Christopher H. Mody MD, FRCPC, FCCP, FACP by 4BA0B5wc

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									 Nursing Home
        Acquired Pneumonia and AECB
             2001

for     New Canadian Guidelines
      Community Acquired
                  Pneumonia
 Christopher H. Mody MD, FRCPC, FCCP,
                FACP
         Pneumonia Guidelines
• Canadian Guidelines
  – Mandell, LA et al, Canadian guidelines for the initial
    management of community -acquired pneumonia: An
    evidence-based update by the Canadian Infectious
    Disease Society and the Canadian Thoracic Society.
    Clinical Infectious Diseases 2000; 31:383-421

• IDSA Guidelines
  – Bartlett JG et al, Community-acquired pneumonia in
    adults: guidelines for management. The Infectious
    Diseases Society of America.
    Clin Infect Dis. 2000; 31:347–82.
Objectives
   Dx and Investigation of CAP

     Admit to Hospital?

     Treatment (Guidelines)

     Tx CAP vs. AECB
       Mortality in CAP
• In a large Canadian study of community
  acquired pneumonia (CAP) and nursing
  home acquired pneumonia (NHAP), the
  mortality was:
                 A. < 5%
                 B. 5-10%
                 C. 10-20%
                 D. 20-40%
                 E. >40%
        Mortality in CAP

•   719 patients, 588 CAP, 131 NHAP
•   48 (7%) cases with bacteremia
•   28 (4%) due to pneumococcus
•   18% required mechanical ventilation




                               Marrie Rev. Infect. Dis. 1989
      Mortality in CAP
• Mortality
  – 17% in CAP
  – 40% NHAP
• Mortality predictors
  – Multilobar pneumonia
  – Advanced age
  – Serious underlying illness
  – Mechanical ventilation
                                 Marrie Rev. Infect. Dis. 1989
       Mortality in CAP
• Mortality
  – 17% in CAP
  – 40% NHAP
• Mortality predictors
  – Multilobar pneumonia
  – Advanced age
  – Serious underlying illness
  – Mechanical ventilation
                                 Marrie Rev. Infect. Dis. 1989
    Risk Factors for CAP
• Low body mass index or recent weight
  loss
• Current smoking > 20 cigarettes/day
• Previous respiratory infection
• COPD/Asthma
• Malignant disease
• Diabetes
• Chronic liver disease
        Diagnosis of CAP
• History
  – No studies have investigated the use of history
    alone to diagnose pneumonia
  – Concern about interobserver variability


• Physical examination - interobserver
  variability based on phys. exam. alone
  – Diagnosis of CAP correct in < 40% of
    examiners
                                  Methlay JP JAMA 1997;278:1440
       Diagnosis of CAP (Cont’d)

• History and Physical Examination -
  suspect pneumonia

  – Fever
  – Cough
  – Purulent tracheobronchial secretions
  – Focal respiratory physical findings


                               Albaum, Chest 1996;110:343
          Etiology of
          Pneumonia
               5%
          6%
     5%                   27%
                                           S. p n eu m o n iae
6%                                         H. in f luen z ae
                                           In f lu en z a
                                           L e g io n e lla
8%                                         Ch lam y d ia
                                           GNEB
                                           P. aer u g in o sa
                                           My c o p lasm a
                            11%            Co x iella
 10%

                    22%

                                  Ruiz,AJRCCM 1999; 160:397
             Etiology of NAP
      6.5%        13%
                                       Streptococcus pneumoniae
                                       Staphylococcus aureus
                                       Morexalla catarrhalis
                                       Enterococcus sp.
                                       Hemophilus influenzae
                                       Klebsiella pneumonia
                                       Escherichia coli
                                       Serratia sp.
                                       Providencia sp.
10%                                    Enterobacter sp.
                                       Pseudomonas aeruginosa
                                       Mycobacterium tuberculosis
                                       Influenza virus
                          45%          Legionella pneumophila




                        El-Solh,AJRCCM 2001; 163:645   (Buffalo NY)
        Etiologic Diagnosis of
        CAP
• Common symptoms, signs and laboratory
  features are not specific in identifying a
  pathogen
• Manifestations of CAP reflect the host
  response more than the pathogen
• Sputum rarely rewarding (recommended in
  IDSA guidelines)
• Blood culture - for inpatients
• Serology not helpful in acute setting
                                    Fang, Medicine 1990:307
    Investigations - Sputum

• Reliable if:
   –   Greater than 25 neutrophils/HPF
   –   Less than 10 epithelial cells/HPF
   –   Beware Hemophilus, Legionella
   –   20% of elderly have mixed flora
   –   Is used to add to regimen
• ATS vs. IDSA guidelines
    Investigations for Risk

• Oxygenation ± ABG
• CBC
• Electrolytes, BUN/Creatinine,
  Glucose
• CXR
• Microbiology
       When to admit to
       hospital
• Would you admit a 20 year old with
  pneumonia?

• A 60 year old?
• A 60 year old woman with COPD?
• A 60 year old man with a HR=130 and
  pH=7.34?
     Admit to Hospital?
• The point system (IDSA)

  – <70 points, mortality is <0.6%
  – 70-90 points, mortality is 2.8%
  – 90-130 points, mortality is 8.2%
  – >130 points, mortality is 29%


                                       Fine NEJM 1997
         Assigning Points
Patient Characteristic            Points
                  Age    1 point/yr (-10 if female)
              Cancer                 30
             pH<7.35                 30

         Liver Disease              20
 Altered Mental Status              20
      Respir Rate >30               20
       Systolic BP <90              20
            BUN>10.7                20
         Sodium <130                20

                                         Fine NEJM 1997
       Assigning Points
Patient Character istic    Points
                    CHF     10
      Cereb roVasc Dis      10
             Renal Dis      10
           Pulse >125       10
          Glucose >1 4      10
     Hem ato crit < 30%     10
                p02 <6 0    10
       Pleura l Effusion    10


                             Fine NEJM 1997
        Canadian CAP Guidelines

Outpatient: No modifying factors
• 1st choice
  – macrolide: erythromycin 500 mg qid x 10 d,
    azithromycin 500 mg then 250 mg x 4 d, or
    clarithromycin 500 mg bid x 10 d
• 2nd choice
  – doxycycline 100 mg bid x 10 d
        Canadian CAP Guidelines

Outpatient Modifying factors
i) COPD (no recent antibiotics or steroids past
   3 months)
• 1st choice
  – azithromycin 500 mg then 250 mg x 4 d OR
    clarithromycin 500 mg bid x 10 d
• 2nd choice
  – doxycycline 100 mg bid x 10 d
          Canadian CAP Guidelines

Outpatient: Modifying factors (cont’d)
ii) COPD (recent antibiotics or steroids)
• 1st choice:
   – respiratory fluoroquinolone (levofloxacin, 500 mg od,
      moxifloxacin 400 mg od) x 10 d po
• 2nd choice:
   – cefuroxime axetil 500 mg bid po OR
     amoxicillin - clavulanate 500 mg tid x 10 days po
                              AND
     new macrolide (azithromycin or clarithromycin)
          Canadian CAP Guidelines

Outpatient: Modifying factors (cont’d)
iii) suspected macroaspiration - concern about oral
     anaerobes
• 1st choice
    – amoxicillin/clavulanate 500 mg tid x 10 d
•   2nd choice:
    – respiratory quinolone (levofloxacin, 500 mg od x 10 d
      + metronidazole 500mg bid or moxifloxacin 400 mg
      od) OR
      clindamycin 300 mg qid
            Canadian CAP Guidelines
Inpatient - Ward
• 1st choice
   – fluoroquinolone IV  po x 10 d [levofloxacin 500 mg od IV]
• 2nd choice
   – cefuroxime 750 mg q8h IV, OR
     3rd generation cephalosporin IV (ceftriaxone 1 g 24h IV) OR
     4th generation cephalosporin IV (cefepime 1 g q12h IV)
                                 AND
     macrolide (azithromycin 500 mg then 250 mg od x 4 d or
     clarithromycin 500 mg bid x 10 d)
         Canadian CAP Guidelines
Nursing Home Patients: In nursing home
• 1st choice
  – respiratory fluoroquinolone po (levofloxacin, 500 mg od
    +/- metronidazole 500 mg bid po , moxifloxacin 400
    mg od) (if aspiration suspected) x 10 d, OR
    amoxicillin-clavulanate 500 mg tid po, + macrolide
    (erythromycin, azithromycin or clarithromycin)
• 2nd choice
  – cefuroxime axetil 500 mg bid po x 10 days + macrolide
    (erythromycin, azithromycin or clarithromycin) +/-
    metronidazole 500 mg bid or clindamycin 300 mg qid
        Canadian CAP Guidelines
Nursing Home Patients: In nursing home (cont’d)
• 3rd choice
  – ceftriaxone IM 1 g q24h
                          +/-
    macrolide (erythromycin, azithromycin or
    clarithromycin)
                          +/-
    metronidazole 500 mg bid or clindamycin
    300 mg qid
        Canadian CAP Guidelines

Nursing Home Patients: In hospital (Ward)
• 1st choice
  – respiratory fluoroquinolone IV [levofloxacin 500
    mg od]
• 2nd choice
  – 3rd ceph. IV (ceftriaxone 1 g q24h), OR
    4th ceph. IV (Cefepime 1 g q12h)
                             +
  macrolide (azithromycin or clarithromycin)
       Is it CAP or Acute
       Bronchitis?
• Many physicians ask “I think my patient has
  pneumonia, do I have to do a CXR?”

• If the patient does not have pneumonia then
  they have AECB. When is it appropriate to use
  the same drugs?

• CXR useful in
   – Dx of pneumonia
   – Detection of Complications
           AECB: Signs and
           Symptoms
                                             Per c ent o f Pat ient s
Sy m p t o m s                    Anthonisen 1987                   Ball 1995
                                       ( n= 1 7 3 )                  ( n= 4 7 1 )

Inc r eased d y sp nea                  90                           45
Inc r eased sp ut um p r o d uc t io n 6 9                           77
Pur ulent sp ut um                      60                           66
Inc r eased c o ug h                    82                     no t r ep o r t ed
Fev er                                  29                           12
A v er ag e ex ac er b at io ns    2 .5 6 / y ear                  3 / y ear

                                  Anthonisen NR et al. Ann Intern Med. 1987; 106: 196-204.
                                  Ball P et al. Q J Med 1995; 88:61-68
 Is it CAP or Acute
 Bronchitis?
• It is pneumonia (not AECB) if:
   – CXR Infiltrate
   – Bronchial Breath Sounds
      • Fever, localized Crackles
• You can’t be certain if:
   – Cough and sputum
   – Fever
   – Dyspnea
PATHOGENESIS OF COPD:
      Sputum Pathogens in
      AECB

      1 9%
                               H. influenzae
17%                     5 0%   S. pneumonia
                               M. catarrhalis
       1 4%                    Other
Classification of AECB
Type 1
• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence
Type 2
• Two of the above
Type 3
• One of the above


                Anthonisen Ann Intern Med 1987;106:196
     Effectiveness of Antibiotics
     in AECB
                Placebo         Antibiotic
80
70
60
50
40
30
20
10
 0
       Type 1        Type 2                  Type 3



                          Anthonisen Ann Intern Med 1987;106:196
         AECB: Antibiotics
• Retrospective review medical records of 60
  patients - 224 AECB
• Objective: determine the antimicrobial efficacy
  and related cost in AECB
• Antibiotic groups:
    - 1st line: Amoxicillin, Co-trimoxazole,
      Tetra., Erythromycin
    - 2nd line: Cefuroxime, Cefaclor, Cefprozil
    - 3rd line: Azithromycin, Amox-Clav,
      Ciprofloxacin

                          Destache J Antimicrob. Chem 1999; 43:S107
                      AECB Treatment Failure Rates

                 25
Percentage (%)




                 20
                                                                     * p < 0.05
                 15

                 10
                                                                     *
                  5

                  0
                       1st line (n=100)   2nd line (n=67)       3rd line   (n=57)


                                               Destache J Antimicrob. Chem 1999; 43:S107
         AECB: Outcome and Cost

                 1st line        2nd line          3rd line

Days of Rx        8.9              8.3               7.5
Infection free    17                23                34
interval (wks)
Total Cost ($)    942              563               542
Pharmacy Cost     10                24                45



                            Destache J Antimicrob. Chem 1999; 43:S107
             Treatment for CAP versus
             AECB
                       Pneumonia
                                              AECB
                    1st Line     2nd Line

      Young no                                No Tx,
     pulmonary     Macrolide   Doxycycline     If Sx
disease, no risk                              persists
                                             Macrolide
       Chronic     Macrolide   Doxycycline   Amoxacillin
     Bronchitis
             Treatment for CAP versus
             AECB
                       Pneumonia
                                              AECB
                    1st Line      2nd Line

    Moderate/    Respiratory     Amox/Clav±  New Macrolide,
 Severe COPD     Quinolone        Macrolide,   Amox/Clav,
                               2nd Gen Ceph±     Cipro,
                                  Macrolide  2nd Gen Ceph,
                                               TMP/SMX

COPD +Recent     Respiratory    Amox/Clav      Rotate
    Antibiotic   Quinolone                     Above
          CAP: Summary
• Diagnosis is made by history, physical
  examination, CXR
• Site of care determined by the prediction
  rule
• Be aware of variety of causative
  pathogens, co-pathogens
• Base antimicrobial therapy on the
  guidelines

								
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