Presentation on theme: "Pneumonia Community acquired Pneumonia ( CAP )"— Presentation transcript:
1 Pneumonia Community acquired Pneumonia ( CAP ) Hospital acquired Pneumonia ( HAP)( Ventilator associated Pneumonia (VAP) )is the most serious form of HAP…Health care Associated Pneumonia (HCAP) 2005
2 Community acquired Pneumonia( CAP) Pneumonia in a Community Resident outside the hospital settingHospital acquired (Nosocomial) Pneumonia( HAP )Pneumonia that occurs 48 hours or more after admissionVentilator associated Pneumonia (VAP)HAP that develops more than 48 hours after intubation.Health care Associated Pneumonia (HCAP)In 2005 ATA /IDSA Introduced HCAP ( previously CAP ) (Multidrug Resistance Pathogens )Residence in a Nursing Home or other long-term care facilityAttend at a Hospital or Hemodialysis clinic within prior 30 daysIV therapy, wound care, or IV chemotherapy within the prior 30 daysPneumonia that occurs in a non-hospitalized patient with extensive healthcare contact…Hospitalization in an acute care hospital for two or more days within the prior 90 days
3 Community Acquired Pneumonia Pneumonia is a lower respiratory infection involving the lungs especially affecting the Alveoli characterized by filling of the alveolar space with inflammatory cells and fluids ….Clinically characterized by respiratory symptoms , cough, sputum , dyspnea , pleuritic chest pain with fever, chills , tachypnea , tachycardia and the appearance of a new infiltrate / opacity on CXRIn the elderly symptoms differ ( with fewer respiratory symptoms ) confusion, failure to thrive, fall, and worsening of chronic underlying illness e.g. CHFSeverity ranges from mild to life threateningEtiology : Pathogens differ in different continents or geographic areas. Outpatients are different from Inpatients , ICU and from Nursing Home
4 Microbiology Pathogens : Bacteria : Strept Pneumoniae , H. Influenzae , Chlamydia , Mycoplasma and LegionellaViruses : Adenovirus, Influenza and Para influenza, …RSVFungal : Histoplasmosis , Coccidomycosis, Blastomycosis, Pneumocystis Jiroveci in HIV , or other immune suppressed patientsRare causes are Fungi and Parasite .Majority are caused by BacteriaS. Pneumoniae ( GPC)H. Influenzae (GNR )ChlamydiaMycoplasmaOther : Staph, Legionella, Moraxella, Gram negative bacilli1/3 of CAP are caused by virusesStreptococcus pneumoniae is the most common cause worldwide.
5 Epidemiology In the US more than 5 million / year 20 % ~ more than a Million HospitalizedIn > diedCost ~ 10 billon /yearAge : Highest at extreme of ages , ElderlyMore in MalesMore in African and Native AmericansMore in WinterMortality highest in hospitalized patients and those with risk factors
6 Pathogenesis Bacteria enter the lung through several routes: 1. Micro Aspiration the most common way. (From previously colonizedoropharynx)2. Macro ( Aspiration ) (stroke, seizure, CVA) Loss of neurologic protection of the upper airway3. Inhalation of Legionella or TB ( airborne)4. Hematogenous: from extra pulmonary sites of infection5. Direct extension / spread from nearby (e.g., liver abscess).6. Critically ill / ICU / Ventilator: Retrograde spread from a colonized stomach to the oropharynxThe lungs are exposed to invading pathogens and colonized oropharyngeal bacteria yet it remains sterile and pneumonia is infrequent because of the antibacterial respiratory defensesPulmonary defenses :Muco-Ciliary, Phagocytes, Antibody Response…Pneumonia develops if Host defenses are overwhelmed by infectious pathogen
7 Pathogenesis…Poor Immune system >> Poor immune response >> PneumoniaImmune dysfunction ( Severe illness, Sepsis or Steroid / Chemo )Chronic Illness ( CHF, DM, CRF, COPD, Chronic Liver Disease)Anatomic abnormalities (endobronchial obstruction, bronchiectasis)OrAdequate Immune System : overwhelmed by virulent microorganism.Virulence factors: some microorganisms develop ways to overcome host defensesChlamydia produces cilio-static factor.Mycoplasma shears off cilia.Influenza virus reduces tracheal muco-ciliary clearance.S. pneumoniae produces factors that inhibits phagocytosisMycobacterium &Legionella are resistant to the anti microbicidal activity of phagocytes
8 Risk factors Impairs pulmonary defenses >> increased risk of CAP Chronic lung diseases , Smokers, Asthma ,COPD, Bronchiectasis ,FibrosisAlcoholics (x9) Homeless , PrisonersImmunosuppressed, Spleenectomy, Cancer , HIV (x 40 )Chronic liver or chronic kidney diseases , CHF ,CVASeizures, DementiaRecent AbxElderlyMalnutritionMilitary recruitsSteroidsInhaled steroids, ipratropium and bronchodilatorsPPI , H2 blockersAntipsychotics
9 Specific risk factorsPNEUMONIAExposure to birdsPsittacosisExposure to bat or bird droppingsHistoplasmaExposure to RabbitsTularemiaCruise ship or hotel previous 2 weeksLegionellaExposure to farm animalsQ fever , Coxiella BurnettiIVDUStaph Aureus, Anaerobes , TBMRSA focus, Live in crowded conditionsCA-MRSABronchiectasisStaph and PseudomonasNeutropeniaRecent AbxGram Negative
10 Mycoplasma Pneumoniae Aspiration / Anaerobes Microbiology Is Changing OUTPATIENTINPATIENTICU / SEVERE CASESS. PneumoniaeMycoplasma PneumoniaeStaph AureusH InfluenzaeChlamydia PneumoniaeLegionellaGram Negative BacilliPseudomonas & E. ColiRespiratory VirusesInfluenza A & BRSV , AdenovirusesPara InfluenzaAspiration / AnaerobesMicrobiology Is ChangingMultidrug Resistance
11 Symptoms:Fever, cough, sputum, pleuritic chest pain, shortness of breath chills & shakes Headache, Nausea, Vomiting, Diarrhea, Fatigue, Myalgia, Joint pain Non respiratory symptoms : Confusion & falls ( in the elderly ) …Pleuritic pain more with bacterial pneumoniaRusty sputum to pneumococcal pneumoniaHemoptysis “ more with Klebsiella & TBConstant repetitive harsh dry cough with fever 3days + more with MycoplasmaPneumonia plus GI symptoms (diarrhea, abdominal pain ) myalgia's, headache confusion and high fever ~ 104 think LegionellaViral pneumonia usually with dry non productive cough , ha, malaiseSigns:Chest signs : ( Bronchial breath sounds, dullness , crackles, pleural rub, rhonchi )Fever , Tachypnea , TachycardiaElderly ( Hypothermia , confusion, hypotension , falls …. )
12 Diagnosis Diagnosis is suggested by symptoms and signs . Should be confirmed by CXR which almost always show some infiltrate …CXR is Indicated in All cases of suspected CAP ( T 100+, P 100, RR > 20 )Rarely false negative CXR …attributed to an infection very early in the course , Neutropenia, Dehydration, and Pneumocystis PneumoniaPneumocystis Pneumonia : 1/3 of patients have normal CXR early in the diseaseCXR is essential in an elderly or chronically ill patient who can have pneumonia with only non respiratory findings “ confusion, hypotension , loss of appetite, fall, failure to thrive “CXR to confirm Dx , can help identify severe , complicated cases(Multi- Lobar Pneumonia , Pleural Effusion, Cavitation )If S&S of pneumonia with Negative CXR : Diagnosis is “ Bronchitis “ therefore NO Abx is needed if no underlying lung disease…
13 Investigations …Labs … WBCElectrolytes ,Glucose , BUN & CreatinineABG ( if hypoxia )PPD ( if suspect TB )2 sets of Blood culture : (T < 95 or > 103 , Neutropenia, Severe CAP , Asplenic, Chronic liver disease , alcoholics, homeless )Pleural Aspiration for pleural fluid > 1 cm on a lateral decubitus CXRSputum: ? Gram stain… and sputum cultureCT ?Bronchoscopy ?Lung Biopsy ?
14 Diagnosis ……Sputum ? Not recommended for OP Low diagnostic yield in CAPNot cost effectivepositive reports can not separate Colonization from InfectionOrganism growing from sputum is not definitive proof that it is the etiologic agent.Only 1/3 of the elderly can produce “ suitable “sampleGram stain: Needs Good quality sputum sample ( < 10 SEC /LPF Squamous epithelial cells, plus Neutrophils ) Most labs reject sputum with more than 10 SECs/LPFDifficult to get a good quality sampleRinsing mouth prior to expectorationNo food for 2 hours prior to expectorationImmediate Inoculation into the culture media …Obtained Prior to antibiotic treatment ( Recommendation is < 6 hours )
15 When to order “ Sputum “Pretreatment sputum is recommended for hospitalized patients …if performed on a good quality sputum with appropriate measures :If Patient …Failed antibiotic therapy (either outpatients or hospitalized patients)Cavitary lesionsSevere obstructive or structural lung disease e.g. BronchiectasisPleural EffusionImmune compromisedActive Alcohol AbuseICU patientsSuspected “ Drug Resistance Bacteria or Unusual Pathogens “Special stains of sputum for certain organisms when clinically indicated (e.g. Acid fast for mycobacteria, Direct fluorescent antibody for Pneumocystis )
16 SerologyRoutine serological tests are NOT recommended because of the time required and the expenseSerology is necessary if :Critically ill or non responders …‘ Pneumonia Outbreak ‘ with negative blood and sputum cultureCoxiella is suspected ( Q fever) or PneumocystisS Pneumoniae : Pneumococcal urine antigen is 80 % sensitive and > 90% specific, positive even after Abx use, and weeks after the illness…Legionella Urine Antigen , sensitivity is 90% specificity is 99%, can be positive even after proper Abx, and weeks after the onset , use in patients with strongly suspected rapidly progressive legionellosisDirect fluorescent antibody test for Influenza virus ‘Rapid Influenza Test’
17 Sensitivity measures the actual positives (the percentage of people who are identified as having the condition).Specificity measures the negatives (percentage of healthy people who are identified as NOT having the condition).
18 Diagnosis: SerologyMycoplasma Pneumoniae : Enzyme Immunoassay (EIA) sensitivity ~ 98 and specificity of 99.7Chlamydia Pneumoniae : Direct antigen testing and PCR.C. Psittica : Complement fixationLegionella :Urine antigenCoxiella Burnetti : PCR and cultureAdenovirus : Culture and EIAPara influenza & Influenza : Rapid diagnostic tests , PCR, EIA
19 Differential Diagnosis Pulmonary Embolism - most serious missedPulmonary EdemaBronchitisExacerbation of COPD or heart failurePulmonary FibrosisLung cancerPneumonitisSarcoidosis
20 Other diagnostic tools CT Scan : Should NOT be used routinelyIndications: Non responders2. Helps identifies Cavitation3. Loculated Pleural effusionThoracentesis : If a pleural effusion of > 1 cm the fluid should be aspiratedBronchoscopy / BAL “ broncho-alveolar lavage ”Lung Biopsy
21 Decision For Hospitalization Who can be safely treated at home ??Decision should be based on medical and social considerationsQ: Able to care for himself , able to take oral meds, Adherence ? Preexisting condition, living conditions , cognition, vitals ,labs, CXR and physical findingsLow risk > Home Moderate risk > Hospital High risk > ICUMost CAP cases are treated as an OPHospitalization IfMultiple risk factors have “ poor outcome ”RR 30 , BP < 90 / < 60 , Multilobar pneumonia , Confusion, BUN > 20 , PO2 <60 , PCO2 > 50 …Acidosis… Require oxygen , ivf , cardiac monitor or iv Abx , ?? severe casesTO assess pneumonia severity …there are Many Prediction Models...
22 PSI = Pneumonia severity index Pneumonia Outcome Research Team ( PORT ) Study Prognostic Scoring IndexMortality prediction rules , helps physicians guide the admission decisionclassifies patients into one of 5 classes , points are calculated on factors such as age, sex, comorbidities, signs, labs , CXR
23 Points Class Mortality Mortality prediction rules classifies patients into one of 5 classesPoints Class Mortality0 – = I % Class I & II : Treat at Home= II %= III % Intermediate : (Individualized )= IV %= V % Class IV & V : Admit
24 PORT : Pneumonia Outcome Research Team Prognostic Scoring Index Questions :Age , Sex , Nursing homeComorbidities :Cancer , Liver disease , CHF , CVA , CKD …Physical Exam :AMS , Pulse > 125 , RR > 30 , SBP < 90 , T < 95 or > 104Labs :PH < , BUN > 30 , Na < 130 , G > , HCT < 30 , PO2 < 60 , O2 Sat < 90 % …CXR : Pleural effusionFor each of variables add points , range is from Points …Calculate
25 Age for a manAge (in years)Age for a womanAge (in years) - 10Nursing home resident+10Coexisting illnessesNeoplastic disease (active)+30Chronic liver disease+20Heart failureCerebrovascular diseaseChronic renal diseasePhysical examination findingsAltered mental statusRespiratory rate ≥30/minuteSystolic blood pressure <90 mmHgTemperature <35°C or ≥40°C+15Pulse ≥125 beats/minuteLaboratory and radiographic findingsArterial pH <7.35Blood urea nitrogen ≥30 mg/dL (11 mmol/L)Sodium <130 mmol/LGlucose ≥250 mg/dL (14 mmol/L)Hematocrit <30 percentPartial pressure of arterial oxygen <60 mmHg*Pleural effusion on chest x-ray
26 C U R B Another way to assess Pneumonia Severity …one point for each C = Confusion U = Urea > 42 mg R = Respiratory rate ≥30/min B = Blood pressure ≤ 90 / ≤60 mmHg 65 = Age ≥ 65 yearsScore 0 or 1 can be treated as OP . Score of 2 …Admit . Patients with scores of ≥ 3 ICU.Simplified C R B - 65For PCP Using clinical judgment without blood testif patient is 65 + and has one of these variable , then admission to hospital is reasonable Confusion , RR > 30 ,BP < 90 / < 60These are Guidelines …Not Rules Use Clinical Judgment …No rule is absolute
27 TreatmentSupportive : Hydration, Oxygen, Analgesics, Antipyretics , IVFEmpiric Therapy : (< 6 hours ) proven to reduce mortality .Empiric Therapy > 90 % respond very well Do NOT wait for diagnostics Guidelines for Empiric treatment are based on:Likely Pathogens , Severity , Comorbidities , Local susceptibilityLocation ( OP / Inpatient / ICU )Modifying factors ( Cardio pulmonary disease or other factors )Clinical Trials, Efficacy of agents , Safety Profile of Abx, CostRisk factors for antimicrobial resistance :( Age > 65 year , Abx past 3 months, Alcoholism, Immunosuppressed , exposure to child in a day-care center)What is proven to lower mortality ?Antibiotic within 6 hoursTwo Abx agents in Pneumococcal Pneumonia with bacteremia
28 Beta Lactams : Penicillin's , Cephalosporin Gram Positive organisms. Monobactams (Aztreonam ) , Carbapenem ( Meropenom , Ertapenem )Macrolides: ( Azithromycin , Clarithromycin , Erythromycin ) S Pneumoniae, H Influenzae, Mycoplasma, Legionella and Chlamydia …also covers Streptococci, staph, enterococciQuinolones : Moxifloxacin , Levaquin & Ciprofloxacin….Once daily , Oral antibiotics ( or iv ) Covers Pneumococci, including drug resistance ( DRSP) , Gram negative and the atypical pathogensThey penetrate very well into respiratory secretions .Highly bioavailable ~ 100 % the same serum level achieved with oral or iv therapy Recommended to give IV , to Ensure Absorption, once the patient shows response , change to oral therapyAnti Pneumococcal Quinolones : ( Respiratory ) Moxifloxacin and LevaquinAnti Pseudomonal Quinolone : ( Ciprofloxacin and Levaquin )Although all anti pneumococcal quinolone are effective against pneumococci, they differ in their intrinsic activity against Pneumococci …on the basis of MIC they can be ranked …the most effective being Moxifloxacin , then Levaquin
29 Empiric Abx for Outpatients Outpatient treatment in otherwise healthy , no recent Abx …Azithromycin 500 mg / day or Doxycycline 100 mg bidOutpatient Tx for patients with comorbidities or who was on Abx last 3 mRespiratory Fluoroquinolone (Moxifloxacin , Levaquin) OrAmoxicillin or Augmentin plus Macrolide ( Zithro )( Can substitute Doxycycline for Zithro )Why ?Those Patients with Comorbidities failed Macrolides alone Tx because of (DRSP )
30 Outcome of Empiric Out Patient Treatment 90% will improve in 2 days ( Less Cough, Dyspnea, WBC ,Pain, and Fever )5% will slowly improve after 48 hours5% will not improve in 2 days or feel worse , need to be reassessed …Therefore : patient need to be informed if after 72 hours , if they don’t improve , or develop fever 101, or are short of breath, hemoptysis , confusion or pleuritic chest pain …to come back to be checked~ Half Of The 5 % experience progression and require hospital admission.The overall mortality rate for the outpatient group is < 1%.Excellent prognosis for the young, or otherwise healthy individualsYoung healthy adults feel well enough to return to work in 4 or 5 days; almost all recover in 2 weeksOlder patient & those with comorbidities can take few weeks to fully recoverPneumonia due to S . Pneumoniae and Influenza virus in the elderly with comorbidities can be fatal
31 Empiric Inpatient Treatment (Not ICU) Treat for Drug resistance pneumococcal and Atypicals …Always with iv AbxMonotherapy with a Respiratory Quinolone (Moxifloxacin , Levofloxacin ) orCombination of β-lactam ( Rocephin, Augmentin ) plus ( Macrolide or Doxycycline ) .For patients with specific risk factorFor Anaerobic infection (Aspiration pneumonia) Use Quinolone or Rocephin PlusAnaerobic coverage “ Clindamycin or Metronidazole or Zosyn or Timentin “If Pseudomonas is a consideration Two Anti pseudomonal Agent ( Zosyn, Timentin, Meropenom , Cefepime) plus Anti pseudomonas Quinolone ( Ciprofloxacin or Levofloxacin )Suspected concomitant Meningitis (? Pneumococcal) Vancomycin & RocephinFor Cavitary infiltrate or Empyema : Treat as MRSA (Vancomycin, Zyvox )Bronchiectasis or ( COPD with Recent Abx & Steroids ):( Treat For Pseudomonas, S Pneumonia & Legionella )Allergy to penicillin : Maxipime =Ceftazidine 3rd gen ,or Fortaz =Cefepime 4th genLegionella : Levaquin or Zithro
32 Principles Of Antibiotic Therapy RECOMENDATIONBased on / EvidenceFirst Dose of Abx Within 6 HoursObservational StudiesTreat all for possible Pneumococci and AtypicalObservational Studies pt. age 65+Macrolide Monotherapy for OP or IP with NO risk for DRSP or Gram Negative or AspirationRandomized controlled trialsFor OP & IP with risk for DRSP or Gram Negative use Macrolide & Oral Beta lactam or2. Quinolone MonotherapyRandomized controlled trials &For OP at risk for DRSP the Oral Beta lactam should be (Cefuroxime, or high dose Ampicillin or Augmentin)In vitro susceptibility and expert opinionIP with risk for DRSP IV Beta lactam should be ( Rocephin, iv High dose Ampicillin or Augmentin )In vitro susceptibility and expert recommendationLimit Anti pseudomonas to patient with pseudomonas Risk factor ( to prevent resistance )Expert OpinionLimit Vancomycin use to empiric therapy of very severe illness ( meningitis ) to avoid overuseChoose most active agent to minimize future resistance and best clinical benefit
33 Monitoring hospitalized patients Most Patients show clinical response in 1-3 days and stabilize in 3–7 .Vital signs, Temp , WBC , Symptoms & Clinical signs.Check sputum and blood culture results If done … adjust therapyEvaluation of Response to Therapy :Clinical improvement, relief of cough, sputum, dyspnea, improved appetite ,ability to take oral medications Normal Temp for 36 hours … WBC declineNormal functioning GI system …switch to highly bioavailable oral AbxPrepare to discharge if medically and socially stableDuration of Abx : 5 – 7 days for mild – moderate CAPIf more serious ( MRSA , Pseudomonas or bacteremia) can take as long as ~ 3 weeksRadiological improvement lags behind clinical improvementHighest Mortality “ Pseudomonas followed by Klebsiella ,E coli, Staph Aureus “
34 Non RespondersPatients Who Do Not Respond Within 72 Hours Of Appropriate AbxWorsening or progressive clinical deterioration …needing ventilatorNon responding , delay in clinical reposeBy day three if pneumonia patient does not improve , despite proper antibiotics, Reconsider the diagnosis …Does the patient has pulmonary embolism, or pulmonary edema or other …If this is an infection , is this an Unusual or virulent organism , Abx resistance,, coinfection, obstructive process, immune suppressed, TB or fungal infection or Cancer ?Workup for Non responders : Start all over … Retake the history, Recheck labs, reports of sputum, blood cultures, CXR , urine …Repeat CXR request CT if not done , Request Pulmonology consult ? Bronchoscopy and BAL to obtain microbiology and cytology , if pleural effusion Diagnostic Tapping …transfer to a higher level of careRisk factors for ( Non responding or treatment failure ) : Multilobar pneumonia ,Cavitation, pleural effusion, leucopenia, high PSI ,liver diseaseProtective factors : Prior pneumonia vaccine & Influenza vaccine,: using Quinolone
35 Radiological Follow up Every patients with pneumonia especially smokers > 40 should have a follow-up CXR after ~ 6 weeks to document resolution which may lag several weeks…behind clinical improvementResolutionBacterial in 2-4 weeksViral : 4 weeks +Mycoplasma : 6 weeks +Persistence of infiltrate after 6 weeks raises suspicious for Cancer or TBUp to 2% of hospitalized patients with CAP have Lung Cancer (with pneumonia distal to an obstructed bronchus)50% of these cancers are evident on the initial chest film.The other 50% manifest as failure of pneumonia to resolve radiologicaly and are diagnosed at bronchoscopy …
36 ComplicationsRespiratory failure , Pleural effusion , Abscess, Empyema, Shock, Sepsis, CHF, MI, GI Bleed, Renal failure, Multi organ failure, Bleeding , Bacteremia which can lead to metastatic infection ( septic arthritis or meningitis ) in addition to worsening of already existing comorbiditiesMore than 60,000 people died in 2005 from CAP ‘Poor prognostic factors includeElderly > 60Multi-LobarWBC < 5000Comorbidities ( Alcoholics, CHF, Chronic Liver or Renal Disease , Immune Suppressed, Positive Blood Cultures)
37 Pleural EffusionSeen in ~ 40% of patients hospitalized for CAP mostly “ simple - Para pneumonic “ must differentiate it from empyema by sampling the fluidPneumococcal pneumonia is the infection most commonly complicated by pleural effusion , other pathogens ( H. Influenzae , Mycoplasma, Legionella and TB)All patients with a pleural effusion should have a lateral decubitus CXR .If the effusion is > 1 cm in height, the fluid should be aspirated.If frank pus Chest tube …Thoracotomy and Decortication may be necessary.
38 Lung abscessUncommonRisk factors : Conditions associated with impaired cough reflex and/or aspiration, such as alcoholism, anesthesia, drug abuse, epilepsy, and CVADental caries , Bronchiectasis ,Bronchial carcinoma and Pulmonary infarctionEtiologyCombination of Aerobic and Anaerobic BacteriaAnaerobic bacteria ( Bacteroides )Aerobic ( Streptococcus milleri , Staph aureus , S. pneumoniae H. influenzae ,Pseudomonas aeruginosa ,E. coli , Klebsiella pneumoniae )
39 Recurrent pneumoniaOf patients hospitalized for CAP ~ 10–15 % have another episode within two years.If the recurrence affects the same anatomic location as the previous episode, the most likely cause is an obstructed bronchus due to either a tumor or a foreign body.CT of the Chest often detects pulmonary anatomic defects (e.g. Bronchiectasis ) that might be the cause of the recurrence.COPD and repeated macro Aspiration are the most common causes of recurrent pneumonia.
40 Prevention Influenza and Pneumococcal Vaccines … Protective ( when patient is afebrile , before discharge )Yearly Influenza Vaccine : > 6 m and upPneumococcal vaccine Q 5 years :Adults …65 +…Age “ high risk “ with Chronic health problems ( Heart disease , lung disease , Sickle cell disease, Alcoholics, DM, Cirrhosis, Immune suppressed , HIV , Asplenics , Asthmatics , Hodgkin's, Lymphoma, organ transplant, Nephrotic )~ 50 % of adultsSmoking Cessation Counseling
41 Avoid “ double “ antibiotic coverage De- escalate Broad spectrum Abx Avoid Abx for simple uncomplicated infection ( Sinusitis, URI, Bronchitis , Asymptomatic UTI )Avoid “ double “ antibiotic coverageDe- escalate Broad spectrum AbxShort courses of AbxNo antibiotics for Single Positive Blood culture for Coagulase Negative Staph( Common colonizer of skin )The most serious pathogens (MRSA , Pseudomonas, Klebsiella, C diff and Multi Drug Resistance Bacteria ) are the product of our Antibiotic abuse20 % of hospitalized patients in the US acquire Clostridium Difficile and about 30% of those develop C diff associated diarrhea ( mild self limiting to severe life threatening pseudomembranous colitis )
42 Health care Associated Pneumonia ( HCAP ) Residence in a Nursing Home or other long-term care facilityAttend Hospital or Hemodialysis clinic within 30 daysHospital Admission for two or more days within 90 daysIV Therapy, or IV Chemo , wound care, within 30 daysIncreased risk for1. Multidrug-Resistant (MDR) pathogens2. Poly MicrobialMicrobiology —Common pathogens include Aerobic Gram-negative Bacilli (e.g. E. Coli, Klebsiella , Enterobacter, Pseudomonas, Acinetobacter) and Gram-positive Cocci ( Staph Aureus, including MRSA, Streptococcus )Same increased risks with “ HAP / VAP “
43 Hospital acquired Pneumonia ( HAP) Pneumonia that occurs 48 hours or more after admissionHighest risk is in patients on mechanical ventilationSputum Gram stain and culture are indicated for all patientsComplicates up to 1% of hospitalizationsMortality: 30-50%
44 Etiology of HAP differs … CVA : Aspiration With Pneumoniae & AnaerobesVentilator : Pseudomonas , Gram negative Coliforms, Staph including MRSAOrgan Failure : Gram negative ColiformsAirway Obstruction : AnaerobicHIV and Chronic Steroid users : Fungi, PneumocystisNeutropenia < 500 : Candida and AspergillusManagement: AntibioticsCombination ( 2 – 3 antibiotics )Primaxin, Aminoglycoside, Meropenom , Clindamycin , add Vancomycin for MRSA or Zithro for LegionellaAntifungal
45 Resistance to Macrolides becoming more common Decision for hospitalization should be based on medical and social considerationsIf pneumonia does not respond think Pulmonary Embolism - most serious missedRespiratory or Pulmonary Quinolones are (Levaquin & Moxifloxacin)Cipro is a Gram Negative AbxAntibiotics within 6 hours proven to lower mortalityAvoid Abx for simple uncomplicated infection ( Sinusitis, URI, Bronchitis …)Healthy Outpatients : Treat with Azithromycin or DoxycyclineOutpatient with comorbidities or who was on Abx last 3 m Treat withQuinolone or ( Zithro ) plus (Amoxicillin or Augmentin )