.0%, 0.0%, 8.0%8.0%GatifloxacinGatifloxacin 0.9%, 0.9%, 8.3%8.3%MoxifloxacinMoxifloxacin 6.3%, 6.3%, 1.8%1.8%CiprofloxacinCiprofloxacin 11.8%11.8%

Saudi ArabiaSaudi ArabiaLevofloxacinLevofloxacin 0.0%, 0.0%, 0.0%0.0%GatifloxacinGatifloxacin 0.0%, 0.0%, 0.0%0.0%MoxifloxacinMoxifloxacin 0.0%, 0.0%, 0.0%0.0%CiprofloxacinCiprofloxacin 2.6%2.6%

IndiaIndiaLevofloxacinLevofloxacin 0.0%, 0.0%, 1.3%1.3%GatifloxacinGatifloxacin 0.0%, 0.0%, 1.4%1.4%MoxifloxacinMoxifloxacin 1.3%, 1.3%, 0.0%0.0%CiprofloxacinCiprofloxacin 4.0%4.0%

Overall rate of multi-drug resistant S pneumoniae was 26.8%

MDR S pneumoniae :

71.4% of isolates from Vietnam

44.9% of isolates from Hong Kong

42.5% of isolates from Korea

30.9% of isolates from Taiwan

MultiMulti--drug resistant drug resistant S S pneumoniaepneumoniae (i.e., resistance to at least 3 (i.e., resistance to at least 3

classes of antibiotics)classes of antibiotics) in 12 Asian countries in 12 Asian countries Jan 2000 Jan 2000 –– Jun 2001Jun 2001

Song JH, et al. ANSORP. Antimicrob Agents Chemother 2004; 48:2101-7

The clinical relevance of DRSP for pneumonia is uncertain Current levels of β-lactam resistance do not generally result in CAP treatment failures when appropriate agents (amoxicillin, ceftriaxone, or cefotaxime) and doses are used (even in bacteremia) There are data to suggest that resistance to macrolides and older FQs (ciprofloxacin and levofloxacin) results in clinical failureTo date, no failures have been reported for the newer fluoroquinolones (moxifloxacin and gemifloxacin)

DrugDrug--resistant resistant S. S. pneumoniaepneumoniae (DRSP)(DRSP)


e

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ished ses tive

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es

.

ERS, ATSERS, ATS20012001, IDSA, IDSA20032003, IDSA/ATS, IDSA/ATS20072007

algorithm for CAPalgorithm for CAPCAPCAP

Outpatient treatmentOutpatient treatment Inpatient treatmentInpatient treatment

No cardiopulmonary

disease

No cardiopulmonary

disease

History of cardiopulmonary

disease

History of cardiopulmonary

disease

Mild to moderateillness

Mild to moderateillness Severe CAPSevere CAP

No modifiersNo modifiers +/- modifiers+/- modifiers

Risksfor Ps aeruginosa

Risksfor Ps aeruginosa

No C/P disease

NoModifier

No C/P disease

NoModifier

+ C/Pdisease

+/orModifier

+ C/Pdisease

+/orModifier

NoNoYesYes

CAP: empirical antibiotic therapyCAP: empirical antibiotic therapyIDSA/ATSIDSA/ATS20072007

Empirical antibiotic recommendations have not changed significantly from those of previous guidelines


IDSA / IDSA / ATSATS

GuidelinesGuidelines20072007

Previously healthy and Previously healthy and no antimicrobial use no antimicrobial use within previous 3 within previous 3 mthsmthsMacrolideMacrolideII [strong recommendation, [strong recommendation, level 1 evidence]level 1 evidence] ororDoxycyclineDoxycyclineIIIIII [[weak recommendationweak recommendation, level 3 evidence], level 3 evidence]

Recommended empirical antibiotics for CAPRecommended empirical antibiotics for CAPInpatient, nonInpatient, non--ICUICUOutpatientOutpatientSite of Site of

treatmenttreatment ICUICU

IDSA/ATS Consensus Guidelines on the management of CAP in adults

Mandell LA, et al. Clin Infect Dis 2007; 44:S27-72



Previously healthy and Previously healthy and no antimicrobial use no antimicrobial use within previous 3 within previous 3 mthsmthsMacrolideMacrolideII [[level 1 evidence]level 1 evidence] ororDoxycyclineDoxycyclineIIIIII [level 3 evidence][level 3 evidence]

Respiratory FQRespiratory FQII ororββ--lactamlactam ++ macrolidemacrolideII





Presence of Presence of comorbiditiescomorbidities ororantimicrobial use within antimicrobial use within previous 3 previous 3 mthsmths oror other other risks for DRSP infectionrisks for DRSP infection

Comorbidities: chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressive drugs

Use of antimicrobials within the previous 3 months: an alternative from a different class should be selected

Increase the likelihood of infection with DRSP and enteric gram-negative bacteria










Moxifloxacin, gemifloxacin or levofloxacin [750 mg]

High-dose amoxicillin 1 g 3 times daily, orhigh-dose amoxicillin-clavulanate 2 g 2 times daily or cefuroxime 500 mg 2 times daily







In regions with high rate (>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII [moderate recommendation, [moderate recommendation, level 3 evidencelevel 3 evidence]] ororββ--lactamlactam ++ macrolidemacrolideIIIIII [moderate recommendation, [moderate recommendation, level 3 evidencelevel 3 evidence]]










Respiratory FQ Respiratory FQ alonealoneII

ororββ--lactamlactam ++ macrolidemacrolideII

In regions with high rate (>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII ororββ--lactamlactam ++ macrolidemacrolideIIIIII



Preferred β-lactamsinclude cefotaxime,ceftriaxone, and ampicillin; ertapenem for selected patients

The major discriminating factor between the 2 regimens is the patient’s prior antibiotic exposure (within the past 3 months).














Doxycycline is an alternative to the macrolide[level III evidence]










For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQRespiratory FQII











For all patients admitted to the ICU, coverage for S. pneumoniae and Legionellaspecies should be ensured by using a potent antipneumococcal β-lactamand either a macrolide or a FQ

Respiratory FQRespiratory FQII






Most common microbial Most common microbial aetiologiesaetiologies of CAPof CAP


S. S. pneumoniaepneumoniaeM. M. pneumoniaepneumoniaeH. H. influenzaeinfluenzaeC. C. pneumoniaepneumoniaeRespiratory virusesRespiratory viruses

S. S. pneumoniaepneumoniaeM. M. pneumoniaepneumoniaeC. C. pneumoniaepneumoniaeH. H. influenzaeinfluenzaeLegionellaLegionella speciesspeciesAspirationAspirationRespiratory virusesRespiratory viruses

S. S. pneumoniaepneumoniaeLegionellaLegionella sppspp..H. H. InfluenzaeInfluenzaeEnterobacteriaceaeEnterobacteriaceae sppspp..StaphStaph. . aureusaureusPseudomonas Pseudomonas sppspp..



File TM. Community-acquired pneumonia. Lancet 2003; 362:1991-2001

A review of 9 recent studies (that included 890 patients with CAP admitted to the ICU):the most common pathogens in the ICU population were (in descending order of frequency) S. pneumoniae, Legionella species, H. influenzae, Enterobacteriaceae species, S. aureus, and Pseudomonas species.

The atypical pathogens collectively account for 20% of severe CAP episodes. The dominant atypical pathogen in severe CAP is Legionella.














The recommended standard empirical regimen should routinely cover the 3 most common pathogens that cause severe CAP, all of the atypical pathogens, and most of the relevant Enterobacteriaceaespecies.








ββ--lactamlactam** ++ azithromycinazithromycinIIII

ororββ--lactamlactam** ++ respiratory FQrespiratory FQII

*β-lactamcefotaxime, ceftraxone, ampicillin/sulbactam,
















For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQ + Respiratory FQ + aztreonamaztreonam




















If If PseudomonasPseudomonas is a is a considerationconsiderationIIIIII

AntiAnti--pneumococcalpneumococcal, anti, anti--pseudomonalpseudomonal ββ--lactamlactam((piperacillinpiperacillin--tazobactamtazobactam, , cefepimecefepime, , imipenemimipenem, or , or meropenemmeropenem)) + + eithereitherciprofloxacin ciprofloxacin oror levofloxacinlevofloxacin(750 mg) (750 mg) oror


















AntiAnti--pneumococcalpneumococcal, anti, anti--pseudomonalpseudomonal ββ--lactamlactam+ + aminoglycosideaminoglycoside + + azithromycinazithromycin ororIn regions with high rate

(>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII ororββ--lactamlactam ++ macrolidemacrolideIIIIII

















AntiAnti--pneumococcalpneumococcal, anti, anti--pseudomonalpseudomonal ββ--lactamlactam+ + aminoglycosideaminoglycoside + anti+ anti--pneumococcalpneumococcal FQ (for FQ (for penicillinpenicillin--allergic patients, allergic patients, substitute the substitute the ββ--lactamlactam with with aztreonamaztreonam))

















If CAIf CA--MRSA is a MRSA is a considerationconsiderationAdd Add vancomycinvancomycin oror linezolidlinezolidIIIIII

AntiAnti--pneumococcalpneumococcal, anti, anti--pseudomonalpseudomonal ββ--lactamlactam+ + aminoglycosideaminoglycoside + anti+ anti--pneumococcalpneumococcal FQ (for FQ (for penicillinpenicillin--allergic patients, allergic patients, substitute the substitute the ββ--lactamlactam with with aztreonamaztreonam))




Duration of antibiotic therapyDuration of antibiotic therapyPatients with CAP should be treated for a minimum of5 days (level I evidence)

Before discontinuation of therapy- should be afebrile for 48–72 h- should have no more than 1 CAP-associated sign ofclinical instability (level II evidence)


Criteria for clinical stabilityCriteria for clinical stabilityTemperature Temperature <<37.8C37.8CHeart rate Heart rate << 100 /min100 /minRespiratory rate Respiratory rate << 24 /min24 /minSystolic blood pressure Systolic blood pressure >>90 mm Hg90 mm HgArterial oxygen saturation Arterial oxygen saturation >> 90% or pO90% or pO22 >> 60 mm Hg on room air60 mm Hg on room airAbility to maintain oral intake*Ability to maintain oral intake*Normal mental status*Normal mental status*

Dean, N. C. et al. Chest 2006;130:794-799

Adjusted OR for 30Adjusted OR for 30--day allday all--cause mortality plotted against cause mortality plotted against compliance with guidelinecompliance with guideline--recommended antibioticsrecommended antibiotics

at Intermountain Healthcare hospitalsat Intermountain Healthcare hospitals

Circle area reflects the number of admissions per hospital

The odds of mortality are 0.92 (p = 0.007) for each 10% increase in compliance

Adjusted OR for 30-day

all-cause mortality

Any advantages in following guidelines?Any advantages in following guidelines?

Reduction in hospital admission rate

Shortens length of hospital stay (LOS)

Reduction in in-hospital and 30-day mortality

? Help control bacterial resistance in the community (minimise use of excessive antibiotics and improves accuracy of therapy) – However, the impact of guidelines on resistance remains to be shown

THANK YOUTHANK YOU

[email protected]@ummc.edu.my

MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA … of CAP in Asia Pacific region.pdf · Chong-Kin LIAM...

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