IDSA/ATS Guidelines on Community-Acquired Pneumonia in Adults Patty W. Wright, MD March 2011 with special thanks to Tom Talbot, MD, MPH.

Slides:



Advertisements
Presentasi serupa
HARI NUGROHO, MD UPT TERAPI & REHABILITASI BADAN NARKOTIKA NASIONAL.
Advertisements

Epidemiologi Dalam Bidang K3
UTILITY THEORY.
Cultural Determinants of Schemas
1. PRESENT TENSE Digunakan untuk menyatakan suatu perbuatan yang biasa kita lakukan misalnya setiap hari, setiap minggu, setiap bulan dan setiap tahun.
Masalah Transportasi II (Transportation Problem II)
1 Pertemuan 22 Analisis Studi Kasus 2 Matakuliah: H0204/ Rekayasa Sistem Komputer Tahun: 2005 Versi: v0 / Revisi 1.
Pertemuan 07 Peluang Beberapa Sebaran Khusus Peubah Acak Kontinu
Verb Tense Tense denotes the time of the action indicated by a verb. The time is not always the same as that indicated by the name of the tense.
INDONESIA INFRASTRUCTURE INITIATIVE IURSP – Monitoring dan Evaluasi IURSP – Monitoring and Evaluation Workshop 3 Steve Brown VicRoads International Projects.
1 Pertemuan 2 Unit 1 - Careers Matakuliah: G0682 / Bahasa Inggris Ekonomi 1 Tahun: 2005 Versi: versi/revisi.
9.3 Geometric Sequences and Series. Objective To find specified terms and the common ratio in a geometric sequence. To find the partial sum of a geometric.
Arafa Rizka Syaputra( ) Hidsal Jamil( ) Padel Aji Pamungkas( )
Chapter 10 – The Design of Feedback Control Systems PID Compensation Networks.
-Do you have a close friend? Does she/he have a problem? -What do you say when she/he tells her/his problem? - Did you ever come to your friend house?
Comparative Statics Slutsky Equation
Keuangan dan Akuntansi Proyek Modul 2: BASIC TOOLS CHRISTIONO UTOMO, Ph.D. Bidang Manajemen Proyek ITS 2011.
Smoothing. Basic Smoothing Models Moving average, weighted moving average, exponential smoothing Single and Double Smoothing First order exponential smoothing.
Samples: Smart Goals ©2014 Colin G Smith
Doctor  what is doctor?  how to be a doctor ?  what we do as a doctor?  the benefit of doctor?  conclusion and suggestion.
Diabetic Neuropathies: The Nerve Damage of Diabetes.
HYPERTENSION Rahmayanti jus’an Rika hartina Rasna Rudi lestari Roselina Syafitrah oktavianti muklis Grup 6 Rusmiati Sepriadi nisa lamba Siti hajar iskandar.
Jartel, Sukiswo Sukiswo
Pradana et al. Maj Kedot Indon, Volum: 59, Nomor: 12, Desember 2009
Cartesian coordinates in two dimensions
Cartesian coordinates in two dimensions
Work and Energy (Kerja dan Energi)
CA113 Pengantar Manajemen Bisnis
1. PRESENT TENSE Digunakan untuk menyatakan suatu perbuatan yang biasa kita lakukan misalnya setiap hari, setiap minggu, setiap bulan dan setiap tahun.
METODOLOGI PENELITIAN ADMINISTRASI NEGARA
Pitfall dalam terapi antibiotik
MANAJEMEN KEPERAWATAN PADA PASIEN ACS
FOKUS MASALAH KULIAH PKP
PARADIGM SHIFT JATI SURYANTO S.PD., MA.
CA113 Pengantar Manajemen Bisnis
Pelayanan kesehatan.
Open and Closed Social Stratification
ACCUMULATION PROBLEMS
Master data Management
Pertemuan 4 CLASS DIAGRAM.
Singapore Hospital Market is Driven by Organic Expansion of Public & Private Hospitals and Increased Government Spending: Ken Research.
Sweden Telemedicine Market is Driven By Increase in the Number of Medical Applications, Rise in the Geriatric Population and Increasing Shortage of Nurses.
(Hepatitics Drug) Website:
Why It Is Necessary to Have More Sells Through the Social Media
How Can I Be A Driver of The Month as I Am Working for Uber?
How the Challenges Make You A Perfect Event Organiser.
Things You Need to Know Before Running on the Beach.
How to Pitch an Event
Don’t Forget to Avail the Timely Offers with Uber
Evidence-Based Medicine Prof. Carl Heneghan Director CEBM University of Oxford.
CA113 Pengantar Manajemen Bisnis
Struktur Sosial.
THE INFORMATION ABOUT HEALTH INSURANCE IN AUSTRALIA.
HughesNet was founded in 1971 and it is headquartered in Germantown, Maryland. It is a provider of satellite-based communications services. Hughesnet.
HOTEL MANAGEMENT OF UNIVERSITAS DIAN NUSWANTORO
Do you want to check your Zoho mail incoming or outgoing logs and unable to check, go through with this article and access Zoho mail incoming or outgoing.
Fix problems opening Norton  Fix problems opening Norton This problem can happen after you update Norton. To fix the matter, restart the computer. Fix.
How do I Add or Remove a delegate to my Gmail account? Google launched delegation service 9 years ago for Gmail that allows you to give permission to access.
In this article, you can learn about how to synchronize AOL Mail with third-party applications like Gmail, Outlook, and Window Live Mail, Thunderbird.
INTERROGATIVE ADJECTIVE. DEFINITION FUNCTION EXAMPLE QUESTION.
Right, indonesia is a wonderful country who rich in power energy not only in term of number but also diversity. Energy needs in indonesia are increasingly.
Unit: 8 The simple past tense Meaning & Use Form (structure) Exercise.
Rank Your Ideas The next step is to rank and compare your three high- potential ideas. Rank each one on the three qualities of feasibility, persuasion,
Vector. A VECTOR can describe anything that has both MAGNITUDE and DIRECTION The MAGNITUDE describes the size of the vector. The DIRECTION tells you where.
Sepsis Nani Zaitun Divisi Tropik Infeksi SMF Ilmu Penyakit Dalam RSU Ulin Banjarmasin.
HANDLING RUSH PRESIDENT UNIVERSITY NURLAELA RIZKINA.
"More Than Words" Saying I love you, Is not the words, I want to hear from you, It's not that I want you, Not to say but if you only knew, How easy, it.
2. Discussion TASK 1. WORK IN PAIRS Ask your partner. Then, in turn your friend asks you A. what kinds of product are there? B. why do people want to.
Wednesday/ September,  There are lots of problems with trade ◦ There may be some ways that some governments can make things better by intervening.
Transcript presentasi:

IDSA/ATS Guidelines on Community-Acquired Pneumonia in Adults Patty W. Wright, MD March 2011 with special thanks to Tom Talbot, MD, MPH

CAP: Objective To discuss the recommendations outlined by the Infectious Diseases Society of America and American Thoracic Society’s guidelines on the management of community acquired pneumonia, with a particular focus on changes from prior versions of these guidelines.

CAP: Definition and Epidemiology Lower respiratory tract infection in people with limited or no contact with medical institutions or settings Up to 5.6 million cases/yr in U.S. Up to $ 9.7 billion spent annually Up to 60,000 deaths each year in U.S.

CAP: Risk Factors Altered Mental Status Smoking Alcohol consumption Malnutrition Immunosuppression Underlying lung disease Age ≥65 years

CAP: Clinical Presentation Symptoms: – Cough (typically productive) – Fever with chills and sweats – Shortness of breath – Chest pain Signs: – Fever, tachycardia, tachypnea – Crackles/rhonchi on lung exam – Leukocytosis

CAP: Diagnosis – Imaging Infiltrate on Cxray (or other imaging) required for the diagnosis of pneumonia If clinically suspect CAP, but negative Cxray consider: – Chest CT – Empiric treatment and repeat Cxray in hrs

CAP: Diagnosis – Imaging Lobar InfiltrateInterstitial Infiltrate

CAP: Microbiology Streptococcus pneumoniae Haemophilus influenzae “Atypicals” – Mycoplasma pneumoniae – Chlamydia pneumoniae – Legionella sp Pseudomonas sp. Viral – Influenza, RSV, Parainfluenza, HMPV

CAP: Diagnosis – Sputum Gram Stain/Culture Optional for routine outpt evaluation Culture-positive rates range from 2-50% If require admission, obtain sputum Gram stain & culture and blood cultures Ideally obtain sputum before abx, but do not delay abx waiting for a sputum sample

Urinary Legionella Antigen – Serotype 1 only – Accounts for 88% of USA isolates – Sensitivity: 70%; specificity: >90% Urinary Pneumococcal Antigen – Sensitivity: 60-90%, specificity: 100% – Recent study found 10% of specimens from pts with non-pneumococcal pneumonia were positive CAP: Diagnosis – Special Tests

CAP: Poor Prognostic Factors Age > 65 years Nursing home resident (HCAP) Presence of chronic lung disease High APACHE score Need for mechanical ventilation

Where to treat: – Many can be treated as an outpatient – Must consider illness severity, comorbidities, home support, adherence to therapy CAP: Treatment Guidelines

Pneumonia Severity Index (PSI) – Prediction rule to stratify risk of death from CAP – Assists in determining location of Rx for CAP – Should not supercede clinical judgment

CAP: PSI Fine, M. J. et al. N Engl J Med 1997;336:

Then, add up their risk points: CAP: PSI RiskScore II< 70 III71-90 IV V> 130

CAP: PSI PSI IndexMortality Rate I % II % III0-2.8% IV % V27-31% Consider Outpt Tx Fine, M. J. et al. N Engl J Med 1997;336: Needs Inpt Tx

CAP: CURB-65 CURB-65 criteria – Confusion – Uremia (BUN >20) – Respiratory rate (RR >30) – Blood pressure (SBP <90 or DBP < 60) – Age 65 years or greater

CAP: CURB-65 CURB-65 ScoreMortality RateTx Location 00.7%Outpatient 12.1%Outpatient 29.2%Inpatient 314.5%Inpatient - ?ICU 440.0%ICU 557.0%ICU

CAP: Treatment Abx initiated in the emergency dept, ideally within 4 hrs Quick administration has been associated with reduced mortality Use of empiric guidelines have reduced costs, mortality, LOS Based upon severity of illness and host immune status Target regimen based upon culture results

CAP: IDSA-ATS Treatment Guidelines Stratify empiric outpatient treatment based on – Drug-resistant Strep pneumo risk > 25% resistance rate (e.g. Nashville, TN) – Presence of co-morbidities Alcoholism/Aspiration risk Bronchiectasis/COPD IVDA Post-influenza – Prior abx use in the preceding 3 months

Empiric Treatment – Outpatient : – No confounding factors: macrolide (azithromycin 500mg x 1 day then 250mg Qday or clarithromycin 500mg po Q12hrs or clarithro-ER 1000mg Qday) or doxycycline 100mg Q12hrs CAP: IDSA-ATS Treatment Guidelines

Empiric Treatment – Outpatient : – Confounding factors present: respiratory quinolone (levofloxacin 750mg Qday, moxifloxacin 400mg Qday) or beta-lactam ( amoxicillin 1g Q8hrs, amox-clav-ER 2gm Q12hrs, cefpodoxime 200mg Q12hrs, cefdinir 300mg Q12hrs, etc) + macrolide or beta-lactam + doxycycline

Empiric Treatment – Hospitalized, non-ICU: – Beta-lactam (ceftriaxone, cefotaxime, ampicillin, or ertapenem) + macrolide or doxycycline or – Respiratory quinolone alone (levofloxacin, moxifloxacin, gemifloxacin) CAP: IDSA-ATS Treatment Guidelines

Empiric Treatment – Hospitalized, ICU: – Beta-lactam (ceftriaxone, cefotaxime, or ampicillin/sulbactam) + macrolide or respiratory quinolone – PCN-allergic = resp quinolone + aztreonam CAP: IDSA-ATS Treatment Guidelines

CAP: Risk Factors for Pseudomonas Structural lung diseases, such as bronchiectasis Repeated exacerbations of severe COPD leading to frequent steroid and/or antibiotic use Health-Care Associated Pneumonia (HCAP)

HCAP: Definition Hospitalized in acute care hospital two or more days within 90 days prior to infection Reside in long-term care facility Received IV abx, chemotx, or wound care in last 30 days Dialysis

CAP: Pseudomonas Coverage Beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) + ciprofloxacin or levofloxacin or Beta-lactam + aminoglycoside + azithromycin or Beta-lactam + aminoglycoside + respiratory quinolone PCN-allergic = substitute aztreonam for the beta-lactam

CAP: MRSA Consider empiric coverage of MRSA if: – HCAP – Necrotizing pneumonia – Post-influenza pneumonia – History of MRSA or recurrent skin abscesses Treat with vancomycin or linezolid

Retrospective analysis of data from two separate, prospective trials (n = 1,019) Patients with nosocomial pneumonia Aztreonam + vancomycin or linezolid No difference in survival except in MRSA pneumonia subgroup (63.5% vs. 80%, p=0.03) Linezolid is an alternative to vancomycin in new IDSA/ATS guidelines CAP: MRSA – Vancomycin vs. Linezolid Wunderink, et al. Chest 2003

CAP: Oral Abx Therapy Switch to po abx when… – Hemodynamically stable – Clinically improving – Able to tolerate po – Have normal GI tract fxn

CAP: Length of Therapy Rx for a minimum of 5 days Before discontinuation of therapy: – Pt should be afebrile for 48–72 hrs – Pt should have no more than one CAP- associated sign of clinical instability Longer duration usually indicated with Legionella, Chlamydia, MRSA

CAP: Criteria for Clinical Stability Temperature <37.8°C Heart rate <100 beats/min Respiratory rate <24 breaths/min Systolic blood pressure >90 mm Hg Arterial oxygen saturation > 90% or pO 2 > 60 mm Hg on room air Ability to maintain oral intake Normal mental status

CAP: Prevention “Pneumonia Prevention Vest, Crochet Version” Vaccinations (I hope you were awake earlier this morning!)

CAP: Example Patient Jane is a 66 yo female with diabetes who presents to the ED with fever, cough, sputum production, and pleuritic chest pain. She denies associated N/V/D. Vital signs: T100.7, RR 24, BP 110/70, P 100. Exam: A&O x 4, left basilar rhonchi. Cxray: left lower lobe infiltrate. Labs: WBC 14k, gluc 215, BUN 27, cr 1.2. Should Jane be admitted?

CAP: Example Patient CURB-65 criteria – Confusion – Uremia (BUN >20) – Respiratory rate (RR >30) – Blood pressure (SBP <90 or DBP < 60) – Age 65 years or greater Jane’s score = 2…Recommend admission

CAP: Example Patient What additional work-up would you recommend?

CAP: Example Patient Blood cultures Sputum Gram stain and culture Consider urinary pneumococcal antigen

CAP: Example Patient Jane has no drug allergies. What antibiotic treatment would you recommend?

CAP: Example Patient Respiratory quinolone alone or Beta-lactam + macrolide or doxycycline If Jane tells you that she took ciprofloxacin for a UTI last month, how would that change your rx choice?

CAP: Example Patient Jane rapidly improves with antibiotics and hydration. After two days of hospitalization, she is afebrile with normal vital signs. She continues to tolerate oral medications without problem. When can you discharge Jane? How many more days of antibiotic therapy does she require?

CAP: Example Patient Jane can be discharged today on po abx to complete a total of 5 days of abx therapy.

CAP: Example Patient Unfortunately, we are not done with Jane… Approximately a month after discharge, Jane falls and breaks her leg. She requires casting, which limits her mobility. She begins to note increasing shortness of breath, low grade fever, and a return of her cough, prompting her to present to her primary care provider for further evaluation.

CAP: Example Patient Jane is sent for CT angiogram of the chest which is negative for pulmonary embolus, but does show a new infiltrate in her right lower lobe with some areas of cavitation. Should Jane be re-admitted to the hospital? What antibiotics should she receive?

CAP: Example Patient Jane now has HCAP and is at risk for resistant pathogens, such as Pseudomonas and MRSA. She should be admitted for iv abx. Rx with beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) + ciprofloxacin or levofloxacin + vancomycin or linezolid.

CAP: Conclusions Not all patients with CAP require hospitalization Outpatients should be stratified by drug- resistant pneumococcus risk, comorbities, and prior abx use in the past 3 months Inpatients should be stratified by severity of illness and Pseudomonas/MRSA risk Patients should be treated with a minimum of 5 days of abx

CAP: Questions?