management of community acquired pneumonia … of cap in asia pacific region.pdf · chong-kin liam...
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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
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
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.
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
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)
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..GramGram--negative bacillinegative bacilliH. H. InfluenzaeInfluenzae
InpatientInpatient(ICU)(ICU)
• 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
IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72
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
200200S S pneumoniaepneumoniae
2121
H H influenzaeinfluenzae
1111
M M pneumoniaepneumoniae
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
K K pneumoniaepneumoniae
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
S S pneumoniaepneumoniae
1212
Chlamydia Chlamydia sppspp
66
ViralViral
66
H H influenzaeinfluenzae
44 5959
AetiologiesAetiologies of CAP Requiring Hospitalization in Asia of CAP Requiring Hospitalization in Asia 1
LocationLocation No. of No. of patientspatients
Rank order / FrequencyRank order / Frequency of microbial cause of microbial cause (%)(%)2211 33 44 55 UnknownUnknown
BangkokBangkok5a5a3 hospitals3 hospitalsWattanathumWattanathum, , et alet al..Chest Chest 2003;123:15122003;123:1512--99
147147S S pneumoniaepneumoniae
2222
Gram Gram --veve bacillibacilli
1818((K. K. pneumpneum 10)10)
C. C. pneumoniaepneumoniae
1616
M M pneumoniaepneumoniae
77
PenangPenang88Hooi LN, Hooi LN, et al.et al.Med J MalaysiaMed J Malaysia2001;56:2752001;56:275--8383
9898M tuberculosisM tuberculosis
1515
K K pneumoniaepneumoniae
77
Ps Ps aeruginosaaeruginosa
66
S S pneumoniaepneumoniae
33
K. LumpurK. Lumpur77Liam CK, Liam CK, et al.et al.Respirology Respirology 2001;6:2592001;6:259--6464
K K pneumoniaepneumoniae
1010
S S pneumoniaepneumoniae
66
H H influenzaeinfluenzae
66
M M pneumoniaepneumoniae
44
Ps Ps aeruginosaaeruginosa
44127127
SingaporeSingapore66Hui KP, Hui KP, et alet al..Singapore Med JSingapore Med J1992;101:4421992;101:442--66
9696M tuberculosisM tuberculosis
2121
S S pneumoniaepneumoniae
1212
Gram Gram --vevebacillibacilli
1010
H H influenzaeinfluenzae
55
M M pneumoniaepneumoniae
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
AetiologiesAetiologies of CAP Requiring Hospitalization in Asia of CAP Requiring Hospitalization in Asia 2
254254S S pneumoniaepneumoniae
1111
B B pseudomalleipseudomallei
11111.4% in Bangkok1.4% in Bangkok5a5a
M M pneumoniaepneumoniae
99
C C pneumoniaepneumoniae
44
K K pneumoniaepneumoniae
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
LocationLocation No. of No. of patientspatients
Rank order / FrequencyRank order / Frequency of microbial cause of microbial cause (%)(%)2211 33 44 55 UnknownUnknown
BangkokBangkok5a5a3 hospitals3 hospitalsWattanathumWattanathum, , et alet al..Chest Chest 2003;123:15122003;123:1512--99
147147S S pneumoniaepneumoniae
2222
Gram Gram --veve bacillibacilli
1818((K. K. pneumpneum 10)10)
C. C. pneumoniaepneumoniae
1616
M M pneumoniaepneumoniae
77
K. LumpurK. Lumpur99Liam CK, Liam CK, et al.et al.Respirology Respirology
2006;11:7862006;11:786--9292
346346K K pneumoniaepneumoniae
1111
M M pneumoniaepneumoniae
99
L L pneumophilapneumophila
66
S S pneumoniaepneumoniae
44
K. LumpurK. Lumpur77Liam CK, Liam CK, et al.et al.Respirology Respirology 2001;6:2592001;6:259--6464
K K pneumoniaepneumoniae
1010
S S pneumoniaepneumoniae
66
H H influenzaeinfluenzae
66
M M pneumoniaepneumoniae
44
Ps Ps aeruginosaaeruginosa
44127127
SingaporeSingapore66Hui KP, Hui KP, et alet al..Singapore Med JSingapore Med J1992;101:4421992;101:442--66
9696M tuberculosisM tuberculosis
2121
S S pneumoniaepneumoniae
1212
Gram Gram --vevebacillibacilli
1010
H H influenzaeinfluenzae
55
M M pneumoniaepneumoniae
55
M tuberculosisM tuberculosis
55
L L pneumophilapneumophila
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
AetiologiesAetiologies of CAP Requiring Hospitalization in Asia of CAP Requiring Hospitalization in Asia 3
254254S S pneumoniaepneumoniae
1111
B B pseudomalleipseudomallei
11111.4% in Bangkok1.4% in Bangkok5a5a
M M pneumoniaepneumoniae
99
C C pneumoniaepneumoniae
44
K K pneumoniaepneumoniae
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
LocationLocation No. of No. of patientspatients
Rank order / FrequencyRank order / Frequency of microbial cause of microbial cause (%)(%)2211 33 44 55 UnknownUnknown
United United KingdomKingdom(4 studies)(4 studies)
185185S S pneumoniaepneumoniae
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)
11481148S S pneumoniaepneumoniae
2222
Gram Gram ––veveenteric bacillienteric bacilli
99
S S aureusaureus
77
C C pneumoniaepneumoniae
77
LegionellaLegionella sppspp
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
H H influenzaeinfluenzae
88
S S aureusaureus
77
B B pseudomalleipseudomallei
77
S S pneumoniaepneumoniae
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
M tuberculosisM tuberculosis
1616
KlebsiellaKlebsiella sppspp
99
S S aureusaureus
99
M M pneumoniaepneumoniae
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
105105B B pseudomalleipseudomallei
2929
S S pneumoniaepneumoniae
2121
K K pneumoniaepneumoniae
1919
H H influenzaeinfluenzae
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%
LocationLocation No. of No. of patientspatients
Rank order / FrequencyRank order / Frequency of microbial cause of microbial cause (%)(%)2211 33 44 55 UnknownUnknown
United United KingdomKingdom(4 studies)(4 studies)
185185S S pneumoniaepneumoniae
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)
11481148S S pneumoniaepneumoniae
2222
Gram Gram ––veveenteric bacillienteric bacilli
99
S S aureusaureus
77
C C pneumoniaepneumoniae
77
LegionellaLegionella sppspp
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
H H influenzaeinfluenzae
88
S S aureusaureus
77
B B pseudomalleipseudomallei
77
S S pneumoniaepneumoniae
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
M tuberculosisM tuberculosis
1616
KlebsiellaKlebsiella sppspp
99
S S aureusaureus
99
M M pneumoniaepneumoniae
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
105105B B pseudomalleipseudomallei
2929
S S pneumoniaepneumoniae
2121
K K pneumoniaepneumoniae
1919
H H influenzaeinfluenzae
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
LocationLocation No. of No. of patientspatients
Rank order / FrequencyRank order / Frequency of microbial cause of microbial cause (%)(%)2211 33 44 55 UnknownUnknown
Nova ScotiaNova Scotia11
MarrieMarrie TJ, TJ, et al.et al.Am J MedAm J Med1996;101:5081996;101:508--1515
149149M M pneumoniaepneumoniae
2323
C C pneumoniaepneumoniae
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
5454S S pneumoniaepneumoniae
1313
M M pneumoniaepneumoniae
77
C C pneumoniaepneumoniae
44
Influenza AInfluenza A
44
Cryptococcus Cryptococcus sppspp44 6565
LausanneLausanneBochudBochud PY, PY, et alet al..Medicine Medicine 2001;80:7522001;80:752--8787
170170S S pneumoniaepneumoniae
2323
M M pneumoniaepneumoniae
1414
Influenza virusInfluenza virus
1212
C C pneumoniaepneumoniae
55
C C burnetiiburnetii
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
169169S S pneumoniaepneumoniae
3737
M M pneumoniaepneumoniae
1414
ChlamydiaeChlamydiae
99
VirusesViruses
88
H H influenzaeinfluenzae
44 4545
LocationLocation No. of No. of patientspatients
Rank order / FrequencyRank order / Frequency of microbial cause of microbial cause (%)(%)2211 33 44 55 UnknownUnknown
Nova ScotiaNova Scotia11
MarrieMarrie TJ, TJ, et al.et al.Am J MedAm J Med1996;101:5081996;101:508--1515
149149M M pneumoniaepneumoniae
2323
C C pneumoniaepneumoniae
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
5454S S pneumoniaepneumoniae
1313
M M pneumoniaepneumoniae
77
C C pneumoniaepneumoniae
44
Influenza AInfluenza A
44
Cryptococcus Cryptococcus sppspp44 6565
LausanneLausanneBochudBochud PY, PY, et alet al..Medicine Medicine 2001;80:7522001;80:752--8787
170170S S pneumoniaepneumoniae
2323
M M pneumoniaepneumoniae
1414
Influenza virusInfluenza virus
1212
C C pneumoniaepneumoniae
55
C C burnetiiburnetii
22 4646
FinlandFinlandJokinenJokinen C, C, et alet al..ClinClin Infect Infect DisDis2001;15:11412001;15:1141--5454
169169S S pneumoniaepneumoniae
3737
M M pneumoniaepneumoniae
1414
ChlamydiaeChlamydiae
99
VirusesViruses
88
H H influenzaeinfluenzae
44 4545
BangkokBangkok3 hospitals3 hospitalsWattanathumWattanathum, , et alet al..Chest Chest 2003;123:15122003;123:1512--99
9898C C pneumoniaepneumoniae
3737
M M pneumoniaepneumoniae
3030
S S pneumoniaepneumoniae
1313
L L pneumophilapneumophila
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
106106M M pneumoniaepneumoniae
2727
S S pneumoniaepneumoniae
1212
C C pneumoniaepneumoniae
1111
H H influenzaeinfluenzae
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
IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72
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
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)
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
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)
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
Yan Man S, et al. Prospective comparison of 3 predictive rules for assessing severity of CAP in Hong Kong. Thorax 2007; 62: 348-53
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
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 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†
Yan Man S, et al. Prospective comparison of 3 predictive rules for assessing severity of CAP in Hong Kong. Thorax 2007; 62: 348-53
† 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†
Yan Man S, et al. Prospective comparison of 3 predictive rules for assessing severity of CAP in Hong Kong. Thorax 2007; 62: 348-53
† 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
2007 IDSA / ATS Consensus Guidelines
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)
Mandell LA, et al. IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72
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
Guidelines for managing CAPGuidelines for managing CAPPrinciples of empirical therapy
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)
Guidelines for managing CAPGuidelines for managing CAPPrinciples of empirical therapy
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
Guidelines for managing CAPGuidelines for managing CAPPrinciples of empirical therapy
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
Mandell LA, et al. IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72
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
Mandell LA, et al. IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72
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)
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%
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
Song JH, et al. ANSORP. Antimicrob Agents Chemother June 2004; 48:2101-7
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%%
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
Song JH, et al. ANSORP. Antimicrob Agents Chemother June 2004; 48:2101-7
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%
Intermediate Intermediate ResistantResistant
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
Song JH, et al. ANSORP. Antimicrob Agents Chemother June 2004; 48:2101-7
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)
Mandell LA, et al. IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72
e
of
ce to
e
ed
ished ses tive
am
.e., oses ae is a
sted ccalvitro,
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 / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72
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
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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
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
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
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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
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
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
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
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
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 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
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
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
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
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).
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
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
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
Preferred β-lactamsinclude cefotaxime,ceftriaxone, and ampicillin; ertapenem for selected patients
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
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
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
Preferred β-lactamsinclude cefotaxime,ceftriaxone, and ampicillin; ertapenem for selected patients
Doxycycline is an alternative to the macrolide[level III evidence]
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
Respiratory FQ Respiratory FQ alonealoneII
ororββ--lactamlactam ++ macrolidemacrolideII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQRespiratory FQII
In regions with high rate (>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII ororββ--lactamlactam ++ macrolidemacrolideIIIIII
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
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
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
ororββ--lactamlactam ++ macrolidemacrolideII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQRespiratory FQII
In regions with high rate (>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII ororββ--lactamlactam ++ macrolidemacrolideIIIIII
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
Most common microbial Most common microbial aetiologiesaetiologies of CAPof CAP
InpatientInpatient(non(non--ICU)ICU)OutpatientOutpatient
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..
InpatientInpatient(ICU)(ICU)
IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72
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.
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
Respiratory FQRespiratory FQII
ororββ--lactamlactam ++ macrolidemacrolideII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQRespiratory FQII
In regions with high rate (>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII ororββ--lactamlactam ++ macrolidemacrolideIIIIII
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
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.
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
ββ--lactamlactam** ++ azithromycinazithromycinIIII
ororββ--lactamlactam** ++ respiratory FQrespiratory FQII
*β-lactamcefotaxime, ceftraxone, ampicillin/sulbactam,
Respiratory FQRespiratory FQII
ororββ--lactamlactam ++ macrolidemacrolideII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQRespiratory FQII
In regions with high rate (>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII ororββ--lactamlactam ++ macrolidemacrolideIIIIII
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
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
ββ--lactamlactam** ++ azithromycinazithromycinIIII
ororββ--lactamlactam** ++ respiratory FQrespiratory FQII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQ + Respiratory FQ + aztreonamaztreonam
Respiratory FQRespiratory FQII
ororββ--lactamlactam ++ macrolidemacrolideII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQRespiratory FQII
In regions with high rate (>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII ororββ--lactamlactam ++ macrolidemacrolideIIIIII
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
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
ββ--lactamlactam** ++ azithromycinazithromycinIIII
ororββ--lactamlactam** ++ respiratory FQrespiratory FQII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQ + Respiratory FQ + aztreonamaztreonam
Respiratory FQRespiratory FQII
ororββ--lactamlactam ++ macrolidemacrolideII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQRespiratory FQII
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
In regions with high rate (>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII ororββ--lactamlactam ++ macrolidemacrolideIIIIII
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
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
ββ--lactamlactam** ++ azithromycinazithromycinIIII
ororββ--lactamlactam** ++ respiratory FQrespiratory FQII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQ + Respiratory FQ + aztreonamaztreonam
Respiratory FQRespiratory FQII
ororββ--lactamlactam ++ macrolidemacrolideII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQRespiratory FQII
If If PseudomonasPseudomonas is a is a considerationconsiderationIIIIII
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
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
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
ββ--lactamlactam** ++ azithromycinazithromycinIIII
ororββ--lactamlactam** ++ respiratory FQrespiratory FQII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQ + Respiratory FQ + aztreonamaztreonam
Respiratory FQRespiratory FQII
ororββ--lactamlactam ++ macrolidemacrolideII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQRespiratory FQII
If If PseudomonasPseudomonas is a is a considerationconsiderationIIIIII
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))
In regions with high rate (>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII ororββ--lactamlactam ++ macrolidemacrolideIIIIII
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
IDSA / IDSA / ATSATS
GuidelinesGuidelines20072007
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]
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
ββ--lactamlactam** ++ azithromycinazithromycinIIII
ororββ--lactamlactam** ++ respiratory FQrespiratory FQII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQ + Respiratory FQ + aztreonamaztreonam
Respiratory FQRespiratory FQII
ororββ--lactamlactam ++ macrolidemacrolideII
For penicillinFor penicillin--allergic allergic patientspatientsRespiratory FQRespiratory FQII
If If PseudomonasPseudomonas is a is a considerationconsiderationIIIIII
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))
In regions with high rate (>25%) of infection with high-level (MIC >16 µg/mL)macrolide-resistant S. pneumoniaeRespiratory FQRespiratory FQIIIIII ororββ--lactamlactam ++ macrolidemacrolideIIIIII
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
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)
2007 IDSA / ATS Consensus Guidelines
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
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