treatment of pneumonia in immunocompromised host
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Treatment of pneumonia in immunocompromised host. Prof. Dr. Volkan Korten Marmara Univ. School of Medicine Dept. of Infectious Diseases. Pneumonia in immunocompromised host. Community acquired Noso c omial Aspiration Rea ctivation Environmental exposure. - PowerPoint PPT PresentationTRANSCRIPT
Treatment of pneumonia in immunocompromised host
Prof. Dr. Volkan Korten
Marmara Univ. School of Medicine
Dept. of Infectious Diseases
Pneumonia in immunocompromised host
• Community acquired
• Nosocomial
• Aspiration
• Reactivation
• Environmental exposure
Pneumonia in immunocompromised host - Etiology
• Conventional bacteria % 37
• Fungi % 14
• Viruses % 15
• Pneumocystis carinii/jirovecii % 8
• Nocardia asteroides % 7
• Mycobacterium tuberculosis % 1
• Mixed infections % 20
Community acquired pneumonia
• Etiology – not changed in imm.comp. host– Focal – segmental infiltrates suggest bacterial
etiology. – Typical - atypical pneumonia
S.pneumoniae, H.influenzae or L.pneumophila etc
• Severely impaired cellular immunity: – CMV, Tbc, MAI
CAP guidelines are valid – according to severity / empiric treatment - similar to pts with underlying diseases
Empiric Ab (antipseudomonal beta-lactams), MRSA ? Legionella ?
Empiric Ab + empiric antifungal
+ PCP ?+ Mycoplasma – legionella ?+ Viral ?
Antipseudomonal beta-lactams• Antipseudomonal cephalosporins
– Cefepime 2 g tid– Ceftazidime ? 2 g tid
• Carbapenems– Imipenem 500 mg qid, 1 g tid– Meropenem 1-2 g tid– Doripenem 0.5-1 g tid
• Beta-lactam/beta-lactamase inhibitors – Piperacilin-tazobactam 4.5 g qid– Cefoperazone-sulbactam 2 g tid
Combinations ? (shock – MDR)- FQ- Aminoglicosides
Risk classification for invasive aspergillosis
Allo BMT + GVHD
Allo BMT ± GVHD
PNL <500/mm3 + Hematological malignancies+ Auto BMT+ Aplastic Anemia+ MDS
SOT, AIDS
High dose steroids
Invasive pulmonary aspergillosis
www.aspergillus.man.ac.uk
Normal lungIPA
IPA occurs in ~7% of acute
leukaemia patients, 10-15% allogeneic
BMT patients
ProbableProbableMycologyClinical features
Host factors + =
MycologyClinical features
Host factors + + = Proven Proven
tissue
Invasive fungal disease - Definitions II
PossiblePossibleClinical features+ =Host
factors
Negativeor
Not done
Clinical features+ =Host
factors
Negativeor
Not done
De Pauw B, Definitions of Invasive Fungal Disease, CID 2008;46:1813-21
Host factors for IA• Recent history of neutropenia (< 500/mm3 for > 10 days)• Allogeneic stem cell transplant• Prolonged use of corticosteroids • T cell immunosuppressants, such as cyclosporine, TNF-
a blockers, specific monoclonal antibodies (such as alemtuzumab), or nucleoside analogues during the past 90 days
• Inherited severe immunodeficiency (such as chronic granulomatous disease or severe combined immunodeficiency)
• Microbiological criteria– Culture– Cytology– Galactomannan, Beta-glucan
• Clinical criteriaCT– Halo sign– Air - crescent sign– Cavity in consolidation
Specific pulmonary infiltrates on CT scan
halo signhalo sign
air crescent signair crescent sign cavitycavity
nodulesnodules
IDSA Clinical Practice Guidelines for Aspergillosis 2008
Walsh TJ, et al. Clin Infect Dis 2008;46:327-60
Risk factors for Pneumocystis pneumonia
• HIV infection - CD4 < 200• Non-HIV
– Glucocorticoid use– Other immunosuppressive drugs: Antirejection medications, Purine analogs (eg,
fludarabine), Infliximab – Defects in cell-mediated immunity– Cancer (particularly hematologic malignancy)– HSCT; especially allo– Solid organ transplantation– Treatment for rejection– Treatment for inflammatory conditions (eg, Wegener's granulomatosis)– Severe malnutrition (especially protein malnutrition)– Primary immunodeficiencies (particularly severe combined immunodeficiency)– Prematurity
Anti-inflammation Therapy:Prednisone: needs definitive diagnosis
• Shown to improve survival in patients with paO2 < 70 or Aa gradient >35 mm Hg.
• Decreases the risk of respiratory failure and death by 50%.
• Tapered dose (40 mg BID x 7, 40mg QD x 7, 20 mg QD x 7).
Nocardia
• TMP-SMZ 15 mg/kg/d TMP iv or po – first 4 wks,– 10 mg/kg/d TMP equivalent 5 months / 1 year in
imm. compromised pts.– cranial imaging
• Imipenem 500 mg qid or Ceftriaxone 2 g/d + Amikacin 1 g/d 3-4 wks, followed by TMP-SMZ
• Linezolid 600 mg bid, po
RSV / Influenza
• Ribavirin aerosol or po
• Ribavirin + palivizumab (monoclonal antibody developed against RSV)
• Oseltamivir / zanamivir