Presentation on theme: "Appropriate Antibiotics use in CAP and HCAP at Sisters Hospital in 2008. Syed Faraz Masood, MBBS Nashat H. Rabadi, MD, FCCP."— Presentation transcript:
Appropriate Antibiotics use in CAP and HCAP at Sisters Hospital in 2008. Syed Faraz Masood, MBBS Nashat H. Rabadi, MD, FCCP
Community Acquired Pneumonia Common : 5 to 6 million cases/year 20% are hospitalized ( 10% in ICU) No. 1 cause of death from infectious disease No. 6 cause of death in adults Mortality rates : –Outpatients = 1-5% –Inpatients = 12% ( higher in ICU- 50%) Costs : 9.7 billion : inpatient – $7,517 vs. outpatient - $264
CAP Definition CXR – infiltrate Auscultatory findings Signs of RTI –Cough +/- sputum –Fever or hypothermia –WBC
CAP - Pathogenesis Aspiration Inhalation Hematogenous Direct extension Reactivation
RESPIRATORY PATHOGENS IN CAP Respiratory Pathogens in CAP
Cultures. Sputum Cx –Not needed as outpatient. –May or may not be needed inpatient. Blood Cx Urinary Antigens.
CURB - 65 C – Confusion U – Urea. BUN > 20 R – Respiratory rate > 30 / min B – Blood pressure. SBP < 90 or DBP < 60 65 – Age > 65 Number of factors Mortality Rate 0 0.7% 1 2.1% 2 9.2% 3 14.5% 4 40% 5 57%
Management. Site of Care: –Inpatient vs. outpatient. –Floor vs. ICU. PSI CURB 65
Empirical Treatment Hospitalized Patients: –2 nd or 3 rd generation Cephalosporins plus a Macrolide. –Floroquinolones. For all critically ill patients, –2 nd or 3 rd generation Cephalosporin + Macrolide or Floroquinolones – necessary to provide coverage for Legionella Pneumophilia. –Change antibiotics – based on culture and sensitivity.
Nosocomial Pneumonia Hospital Acquired Pneumonia: –> 48 hours of admission to hospital. Ventilator associated Pneumonia. –> 48 hours of intubation.
Health-care Associated Pneumonia. Antimicrobial therapy in preceding 90 days. Hospitalization for 2 or more days in the preceding 90 days. Residence in a NH or an extended care facility. Home infusion therapy. Chronic Dialysis within 30 days. Immunosuppressive state and/or therapy.
Health-care Associated Pneumonia. Epidemiology extrapolated from HAP/VAP Second most common Nosocomial Infection. High morbidity / mortality. Increase hospital stay by 7-9 days. Excess cost of $ 40,000 per patient.
Early VAP/HAP (<5 days) –Similarly as CAP –No MDR pathogens. Late VAP/HAP (>5 days) treated similarly as HCAP: –MDR pathogens.
Appropriate antibiotics in ER:4.4% Partially appropriate in ER:15.5% Inappropriate antibiotics in ER:78.8% Appropriate change in 24 hours:16.27%
Cultures performed:97.7% Positive cultures: 18.1% Average Length of Stay: 9.5 days Average age: 71.2 years
Mortality Total Number of Deaths: 11/90 Mortality Rate: 12.2% Deaths on Inappropriate Antibiotics: 9/11
Comparison Variables HCAPCAP Age71.2 years69 years Females71.5%54.5% Sputum Cx yield26.8%16.2% Blood Cx yield4.6%3.2% Urinary Ag yield10.8%2.4% Mortality12.4%4.2% LOS9.5 days5.8 days Housestaff covered 27.7%29.3%
Where’s the problem? Pneumonia CAPHCAP RECOGNIZE THE DIFFERENCE
HAP,VAP or HCAP Suspected Obtain Blood & Lower Respiratory Tract Cultures Early, Appropriate, Adequate Antibiotics Assess Clinical Response Check Microbiology Clinical Improvement (24-48 hrs) YES NO Streamline Antibiotics. Treat Uncomplicated patients for 7 days. Reassess & Follow up. Search for Complications: Abscess or Empyema Untreated Pathogen Non-Infectious Cause ATS Consensus Statement. AJRCCM 171: 2005
Strategies to Improve HCAP Outcomes Education. Order Sheets. De-escalation. Consultation. Re-evaluation.
References National Center for Health Statistics. Health, United States, 2006, with chart book on trends in the health of Americans. Available at: http://www.cdc.gov/nchs/data/hus/hus06.pdf. Accessed 17 January 2007.http://www.cdc.gov/nchs/data/hus/hus06.pdf. Accessed 17 January 2007 American Thoracic Society; Infectious Diseases Society of America. (2005). "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". Am. J. Respir. Crit. Care Med. 171 (4): 388–416. Alvarez-Lerma F, et al. Intensive Care Med. 1996;22:387-394Alvarez-Lerma F, et al. Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. Intensive Care Med. 1996;22:387-394 Ibrahim EH, et al. Chest. 2000;118L146-155.Ibrahim EH, et al. The Influence of Inadequate Antimicrobial Treatment of Bloodstream Infections on Patient Outcomes in the ICU Setting*. Chest. 2000;118L146-155. Kollef MH, et al. Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Mortality Among Critically III Patients. Chest. 1999; 115:462-474.Kollef MH, et al. Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Mortality Among Critically III Patients. Chest. 1999; 115:462-474. Kollef MH, et al. The Influence of Mini-BAL Cultures on Patient Outcomes*: Implications for the Antibiotic Management of Ventilator-Associated Pneumonia Chest. 1998;113:412-420.Kollef MH, et al. The Influence of Mini-BAL Cultures on Patient Outcomes*: Implications for the Antibiotic Management of Ventilator-Associated Pneumonia Chest. 1998;113:412-420. Luna CM, et al. Impact of BAL Data on the Therapy and Outcome of Ventilator-Associated Pneumonia*. Chest. 1997;111:676-685.Luna CM, et al. Impact of BAL Data on the Therapy and Outcome of Ventilator-Associated Pneumonia*. Chest. 1997;111:676-685. Rello J, et al. The Value of Routine Microbial Investigation in Ventilator-Associated Pneumonia Am J Respir Crit Care Med. 1997;156:196-200.Rello J, et al. The Value of Routine Microbial Investigation in Ventilator-Associated Pneumonia Am J Respir Crit Care Med. 1997;156:196-200.
Acknowledgement Dr. Nashat Rabadi. Cliff Gadra and the Medical Records team. Dr. Varuna Nargunan. Danielle Casucci. Dr. Sateesh Satchidanand IRB team.